A SYSTExM OF MEDICINE
•nS'
^^^^
<#
A
SYSTEM OF MEDICINE
BY MANY WRITERS
EDITED BY
THOMAS CLIFFORD ALLBUTT
M.A., M.D., LL.D., F.R.C.P., F.R.S., F.L.S.. F.S.A.
REOIUS PROFESSOR OF PHYSIC IN THE UNIVERSITY OF CAMBRIDGE,
FELLOW OF UONVILLE AND CAIU3 COLLEGE
VOLUxME IV
ILontfon
MACMILLAN AND CO., Limited
NEW YORK : THE MACMILLAN COMPANY
1897
All rights reserve.d
V. 4-
CONTENTS
DISEASES OE THE LIVER
PAGE
Anatomy of the Liver. Dr. William Hunter . . . .3
Functions of the Liver and their Disorders. Dr. William Hunter , 6
Congestion of the Liver. Dr. William Hunter . . . .42
Jaundice. Dr. William Hunter . ...... 51
Toxemic Jaundice. Dr. William Hunter . . . . .83
Weil's Disease. Dr. William Hunter . . . . . .95
Acute Yellow Atrophy of Liver. Dr. William Hunter . . . iOl
Perihepatitis. Dr. W. Hale W^hite ...... 118
Suppurative Hepatitis. Dr. Andrew Davidson .... 123
Am(ebic Abscess of the Liver. Dr. Lafleur ..... 153
Cirrhosis of the Liver. Dr. Hawkins . . . . .170
Tumours of the Liver. Dr. Hale White . . ' . . . 194
Diseases of the Gall-Bladder and Bile-Ducts. Mr. Mayo Robson . 211
Cholangitis. Mr. Mayo Robson ...... 249
Congenital Obliteration of the Bile-Ducts. Dr. John Thomson . 25.''
Icterus Neonatorum. Dr. John Thomson ..... 258
DISEASES OF THE PANCREAS. Dr. Fitz . . . . .262
DISEASES OF THE KIDNEYS
General Pathology of the Renal Functions. Dr. Rose Bradford , 281
Nephroptosis. Professor Macalister ...... 338
Diseases of the Kidney characterised by Albuminuria. Dr. Dickinson 352
Other Diseases of the Kidneys. Mr. Henry Morris —
Perinephric Extravasations ...... 414
Renal Fistul^e ........ 416
Perinephritis and Perinephric Abscess . . . .417
Traumatic Nephritis . . . . . . .421
Suppurative Nephritis, Pyelitis, and Pyelonephritis . . 422
vm
SYSTEM OF MEDICINE
Oxiiiin Diseases of the Kidneys, continued —
Kexal Abscess ...
Hvi>Ut)XEPHKOSIS
pvonki'iirosis ...
Ureterectomy for Diseases of Ureter
Renal Calculus
MoRiJii) Growths
Cysts of the Kidney
Hydatids of the Kidney .
Diagnosis of Renal from other Tumours
PAGE
427
430
434
437
439
445
450
454
457
DISEASES OF LYMPHATIC AXD DUCTLESS GLANDS
Diseases of the Thyroid Gland —
Introductory Remarks. Dr. AV. M. Ord and Dr. Hector Mackenzie . 465
MYxtEDEMA. Dr. W. M. Ord . . . . . .469
Sporadic Cretinism. Dr. W. M. Ord and Dr. W. W. Ord . . 484
Graves' Disease. Dr. W. M. Ord and Dr. Hector Mackenzie . . 489
Diseases of the Spleen. Dr. H. D. Rolleston .... 516
Addison's Disease, and other Diseases of the Suprarenal Bodies.
Dr. H. D. Rolleston ....... 540
Hodgkin's Disease. Dr. George R. Murray ..... 573
Scrofula. Professor Allbutt and Mr. Pridgin Teale .... 597
OBESITY. Sir Dyce Duckworth . . . . . .607
DISEASES OF THE EESPIRATOKY ORGANS
General Pathology of Respiratory Diseases. Dr. A. Ransome . . 625
The Treatment of Asphv.ma. Dr. A. Ransome .... 648
Physical Signs of the Diseases of the Lungs and Heart. Dr. Hector
Mackenzie ......... 652
DISEASES OF THE NOSE, PHARYNX, AND LARYNX
I. Diseases of the Nose. Dr. de Havilland Hall, Dr. Greville MacDonald,
Sir Felix Semon, and Dr. Watson Williams . . . .671
11. l)i-EASES of the Pharynx. Sir F. Semon, Dr. W. Williams, and Dr
do Havilland Hall ....•••• 723
III. Diseases of the Laryn.x. Sir F. Senion, Dr. W. Williams, and Dr
de Havilland Hall ....•••
INDEXES
780
865
ILLUSTRATIONS
FIG. PAGE
1. Pulse-tracing in Acute Nephritis of 14 days' standing in a Boy aged 14 . 368
2. Casts of Nephritis containing Fibrin, Epithelial Cells and Granular Matter 370
3. Pulse-tracing in a case of Granular Kidney in a Painter aged (55 . . 389
4. Casts obtained from Cases of Granular Kidney . . . . 401
5. Pulse-tracing in Lardaceous Disease of Kidney .... 407
e. Casts from the Lardaceous Kidney ...... 407
7. Before MyxcBdenia ........ 473
8. Pronounced Myxcedema . . " . . . . . 475
9. The same Patient as in Figs. 7 and 8 after two Years of Treatment by
Administration of Preparation of Thyroid Gland .... 477
10. Case of Acromegaly, Exophthalmic Goitre, Phthisis, and Glycosuria . 491
11. Thoracic Callipers ........ 627
12. Rib Goniometer ........ 627
13. Two-plane Stethograph . . . . . . .628
14. Movement of the Clavicle in a Healthy Man, aet. -39 . . . 629
15. Movements of the Third Ribs in a Healthy Woman, set. 29 . . 629
16. Healthy Adult Man. Movements of Third Ribs . . . .629
17. Same Case, Fifth Ribs . . . . . . .629
18. Same Case, Seventh Ribs . . . . . . .629
19. Same Case, Eighth Ribs . . . . . . .629
20. Action of the Ribs in Nose-blowing ...... 632
21. Single Acts of Coughing ....... 632
22. "A Yawn" ......... 633
23. "A Sneeze" ......... 633
24. Varieties of Cough ........ 633
25. Double Cou2;h ......... 633
SYSTEM OF MEDICINE
26. Double Cough .....
27. Three Acts of Coughing
28. Chronic Phthisis. Movements of Third Ribs
29. Cough in Chronic Phthisis
30. Relative Dimensions of Healthy Movements
31. Dimensions of Movements in a Case of advanced Emphysema
PACK
• 0
. G.'34
• •
. 634
• •
. 634
•
. 634
•
. 636
mphysema
. 636
PLATE
Section of a Lardaceous Kidney
To face page 411
LIST OF AUTHORS
Allbutt, Thomas Clifford, M.D., LL.D., F.R.C.P., F.R.S., Regius Professor of
Physic in the University of Cambridge, Fellow of Gonville and Cains College,
Consulting Physician to the Leeds General Inlirniary.
Bradford, John Rose, M.D., D.Sc, F.R.C.P., F.R.S., Professor of Materia Medica
and Therapeutics in University College, London; Physician to University Col-
lege Hospital ; Professor Superintendent of the Brown Institution.
Davidson, Andrew, M.D., F.R. C.P.Ed., late Visiting and Superintending Surgeon,
Civil Hospital, and Professor of Chemistry, Royal College, Mauritius.
Dickinson, W. Howship, M.D., F.R.C.P., Consulting Physician, St. George's Hos-
pital and Hospital for Sick Children ; Honorary Fellow of Gonville and Caius
College, Cambridge.
Duckworth, Sir Dyce, M.D., LL.D., F.R.C.P., Physician and Lecturer on Medi-
cine, St. Bartholomew's Hospital.
Fitz, Reginald H., M.D., Hersey Professor of the Theory and Practice of Physic
in Harvard University ; Visiting Physician to the Massachusetts General Hos-
pital.
Hall, F. de Havilland, M.D., F.R.C.P., Physician and Lecturer on Medicine at the
Westminster Hospital.
Hawkins, Herbert P., M.D., F.R.C.P., Assistant Physician and Joint Lecturer on
Pathological Anatomy at St. Thomas's Hospital ; Assistant Physician, London
Fever Hospital.
Hunter, William, M.D., CM., F.R.C.P., Senior Assistant Physician, London Fever
Hospital ; Assistant Physician, West London Hospital ; Pathologist, Charing
Cross Hospital.
Lafleur, Henri A., M.D., Assistant Professor of Medicine and Associate Professor
of Clinical Medicine, M'Gill University ; Physician to tlie Montreal General
Hospital.
Macalister, Alexander, M.D., LL.D., D.Sc, F.R.S. , Professor of Anatomy in the
University of Cambridge ; Fellow of St. John's College, Cambridge.
MacDonald, Greville, M.D., Assistant Physician for Diseases of the Throat, King's
College Hospital, London.
xii SYSTEM OF MEDICINE
Mackenzie, Hector W. G., M.D., F.R.C.P., late Fellow of Emmanuel College,
Cambridge ; Assistant I'hysician and Pathologist, St. Thomas's Hospital ;
Assistant I'hysician to Brompton Consumption Hospital.
Morris, Henry, M.A., M.B., F.K.C.S., Senior Surgeon to the Middlesex Hospital;
Member of the Council and of the Court of Examiners of the Koyal College
of Surgeons, England.
Murray, George Rodniayne, M.D., M.R.C.P., Heath Professor of Comparative
I'athology in the University of Durliam ; Physician to the Newcastle Royal
Inlirniary.
Ord, William M., M.l)., F.R.C.P., Physician and Lecturer on Medicine to St.
Thomas's Hospital.
Ord, W. Wallis, M.D. Oxon., late Physician to the West End Hospital for Nervous
Diseases, and Assistant Physician to the Victoria Hospital for Children, Lon-
don.
Ransome, Arthur, M. D., F.R.S., Hon. Fellow of Gonvillc and Cains College, Cam-
bridge ; Consulting Physician, Manchester Hospital for Consumption.
Robson, A. W. Mayo, F.R.C.S., Professor of Surgery at the Yorkshire College,
and Senior Surgeon, Leeds General Infirmary.
RoUeston, Humphry Davy, M.D., F.R.C.P., late Fellow of St. John's College,
Cambridge ; Senior Assistant Pliysician and Lecturer on Pathology to St.
George's Hospital ; Physician to Out-patients, Victoria Hospital for Children.
Semon, Sir Felix, M.D., F.R.C.P., Physician for Diseases of the Throat to the
Queen's Square Hospital for Paralysed and Epileptic.
Teale, T. Pridgin, M.B., F.R.C.S., F.R.S., Consulting Surgeon, Leeds General
Infirmary.
Thomson, John, M.D., F.R.C.P.Ed., Extra Physician to the Royal Hospital for
Sick Cliildren ; Lecturer on Diseases of Children, School of Medicine, Edin-
burgh.
Wliite, W. Hale, M.D., F.R.C.P., Physician and Lecturer on Pharmacology and
Therapeutics to Guy's Hospital.
Williams, P. Watson, M.D., M.R.C.S., Physician to Out-patients, and for Diseases
of the Throat, Bristol Royal Infirmary ; Physician to the Deaf and Dumb
Institution ; and Pliysician to Clifton College.
In order to avoid frequent interruption of the text, the Editor has only inserted
the numbers indicative of items in the lists of " References'''' in cases of emphasis,
where two or more references to one author are in the list, ichere an author is
quoted from a work published under another name, or where an authoritative state-
ment is made without mention of the author's name. In ordinary cases an author''s
name is a sufficient indication of the corresponding item in the list.
DISEASES OF THE LIVER
VOL. IT
ANATOMY OF THE LIVER
Topographical Anatomy. — The liver is the largest gland in the body,
and the largest of all the abdominal organs. It occupies the right hypo-
chondrium and the epigastric region, a,nd frequently extends also into
the left hypochondrium.
Its anatomical relations are both numerous and important.
Above it is in relation to the diaphragm, filling up its vault, and,
through the diaphragm, to the lungs and heart.
Below it is in immediate relation to the stomach, the first part of
the duodenum, and the transverse colon with its hepatic flexure ; and,
more posteriorly, to the suprarenal capsule and the head of the right
kidney. The narrow edge of the left lobe overlaps and hides the lesser
curvature of the stomach Avith its pyloric and cardiac orifices ; a relation
maintained irrespective of the degree of distension of stomach.
In front the greater part of it is covered by the diaphragm and the
lower margin of the right lung protected by the costal cartilages and
lower ribs (5th to the 9th) ; and it only comes into immediate relation
with the abdominal walls over a small area occupying the subcostal
angle.
Laterally on the right side it is protected by the lower ribs (7th to
11th inclusive) ; on the left it tails off over the stomach, and may extend
into the left hypochondrium and come into relation with the spleen.
Its upper border is much curved, rising from the lower end of the
sternum (base of the xiphoid cartilage) in the middle line to the upper
border of the 5th rib in the mammary line, and then falling to the upper
border of the 7th rib in the mid axillary line, of the 9th rib in the
scapular line, and of the 1 1th rib in the dorsal line.
Its loiver border corresponds on the right side in the mammary line
with the lower edge of the costal arch, and stretches obliquely across
the epigastrium in the region of the pit of the stomach at a somewhat
varying level (7th to 8th costal cartilages), about midway between the
umbilicus and xiphoid notch.
Relations on percussion. — The liver being for the most part in
contact with organs containing air, — the lungs above and the stomach
and colon below, — its boundaries can be more easily determined by per-
cussion than is the case with any other organ in the abdomen. The
only solid organ besides the kidney with which it is in close relation
SYSTEM OF MEDICINE
— separated, however, by the diaphragm — is the heart Avith its
pericardium. In the middle line up to the left, therefore, its upper
limits cannot be determined by percussion. On the right side,
■where it is in relation to the right lung, they are easily determined.
The upper line of licer duiness is curved, being found in the mammary
line at the upper border of the 5th rib; in the mid axillary line
two interspaces lower — namely, at the upper border of the 7th rib, in
the scapular line at the 9th rib, and behind at the 11th rib. The dul-
ness at these points is, however, not absolute, the lower edge of the
lungs, especially in front, intervening between the liver and the chest
wall for a varying distance, according to the degree of expansion of the
lung. During quiet breathing the upper limit of absolute dulness in the
mammary line is found about an interspace lower ; namely, the upper
border of the 6th rib. By forced inspiration the lung can be made to
descend an interspace ; namely, to the upper border of the 7th rib.
The hirer edge of the liver is in relation throughout to air-containing
organs, but its exact delimitation by percussion is rendered somewhat
ditfii-ult by the circumstance that the relations obtaining at the upper
border are here reversed. At the upper border the visceral mass is
constituted by the solid liver, which is only slightly overlapped by a thin
margin of resonant lung substance. At the lower border the visceral mass
— stomach and transverse colon — is resonant, while the edge of the liver
is for the most part thin and overlapping. This applies especially to that
portion of the right and left lobes which comes into immediate contact
with the abdominal wall. It overlies the stomach, and the dulness due
to it is liable to be modified by the resonant note of the stomach sub-
jacent to it.
In expiration and quiet breathing the lower limit of the hepatic
dulness in the middle line is found about an inch below the xiphoid
cartilage; the hepatic dulness at this point occupying the upper third
of a line between the xiphoid cartilage and the navel. During deep
breathing it descends an inch or an inch and a half, or even more ; so that
the dulness occupies approximately the upper two-thirds of the same line.
On the right side the lower limit of dulness is found, during quiet
breathing, in the mammary line about the edge of the costal arch, half
an inch above or below. From this it extends to the left somewhat
obliijuely upwards across the subcostal angle, from about the 9th costal
cartilage (ju the right side to the 7th costal cartilage on the left. In the
right axillary line it corresponds to the 10th intercostal space ; in the
right scapular line to the 12th rib, where, however, it becomes difficult
to distinguish it from the dulness of the kidney.
Within the above limits the jjosition of the liver is not fixed, but is
much influenced on the one hand by the respiratory movements of the
diaphragm, and on the other by the degree of distension of the other
abdominal organs.
The foregoing boundaries and limits apply to the liver during
expiration or quiet breathing.
ANATOMY OF THE LIVER
Dui-iug deep inspiration the liver is lowered an appreciable distance —
according to Sibson as much as two inches, according to Murchison only
half an inch. On the right side its lower edge descends an inch or more
below the edge of the costal margin, while its left lobe descends as low
as the upper two-thirds of the line between the navel and the tip of the
xiphoid cartilage. As pointed out by Sibson, this greater prominence
of the liver during inspiration is due not solely to the descent of the
diaphragm, which pushes the liver downwards and slightly forwards, but
also in part to the elevation and rotation outwards of the lower ribs and
costal cartilages. In relation to the ribs the descent of the liver is thus
greater than its actual descent in the abdomen. It is probable, also, that
the lowering of the liver during forced inspiratory movements would be
still greater but for the fact that the liver itself is compressible, and
becomes somewhat flattened out from side to side by the force of the
diaphragm, its blood being forced freely out of its hepatic veins into
the right auricle.
The dulness over the right lobe is even more affected by forced
inspiratory movements than over the left, being thrust downwards by
the contraction of the right half of the diaphragm a distance of two
inches or more below the costal margin.
The above delimitations apply to the adult healthy liver. It remains
to be noted that in the new-born child, and in early infancy, the liver is
relatively much larger than in the adult. At birth it occupies nearly
one-half of the abdominal cavity. Below, the right lobe extends nearly
to the iliac crest. Moreover, the left lobe is relatively much larger than
in the adult, and extends across into the left hypochondrium, coming
into contact Avith the abdominal wall and the spleen.
Nerve-supply, — The liver receives its nervous supply from the left
pneumogastric nerve and the solar plexus of the sympathetic, both sets of
branches entering through the portal fissure. Its nervous supply is thus
the same as that of the stomach and intestines. The sympathetic branches
accompany the hepatic artery ; some also accompany the portal vein.
Within the liver the nerves are distributed to the walls of the blood-
vessels and biliary ducts, and pass also between the hepatic cells of the
lobule, following the course of the bile canaliculi ; they probably end in
a hue network which ramifies between and over the liver-cells, as has
been shown by Korolkow to be the case in animals.
The Bile-ducts take origin in minute canaliculi — intercellular pas-
sages— lying between and around the individual cells. A liver-cell
is always interposed between canaliculus and capillary vessel. These
canaliculi appear to be without any definite walls, and to have rather
the character of intercellular channels. If they have walls, these are
not distinguishable from the walls of the liver-cells between which they
run. They form a network around the individual liver-cell, which is
much finer and closer than that of the capillary network.
The most recent observations (Pfliiger and Kupfer) seem to demon-
strate even a closer relationship between the liver-cells and the canaliculi^
SYSTEM OF MEDICINE
for the}' show the existence of vacuoles within the liver-cell communi-
cating by minute channels with the adjacent canaliculi.
Blood-supply. — The blood-supply of the liver is of a peculiarly rich
character, being a double one ; it flows partly through the portal vein,
partly through the hepatic artery. Both these vessels enter the liver
through its transverse Assure, and along Avith the biliary ducts their
branches occupy the portal canals throughout the liver.
The branches of the portal vein ramify between the lobules (inter-
lobular) and end in a capillary network within the lobule itself. Within
the portal canals the branches of the portal vein receive small veins
returning the blood distributed by the hepatic artery.
The hepatic artery is distributed (a) to the walls of the ducts and
vessels and the surrounding connective tissue of the portal canals ;
(h) to the capsule of the liver ; and (c) it finally breaks up bet .veen the
lobules, supplying blood to the walls of the interlobular blood-vessels
and the bile-ducts. Whether it transmits any blood directly to the
lobule seems to be doubtful.
Within the lobule the capillary network is of the closest description,
the capillaries being separated froin one another by intervals commonly
not larger than the diameter of two liver-cells. In the centre of each
lobule the blood is collected into the central {intraJohiilar) branches of the
hepatic vein, which in turn collect and form larger branches (siiblobular);
these in turn merge into the large venous trunks of the hepatic vein,
which Anally opens into the inferior vena cava. Throughout their course
the branches of the hepatic vein are distinguished by the thinness of
their walls.
FUNCTIOXS OF THE LIVER AND THEIR DISORDERS
Functions and the Disorders connected with them,
i. Assimilative. (Glycogenetic, Proteolytic.)
ii. Excretory.
(a) Water.
(b) Bile Pigments.
(c) Bile Saks.
(d) Cholesterin (Cholelithiasis).
(e) Drugs and Poisons (Jaundice and Biliousness),
iii. Digestive.
Introduction. — Probably no organ of the body discharges functions at
one and the same time so many, varied, and complex as the liver. It is
at once a digestive organ, an important organ of excretion, and the chief
assimilative organ in the body.
Its digestive and excretory functions are carried out through the agency
of its secretion — the bile. The part played by this fluid in digestion is
an extremely small one. It has no action on proteids or carbohydrates ;
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 7
its only action is on fats, which it emulsifies and thereby facilitates
their absorption.
On the other hand, as an organ of excretion the functions of the liver
are of the highest importance. This excretory function is among the
first to be called into requisition. Bile is formed as early as the third
month of intra-uterine life, long before any necessity has arisen for
digestive functions. The liver may be described as the excretory organ
of the portal circulation, discharging the functions in relation to that
circulation that the kidneys do in relation to the general circulation.
Its appearance in the animal scale is contemporaneous with the
appearance of haemoglobin in the body juices; and one of its chief
functions throughout life, as it is one of its earliest, is to remove effete
haemoglobin from the body.
But its excretory functions are by no means confined to the pigments
formed from haemoglobin ; they extend to the other products of proteid
metabolism, some, like the bile acids, formed in the liver itself, others
derived from the portal blood. Thus a large number of medicinal
substahces are excreted in the bile ; while with regard to others not
so excreted the liver exercises a function equally useful and effective,
namely, that of destroying or modifying them. This function of the
liver is probably of the utmost importance in protecting the body against
a series of crude and more or less poisonous products formed during
the process of digestion.
It is, however, in respect of nutrition that its functions are most
varied and complex, and unfortunately still the most obscure. The
liver elaborates and modifies nearly every product of digestion conveyed
to it in the portal blood, acting not only on the primary products,
such as peptones and sugar, but also on secondary products of amido-
acid or aromatic nature, like leucin and tyrosin, or of basic nature,
like lysine, lysatinine and ammonia, transforming them into urea, and
possibly, in the case of the amido-acids, building them up again into
more complex bodies.
The sum-total of this activity is evidenced by certain definite changes,
among which the most notable are, first, the appearance of glycogen
— followed later by its disappearance, the formation and excretion of
bile acids in the bile, and the formation of urea.
It is convenient to speak of these as so many several processes ; but
it is important to bear in mind that they are probably all carried out in
close connection with each other. At any rate, this is so in health.
There is nevertheless a certain independence among the processes.
Thus the formation of bile pigments and of bile acids, the two specific
constituents of the bile, do not always go hand in hand, as was formerly
thought. The bile pigments may be greatly increased (thus represent-
ing activity of the liver-cell in breaking up haemoglobin) without any
increase of bile acids (products of proteid metabolism). Indeed, the
latter may be at the same time greatly diminished. As will afterwards
be seen, this result is characteristic of most of the poisons that destroy
8 SYSTEM OF MEDICINE
the blood. They supply an increased amount of ha3mogloVjin to the
liver -wherewith to form bile pigments ; but they appear rather to inter-
fere with the general proteid metabolism on which the formation of
bile acids depends.
The above summary of the various processes in the liver-cell may
indicate in how many and various directions this element is o})en to
functional disturbance which must affect the character of the blood
and, indeed, nutrition generally.
The manner in which the liver-cell disposes of the products of its
activity also calls for notice. AVhile some of them return to the blood,
others it no less invariably excretes into the bile, a fluid which is ex-
creted at a low pressure along a long system of narrow passages, the
lining epithelium of which is also excretory.
Both as regards the complexity of its processes, and the manner in
which it gets rid of the products of its action, it is thus easily conceiv-
able that disturbance of function may affect the bodily nutrition and
health in mau}^ ways. To what extent it does so it is impossible within
the limits of this article adequately to discuss. But some reference to
the subject is necessary before entering on any consideration of disease
of the liver, seeing that functional disorders of this organ bulk so largely
in the minds of many persons as prominent factors in the causation of
many diseases.
Three stages in our views of this matter may be distinguished.
For many centuries the liver was regarded as the chief organ of the
vegetative processes within the body — the seat of sauguitication and
the centre of animal heat.
At a later period this view gave place to another, less general in
character, Avhich held sway during a period of two centuries. The chief
function of the liver was held to be the secretion of bile, and all its
disorders were discussed in relation to this function under the three
heads of (a) diminished secretion, (6) increased secretion, (c) morbid
secretion, that is, the secretion of morbid bile.
It is only with the infornuxtion su})plieil by the researches of the
present century, notably since the epoch-making discovery by Claude
Bernard of its glycogenetic functions, that more extended and compre-
hensive views have been possible regarding other relations of functional
disorder of the liver in disease. To no one are we more indebted for
this result than to Murchison. In his well-known Croonian Lectures
(1874) the first systematic attempt was made to give precision to the
vagiie and indefinite views held on the subject, and to show that func-
tional disorder of the liver may extend into other spheres and affect
processes no less important to the organism than that of bile secretion
— such processes, for example, as glycogenesis, the destructive metOr
morphosis of albuminoid matter generally, the formation of urea, and
other nitrogenous jiroducts.
Murchison's views. — Tlie classification Murchison proposed for such
disorders was the following : —
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 9
a. Abnormal mctrition. — Both corpulence and emaciation may be the
results of functional disorder, depending possibly on deficient formation
of bile, with consequent defective assimilation of fatty and albuminous
matters ; or, on the other hand, on imperfect glycogenesis. The wasting
of other diseases, such as phthisis or waxy disease, might also perhaj)S
be referable to some functional disorder of the liver.
(3. Abnormal elimination. — The disorders coming under this head are
those connected with deficient elimination of bile ; namely, costiveness,
pale colour of stools, loss of appetite, furred tongue, bitter taste in the
mouth, flatulence, sallowness of complexion, dingy conjunctivae, languor
and disinclination for work, frontal headache, dulness and heaviness,
drowsiness after meals, great depression of spirits amounting occasionally
to hypochondriasis, and lastly, frequent deposits of lithates in the urine.
This group of symptoms might not unfitly be attributed to " torpor of
the liver." The ensuing " engorgement of the liver " may well interfere
with the normal processes of disintegration of albumin in the gland, and
thus lead to the accumulation of deleterious products in the blood.
y. Abnormal disintegration includes those disorders, probably the
most important of all, due to imperfect disintegration of albuminous
matters, and to the replacement of urea by other nitrogenous products.
The commonest example of this derangement Murchison conceived
to be what he named " Lithuria," — that is, the deposits in the urine of
urates, uric acid, and pigmentary matters so commonly found in liver
affections.
Si/mptoms of litlimmia. — Lithuria Murchison conceived to be as
definite a disorder of liver function as glycosuria, and to be the result
of abnormal albuminous disintegration and of a condition of blood
(" litheemia ") induced thereby. This state of lithaBmia, he said, may
manifest itself in other ways than by the above-mentioned deposits ;
namely, by an extended train of symptoms, including a sense of weight
and fulness in the epigastrium and region of the liver, flatulent disten-
sion of the stomach and bowels, heartburn and acid eructations, oppres-
sion and weariness, sleepiness after meals, bitter taste in the mouth,
variable appetite, nausea, excessive secretion of viscid mucus in the
fauces and at the back of the nose, furred tongue often large and
indented at margins, constii^ation with scybalous motions sometimes
dark at others clay-coloured, or diarrhoea, palpitation of the heart,
irregularity or intermittence of pulse, frontal headache, restlessness at
nights, bad dreams, and attacks of vertigo or dimness of sight often
induced by particular articles of diet.
Lithaemia may manifest itself in gout, the foregoing train of symptoms
being common in gouty people, and known as those of " gouty dyspepsia "
or as "suppressed," "anomalous," or "latent" gout. In his opinion,
articular gout is, so to speak, a local accident occurring in the midst of a
train of phenomena due to abnormal albuminous disintegration within
the liver. Gout, like diabetes, is in this case the result of functional
derangement of the liver.
lO SYSTEM OF MEDICINE
Lithaemia may also manifest itself by the formation of urinary calculi.
Not only uric acid, which forms live-sixths of most urinary calculi, but
also cystin, of which some are composed, are of hepatic origin. Xanthin
also, and even oxalate of lime, are probably also connected with disorder
of the liver, although evidence on this point is wanting. Anyhow, the
symptoms of oxaluria closely resemble those of lithaemia as above
described. In the great majority of cases of urinary calculi the liver is
the organ primarily at fault.
As with urinar}' calculi, so also with biliary calculi; these also are
frequently found in lithaemic persons, and are the result of functional
derangement of the liver.
Another consequence and manifestation of this lithaemic dyscrasia
may be degeneration of the kidneys. Murchison regarded litliEemia as the
chief cause of acute nephritis ; also of the granular, contracted, or gouty
kidney ; also of the degeneration of kidneys occurring as a sequel to
diarrhoea ; and lastly, of functional albuminuria, such as that connected
with digestion, occurring independently of structural alterations.
Another couseqnenceoflit\V(Snua,nughthestructural diseases of theliver,
such as the fatty degeneration met with in alcoholics, catarrhal jaundice,
some cases of cirrhosis, and, lastly, even primary cancer of the liver.
Other manifestations of lithaBuiia he conceived to be the degenerations,
fatty and calcareous, met with in old age, and probably traceable to tlie
functional inactivity of advancing years. When occurring earlier in life
these degenerations are met with more often in those subject to lithaemia,
in the gouty, for example, than in persons free from such tendencies.
Local inflammations are also favoured by the condition of lithaemia,
persons of lithaemic habit being more prone than others to suffer from
febrile colds and local inflammations generally.
Lastly, the lithaemic diathesis may influence the incidence and course
of constitutional diseases. The liver is one of the organs that suffer most
from the action of blood poisons, and at the same time contributes most
to produce morbid states of the blood generally, such as diabetes or gout.
Many constitutional diseases thus probably owe their origin to de-
rangement of the liver. Among these he cited acute yellow atrophy of
liver, erysipelas, pyaemia, acute rheumatism, tendency to thrombosis — a
tendency especially well marked in tropical regions where hepatic derange-
ments are so common (Fayrer) — deficiency of red corpuscles in anaemia,
chlorosis, scrofula. Indeed, constitutional diseases generally" he attrib-
uted in the first instance to some defective action of the liver.
The above summary will indicate both the character of the symptoms
usually ascribed to disturbance of liver function, and also the wide sphere
of influence it is possible to ascribe to functional liver disorder in the
production of disease. Murchison's teaching represents, in my opinion,
the extremest view it is possible to take of the importance of functional
disorder of the liver in producing disease. The information gained since
his views were originally put forth has thrown fresh light on many of
FUNCTIONS OF THE LIVER AND THEIR DISORDERS ii
the points he dealt with, and has necessitated some modifications of the
above opinions.
In the present account I shall confine myself to the consideration of
such facts as appear to throw fresh light on the subject ; but the general
outcome of my inquiry will be to show that in a large number of
disorders assigned to the liver, the liver is as much the sufferer as the
cause of suffering. Its disturbances, in a great majority of instances,
arise not so much from any fault of its own, as from the fault of
other organs connected with the portal circulation — to the presence of
faulty products of digestion poured into the portal blood with which it
has to deal. In another large group of cases the disturbances arise, not
primarily in the liver-cell itself, but from morbid conditions in the bile
passages, created (it may be) by the excretion of morbid products,
whereby the due excretion of the bile is prevented.
I shall have to point out again and again that some of the chief
hepatic disturbances — as, for example, biliousness, jaundice, diminished
excretion of bile, cholelithiasis — are the result of changes, not in the
liver-cell, but in the lining membrane of the bile passages ; and that the
disturbances of function of the liver-cell are consequences of these.
The FUNCTION'S of the liver. — The functions of the liver may
conveniently be considered under two headings: —
A. Assimilative. (Glycogenetic, Proteolytic, Metabolic.)
B. Biliary. (E^^-etmy.
•^ ( Digestive.
Under the word "Assimilative " I include not only glycogenesis, but
also the whole series of important nutritive functions of which glyco-
genesis is but one feature ; as the result of these functions proteid and
carbohydrate materials are prepared and made assimilable for the tissues
generally, while other derivatives of proteids are modified or built up
into forms ('urea) suitable for removal from the body.
A. Assimilative functions. — The disturbances connected with dis-
order of these functions may be dealt with briefly ; not because of their
small importance, but because we are in great ignorance of their nature.
Glyrogenetic. — Thus with regard to glycogenesis, we know that the
liver possesses a remarkable power of forming glycogen very easily from
sugar ; not only so, but also, in the absence of sugar, from ordinary proteid
material. Glycogen accumulates in the cell during digestion, and in the
intervals between meals disappears again ; it is markedly increased on a
diet. rich in starchy food or sugar, but is not absent even when such
food is withheld and proteids only are given ; it is specially abundant
in the liver of the healthy and well-nourished man ; a suitable quantity
of it seems essential for the efficient discharge of the many functions
of the liver-cell ; and either directly or indirectly it is thus essential
to the nutrition of the body generally. We know further that the
"glycogenetic" function of the liver is not an independent one carried
out by the liver without relation to other processes within the liver-
12 SYSTEM OF MEDICINE
cell ; for example, as I shall show later, the presence of glycogen greatly
favours the destruction of haemoglobin, and is most active when the
supply of food material to the liver is greatest.
Nevertheless, while this is so, we know, both from experiment and
from disease, that the function enjoys a certain independence ; that, for
example, certain drugs (phlorizin) possess the power of causing glycosuria,
even in the starving animal, at a time when presumably the liver is free
from glycogen, and no food material is reaching the liver ; and, again,
that in diabetes it seems to be affected to a special degree. It is thus
easy to speculate that disturbance of this glycogenetic function may
play an important part in disease ; that in one case it may be responsible
for leanness and wasting, while in another it may be responsible for the
opposite effect of corpulence. But such speculations do not carry us far.
In the absence of more precise information as to the nature of the
disturbance, they are only other ways of saying that in the one case
there is malnutrition and wasting, while in the other nutrition is good.
Even if some disturbance there be, there is no evidence that it is the
primary one, that it is not a concurrent effect of some change affecting
the organs of nutrition and the tissues generally, and not the liver
especially.
Apart then from its effects on nutrition, we know little definite with
regard to disturbances of this hepatic function in disease. That it is
gravely affected in many conditions of disease is certain ; but, Avith the
exception of diabetes, it is probable that altered glycogenetic activity is
only one expression of a general disturbance affecting the general activity
of the liver-cell in relation to nutrition. I say especially " in relation to
nutrition," for I shall have to point out later that the excretory activity
of the liver may be unaffected, while its nutritive activity, jiidged by the
formation of glycogen and the formation of bile acids, is in abeyance.
Thus, as will presently be seen, poisons may induce a greatly increased
formation of bile pigments by the liver, while the bile acids are reduced
to a minimum, and no trace of glycogen is discoverable. Similarly in
disease, the power of forming bile is retained by the liver to the very
last, long after the power of forming glycogen \\\^y have been lost.
Proteolytic. — With regard to the other functions of the liver in relation
to nutrition, the breaking up of proteid material, the dealing with the
various secondary products, whether formed within itself (for example,
glycocine), absorbed from the intestine (for example, leucin and tyrosin),
or conveyed to it from the tissues generally, we know that grave dis-
turbances also occur in disease.
Urea represents the chief form in which the waste nitrogen is
removed from the body. All evidence go(>s to show that it is formed
within the liver by synthesis from ammonia; and that uric acid (a com-
bination of glycocine and urea) probably represents a product of a
metabolism witliin the liver-cell slightly divergent from that leading
to urea. In rare cases, again, wliere the liver-cell undergoes rapid
destruction (as in acute yellow atrophy), urea may almost disappear,
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 13
and its place be taken by products such, as leucin and tyrosin, which,
ordinarily, are duly arrested and broken up by the liver. We know
further that this last extreme is producible by the action of certain
poisons on the liver-cell (for example, phosphorus), precisely as we saw
that the glycogenetic function could be specially affected by other
poisons (phlorizin), or the bile-forming function by others again
(toluylendiamin).
It is thus extremely probable that in disease these particular activities
may be gravely affected, and that in this way disturbances in nutrition
and metabolism may be produced. Indications that this is the case we
often obtain, indeed, from the urine, in the changed character or quan-
tity of the colouring matters ; in the increase of urates or uric acid ; in
increase of ammonia at the expense of urea. But beyond this we know
little. We do not know to what extent these disturbances of functions
are themselves the primary or chief disorder, or, on the other hand, are
but the effects of morbid change elsewhere. Thus for the large group of
cases included by Murchison under the title of " lithaemia," and regarded
by him as in a special degree the result of functional disorder of the
liver, I shall presently have to show that the functional disturbances
which undoubtedly do occur are not the primary, and may not be even
the most important ; that in all probability they are really secondary to
disturbances initiated elsewhere, perhaps in the gastro-intestinal area.
Further, I have now to show that increase of uric acid and urates
may be an evidence of changes in lymph-forming structures, rather than
in the liver.
Thus with regard to the assumed connection between increase of uric
acid and of urates in the urine and liver disturbance, some modification
of our views is rendered necessary in the light of recent knowledge.
For certain observations indicate that uric acid may have more than one
origin in the body — not merely by synthesis of urea and glycocine
in the liver (or kidney, Luff), but independently of the liver from
the nuclein constituent of cells generalh^, especially lymphatic cells.
Hence they suggest that in certain cases increase of urates and uric
acid may represent a disorder of the blood rather than of the liver
itself. There is found to be a parallelism between the excretion
of uric acid and the number of leucocytes in the blood ; increase of
leucocytes after food is accompanied by an increased excretion of uric acid ;
diminution of the leucocytes during inanition by a diminished excretion.
Quinine, which reduces the number of leucocytes, diminishes the excretion
of uric acid ; pilocarpine, which causes a decided increase of leucocytes,
increases the uric acid. This connection between leucocytosis and uric
acid excretion is. however, best shown in leucocythsemia. The excretion
of uric acid in this disease is notably increased, sometimes more than
doubled ; the source of the uric acid in these cases has been shown to
be nuclein — the substance which forces the main constituent of the
nuclear part of cell. Again, the administration of nucleins causes an
increased excretion of uric acid. According to Horbaczewski, the chief
14 SYSTEM OF MEDICINE
seat of origin is the lymphatic elements of the spleen ; though it like-
wise appears that all organs of the body contain substances, of the nat-
ure of nucleins, capable under given conditions of being split up into
uric acid, but none so richly as the spleen. It is probable that
the increase of uric acid which rapidly occurs after digestion of food
is directly related to the increased activity of the leucocytes of the
blood and lymphatic elements, generally both in the spleen and the
gastro-intestinal mucosa, which always occurs at this period. This leuco-
cytosis is noticeable as early as one hour after digestion, and reaches its
maximum about the third hour, after which time it falls ; sometimes more
quickly, sometimes more slowly. The increase varies from 36 per cent
to as much as 14G per cent ; the average of fifty observations was 78
per cent (Pohl). The rise in the urie acid excretion is related to
this increase of leucocytes, not merely to the food taken ; for in those
exceptional cases in which no leucocytosis occurs after digestion of food,
the increase in uric acid is also Avanting. The increase of urates and uric
acid in the urine may thus denote functional disturbance of lymphatic
structures rather than disturbance of liver function.
B. Biliary functions. — 1. Excretory functions. — The Bile. — Normal
bile is a somewhat viscous liuid of a golden yellow or olive-green colour,
faintly alkaline reaction, sweet bitter taste, and mean specific gravity
about 1008. Its average daily quantity is about 1 to 1^ pint, contain-
ing about l^to 2 percent of solids. Its chief constituents are : — (i.) Bile
pigments: bilirubin, biliverdin. (ii.) Bile salts : glycocholate and tauro-
cholate of soda, (iii.) Mucus, derived from bile passages and gall-bladder,
formerly thought to consist of mucin, but now known to be more complex
— a mucoid nucleo-albumin. (iv.) Cholesterin ("Bile fat"), (v.) Fats:
palmitin, stearin, and olein. Soaps : alkaline salts of palmitic, stearic,
and oleic acids, (vi.) Lecithin or products derived from its decomposi-
tion, (vii.) luorganic salts : about 0-8 per cent, consisting chiefiy of
chloride of sodium and phosphate of sodium, with smaller traces of
carbonate of soda, phosphate of iron, phosphate of lime.
Conditions influencing the amount of bile. — The secretion of bile is
probably continuous, though varying in activity from time to time. Its
discharge into the duodenum, however, is intermittent, and takes place
chiefly in relation to digestion. It does not flow continuously, but is
expelled from time to time, in a series of jerks, by the peristaltic con-
tractions of the walls of bile-ducts and gall-bladder. The walls of the
bile-ducts, even to their smaller branches, are richly supplied with
unstriped muscular fibres, both circular and longitudinal. The conditions
influencing the character and flow of bile have been chiefly studied in
dogs with biliary fistula. Opportunities for such studies in man rarely
present themselves; of late years some valuable observations in such
ses have been recorded by Copeman and Winstcm (1889), jMayo
],ub.son (1890), Noel Baton and Balfour (1891), and Noel Baton (I8<)ii).
These observations show that the amount of bile secreted varies
greatly under the influence of many different factors — most of them
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 15
being still obscure. Throughout the twenty-four hours its flow is irregu-
lar, but in general it is highest about the middle of the day (12-4), and
lowest in the early hours of the morning. Taking food is undoubtedly
the chief factor which influences its flow in health; the flow of bile
increases when food is taken, and falls when food is withheld. But
even the influence of food is not au immediate one, for the largest amount
of solids is not excreted when digestion is actively going on, but sub-
sequently, Avhea presumably the liver is dealing with the products
absorbed.
The flow of bile is greatly influenced by the amount of fluid taken,
and this probably accounts for the increased flow during the day. But
this excretion of water is no mere mechanical filtration; the pressure at
which the bile is secreted is several times higher than that of the portal
blood from which the water is obtained. The amount of water excreted
is thus primarily dependent upon the activity of the liver-cells, not upon
the amount of water in the blood. The injection of water directly into
the blood, or its administration by the mouth or rectum, does not
necessarily cause any increased flow ; indeed, according to Stadelmann,
it has no influence upon it at all. But notwithstanding these experimen-
tal results, there can be no doubt that increased consumption of water, if
not directly by its mere presence in the blood, then indirectly by the
products which it carries with it in increased quantity from the intes-
tines and tissues, has a notable effect on the amouat of bile excreted.
And it is this flushing of the biliary system with water which serves to
explain the remarkably beneficial action of the larger number of the
mineral springs. That the excretion of water is influenced by the
activity of the liver-cell, rather than by mere amount of water, is shown
by the fact that while large quantities of water administered by the
mouth may have little or no apparent effect, the administration of food,
or still more markedly the introduction of bile into the intestine, is
always followed by an increased flow. No product absorbed from the
intestine seems to have so remarkable a stimulating action on the liver-
cell as its own bile salts.
Influence of Drugs. — Among drugs found by Prevost and Binet to
possess any power of increasing the flow of bile in dogs with biliary
fistulse, were turpentine, chlorate of potash, benzoate and salicylate of
soda, salol, euonymin, and muscarin ; none of these, however, was so
powerful in this respect as the bile or bile salts.
The folloAving were found weak and uncertain in their action : bicar-
bonate of soda, sulphate of soda., chloride of sodium, Carlsbad salts,
antipyrin, aloes, rhubarb, ipecacuanha, hydrastis Canadensis.
The flow was diminished by calomel, iodide of potassium, iron,
copper, atropin, and strychnine.
It was quite unaffected by phosphate of soda, bromide of potassium,
arseniate of soda, corrosive sublimate, alcohol, ether, glycerine, quinine,
caffeine, pilocarpin.
Nissen (1890), who carried out a similar investigation, found that
1 6 SYSTEM OF MEDICINE
alkalies like bicarbonate of soda, chloride of sodium, sulphate of soda,
Carlsbad salts, acetate of potash, sulphate of potash, salicylate of soda,
in small doses were without influence, while in stronger doses they caused
a diminution ; bile and bile salts, on the other hand, caused an increase
both of bile and the bile salts, but no increase of bile pigment. With
regard to one of the above salts — salicylate of soda — a consensus of
opinion is against Nissen's result. Thus Kosenberg (1889) found that
in doses of fifteen to thirty grains it caused an increased flow wath
diminished consistence. Lewaschew (1884) found that it caused a
notable increase (more than double), while the solids w^ere reduced to
less than one-third their former amount ; it had indeed a more intense
influence on the amount (and character) of bile than any other alkali.
This result agrees with that obtained by Professor Kutherford, to
whose well-known researches we are indebted originally for most of our
knowledge regarding the action of drugs on the amount of bile. He
found salicylate (as also benzoate) of soda to be eminent examples of
pure " hepatic stimulants," that is, of stimulants acting on the liver and
not on the intestinal glands. In their case of biliary flstula i!^oel Paton
and Balfour were able to conlirm this conclusion, for they found that
administration of salicylate of soda caused an increase of bile from
492 c.c. to 580 c.c.
The drugs found by Rutherford to increase the flow of bile were
sodium phosphate, mercuric chloride, ipecacuanha, colchicum, jalap,
aloes, colocynth ; rhubarb and dilute nitro-hydrochloric acid were also
found to be hepatic stimulants, but much feebler in their action. Calo-
mel he found to stimulate the intestinal glands, but not the liver.
Drugs, like magnesium sulphate, gamboge, and castor oil, which acted
as purgatives diminished the secretion of bile.
Other drugs, the action of which on the flow of bile has been studied,
are olive oil and Durand's remedy (oil of turpentine and ether).
Rosenberg (1889), experimenting on a dog with biliary fistula, found
that 50 to 120 grammes of olive oil by the mouth always caused within
thirty to forty-five minutes a considerable increase of bile with dimin-
ished consistence ; whereas bile always caused an increased secretion
with increased consistence. Durand's remedy caused a slight increase
due to the turpentine (ether had no effect). Carlsbad salts, given in
gelatine capsules, diminished the secretion and were without cholagogue
action. The best cholagogue, next to the bile itself, he considered to
be olive oil.
Some valuable observations were made by Mr. Mayo Robson in his
case of biliary fistula. On different occasions he administered calomel
(gr. v.), euonymin (gr. iv.), rhubarb ( 5 ss. and 3j- of tincture), podo-
phyllin, iridin (gr. iv.), turpentine ("L xv. in capsule), aerated soda water
and benzoate of soda. The only two of these that had any cholagogic
action were aerated soda water, which produced a distinct increase
maintained for some ti me, and iridin, which increased the flow temporarily,
without however augmenting the total quantity in twenty-four hours.
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 17
The other drugs seemed rather to diminish the flow of bile than to
increase it.
The most recent observations on this subject, carried out by various
pupils of Stadelmann (1890-02), also throw doubt upon the existence of
so-called cholagogue drugs. Thus Glass (1892) tested the action of
bicarbonate of soda, chloride of sodium, sulphate of soda, and artificial
Carlsbad salts on a dog Avith biliary fistula, and failed to find any
cholagogue action. None of these drugs passed into the bile or in-
creased its alkalinity.
The whole tendency of later observations appears thus to cast doubt
on the existence of any drugs possessing the power of stimulating the
liver directly to increased secretion of bile ; and some observers have
gone so far as to assert that cholagogues do not exist (jSTeumeistei-, 1893).
This view is not shared by Gamgee, who considers that judgment
should be withheld until further observations are made. With this view
of Gamgee I am disposed to concur. Although the action of many of
the agents above considered has been overrated, and powers ascribed to
them in this respect which they do not possess, there appears to me to
be no sufficient ground for doubting the existence of drugs capable of
influencing the action of the liver-cell directly. The strongest argument
to the contrary is that the bile salts certainly possess such a power to a
remarkable degree. Their administration, or that of bile, always occa-
sions an increased flow of bile as well a.s an increase in the solids. Among
the drugs mentioned above, the one for which some similar power appears
to be most fully ascertained is salicylate of soda. All observers, except-
ing Nissen, have found it to cause an increase of the bile.
The whole subject, however, is one of great complexity. As Professor
Rutherford has Avell pointed out, it is impossible to ascertain the factors
which bring about an increase of the bile in the stools after administra-
tion of a particular drug. The factor may be (a) stimulation of the
hepatic secreting apparatus ; (/S) the stimulation of the muscular fibres
of the gall-bladder and larger bile-ducts, that is, the bile-expelling
apparatus ; (y) the removal of a catarrhal or congested state of the orifice
of the common bile-duct, or of the general extent of the larger bile-
ducts ; (8) the removal from the intestines of substances which had been
passing into the portal vein and depressing the action of the hepatic
cells ; (e) or the stimulation of the intestinal glands, which drains the
portal system, and relieves the " loaded " liver. To these I would add
as another possible factor {I) the stimulation not merely of the intestinal
glands, but of the whole mass of lymph-cells in the mucosa of the intestine,
and of the cells of the spleen, the action of which, according to my observa-
tions, is so important in determining both the character of the products
carried forward to the liver and the constitution of the blood itself.
Inactivity of this mass of cells, by allowing injurious products to reach
the liver, may be the chief factor responsible for ineificient activity of
the liver and deficient flow of bile. Drugs Avhich influence the action
of this group of cells may thus affect the flow of bile, not directly in
VOL. IV c
1 8 SYSTEM OF MEDICINE
virtue of auy special action on the liver-cell, but indirectly through
their action on these other tissues.
Until, then, our information concerning the mode of action of such
drugs on biliary secretion be more detiuite, I think it would be better not
to apply the title of "hepatic stimulant" to tliem so freely as is some-
times done, not to speak as if the whole force of theii action fell on the
liver-cell, whereas it is possible, as above indicated, that many other
factors may be at work. And if, as is convenient, the name cholagogue
be applied to them, it should be with the distinct reservation that we
are still ignorant of the part played by the liver-cell itself, by the expel-
ling apparatus, and, lastly, by the tissues outside the liver — notably
those of intestinal mucosa and spleen — respectively in the production
of the increased flow of bile.
Conclusion. — To sum up the influences causing an increase in the
quantity of bile, the three chief are increased supply of water, the
absorption of bile or bile salts, and the absorption of the food products.
The action of water is not a direct one ; mere wateriness of blood —
produced, for example, by injection of water directly into the blood — does
not cause an increased flow of bile. So that its effect in increasing the
flow when administered by the mouth or by the intestine is probably
due to products washed out from the intestinal walls and carried to the
liver. To get the full effect of this action of water in diluting the bile,
care should be taken not to give the water with the food. Food alone
causes an increased flow of bile ; for instance, the most copious flow is
during the day, and a fall takes place during the night ; nevertheless it
is during the night that the bile is richest in solids. If, then, our object
be to increase the fluidity of bile, that object is best attained by giving
water when the natural tendency is for the bile to become more con-
centrated, that is, either between meals or at night time several hours
after the last meal. As a matter of clinical experience I have found
this practice yield the best possible results; for example, in cases of
jaunclice due apparently to highly concentrated bile and "biliary sand"
in the l)ile-ducts.
So far as drugs are concerned, some few (salicylate of soda, benzoate
of soda, turpentine, olive oil) seem to possess the power of exciting an
increased flow of bile ; but the action of most other so-called " chola-
gogiies" is uncertain, and, even in the case of those above mentioned,
their mode of action is quite undetermined.
So far I have had under consideration the various agents capable
of exciting an increased flow of bile. For it is to combat successfully
the conditions which lessen the flow of bile that our chief ctforts are
directed in disease.
Diminished flow of bile. — Some interesting information regarding the
mechanism underlying bile secretion is obtainable from a study of the
factors concerned in reducing the quantity of bile; and to these I must
now draw attention.
Injiuence of fever. — All observers are agreed that fever diminishes the
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 19
secretion of bile. Thus in. a ease of a biliary fistula recorded by Eiffel-
mann it was noticed that on the onset of pneumonia, and again of an
attack of dysentery, the flow of bile ceased. In the case recorded by
Paton and Balfour the patient suffered from time to time from feverish
attacks, and this condition had the most distinct effect upon the amount
of bile excreted. During the 11 days of the first attack the amount
fell from an average of 650 c.c. a day to 475 c.c, while the solids fell
from 8 and 9 grammes to o'T grammes. The subsequent restoration to
the normal was slow. In a second attack, on a rise of temperature to
99-6° F., the bile fell from 592 c.c. to 238 c.c, and the solids from 9-2
to 3-2 grammes.
These observations agree with the experimental results obtained by
Pisenti (1886), who finds that fever invariably causes a diminution in the
excretion of bile — the diminution being one-third to one-half the normal.
This diminished excretion of water appears to be the result of fever
itself, irrespective of its nature ; the diminution in the amoinit of solids,
on the other hand, appears to depend upon the nature of the fever.
Moreover, in fever the bile always contains a larger amount of mucin ;
and the colouring matters seem also to undergo alteration, the bile
becoming much darker, almost black; sometimes of a dark green colour.
All these changes are purely functional, as examination of the liver
failed to reveal any organic change.
In the case of Noel Paton and Balfour, a noteworthy change in the
bile was that during attacks of fever the excretion always became
markedly paler, and on several occasions was quite colourless.
Influence of poison. — A varying and sometimes notable concentration
of bile has been shown by Stadelmann to be one of the chief features
of the action of hemolytic poisons generally. Thus, after injection of
hagmoglobin, for the first teji hours there is no obvious change in the bile ;
then the quantity falls, and the bile becomes thicker, more concentrated,
and very dark in colour : this variation continues for twenty -four hoiirs,
the bile being reduced to one-third its normal amount. (At the same
time the bile pigments are greatly increased by as much as 56 per cent,
the bile acids being diminished by about the same amount.)
Toluylendiamin — a drug possessing marked haemolytic and ictero-
genetic properties — causes similar changes. In the first stage, lasting
about twelve hours, the bile is increased in quantity (and is very rich in
pigments) ; then follows a second stage, during which it appears to lose all
the characters of bile, and is replaced by a small quantity of extremely
viscid colourless nmcus. After sixty to seventy hours the bile gradually
regains its normal character.
Phosphorus also is found to act similarly ; at first it causes an increase
of bile ; the bile then falls to one-fifth of its former amount, and becomes
clearer and more mucoid.
The action of arseniuretted hydrogen is also attended with a
remarkable concentration of bile, the gall-bladder and bile-ducts being
filled with thick viscid bile, which frequently contains large quantities of
20 SYSTEM OF MEDICINE
amorplious sediment as Avell as numerous ciystals of bilirubin. The bile
is reduced to as much as one-tifth its former amount (while the bile pig-
ments are increased to as much as 3^ times, and the bile acids are di-
minished to as much as one-tenth of their former amount).
The importance of these observations in connection with the jaundice
produced by poison I shall discuss fully elsewhere (art. " Jaundice ").
These observations have, however, an importance in relation to the
whole of the class of liver disorders attended with a diminished flow of
bile — for no factor is more important in producing functional liver dis-
orders than this of diminished secretion of bile. The troubles it occa-
sions arise not so much from diminution of the output of the specific
constituents of the bile — the bile pigments and bile acids — for the
former, indeed, are usually much increased while the latter are usually
even more markedly diminished, as from the temporary stagnation of
bile which gives opportunity for the absorption of its constituents, and
reacting on the liver-cell disturbs its function.
What, then, is the cause of this diminished flow ? Is it the result of a
specific action of the poison on the hepatic cell, wdiereby its excretory
function is temporarily arrested ? That the action is in some degree spe-
cific seems to be indicated by the remarkable difference in the behav-
iour of the chief bile constituents ; the bile pigments are usually notably
increased, thiis indicating great activity of the liver-cell in taking up
and destroying the hemoglobin conveyed to it, while the bile acids on
the other hand are no less remarkably diminished, indicating a lessened
proteid metabolism within the cell.
It is possible that by the direct action of a poison the excretion of
water may be temporarily lessened. The concentration of the bile in such
cases may then be due in part to a lessened aqueous excretion on the part
of the hepatic cell. But the chief cause underlying it I believe to be an
increased formation of mucus by the epithelium lining the bile passages.
The action of the poison is not limited to the hepatic cell, but extends to
the lining of the bile passages. As we shall presently see, the bile is an
important channel for the excretion of poisons and drugs present in the
blood ; and it is the excretion of such more or less irritant products that
is apt to excite catarrh of the bile passages, increased secretion of mucus,
and consequent increased viscidity of bile.
If the excreted products be harmless, their passage along the bile-
ducts is without ill effect on the lining epithelium. If, however, they
possess any irritant properties they will tend to excite increased secre-
tion of mucus, not only from the mucous glands of the larger bile-ducts
and the gall-bladder, but from the epithelium of the smaller bile pas-
sages; and in proportion to their irritant character and the resulting
increase of nuicus will be the tendency for the flow of bile, excreted
under very low pressure at all times, to be retarded, and for the bile
thus to become more concentrated.
Such, briclly, I consider to be the -way in which the amount of bile
can be diminished by changes in the bile passages. Under ordinary cir-
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 21
cumstances the only effect is to favour and promote absorption of its
water as it j^asses along them. If it pass a certain degree, however, some
of its bile constituents may also be absorbed; and thus arises the slight
icterus of the conjunctiva3 (from absorption of some bile pigment)
characteristic of the condition termed " biliousness."
If the conditions underlying these changes persist or frequently recur,
then the ill effects of diminished wateriness of bile extends beyond the
production of mere " biliousness." Kepeated irritation of the lining of
the bile passages by such products tends to promote a chronic tendency
in the bile passages and in the gall-bladder (where the bile rests for some
time and becomes more concentrated) to catarrh. The basis is thus laid
not only for more or less chronic biliousness, but also for the production
of some of the chief changes in the bile which underlie the formation of
gall-stones ; these are stagnation of bile, increased formation of cholesterin
by the epithelium of the bile passages, precipitation of bilirubin-calcium,
and presence of inspissated mucus.
Sammarij. — Our consideration of the chief conditions influencing the
amount of water in the bile has thus led to some important conclusions.
1. There is no evidence that any disturbance ever arises from too
great an excretion of water in the bile, if indeed such dilution ever
takes place.
Older writers recognised the existence of a '•' polycholia " — an
increased flow of bile — and were disposed to attribute certain ill
effects to it, — notably an increased absorption of bile pigment from the
intestine and the production thereby of a form of jaundice (Frerichs). As
I shall show later (art. " Jaundice," p. 74), the origin of a jaundice in
this way is exceedingly doubtful. It is true one important form of
jaundice — that connected with blood disorder and increased destruction
of haemoglobin — is frequently associated with an increased flow of bile
rich in colouring matters. The essential change of the bile in such cases is,
however, not increase in its quantity, but increase in its pigments. It is
not a polycholia, which is a name only rightly applicable to an increase of
all the bile constituents, but a polychromia ; and the jaundice so frequently
associated with tliis change is due, not to increased absorption of bile
from the intestine, but to absorption from the bile passages as the result
of increased viscidity. So far from any aqueous dilution ever being a
cause of disturbance, it is the one condition of bile which all our efforts
are directed to produce ; and the task is by no means easy.
2. On the contrary, one of the most potent factors in hepatic de-
rangement is diminished fluidity with lessened flow of bile. This may
be the outcome of defective excretion on the part of the liver-cell; and
such is probably its character in fever, in which the amount of bile is
always diminished.
But another and, in my opinion, more common and potent factor is
increase of resistance to its flow (at all times under very low pressure)
along the bile passages. This increased resistance may arise from one
of two sources : either from sluggish peristaltic action of the walls of
22 SYSTEM OF MEDICINE
the bile-ducts (and gall-bladder ?), one of the most important factors in
the passage of bile from the bile-ducts; or from increased secretion oi
mucus, and corresponding abnormal viscidity of bile.
Both these conditions, but more esi:)ecially the latter, underlie the
state of " biliousness " ; and the increase of mucus is the result of the
irritant action of products excreted in the bile. For the formation of
these products in the first instance the liver may not be in any way
responsible : they have been formed elsewhere ; they reach it in the
portal blood, and it has duly excreted them. Were it not for their
irritant action on the bile passages in the course of their excretion,
few or no ill effects might be produced. But the increased formation
of mucus excited by their action as they pass along the bile passages
has as its result an increased viscidity of bile — a retardation of its flow
and a diminution of its quantity.
Whether, then, the diminution of bile be caused directly by impaired
action of the liver-cell, or indirectly by increased resistance in the bile
passages, it is im])ortant to note that the primary cause of the mischief
is not necessarily the liver itself. The disorder is set up by products
conveyed to it in the portal blood. Thus all agents which promote
healthy action of the gastric and intestinal mucosa may, by preventing
the formation and absorption of abnormal and possibly irritant prod-
ucts, and by freeing the liver and its bile passages from their injurious
presence, promote an increased flow of bile, and thus indirectly have
a cholagogue action.
Excretion of bile pigments. — The bile acids and the bile pig-
ments are the two specific constituents of the bile. Owing to their
remarkable staining power, the pigments are the most conspicuous of the
constituents ; hence their behaviour in disease has always attracted a
special amount of interest. Their presence in the blood and tissues
constitutes jaundice ; and no symptom connected with liver disturbance
is so prominent or has excited so much attention as this. The source of
these bile pigments, the conditions influencing their amount, the variar
tions, quantitative and qualitative, to which they are subject in disease,
the factors determining their presence in the blood and tissues, have
thus an exceptional interest for the physician. The formation of bile
pigment is one of the first functions discharged by the liver in intra-
uterine life. Bile pigment begins to be formed and to be excreted as
early as the third month of intra-uterine life, before there is any necessity
for digestive juices, even before there is any evidence of a glycogenetic
function on the part of the liver. The meconium present in the
intestine at birth is made up of bile pigment-^without a trace, as it is
interesting to note in passing, of any reduction products like hydro-
bilirubin (stercobilin), which constitute the chief colouring matters of
the faeces in extra-uterine life. As it is one of the first functions to
appear, so pigment formation is one of the last to disappear. Tliroughout
life the formation and excretion of bile pigment continue to be the most
persistent function of the liver.
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 23
The two chief bile pigments are bilirubin and biliverdin. It has
been customary to regard the former as the more important of the two;
but Ave may note that Mayo Kobson, and Copeman and Winstow, who
have had opportunities for studying the bile in cases of biliary fistula,
agree in the opinion that biliverdin is the more important. The main
point with regard to their formation is that they do not exist preformed
in the blood : they are not merely excreted by the liver; they are both
formed and excreted by this organ.
The question of the possible extrahepatic (haematogenous) origin of
bile pigment, which has played so prominent a part in the discussions
on the origin of certain forms of jaundice, is, in my opinion, finally
answered (see art. " Jaundice," p. 57). The formation of bile pigment
is a purely hepatic function discharged by the liver-cell itself. It is
stopped by removal of the liver.
Bile pigment, then, is formed from haemoglobin within the liver
itself, and is excreted thence into the bile. It is the chief mode in which
the pigment element of hgemoglobin is excreted from the body. Thus the
mode of its formation has a special significance in relation to the ultimate
fate of haemoglobin. The appearance of haemoglobin in the scale of animal
development, and the appearance of an organ like the liver, are contem-
poraneous. It would thus appear that there is a certain wear and tear
of the hgemoglobin in the discharge of its important functions in the
blood ; and that this necessitates its destruction and removal from the
body. This removal the liver effects; it breaks up the haemoglobin,
excreting one part of it in the form of bile pigment, but retaining within
itself most of the important element — the iron — probably for further use.
The relation of the bile pigment to haemoglobin may thus be com-
pared with that of urea to proteid material generally; it is the form
in which a waste product is removed from the body. It is a purely
waste product : it subserves no function ; and, according to Bouchard,
whose observations, however, on this point have not been confirmed, it
is not only a waste product but also a poisonous one.
Whatsoever interest, then, may attach to it is connected with its
relationship to haemoglobin on the one hand, as an index of the amount
of haemoglobin daily broken up and renewed, and with its relationship
to the liver-cell on the other, as an index of its activity.
The liver as a haemolytic organ. — It is in virtue of the un-
doubted derivation of bile pigment from haemoglobin that the liver
is usually regarded as the most important seat of haemolysis within
the body. Certainly no organ has so much to do with getting rid
of haemoglolnu set free within the blood as the liver. But there is,
I think, some confusion in this matter. By haemolysis I mean those
series of changes in the blood — in its plasma, leucocytes, and red
corpuscles — which tend to their disintegration. In the case of the
red corpuscle such changes result in the liberation of the haemoglobin;
but the place where this liberation occurs is not necessarily the place
where the haemoglobin is ultimately broken up and disposed of. My
24 SYSTEM OF MEDICINE
investigations on this point indicate that such haemolytic change in
liealth occurs almost exchisively within the portal blood system. But
this haemolysis is by no means confined or even mainly confined to
the liver. According to my observations, the spleen and the mass of
capillaries in the mucosa uf the intestinal canal are even more important
seats of this change than the liver. Increased haemolysis is a periodic
event coincident with the digestion of the food products, and caused by
the activity of the mass of cells concerned in absorbing these i)roducts.
It may be increased by the action of drugs, which set free inore luijmo-
globin ; but even drugs only act indirectly by stimulating activity of
the cells in closest relation in the blood — especially those of the spleen
and the gastro-intestinal mucosa. Thus I found with toluylendiamin,
a drug possessing a marked hajmolytic action, that removal of the
spleen markedly lessens its destructive action. If this drug be injected
directly into the blood of rabl)its from which the spleen has been
previously removed, its destructive action is reduced by more than one-
half ; indeed, the action of moderate doses is destroyed. The spleen
then, more than any other organ, seems to be concerned in the luemolysis
caused by this drug; although, judging from the evidences of its action
on the liver when injected into the healthy aninuil, namely, the increase
of bile pigment and deposit of iron in the liver-cells, the liver rather
than the spleen would have appeared to be the chief seat of the luBuiolysis.
Complete removal of the spleen, however, arrested all such changes,
notwithstanding the injection of double the dose of the drug.
As the result of these investigations, then, I find mj^self unable to
regard the liver as the most important organ concerned in h<emolysis.
It is hardly possible, indeed, to doubt that hsemolytic changes consequent
on the activity of its cells do occur in its capillaries. But these, in my
opinion, are less important than those which go on within the spleen,
where the blood is brought most closely into relation Avith active cells;
and are even less than those which go on in the mass of capillaries
in the gastro-intestinal mucosa. I consider that the chief f uiiction of the
liver in relation to haemolysis is to arrest and get rid of tlu^ jiroducts of
haemolysis conveyed tt) it in the portal blood from the si)leenaud intes-
tines ; and the most prominent of these products is haemoglobin.
It is important to bear these distinctions in mind. For it will then
be clear that increased formation of bile pigment, if rightly regarded,
affords not only an index to the activity of the liver-cell in breaking up
hiemoglobin, but to a certain extent is also an index of the activity of
the spleen and the cells of the gastro-intestinal mucosa, which parts are
chiefly concerned in lil)eratiiig luemoglobiii.
deficient formation of bile pigment nuxy thus have as its cause, not
inactivity of the liver, but a lessened haemolysis due to inactivity of the
other organs in relation to the jwrtal blood. Conversely, increased
formation (jf bile ])igiiient must always liave been jn-ceeded by an in-
creased luemolysis, denoting increased activity of organs other tlian the
liver. Thus to say of a drug, which induces an increased formation
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 25
of bile pigment, that it has " stimulated the liver to increased secre-
tion," by no means embodies all the truth in respect of the manner in
which this increased secretion is produced. It has not only stimidated
the liver, but it has also stimulated the other organs of the portal circula-
tion responsible for the preceding haemolysis. Thus with regard to one
of its most specific functions — the formation of bile pigments, the point is
brought out that the liver is dealing with haemoglobin liberated mainly
elsewhere, and conveyed to it in the portal blood. Deficient formation
of bile pigment — which, on the view that the liver is alone responsible for
haemolysis, would be peculiarly a symptom of " sluggish liver " — implies,
then, sluggishness of organs other than the liver.
Passing from these general considerations to the variations met with in
health and disease, I have to note that the actual amount of bile pigment
which gives its colour to the bile is very small, though its staining powers
are very high. The daily excretion in health, though differing in differ-
ent individuals, is probably fairly uniform. In general the variations
that occur seem closely to follow the variations in the other solid con-
stituents. They are increased by food, diminished when food is with-
held.
Polychromia and its relation to jaundice. — For the information we
possess as to the variations that occur in disease, we are indebted
mainly to observation of the pigments present in the urine ; but Ave
have also a few observations made directly. Thus a large increase
ahvays follows the injection of haemoglobin into the blood, or again,
of haemolytic agents that set free haemoglobin ; such as distilled water,
toluylendiamin, and arseniuretted hydrogen (Stadelmann). This in-
crease may run as high as three to four times the normal amount. It
usually makes itself manifest in from 3 to 4 hours after the injection of
the haemoglobin. If the injection be merely subcutaneous it is later — 12-
14 hours. This " polychromia," as it has been named by Stadelmann, is
not necessarily accompanied by an increase of bile ; on the contrary, the
bile is generally diminished in quantity and highly concentrated — some-
times to a notable degree. Even more remarkable is the behaviour of the
bile acids ; instead of being increased, they are reduced to mere traces.
Great activity of the liver-cell in one direction (formation of bile pig-
ment) is thus compatible with lessened activity in others (excretion of
water, formation of bile acids). These observations are of special interest
in regard to the bile acids. Absence of bile acids has usually been re-
garded as an important evidence of inaction of the liver ; and hence came
the notion that jaundice without bile acids in the urine denotes that the
bile pigment must have been formed elsewhere than in the liver (•• htema-
togenous jaundice"). It is now made clear that no such significance
attaches to the absence of bile acids ; their defect is quite compatible
with a greatly increased formation of bile pigments by the liver.
A similar increase of bile pigments is a feature common to all condi-
tions in which blood-destruction is increased. According to my observa-
tions, it is a constant and most notable feature of the bile in pernicious
26 SYSTEM OF MEDICINE
aiiffiniia ; in no morbid state does the bile possess such extraordinary
staining power as in this disease. An increase of bile pigments likewise
attends the absorption of large extravasations of blood, and is a feature
also of most of the forms of jaundice caused by poisons.
It is in relation to jaundice that the cliief interest has hitherto
attached to this increase of bile pigments. The occurrence of jaundice
in association with excess of bile in the stools has long been noticed ; it
constitutes the ''jaundice from polycholia " of old -writers. The doctrine
taught by Frerichs was that the jaundice in such cases is due to excess
of bile pigments, their increased absorption from the intestine, and their
deficient disintegration in the blood. The later form of this teaching is
that bile pigments are absorbed in sitch excess that the liver is unable
to excrete them all, so that some escai)e through the liver into the general
circulation and produce the jaundice. These doctrines I shall discuss
more fully elsewhere (vide art. "Jaundice," p. 74). At present I will
only say that, in my opinion, there is no sufficient evidence that jaundice
ever arises in this way. Some bile pigment is probably always absorbed
from the intestine to be excreted again in the bile ; but the extent to
which such an absorption occurs is doubtful, and in all probability has
been much exaggerated. It may be regarded as certain, however, that
any pigment so absorbed is excreted again, for the liver rapidly takes up
and excretes any bile jugment present in the blood. Thus bilirubin
injected directly into the blood is entirely excreted through the bile in
from two to four hours after its injection. Similarly the increase of bile
pigments following injection of bile into the duodenum, as shown by
Schitf and Rutherford, is always greater when bile is introduced than
when a corresponding amount of bile salts are so introduced.
In the absence, then, of any other explanation of the jaundice with
polycholia, we might attribute it to an increase of this absorption —
of tliis " circulation of bile pigment." But Stadelmann's observations
show that drugs which cause polychromia usually cause other changes in
the bile — one of the most notable being that at one time or other there
is a remarkable increase in its viscidity, leading sometimes to arrest of its
flow. This arrest it is that causes the jaundice. The jaundice results
from absorption of bile from the bile-ducts, not from the intestine.
Both preceding and following this stage of increased viscidity there is
a greatly increased excretion of bile i)iginents; hence the abundance of
bile pigment in the intestines, so frequently noted in these cases. The
** jaundice of polycholia" is thus hepatogenous (obstructive), and is not
due to an increased absorption from the intestine.
Excretion ofhrpmor/Johia into the bile. — I have now to point out, with
regard to this action of the liver on haemoglobin, that it is not simply
a rpiestion of mere amount. — of so much free haemoglobin in the
blood, with resulting formation of so much bile pigment. Increase
of bile pigments is not necessarily proportionate to the amount of
free hapmoglobin in the blood. Thus the injection of distilled water or
pyrogallic acid produces intense haemoglobinoemia with hajmoglobinuria,
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 27
but only a moderate increase of bile pigments. On the other hand,
toluylendiamin, which in dogs causes but a moderate blood-destruction
without haemoglobinuria, causes a large increase of bile pigments. Thus
it appears that the liver can be specially stimulated, and that the
amount of bile pigment formed depends not only on the amount of free
hsemoglobin available, but also on the activity of the liver-cell. Under
certain circumstances this latter element may be so affected that htemo-
globin passes unchanged through it into the bile. This condition of
" haemoglobincholia " is usually the result of the action of certain severe
poisons. Thus, according to Filehne (1889), after poisoning with
phenylhydrazin, toluylendiamin, aniline derivatives, pyrogallic acid,
chlorate of potash, and glycerine, all agents intensely haemolytic in their
action, hsemoglobin is constantly found in the bile. The same results,
after poisoning with aniline and toluidin, have been found by Wertheimer
and Meyer (1890). I produced such a " hsemoglobincholia " in one
instance by ligaturing the hepatic artery and then injecting distilled
water. All these observations apply to rabbits. In dogs, on the other
hand, Filehne could never find any free haemoglobin in the bile.
This passage of haemoglobin unchanged through the liver-cell into
the bile must be regarded, then, as betokening a grave disturbance of
liver function. It is probably an extremely rare process in disease, and
is probably confined to the last stages of such severe toxic conditions
as acute yellow atropy and the severest forms of malignant jaundice.
But, apart from these extreme effects, this occurrence, rare though it
be, is of interest as denoting that the activity of the liver in breaking
up haemoglobin can be directly influenced by drugs.
In what way the destruction is effected Avithin the liver-cell we have
no definite knowledge. As I have pointed out, an increased formation of
bile pigments may occur while the formation of bile acids is diminished,
indicating that the two processes, of haemoglobin-destruction and break-
ing up of proteid material, respectively underlying these are to a certain
extent independent of each other. Nevertheless certain interesting
observations, to Avhich I must now draAv attention, no less clearly indi-
cate that the activity of the liver-cell in breaking up hasmoglobin depends
upon its general nutritive activity.
Schmidt and his pupils have studied the action of liver-cells on
haemoglobin outside the body, and they find that the destruction of
haemoglobin (and formation of bile acids) is much increased by the
presence of glycogen, and still more of grape sugar ; in the al)sence
of these, indeed, the destruction of hsemoglobin ceases.
Lessened formation of bile pigments. — Again, among the conditions
which appear to diminish the amount of bile pigments I have to note
fever. This sequence was very noticeable in the case of biliary fistula
recorded by Paton and Balfour. Irregular attacks of fever occurred
from time to time, and during these the bile not only fell in quantity,
as also in the amount of solids, but became obviously pale ; on several
occasions, indeed, quite colourless.
28 SYSTEM OF MEDICINE
This diminished formation of bile pigments is of special interest in
relation to the theory of jaundice by suppression. This theory took its
origin when it was thought that the bile pigments existed preformed in
the blood, and that the only function of the liver was to excrete them.
If the liver ceased to act, the pigments accumulated in the blood, and
jaundice ensued. It is now certain that the bile pigments are formed
by the liver, not within the blood. But the theory of a jaundice by
suppression is still held by many ; and the form it now takes is that any
temporary inaction of the liver in forming bile pigments is bound to
throw pigments into the circulation which would otherwise have been
excreted; whereby jaundice is induced. Now I have shown one possible
effect of such inaction, namely, that haemoglobin passes through the liver-
cell unchanged. But such an event is only producible experimentally
by the action of severe poisons, and even then with difficulty ; in dis-
ease it is probably of the rarest occurrence. The other possible effect
is that illustrated by the action of fever, when less bile i)igment is formed.
There is no evidence, however, that such a diminished formation of
necessity produces jaundice. On the contrary, in the case of the great
majority of poisons that act most severely on the liver-cells, and are most
likely to cause suppression of function, there is direct evidence that they
stimulate the liver to an increased formation of bile pigment. The
jaundice they give rise to is not a jaundice of suppression, but one of
increased activity with increased viscidity of bile consequent on the
action of the poison on the intrahepatic bile-ducts (toxsemic catarrh).
Qualitative variations in the bile pigments. — The changes in the bile
pigments in disease are not restricted to mere variations in quantity.
They extend also to the quality of those formed.
In health, as we have seen, the chief pigments are bilirubin and
biliverdin. AYithin the intestine these are reduced by the action of the
micro-organisms present to hydrobilirubin (stercobilin) — the colouring
matter of the faeces.
lielation of bile and urinary pigments. — Within the urine the chief
pigments are : —
i. Urochrome, first described by Dr. Tliudichum in 1864, and recently,
with the aid of much better methods, carefully studied and redescribed
by Dr. A. E. Garrod (1896).
ii. Urobilin, the relation of which to bile pigment, long a matter of
discussion, may now be regarded as definitely settled. It has been
shown to be producible directly from bile pigment by the action of the
micro-organisms of the intestine (Mliller) ; and more recently, in a very
careful research, Garrod and Hopkins have shown that the pigment of
the faeces, variously named hydrobilirubin or stercobilin, is only an
impure form of urobilin.
iii. UrohrpymntoporpJn/rin was first described by Mac!>[unn. and has
since been shown to be a constant constituent of normal urine (A. E.
Garrod), and to undergo variations in disease. It is the representative
in the urine of htematoporphyrin, a pigment formed from haemoglobin.
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 29
The last two pigments are undoubtedly derived from haemoglobin.
The origin of urochrome, long obscure, seems also to have been placed
beyond doubt by recent observations (1897). This pigment and urobilin
are convertible into one another by the action of suitable agents.
Increase of the pigment of the urine is a common feature of liver
disorder. Not only those above named become increased, but others also,
of doubtful nature, make their appearance. The chief of these is the
reddish pigment {uroenjtlirine) which so frequently colours deposits of
urates.
The questions that now present themselves are : — Does the increase
of such pigments indicate disorder of hepatic function especially ; or
on the other hand, indicate merel}^ disorder of intestinal functions ? Or
as it may otherwise be piit : — To what extent are these pigments derived
from the bile pigments within the intestine, and thus only indirectly from
the liver ? Or, are they the direct products of hepatic metabolism,
formed by the liver just as bile pipnents are?
AVith regard to urobilin, — the chief representative of these urinary
pigments, and the one which has been most fully studied in disease, —
an increase is found in the urine in a number of conditions, such as
fever, absorption of blood, pernicious anpejnia, febrile forms of jaun-
dice, and the action of certain drugs, such as trional. These con-
ditions are chiefly such as are marked by some increased destruction
of blood. The increase of urobilin may denote merely an increase
of bile pigments with an increased formation of urobilin from these
within the intestine, and not necessarily any disturbance of hepatic
function. A notable increase of bile pigment takes place during a.bsorp-
tion of extravasated blood, as shown by Stadelmann ; and according to
my observations in pernicious anaemia no feature is more constant or
more striking than the extraordinary colouring power of the bile, denot-
ing great richness in pigments. And in no two conditions is urobilinuria
so marked as in these.
There are other facts, however, which denote that the intestine is not
the only seat of origin of urobilin ; it is also formed elsewhere in the
body. Thus in cases of obstructive jaundice where no bile enters the intes-
tine urobilin is still found m the urine. In the case of biliary fistula
described by Copeman and Winston no bile entered the intestine, nor was
any bile pigment to be found in the urine. All the bile escaped through
the fistula. Xevertheless the urine remained of normal colour, and its
colouring matters must therefore have been formed elsewhere than in the
intestine. Under these circuuistances it is assumed that the pigment has
been formed within the liver itself, as a direct product of hepatic activity.
And it is from this point of view that so much interest is attached by
some observers to increase of urobilin (and other pigments) in the urine
in relation to hepatic disorder ; for an abnormal increase of urobilin may
thus denote not merely an increase of bile pigments- but also an abnormal
activity of the liver-cell, and may be an index of hepatic disorder. Thus
urobilin has been regarded as essentially the pigment of a diseased liver
30 SYSTEAf OF MEDICINE
(Hayem). Its formation by the liver may, I think, he thus conceived.
Formed in small amount in health, as a by-product in the course of the
formation of bile pigment by the liver-cell, in disease it may be formed
in disproportionately large amount, not from the bile pigments, but, so to
speak, at the expense of the bile pigments. An increase of urobilin in
the urine may denote not merely an increased hjemolysis with an in-
creased formation of bile pigment — this it necessarily does — but it may
denote, further, some hepatic inefficiency in dealing with the liaMuoglobin
or pigments derived from this haemolysis. 1 would jwint out a third
alternative : — The conditions in which it is chiefly juet Avith — toxic
forms of jaundice, pernicious anaemia, and the like — are chiefly those
denoting marked disorder of the blood, and the fault may possibly
be not so much increase of bile pigments (intestinal origin) or hepatic
inefficiency (hepatic origin) as some abnormal character of the luemo-
globin and other pigments set free within the portal area and con-
veyed to the liver in the portal blood. I consider it to be probable
that some part of the nrobilin and chromogens of the \irine are normally
formed within the portal area, notably within the sj)leen, where, accord-
ing to my observations, haemolysis is most active; and their increase in
disease may denote abnormal blood changes antecedent to any subse-
quent he})atic inefficiency.
In deciding to which of these various possible causes urobilinuria is
due in any particular case, we must be guided, I think, by the general
characters of the symptoms rather than by any jiarticular view as to
the source of urobilin. Thus, in absorption of exti'avasated blood I re-
gard the urobilinuria as not necessarily of the same signiflcance as it
has in severe forms of febrile (toxaemic) jaundice. In all cases it denotes
increased luemolysis. But suliject to this, it may in some denote intestinal
derangement — increased putrefactive changes, with increased formation
of urobilin from the bile pigments within the intestine ; in others it may
denote abnormal haemolysis with formation of abnormal pigments in the
tissues (extravasated blood) or in the spleen ; and lastly, in a third group
it may possibly denote hepatic inefficiency in dealing with the luemo-
gl6bin supplied to it. The data we possess, then, by no means justify
the view that urobilin is essentially the pigment of hepatic disorder.
Bilirubin calculi. — Before passing from this subject of the variations
in the character of the bile pigments presented in disease, and their
possible significance in relation to disorder of the liver, I must refer to
one other modification of a (pialitative character, which may not only
denote but actually be the immediate occasion of severe disorder of the
liver ; 1 refer to that change which leads to the i)recii)itation of bilirubin
in insoluble form within the intrahepatic bile-ducts or within the gall
bladder, and to the fornuition of bilirubin calculi.
IHlirubin itself is never precipitated; but under certain comlitions it
forms a combination with calcium, and is then precipitated as an insolubli^
compound. In this form it is the nucleus of a considerahle proportion of
the ordinary gall-stones ; in a smaller proportion it is itself the calculus,
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 31
and may constitute the gritty particles — the so-called biliary sand — found
within the intrahepatic ducts, or the small calculi found either in these
ducts or in the gall-bladder.
Two forms of these calculi are met with ; in the one the billrubin-
calcium is mixed with cholesterin, as much as 25 per cent of the latter
being present; the remainder being made up of bilirubin-calcium, usually
with small quantities of copper and traces of iron. The calculi of
this kind are usually of large size, as large as a cherry or larger ; and
lie singly, or at most in groups of three or four, in the larger bile-ducts
or gall-bladder. In the other form this insoluble compound of bilirubin
forms the whole calculus. These stones are of small size — from that of
a grain of sand to that of a pea — and form solid brownish black concre-
tions with rough, irregular surfaces ; sometimes of wax-like consistence,
sometimes hrm, hard, and brittle. They consist almost entirely of the
calcium compound of bilirubin or biliverdin, without any cholesterin, or
at most with mere traces of it.
Besides these forms of calculi, in which it forms the chief constituent,
bilirubin-calcium is a common constituent of most gall-stones, either
intermixed with the cholesterin or sometimes forming the central nucleus.
A special interest attaches to these calculi of bilirubin-calcium; inas-
much as, unlike the ordinary mixed cholesterin calculi, the seat of the
formation of which is the gall-bladder, or very rarely the larger bile-
ducts, small bilirubin-calcium calculi are frequently found in the intra-
hepatic ducts. What determines their formation ? Both bilirubin and
calcium are normal constituents of the bile. Yet in whatever amount
they are present, or however highly the bile may be concentrated, they
can never be made to combine to form this insoluble compound. Mere
excess of bilirubin appears insufficient of itself to bring this about in
normal bile. Addition of lime water, however, leads eventually to a pre-
cipitation of bilirubin-calcium. But certain substances in the bile ap-
pear capable of hindering this precipitation even when lime is present in
abundance. Tho bile salts possess this power. Nanny n finds that in the
presence of bile salts the calcium combines at first with the bile acid ; and
it is not until a large excess of lime is added that precipitation takes place.
It is not likely that the precipitation of this compound is solely de-
pendent upon an increase of lime in the bile. It is suggested that excess
of lime in drinking-water may give rise to calculi by favouring the pre-
cipitation of bilirubin-calcium ; there is no evidence, however, that the
amount of lime in the bile is affected by the administration of lime in
the food (Naunyn). Its source in all probability is the mucous membrane
of the bile passages, as pointed out by Frerichs. More important than
any mere increase of lime or amount of bile pigment in determining the
precipitation of bilirubin-calcium is the presence or absence of albumin in
the bile. Thus q%^ albumin brings about a precipitation of bilirubin-
calcium from bile, and from a solution of bile salt containing bilirubin..
Ic is highly probable, then, as Naunyn says, that albumin is the chief
factor in determining the precipitation of these biliary concretions
32 SYSTEM OF MEDICINE
witliin the bile-ducts, the albuiniuous material being derived from the
desquamation and disintegration of the epithelium of the bile passages.
These small intrahepatic calculi of bilirubiu-calcium seem to play
an important part in producing cholelithiasis. They are carried into the
gall-bhuldcr, where they act on its mucous membrane as foreign bodies,
and favour the catarrhal condition which leads to the formation of
cholesterin. In the centre of gall-stones a small nucleus of this com-
pound is frequently to be found.
Conchisioti. — The precipitation of bilirubin in insoluble form, with
the production of biliary concretions of bilirubin-calcium, is thus to be
regarded as evidence of disorder of the bile passages, not of the liver-
cell itself.
Excretion of bile salts. — The salts of the bile are the soda salts of
the two bile acids, glycocholic and taurocholic acid. The bile acids
are combinations of a common acid — cholalic acid — with glycocine
and taurine respectively ; products of the decomposition of albuminous
material within the liver. The formation of bile acids is thus a special
index of the amount of albuminous metabolism withiai the liver-cell.
How closely it is related to other functions of the liver-cell is indi-
cated by the interesting studies made by Schmidt and his pujjils, to
which reference has already been made. They find that even outside the
body the liver-cell can form bile acids from albumin, but that it cannot
do so unless glycogen, or, what is even better, grape sugar, be present.
The fate of the bile acids within the intestine is interesting. A small
proportion only can be accounted for in the faeces. A large proportion,
as much as seven-eighths according to Bidder and Schmidt, is again
absorbed and again excreted in the bile. It is this remarkable be-
haviour of the bile salts that has led to the view, originally projiounded by
Schiff, that there exists within the portal area " a circulation of bile."
The bile obtained from a fistula is much poorer in solids than normal
bile, and the difference is almost entirely due to want of bile salts. No
substance or drug has so powerful a stimulant action on the liver-cell
as its own bile salts.
We have little information as to the variations in their excretion met
with in disease. Clinically our chief interest is directed to the bile salts
in connection, first, with their solvent action on cholesterin, the chief
constituent of gall-stones ; and, secondly, with their a])pearance in the
urine in cases of jaundice. Cholesterin is held in solution in the bile
mainly by the ])resence of the bile salts ; it is insoluble in water or
arpicous saline solutions, but easily solu])lc in solutions of the bile salts;
solutions containing \ to '2k per cent of bile salts can dissolve about a
tenth part of their own mass of cholesterin (Naunyn). One of the oldest
views of the origin of gall-stones is, that owing to decomposition of the
l)il(! acids witliin the gall-bladder, the cholesterin is no longer held in
solution and becomes preciiiitated (Frericlhs). There is no conclusive
evidence, however, that calculi ever arise in this Avay. The evidence
presently to be considered goes rather to show that gall-stones arise from
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 2,2
increased secretion of cholesterin from the walls of the gall-bladder, not
from simple precipitation of the cholesterin held in solution.
Much importance was formerly attached to the presence of bile acids
in the urine in certain cases of jaundice, and to their absence in others, as
an important gauge of the degree of activity of the liver. Since the bile
acids are admittedly formed by the liver, and by the liver alone, their
absence from the urine, in any case of jaundice, was held to be due to
inactivity of the liver. Hence the vicAV of a hajmatogenous as distinct
from a hepatogenous jaundice. This matter will be considered fully else-
where (art. "Jaundice"). Here it can only be said that the studies of
Stadelmann have thrown an entirely fresh light on this subject. So far
from the formation of bile pigments and of bile acids by the liver-cell
necessarily going hand in hand, as hitherto assnmed, these studies show
that a large increase of bile pigments in the bile is frequently attended
with a no less marked diminution in bile acids. This peculiar result is
especially characteristic of the action of certain poisons which possess
powerful icterogenetic properties (toluylendiamin, phosphorus). The
jaundice caused by such agents is always marked by a greatly diminished
formation of bile acids ; and hence at the very time the urine is loaded
with bile pigment there may be little or no trace of bile acids.
Pettenkoffe/s reaction. — The test for the detection of bile acids in
the urine is the well-known one which goes by the above name. A
small quantity of the urine is placed in a porcelain capsule, and to it two
or three drops of a solution (10 per cent) of cane sugar are added. Then
strong sulphuric acid is added drop by drop, when the fluid first becomes
opalescent, then clear, and successively assumes a pale cherry red, a dark
red, and finally a purple-violet tint. The reaction depends, as it has since
been shown, on the production of furfurol by the action of the acid on the
sugar. Hence a modification of the test has been suggested, a solution
of furfurol in water of 1 per mille being employed instead of sugar.
To 1 c.c. of an alcoholic solution of the urine a single drop of this furfurol
solution is added; then 1 c.c. of strong sulphuric acid. The method
gives a perceptible reaction with quantities so small as even -^^t\\ to -g^oth
of a milligramme. For clinical purposes the test is of little value, as the
reaction is often given by other organic substances present in the urine.
According to Prof. Halliburton, with whom I entirely agree, it is never
possible to detect bile salts in the urine by the direct means of this test.
They must always be separated by evaporating the urine to dryness,
extracting with alcohol, and then precipitating the bile salts by adding
12 to 20 times its bulk of ether. The precipitate is then dissolved in
water, and decolorised with charcoal before applying the test. Even
then I have failed to get any definite reaction in cases of undoubted
simple obstructive jaundice, where there was every reason to expect
bile salts to be present ; and I have got it where no bile was present.
Many substances present in the urine — such as albumin, fatty acids,
and phenol compounds — give a reaction with Pettenkoffer's test, so
closely resembling that of bile acids " that were it not for the method
VOL. IV D
34 SYSTEM OF MEDICINE
of spectroscopic observation Ave should be unable to pronounce an oi)inion
concerning the identity or non-identity of the colouring matters which
are produced in each case" (Gamgee). Applied in the way usually
recommended for clinical purposes, the test is then, in my experience
and judgment, quite useless. Further, the information it yields, even
when accuratel}' obtained, is hardly commensurate with the labour in-
volved in acquiring it, now that it has been shown that the formation of
bile acids by the liver varies so greatly, and that their presence or ab-
sence from the urine has not the significance formerly attached to them.
Excretion of cholesterin. — Cholesterin is a constant constituent of
the bile; but unlike the constituents just considered — the bile pigment
and the bile acids — it is by no means peculiar to the bile. It is a sub-
stance very Avidely distributed in the animal body ; it is especially
abundant in nervous tissue, and is found also in the corpuscles and
plasma of blood, in milk, sweat, in serous exudations, pus, and in the
secretions of mucous membrane generally. It is held in solution in the
bile by the bile salts and by the traces of fats and soaps present.
Cholelithiasis. — The chief interest attaching to it is that it forms the
most abundant constituent of gall-stones. The conditions determining
its amount and its solubility within the bile are thus of special interest.
With regard to its source there is still difference of opinion. Its wide-
spread distribution within the body would suggest that it is excreted by
the liver. In cases of jaundice with complete obstruction it is said to
accumulate in the blood (Fi-erichs), but this statement lacks confirmation.
A more recent view is that it is not merely excreted from the blood, but
tliat it is formed by the mucous lining of the gall-bladder and the larger
bilo-ducts (Xaunyn), and that it is really a product of degeneration of the
epithelium of their coats. According to the experiments of Naunyn, whose
studies are the most exhaustive yet made, cholesterin is not simply
excreted by the liver, for he found no noteworthy increase in the bile
after administration of large quantities of cholesterin, both by the mouth
and subcutaneously ; he concludes, indeed, that no separation whatever
of cholesterin frona the blood takes place through the bile. He finds,
moreover, that the amount of cholesterin. is not dependent upon diet.
He also investigated the excretion of cholesterin in various diseases, but
failed to find any notable increase of the substance, imless gall-stones
were also present. He concludes, then, that the cholesterin of the
bile is neither a product of general metabolism nor a specific secretion
product of the liver.
On the other hand, the secretion of mucous membranes constantly con-
tains cliolesterin, sometimes in no less quantity than the bile itself. In
bile the ])roportion varies from Oo to 3-5 per 1000. In sputum of
catarrhal bronchitis Xaunyn found it to the amount of 01) in 1000, and
in sputum of putrid bronchitis he found it to the amount of 1-5 per
1000. In pus it has been found in even higher amounts. In all these
cases there has been actual iufiamiuation and an abnormally large amount
of degeneration of cells and epithelium ; and Naunyn thinks it probable
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 35
that a considerable shedding of epithelium from the biliary passages,
induced by the deleterious action of the bile itself (as a protoplasmic
poison), constantly goes on.
Whatever view we may take of the source of the cholesterin of the
bile in health, whether hepatic, as Frerichs and Gamagee maintain, or
biliary, as Naunyn suggests, there can be little doubt, I think, that the
latter is its source in disease. An increased formation of cholesterin
in connection with subacute inflammatory and catarrhal conditions of the
lining membrane of the bile passages, especially of the gall-bladder, is
the chief factor underlying the formation of gall-stones in disease. The
cholesterin which goes to form gall-stones has never been in solution in the
bile. It is formed as viscous material within the degenerated epithelium
thrown oif from the gall-bladder ; and it collects, as such, either around
amorphous particles made up of degenerated epithelium, or around small
solid concretions of bilirubin-calcium. Once formed, the calculus grows by
further accretion either of cholesterin or bilirubin-calcium, or both. The
cholesterin, according to Naunyn, may accumulate in two further ways ;
it may come either from degeneration of the epitlielium lying around it, as
in the cases in which a stone lies in a pocket embracing it so closely that
no bile may have entered for some time ; or, on the other hand, when
the stone is bathed in bile, it may grow by crystallisation of the cholesterin
in the bile. But this mode of increase is rare. In the great majority
of calculi the superficial layer is not crystalline, but at first is amorphous ;
it is at a subsequent date that this amorphous cholesterin undergoes
crystallisation.
What is it that determines this increased formation of cholesterin ?
The facts with regard to the general etiology of gall-stones are Avell
known. Gall-stones are uncommon in young people under 30 years, and
most common in old people over 60. They are much commoner in
women than men — among males in 4-4 per cent of bodies examined,
among women in 20-6 per cent. Among women they are much more
frequent in those who have borne children. Thus it appears that the
formation of gall-stones is facilitated by anything which interferes Avith
or retards the flow of bile ; as, for example, by the habit of lacing in
women, which diminishes the movements of the diaphragm ; by preg-
nancy, which acts in the same way ; by the less active habits of ad-
vancing life, and the atrophy of muscle which attends it. According
to Charcot, the unstriped muscular fibres of the walls of the bile-ducts
undergo extensive atrophy in old people. Stagnation of bile is an etio-
logical factor about which there is no dispiite.
How, then, does stagnation of bile lead to the formation of biliary
calculi ? We have seen that such formation is the result of morbid
processes in the lining membrane of the gall-bladder ; Frerichs taught that
in stagnating bile the bile salts were apt to undergo decomposition, the
reaction of the bile to become acid, and the cholesterin, previously
held in solution by the bile salts, to be precipitated. The recent
observations of Naunyn throw another light on the subject. According
o
6 SYSTEM OF MEDICINE
to Xaunyn, the catarrh responsible for the increase of cholesterin is set
np by presence of micro-organisms. Normal bile is sterile; Gilbert
and Girode found it so in G out of 8 cases, even 24 hours after
death ; Xaunyn found it so in 4 cases, and I found it so in 2 out
of 3 cases. J>ut when it stagnates, organisms may be found in it.
The organism most commonly present under such circumstances is
the Bacillus coli communis; and this organism Naunyn regards as the
commonest cause of the disease of the mucous membrane which leads
to the formation of stone. The sequence of events he considers to
be stagnation of bile, favouring invasion of this organism ; then some
degree of cholangitis and cholecystitis, which this organism can un-
doubtedly cause, and, as the residt of this inflammation, formation of
gall-stones and cholelithiasis.
The importance of stagnation of bile is evident from certain ex-
periments made by Xaunyn. After ligature of the common duct, the
injection of this organism caused acute inflammation of the bile passages
an<l death of the animal. On the other hand, its injection into the
healthy ducts without previous ligature produced no sj'mptoms what-
ever.
The invasion of the bile passages takes place from the intestine.
Invasion from the blood plays no part in the etiology of cholelithiasis.
Prof. Sherrington found that at a time when the blood was teeming with
organisms there might not be the slightest penetration of them into the
bile. When organisms do appear in the bile, as undoubtedly they do, this
occurs later, when some damage has occurred to the walls of the capillaries.
An important point remains to be noted. For the formation of gall-
stones in the number that we so often meet them, it is by no means
necessary to assume a continuous infection with organisms. On the
contrary, what probably happens is that a transitory invasion suftices to
set up a certain degree of catarrh sufficient to lead to the formation of a
few gall-stones. Afterwards the gall-stones themselves, even in the ab-
sence of organisms, suffice as the irritant: they irritate the mucous
membrane mechanically, and lead to an increased formation of choles-
terin. and by causing obstruction favour subsequent reinfection.
Conclnsion. — Thus it appears that the large group of anorbid con-
ditions comprised under the term cholelithiasis are due primarily to
disorder of the bile passages, not to functional disorder of the liver.
Excretion of drugs and poisons. — The excretory functions of the
liver art' not coutined to the more or less specific constituents just con-
sidered, but extend also to a class of other substances, medicinal and
otherwise, which may be present in the blood. Thus it has been shown
that a number of drugs, when given b}- mouth or injected subcutane-
ously, are to be found in the bile; for example, zinc, ferrocyanide of
potassium, iodide of potassium, cane and grape sugar, sulphate of copper,
oil of turpentine, bromide of potassium, iron, lead, nickel, arsenic, silver,
bismuth, antimony, carbolic acid, salicylate of soda, toluylcndiamin,
chlorate of potash. In some cases this excretion takes place very quickly.
FUNCTIONS OF THE LIVER AND THEIR DISORDERS ■ 37
Thus Peiper found salicylate of soda in the course of half an hour after
its administration by the bowel ; iodide of potassium after some six to
eight hours. In the case of toluylendiamin, a drug notable for its power
of inducing jaundice in dogs, I was able to detect it in the bile within
half an hour of its intravenous injection; and in three to four hours
it was present in quite an appreciajjle, albeit very small quantity. In
respect of such substances the liver is, however, no mere filter. AVhile
excreting some of them, others it appears to arrest or destroy. Thus
atropine, muscarin, strychnine, kairin, antipyrin, quinine are not to be
found in the bile after their administration.
This power of arresting poisons is one of the most important func-
tions discharged by the liver, as it prevents the escape into the general
blood current of crude products of digestion, many of which possess
poisonous properties. Thus Koger (1893), experimenting on guinea-
pigs, found that a watery extract of liver was some sixteen times more
poisonous than that of muscle, and about five times more poisonous
than that of kidney.
There are two sets of observations with regard to the action of the
liver upon strychnine : Jacques found that a dose of 0-74 milligramme
per kilo injected into the portal vein of a dog caused scarcely any
noticeable effect, whereas less than the half of this dose (0'36), injected
directly into a peripheral vein, killed the animal in three minutes.
Roger made a number of comparative experiments on healthy frogs, and
on frogs deprived of the liver. (The latter animals live four to five days.)
While a healthy frog survived the injection of 0-0.'> milligramme of
strychnine for 40 hours, a smaller dose (0-02) killed the liverless frog
in 17 hours. The results were still more striking if smaller doses
were injected more gradually (over an hour). Thus a healthy frog
received 0-016 milligramme subcutaneously without any ill effect ; while
a smaller dose (0-012) killed tlip liverless one Avith violent convulsions.
As regards atropine, some interesting experiments of Kotliar (1893)
made on dogs seem to point to a similar conclusion, namely, that the
liver has a protecting power against its action. If the poison were made
to pass through the liver, the animal was more resistant than in the
case of direct injection into the general blood current.
As suggested by Dr. Lauder Brunton, some interference with this
function of the liver in regard to alkaloidal and other deleterious
products reaching it from the intestine is probably accountable for cer-
tain of the more common symptoms usually ascribed to disorder of the
liver, such as a bitter taste in the mouth, giddiness, cloudiness of in-
tellect, drowsiness, irritability, depression. Products which the healthy
liver ordinarily destroys may escape into the general blood.
This function is indeed bound up with the general metabolic activity
of the liver-cell. Thus leucin and tyrosin — secondary products formed
in pancreatic digestion — are arrested and transformed within the liver-
cell. In cases where the liver undergoes excessive degeneration, as in
acute yellow atrophy or phosphorus poisoning, these products pass
38 SYSTEM OF MEDICINE
through unchanged and appear in the urine. Along with them doubt-
less pass a series of other products normally arrested by the liver.
Another fertile .st)urce of disturbance is the excretion of such i)roducts
into tlie bile. In relation to the pathology of jaundice ant' disorder of
the bile passages generally, this excretory function of the liver is, I
consider, all-important. The power possessed by certain drugs and
organic poisons of causing jaundice is, according to my observations,
connected with their irritant action on the lining of the bile passages in
the course of their excretion by way of the bile. Such poisons usually
cause more or less marked changes in the blood. But, as I have shown,
their power of inducing jaundice is proportioned, not to the action on
the blood (phosphorus, for instance, has no luemolytic action at all),
not to the amount of haemoglobin set free, not to the amount of bile
pigments formed, but solely to the degree of viscidity of the bile
induced.
It is in this relation that the observations on the excretion of
toluylendiamin through the bile are of most interest. This drug is the
most notable of all icterogenetic poisons ; and my observations with regard
to it (1895) show that the increase of viscidity of the bile, which is the
immediate cause of the obstructive jaundice, is the direct result of the
irritant action of products in the bile. So irritant, indeed, is its action
that, with large doses, an intense inflammation of the duodenum can be
set up. definitely beginning at the oriflce of the bile-duct where the
poison (injected subcutaneously) reaches the duodenum. When the
action of the drug is at its height the whole of the intrahepatic ducts
are found filled with thick viscid bile. Lower down colourless
mucus fills the common duct, and may be seen exuding slowly through
the opening of the bile papilla into the duodenum. The duodenum is
also filled with similar viscid mucus free from bile ; its mucous membrane
is acutely inflamed, red, studded with punctiform haemorrhages, and
swollen to three times its normal thickness. The whole of the bile
passages, in short, are in a condition of acute catarrh, set up" presumably
by products contained in the bile. For be it noted the catarrh is of
intrahepatic, not of duodenal origin. It extends from the smaller ducts
down to the duodenum. Aifection of the duodenum is indeed by
no means necessary. The catarrh and the accom])anying jaundice are
producible even when the common bile-duct has been ligatured and a
biliary fistula e.stablished.
The production of catarrh in this way, by excretion of products in the
bile, I consider to be, as I have already pointed out, a most ini]iortaiit
fact in relation not merely to .severe forms of jaundice produced by
poisons, but to the pathology of liver disorders generally.
The normal products of digestion, carried to the liver and excreted
in the Ijile, are nrm-irritant. If at any time, as the result of iiujiaired
digestion or other such cause, abnormal products are formed in the
intestine and absorbed into the blood, the duty falls upon the liver to
arrest them, cither by modifying them or by excreting them. Tliis
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 39
function it discharges successfully, and in the great majority of cases
probably with little or no disturbance to itself; for it is with crude
products that it is accustomed to deal. Did it pour its secretion
directly into the intestine, no disturbance would arise, — no further
opportunity would be given for any of the abnormal products to produce
ill effects. As it happens, however, the bile, with any injurious pro-
ducts it may contain, has to pass at a low pressure along the system
of bile passages lined with epithelium, the larger of them having a
mucous lining supplied with mucous glands. If, then, such products
have any irritant qualities whatever, the effect is to increase the amount
of secretion thrown off from the epithelium of the bile passages ;
and in proportion to the increase of mucus there is a tendency for the
flow of bile to be retarded.
Fortunately only certain organic poisons, and these not common ones,
possess irritant qualities to any notable degree. Their action is simi-
lar to that of toluylendiamin, in that they cause such an increase of
viscid mucus that the flow of bile is temporarily arrested, and jaundice
results. The obstruction then is chiefly intrahepatic. Of this nature,
I consider, the various more or less specific forms of jaundice are —
"epidemic" (catarrhal), probably also ordinary "catarrhal" jaundice;
"malignant jaundice," " febrile jaundice," "infectious jaundice (Weil's
disease)," "acute yellow atrophy of liver," also the jaundice of yellow
fever, relapsing fever, malarial fevers, pycemia, and other febrile condi-
tions.
But probably many products of abnormal digestion possess some
irritant quality ; falling far short indeed of that above described, but
yet capable of producing a certain amount of disturbance. The
excretion of these may occasion a certain retardation in the flow of
bile, and thus lead to some absorption of bile constituents. This is one
of the conditions underlying the ailments variously knoAvn as " bilious-
ness," "torpor of the liver," and cause the icteric tinge of conjunctivae
characteristic of tliese ailments.
It is easy to understand hoAv the liver-cell, which originally had
escaped injury, may suffer in its functions secondarily to this condition
of bile and bile passages; how, in short, many of the classical symptoms
of "lithaemia" may arise — not merely a sluggish flow of bile, but also an
altered metabolism, evidenced by increase of urates and uric acid in the
urine characteristic of the condition; and how by the continuance of the
disturbing factors — faidty products conveyed to the liver on the one
hand, retarded excretion along the bile passages on the other — we may
have biliousness established as a more or less chronic habit of body.
The primary fault lies not with the liver, but with the organ respon-
sible for the products conveyed to it in the portal blood. Under these
circumstances, to speak of "lithasmia" as a substantive condition due
primarily to disorder of liver function, as Murchison does, is hardly
justified. The only fault in the liver may be that it merely excretes
certain of the abnormal products into the bile, and fails to destroy or
40 SYSTEM OF MEDICINE
mollify them on the way. But to excrete can be hardly deemed a
primary error of function on the part of an excreting gland.
While, tlierefore, fully recognising the important part played by dis-
turbance of liver function in disease, it is in my view no less im})ortant
to recognise the precise relation in which such functional disturbance
stands to disease elsewhere. In most cases it is not the prijnary
disorder, but is itself the result of functional disturbance elsewhere ;
either in the organs responsible for the products sup})lied to it, or, as in
the eases just considered, in the bile passages.
So far I have considered this condition of intrahepatic (toxaemic)
catarrh solely in relation to jaundice and biliousness, and to the condition
termed litha^mia. I have now to point out that in relation to chole-
lithiasis and the formation of gall-stones it may also play an im})ortant
part. "We have seen that in many cases the nucleus around Avhich
the deposit of cholesterin takes place is formed of the insoluble body
bilirubin-calcium, that in a number of cases the calculi nu\y consist
entirely of this material, and that, unlike the ordinary calculi consisting
of cholesterin, which are formed exclusively in the gall-bladder, small
calculi of bilirubin-calcium are not infrequently found in the intrahepatic
ducts, either as *' bile sand " or as definite calculi. AVe saw, moreover,
that what determined more than anything else the precipitation of
bilirubin in this insoluble form was the presence of albuminous matter.
It is thus extremely probable that long-standing conditions of intra/-
hepatic catarrh, by leading to shedding of epithelium, may be tlie chief
etiological factor in the formation of this bile sand. And thus indirectly
it may be a potent factor in the production of larger gall-stones ; inas-
much as we saw reason to believe that, apart altogether from microbic
infection of the bile passages, these small calculi of bilirubin-calcium
might, in certain cases, by the mechanical irritation they set up within
the gall-bladder, lead to the formation of cholesterin.
Condaxion. — Disturbances of the excretory functions of the liver
play the chief role in the production of functional disorders of the liver.
Digestive functions. — The functions of the bile in digestion, long
regarded as of the first importance, have now been shown to lie within
comparatively narrow limits. On starches and ])roteids, the two chief
food constituents, it exerts practically no action whatever. Its action is
restricted to fats, which it emulsifies, thereby facilitating their absorption.
"When l)ile is cut off from the intestine, the fseces contain a large
excess of fat ; instead of containing only about 1 per cent of the fat
administered, the amount thus lost may be as much as GG per cent. It is
the presence of this fat which gives the peculiar clay colour to the faeces
in cases of obstructive jaundice ; it may constitute as much as 11 to 13 jier
cent of the weight of the fa'ces. It may be in ]iart responsible for the
peculiar sickening fcetor which faeces free from bile usually have; Init
Gamgee, on the other hand, has ol)served the complete absence of fretor,
in spite of large quantities of unabsorbed fat, in cases of fatty stool due
FUNCTIONS OF THE LIVER AND THEIR DISORDERS 41
to disease of the pancreas without pressure on the common bile-duct.
It is certain, however, that if dogs with biliary fistula be fed on carbo-
hydrates instead of fat, the foetor in great part disappears.
It is this peculiar foetor of the faeces in the absence of bile that has
led to the view that the bile has powerful antiseptic properties. It
certainly has no direct antiseptic action, for micro-organisms of various
kinds have been shown to grow freely in media containing bile (Copeman
and Winston, Sherrington). On the other hand, it is found by other
observers, as pointed out by Gamgee, that free bile acids have powerful
antiseptic properties. It is probable that as soon as the bile comes into
contact with the intestinal contents, the bile salts are decomposed, and
bile acids set free ; and it has been suggested (Gamgee) that the pres-
ence of these acids may modify in some way the putrefactive changes
which albuminous substances undergo in the intestine. Whether this be
so or not, it is certain that their place may be taken by other agents. For
in the case of biliary fistula recorded by Mayo Kobson, where for fifteen
months all bile was discharged externally, the odour of the fseces did not
differ from that of a healthy motion, and the bowels were quite regular
throughout without the use of aperients. That the presence of bile
is not essential to good nutrition, is further evidenced by the case of
biliary fistula recorded by Paton. The woman returned after a year's
interval in a state of robust health, having put on a stone in weight
notwithstanding the complete absence of bile from the intestine.
REFERENCES
1. BuNGE. Phyxiologische und ixttlwlor/ischp Ohemie. Leipzig, 1887. — 2. Copeman
and AViNSTOX. "Observations on Human Bile obtained from a case of Biliary
Fistula," Juur. of Fh;/<iol. vol. x. p. 213, 188!). — 3. Eiffelmann. D. ArrJiiv f. klin.
Med. xxiv. p. 228. — 4. Filehxe. Virchow's Archiv, cxvii. pp. 415-117, 1889. — 5.
Gamgee. F.'njsiolor/ical Vhemistri/ of the Aiiiiiuil Body, vol. ii. Macniillan & Co. 1893.
(The reader is refe- red to this for an account of the subject of the Bile which is admirable
in all respects.) — (>. Gerald F. Yeo and E. F. Herroun. "A note on the com-
position of Human Bile obtained from a Fistula," Journal of Phyniol. vol. v. p. 116.
— 7. Glass. Arrhiv f. exp. Path. xxx. pp. 241-274, 1892.— 8. Halliburton. Text-
Book of Chem ical Physiology a nd Pafholoyy, 1891 . — 9. Kotliar. Arch ive.i des sciences
biolof/iques. vol. ii. pp. 586-631, 1893. —10. Lewaschevv. D. Archiv f. klin. Med.
XXXV. 1884. — 11. Mayo Robsox. "Observations on the Secretion of Bile in a case of
Biliary Fistula," Proc. Royal Soc. vol. xlvii. p. 499. 1890. — 12. Nauxyx. A
Treatise on VhoMithia.ns. Svden. Soc. Trans., by A. E. Garrod. 1896.- 13. Nlssex.
Jahres.u. thier. C'lemie, xx." 1890.-14. Noel Paton and Balfour. "On the Com-
position, Flow, and Pliysiological Action of the Bile in Man," Labor. Reports, Edin.
Royal Coller/e of Physicians, p. 191, 1891.-15. Noel Paton. Ibid. vol. iv. 1892.—
I6.PAIJKULL and Hammarsten. " Ueber die Schleimsubstanz der Galle," Zeitsch.f.
physiol. C'hende, xii. p. 196, 1887.-17. Pisexti. Arch. f. erp. Path. xxi. p. 219,
1886.-18. Prevost and Bixkt. Couipt. rend. cvi. p. 1(;90, 1S88. — 19. Roger.
Archiv d. Physhd. vol. xxiv. 1893. — 20. Rosexberg. Prtih/er's Archiv, xlvi. 1889. —
21. Werthei.mer and Meyer. Conipt. rend, cviii. pp. 357-359.
For other references see art. " Jaundice."
42 SYSTEM OF MEDICINE
COXGESTION OF THE LIVER
SYxoxYiM. — Hypenemia of the Liver
Definition. — A pathological condition associated with a number of diseases,
not itself constituting a disease, but conveniently considered separately
on account of the size and importance of the organ ; consisting in the
presence of a large excess of blood within the blood-vessels of the liver;
clinically characterised by a varying degree of enlargement of the
organ beyond ph3^siological limits and by disturbances of liver function ;
caused by two distinct sets of conditions, one of chomioal (gastro-
intestinal) origin — '' active congestion,"' the other of mechanical (cardiac)
origin — " passive congestion " ; resulting in recovery on removal of the
cause.
Varieties. — The condition known as "congestion of the liver"
cannot be regarded as a distinct disease. Under any circumstances
the border-line between physiological and pathological hypericmia
of any organ is ill defined ; and this must especially be the case in
an organ sidjject, like the liver, to great physiological variations in
the quantity of blood it contains. If therefore a pathological condition
like congestion, common in varying degree to all organs alike, be digni-
fied with the title of disease, it must be on some special ground, such as
the size of the organ or the imi)ortance of its functions, and the con-
secpient gravity of the effects connected with disturbance of them.
E.xamples of such organs we have in the case of the brain and spinal
cord.
It is only on this ground that congestion of the liver has any claim to
be considered as a formal malady ; for it is always associated with
and depends upon diseased conditions elsewhere — notably, for instance,
upon congestion of the gastro-intestinal tract. In the case of the gastro-
intestinal tract the effects of congestion are widespread and ill defined;
in tlie case of the liver they are concentrated, and thus arrest the
attention alike of patient and medical observer. These effects in the
liver occasion a distinct local distress, as well as more general symptoms
referable to disturbance of the gostro-intestinal functions.
Again, the liver is particularly snbject to congestions, ])artly on
account of the character and the richness of its donltle blo()d-su])ply ;
partly on account of its situation at the outlet to the portal system on
the one hand, and of its neighl)ourhood to the hearr on the otlier. Thus
it hns to share in every congestive trouV)le arising thi'oughout the exten-
sive area from which lln^ portal blood is drawn; while its ])roximity to
the heart renders it one of the first organs to be affected by any obstruc-
tion to the flow of blood through the right side of the heart.
CONGESTION OF THE LIVER 43
According as the increase of blood is brought about by increased
inflow through the portal vein, or obstructed outflow through the hepatic
veins, it is possible to distinguish two varieties of congestion of the liver,
different alike in their causes, their clinical features, and their pathology.
Hence the distinction between them is of practical importance. The
congestion due to obstructed outflow is rightly called "Passive,^' as it is
brought about by mechanical causes, and is attended with corresponding
lesions — such as dilatation of capillaries, fatty degeneration, and atrophy
of cells — the results of increased pressure. That connected with increased
infloAV, on the other hand, is in the first instance an exaggeration of the
normal condition of the organ during the times of its activity ; it is the
result of chemical and nervous influences, such as operate in health during
digestion ; and the anatomical changes are also those of increased activity,
and not of increased pressure. This form again is rightly called "Active.^'
As an independent affection it is this latter form of congestion only that
really needs consideration. Passive congestion of the liver is best
described under the title of " the cardiac liver," usually given to it by
French writers, and considered as one of the sequels of heart affections.
Active congestion. — Conditions influencing the quantity of blood in
liver. — Rightly to understand the causes of active congestion it is neces-
sary to have in mind the chief conditions influencing the circulation within
the liver in health. Of these the first and most important is digestion.
An increased flow of blood through the liver with considerable increase in
its size is an event of daily periodic occurrence during the process of diges-
tion. The greater part of this inflow is the result of that general vascular
dilatation tliroughout the gastro-intestinal area which attends the process
of digestion, and the consequent greater inflow of blood into the portal
system. To a much less extent the inflow is due to a corresponding
dilatation of the hepatic artery ; but the quantity of blood conveyed to
the liver through this channel seems very small when compared with
that carried to it by the portal vein. It is thus obvious that, to a much
greater extent than is the case with other organs, the amount of blood
within the liver is regulated by changes occurring outside it, namely,
in the gastro-intestinal area. Whatever amount of blood is allowed to
enter the portal system, as the result of the changes going on in that
area, must necessarily pass through the liver, whether the liver be con-
cerned in the activity of that area or not. As a matter of fact, however, the
period of engorgement of the liver during digestion corresponds with the
period of its greatest functional activity consequent on the supply of food
products conveyed to it. The primary influence, therefore, regulating the
amount of blood in the liver at any time, whether directly through
the hepatic artery or indirectly through the stomach and intestine, is the
presence or absence of food products in the portal blood. Or, as it may
otherwise be expressed, the degree of congestion of the liver in health is a
question mainh/ of gastro-intestinal chemistry.
This activity is doubtless conditioned by the nervous system, but of
44 SYSTEM Of MEDICINE
the nervous mechanism concerned we know but little. It is probably
in the main peripheral. But that there is also some central nervous
control over the bloocl-.suppIy of the liver api>ears in the well-known
experiment of Claude Bernard in which, by puncture of the tioor
of the fourth ventricle, it is possible to induce intense (albeit only tem-
porary) hyperaemia of the liver with glycosuria. Some vaso-inhibitory
influence seems thus to be exerted (m the organ directly from the brain;
its course being down the cord as far as the tliird pair of dorsal nerves,
thence into the sympathetic, and through the splanchnics to the liver.
An opposing vaso-constrictor influence is attributed to the vagi. What-
ever the nature of this central nervous control, there is little reason,
except the experiment above noted, to suppose that it plays any pro-
minent part in regulating the quantities of blood in the liver in health;
and its part in disease is probably still less. The peripheral mechanism
which I have indicated is resident in the vessels themselves.
Ri^apindovy movements. — While, then, the chenustry of the gastro-
intestinal area, acting through the nervous system, is the chief factor
regulating the amount of blood within the liver, there is another factor
the influence of which is not to be overlooked — namely, the influence of
the respiratory movements.
The blood-pressure within the portal system is both feeble and vari-
able, varying from 7 to 24 millimetres of mercury ; that in the hei^atic
veins is still less, oscillating between a maximum of -|-4 millimetres and
a minimum of —5 millimetres. When the ])ressure is at its lowest in
the portal system, there is thus but little difference between it and that
in the hepatic veins. The difference is sufficient, however, to enable the
blood to pass from the portal into the hepatic veins, aided as the flow
probably is by the rhythmical contractions of the trunk of the portal
vein and intestinal j^eristalsis on the one side, and by the aspirat-
ing action of the right heart in diastole on the other. Of most im-
portance, however, in this relation are the respiratory movements of
the diaphragm. During insi)iration the abdominal pressure rises, while
the intra-thoracic pressure tends to fall ; moreover, as the liver is directly
pressed upon by the descending diaphragm, the flow of blood through the
liver is greatly facilitated by both means. Both a suction and a forcing
power are exerted on the flow of blood during insjnration, and this is
the greater the more forced and deeper the inspirations.
Exercise, therefore, which calls forth such forced movements in
greater degree, greatly facilitates the flow of blood ; while sedentary
habits tend to its retardation.
Etiology. — The causes of active congestion of the liver in disease
consist in an exaggeration or undue persistence of the comlitions which
favour ]jhysiologic!al hy penemia: these may briefly be described as (fustro-
i)itestiii((l in origin, and chemical in nature ; and thus they are sharjily
distinguishal)le from those of '* passive congestion," which are cartliac in
origin and mechanical in nature. Two main groups of causes may be
distinguished — (i.) gastro-iutestinal, (ii.) toxic. The former group
CONGESTION- OF THE LIVER
45
comprises the great majority of cases met with in this country, where
the hepatic congestion is traceable to morbid congestions of stomach
and intestine arising from errors in food and drink; the latter includes
the cases, common rather in tropical climates, in which the congestion
seems to be due to some toxic intiuenee, as in malaria, dysentery, yellow
fever, icterus gravis, AVeil's disease, bilious typhoid. It will be noted,
even in these cases, that the entrance of the poison is chiefly by the
gastro-intestinal tract.
(i.) Gastro-intestinal influences. — The most common causes of active
congestion of the liver undoubtedly are gastric catarrh and associated
intestinal congestions set up by undue indulgence in food and drink.
It is most commonly found in persons Avho habitually eat and drink
much, and take little exercise. Rich and highly seasoned foods which
tend to produce or aggravate the conditions of catarrh and congestion
of the mucous membranes are potent for evil.
Excess in malt liquors, wines, or spirits is undonbtedl}^ also a very
potent cause of congestion, and more common perhaps than excess in
eating alone. That these agents exert a directly injurious action on the
liver itself is proved by the occurrence of cirrhosis of liver. It is in the
habitual toper that the best-marked attacks of congestion of the liver
are to be met Avith in this country.
Over-indulgence in liquids of any kind, especially if taken Avith
food, also favours the occurrence of the condition in persons of plethoric
habit of body.
Not only excess, however, but irregularities in the times of taking
food, insufficient mastication, and other causes of gastric catarrh, will
produce congestion of the liver in persons liable to it ; for certain patients
appear to have a proclivity to hepatic congestion. Such patients are
usually of stoutish build of body, of phlegmatic habit, and of sallow,
muddy, so-called " bilious " complexion. There is a want of tone about
them generally, which seems especially to affect their portal vascular
system. Causes which in ordinary persons would set up a temporary in-
digestion at worst will in them produce well-m arked congestion of the liver.
Most of the above causes operate strongly at or near the middle age,
when a sedentary life is more usual.
Congestion of the liver is frequently a premonitory sign of an attack
of gout ; and the connection between these two conditions was insisted
upon long ago, chiefly by English observers (Scudamore, Gairdner,
Gar rod).
The foregoing causes operate by producing and maintaining condi-
tions of congestion and catarrh in the stomach and intestine. Among
the rarer causes may be mentioned dilatation of the stomach, which,
according to Bouchard, may set up active liver congestion. This asso-
ciation I have also had occasion to note.
(ii.) Toxic conditions. — In warm climates the various forms of aguish
and miasmatic affections, such as malaria, dysentery, and intermittent
fevers, are active causes of congestion of the liver. To the same group
46 SYSTEM OF MEDICINE
also belong the various forms of febrile jaundice, such as yellow fever,
icterus gravis, WeiFs disease, and bilious typhoid, in connection with
which congestion of the liver is a regular occurrence.
It is prubiible that in most if not in all these cases the influence on
the liver is brought to bear through the intestines, as in dysentery,
malaria, bilious typhoid ; and that it differs from that operative in the
foregoing group of cases in being of a poisonous nature. Well-marked
swelling and congestion of the liver are, in my experience, a common
accompaniment of the action of the drugs which produce jaundice,
such as toluylendiamin.
It is in connection with this group of affections that the influence oj
climate in favouring congestion of the liver may most conveniently be
considered. So much more common is the malady in hot climates than
in cold that it has been attributed to great heat alone independently of
infections. But the two kinds of agency cannot be dissociated, nor
should we forget the changed habits of life in food, drink, and exercise.
According to the two French observers, Kelsch and Kiener, nearly all
cases of congestion of the liver occurring in warm climates can be traced
back to malaria, dysentery, and similar influences. At the same time
changes of temperature greatly dispose to attacks by intensifying the
operation of those dietetic and other influences which in more temperate
climates are less effective. Cold also seems to play a part. The vague
condition called " liver-chill " is regarded by some avithors as a form of
active congestion of the liver.
Lastly, there remain one or two other conditions which have been
regarded as causes of congestion of the livei-.
The first of these is su^ij^ressed menstruation, in connection with which
some degree of congestion is said not infrequently to occur ; sometimes
with jaundice. Four such cases of " menstrual jaundice " are described
by Senator. This variety of congestion is usually met with either at
the catamenial period or at the approach of the climacteric ; and it has
been supposed to arise directly from vaso-motor disturbance. Perhaps
these cases ought to be regarded as belonging to the large ill-delined
group in Avhich the title " congestion of the liver " is used as a conven-
ient and popular name for ill-understood disorders.
la di(0)f'tes meUitus, also, some degree of congestion occurs. Since
the time of Bernard it has often been assumed that in diabetes some
disturbance of the central nervous system might be one of the factors
operating through the liver to bring about this condition. A more
proVjable explanation of the congestion of the liver in such cases appears
to me to be the increased work thrown on the organ by the consumption of
the large quantities of food and drink necessitated by the condition itself.
Symptoms. — The symptoms of active congestion group themselves
into two classes : those connected with the condition, gastro-intestinal or
other, with which the congestion is associated ; and those referable to the
disturbances in the liver itself. The common symptoms are those of
gastric or gastro-duodenal catarrh — headache, malaise, loss of appetite
CONGESTION OF THE LIVER 47
or sickness, bitter taste in mouth, coated tongue, constipation — to which
are added a sense of discomfort, weight, or even actual pain and tender-
ness over the region of the liver itself; the patient at the same time
usually presents the muddy complexion and the yellow eyes so char-
acteristic of liver disorder. The pain and discomfort over the liver are
aggravated by pressure or by movement ; they may be affected even by
pressure of the clothes. Not infrequently the pain is referred to the
right shoulder.
The liver is found appreciably enlarged; it projects below the costal
margin, and is tender to touch.
There is usually a slight degree of jaundice ; in the group of cases
depending on toxic influences it may be considerable, even intense.
The urine is high-coloured, concentrated, of higher specific gravity
than normal, and usually loaded with urates ; not infrequently also it
contains uric acid crystals. Bile pigment is usually absent, except in
the presence of jaundice.
The nervous disturbances are not the least prominent and disagree-
able, including as they do not only headache and feelings of giddiness,
but also great irritability of temper and mental depression.
Clinical varieties. — According to the severity and duration of the
attack, two varieties are to be recognised — acute, met with in fevers,
and marked by much constitutional disturbance ; chronic, Avhere the
symptoms are more those of disorder of digestion, connected with long-
standing habits as to food, drinlc, and exercise.
Morbid anatomy. — The anatomical changes found after death in cases
of active congestion are ill marked. The liver is swollen, enlarged, dark
in colour ; and on section its vessels are found very full of blood. This
overfilling is not limited to the central portions of the lobule, as in the
''cardiac liver" (chronic congestion). The lobules may show some
appearances of fatty change; but the mottling (nutmeg appearance), so
characteristic of the cardiac liver, is not seen. On microscopic examina-
tion the liver-cells are swollen and often fatty ; or they show some de-
grees of parenchymatous degeneration and cloudy swelling.
The changes as a whole are significant of over-activity, and differ
from the atrophic and pressure changes presented by the "nutmeg " liver.
Diagnosis. — The diagnosis rests on a concurrence of symptoms of
gastro-intestinal disturbance with enlargement of the liver, and pain and
discomfort in the region of that organ.
Prognosis. — The condition is not dangerous in itself. It derives its
importance from its causes.
Treatment. — The indications in treatment are mainly two: (a) To
correct the habits of life on which the condition mainly depends ; (h) To
remove the gastro-intestinal conditions and the associated hypereemia
which prevails throughout the portal system.
(a) If the error be one of excess the food must be smaller in quantity,
less bulky, and less stimulating in character, and the intervals between
meals longer. In the choice of food regard must be had to the
48 SYSTEM OF MEDICINE
stomach, and only such food given as will be readily digested without
giving rise to irritating products. Sauces and all dishes containing over-
heated fats, such as entrees, pastries, and the like, should be avoided.
Fat in any form should be taken sparingly. The safest meats are those
roasted, or, in the case of fish, boiled or broiled.
If the immediate cause of the congestion be alcholic excess, as it
often is, alcohol in every form should be cut oif for the time being. If
alcohol be only one of the factors it should be taken in strict moderation,
and only with meals. Indeed, the quantity of liquid of any kind taken
with meals should be small; liquids are better taken on an empty
stomach between meals. Our object in these measures is to avoid luidue
dilution of the gastric juice during active digestion — to restrict the inflow
of blood into the portal system and lessen the amount of digestive work
to be done.
(6) In carrying out these measures we are doing much to carry out
the second indication of treatment ; for by regulation of the diet we
diminish and get rid of the gastric catarrh, with the associated hy peraemia
throughout the portal tract. Much can also be done in this direction
by use of medicines, such as bismuth with alkalies and bitter tonics
given before food; or dilute acids, especially nitro-h^^drochloric acid
with nux vomica, after food.
But our chief means of diminishing the hyperaemia throughout the
portal system is free depletion of this system by purgatives. At the
same time the patient must be led to take more exercise. For the former
purpose we prescribe the various saline purgative mineral matters —
Carlsbad salts, preferably in effervescing form, ]\Iarienbad, Homburg, or
Johannis — taken on an empty stomach in the morning, with an occasional
pill at night time, containing one or more of such drugs as podophyllin,
mercury in the form of blue pill, aloes or aloin, nux vomica, or rhubarb
(compound pill). How much such measures are calculated to relieve the
condition is shown incidentally in cases where a copious bleeding from
piles is immediately followed by great relief to the more distressing
liver symptoms, possibly even by appreciable diminution in size of the
liver itself.
When, as often happens, the liability to siich congestive attacks be-
comes a habit of life, the treatment becomes a much more diiftcult task.
In addition to the foregoing measures, it is in such cases that great bene-
fit is derived from periodic visits to such watering-places as Homburg,
Carlsbad, Marienbad, or Vichy. The benefit thus obrained is partly due
to the use of the various purgative waters, partly also to the more regular
life and the more restricted diet to which patients, otherwise unamen-
able to advice, more readily conform.
REFERENCES
1. Chauffard. "Maladies da Foic," Trrtiti de rri(<<Jrrh)fi, vol. iii. 1R02. — 2
Kf.lsch and Kien'kr. Traits drs maladies des pays chauds, Paris, 1S8!>, p. 172.— 3.
Senator. Berl. klin. Woch. 1872.
CONGESTION OF THE LIVER 49
Passive congestion. — Synonyms. — Nutmeg liver; Cyanotic atrophy
of liver; Cardiac liver. — Definition. — A pathological condition consist-
ing in an excess of blood within the liver, caused by obstruction to the
outflow of blood from the organ, in the great majority of cases as the re-
sult of cardiac disease ; characterised at first by enlargement of the liver,
in the later stages by shrinking and atroi^hy, with symptoms of impeded
portal circulation.
Etiology. — This form of congestion differs essentially from the one
already considered in being of purely mechanical origin. It is the result
of impeded outflow of blood from the hepatic veins, consequent on back-
ward pressure of blood in the inferior vena cava. The conditions which
lead to this are such as interfere with the free passage of blood through
the heart, and include, therefore, all those lesions, whether of cardiac
or of pulmonary origin, which tend to functional incompetence of the
right side of the heart. Of the cardiac conditions the most common is
mitral disease, both dilatation and stenosis, especially the latter ; but all
other heart lesions, whether valvular or inflammatory, and degenerative
alterations of the cardiac muscle, tend to produce this condition in pro-
portion as they throw increase of work upon the right side of the heart,
and ultimately weaken it.
Certain pulmonary conditions, in so far as they impede the circulation
through the lungs and throw increased work upon the right side of the
heart, also favour its production. The most common of these is general
emphysema with chronic bronchitis. Other conditions are chronic inter-
stitial pneumonia, congenital atelectasis, pneumonia, atrophy of lungs,
and compression of lungs, whether by pleuritic exudations (especially of
the left side) or by intrathoracic tumours (aortic aneurysms, mediastinal
tumours).
Lastly, in quite exceptional cases the obstruction to the outfloAv of
blood from the liver may be produced by more local lesions — constric-
tion of the hepatic veins themselves as the result of chronic periphlebitis,
or narrowing of the vena cava above the junction of the hepatic veins by
tumours in this region (aneurysms, enlargement of glands), or exten-
sive effusions into the left pleural cavity. The latter may push the
mediastinum so much to the right as to bend the vena cava almost at a
right angle.
Morbid anatomy. — The result of these various changes is an en-
gorgement of the venous system of the body wiiich tends especially
to affect the liver, as the organ nearest the obstruction. The liver is
engorged with blood and greatly enlarged ; and inasmuch as the cause of
the hyperaemia is usually permanent (for example, valvular disease),
the hypersemia itself is permanent, and ultimately leads to permanent
structural changes. The engorgement of the vessels especially affects the
capillaries in the centre of the lobule in immediate relation "with the
hepatic veins. They become greatly dilated, the liver-cells around are
shrunken and atrophied by pressure, and usually contain much yellow
blood pigment. The centre of the lobule thus presents a deeply con-
VOL. IV B
50 SYSTEM OF MEDICINE
gested pigmented appearance ; and, inasranch as the cells in the outer
zone of the lolnile are usually fatty, there is a marked contrast between
the congested and the fatty zones. On section the liver thus shows a
mottled appearance, like that of a nutmeg — hence the title "nutmeg
liver."
In course of time other secondary changes ensue. The increased pres-
sure leads to an increase of the connective tissue in the centre of the lobule,
and eventually to a well-marked induration and shrinking of the liver
substance. In the later stages of the condition, then, enlargement gives
place to an atrophy and induration of the organ (cyanotic atrophy, or
induration of the liver).
Symptoms. — The symptoms accompanying the above condition are
mainly tliose of the cardiac or pidmonary condition giving rise to
it ; but there are in addition others more directly due to the liver it-
self. Chief among these is the enlargement of the liver, sometimes recog-
nisable only by percussion, at other times so great as easily to be made
out by palpation. In severe cardiac cases it may be so great as to
form a prominent swelling on the right side of the abdomen, extending
a hand's-breadth or more below the costal margin ; not infrequently
in early stages of congestion it pulsates synchronously "with the heart's
beat, but as the congestion becomes chronic, and the liver hardens, this
phenomenon disappears.
The patient experiences a great feeling of fulness or tension on the
right hypochondrium, aggravated by external pressure or forced respirar
tory movements, usually also much increased l)y lying upon the left
side.
Gastro-intestinal symptoms are usually more or less marked. They
are the result of the congestion produced throughout the whole portal
tract by the obstruction to the outflow of blood from the liver. They
take the form of disturbed digestion and impaired peristalsis, sometimes
also of haemorrhoids.
Ascites is also common. In the early stages it is only a part of a
general dropsy. In the later stages, Mdien atrophy and induration of the
liver occur, it may be the direct result of the state of the livtn-. A degree
of ascites, then, out of proportion to the general dropsy may indicate
cyanotic induration of the liver.
A more definite symptom of liver disorder is the occurrence of
jaundice. A certain degree of jaundice is very common in severe cases,
causing, Avith the cyanosis, the peculiar du.sky green discoloration of face
which such patients present. It is the result of obstruction, occasioned
by congestion and tumefaction of the tissues and catarrhal swelling of
the epithelium of the bile-ducts.
Tlie course and duration of these symptoms depend entirely on that
of the conditions which give rise to the obstruction. In lieart disease
they are gradually estaldished ; and they vary from time to time according
to the cajiacity of the right ventricle. It is only when the condition has
been so long established as to lead to induration and atrophy that it
JAUNDICE 51
may be said to have an independent existence, causing, it may be, more
or less permanent ascites. Short of this the condition cannot be said to
be an independent one, or in itself dangerous to life.
Treatment. — The treatment is mainly, of course, that of the cardiac or
pulmonary condition which gives rise to it. At the same time the local
symptoms can be much relieved by diminishing the portal congestion,
either indirectly by cathartics, or more directly by applying half a dozen
leeches over the liver.
To fulfil the first indication, great benefit will be got by occasional
doses of calomel, or of smaller and more regular doses of blue pill, often
in combination with digitalis. When given in repeated doses calomel acts
in such cases not only as a cathartic, but as a powerful diuretic also.
Vegetable aperients are also usefvd ; podophyllin, rhubarb, aloes : also the
various mineral salts, such as sulphate of soda, sulphate of magnesia, or the
mineral waters containing them — Carlsbad, Marienbad, Homburg, and
others.
JAUNDICE
The General Pathology of Jaundice
SUIOIARY of contents
Historical Introduction — Theories of Jaundice : (1) Frerichs' hypothesis ; (2) Heemato-
genous hypothesis ; (3) Suppression hypothesis.
Various Factors producing Jaundice —
A. Hfematogeuous origin of Bile Pigment.
B. Action of Poisons.
C. Increased Blood-destruction.
D. "Suppression" of Function.
E. " Polycholia " — increased secretion, and absorption of bUe from the intestine.
F. Nervous Influences : Jaundice from emotion.
Summary.
Definition. — A general condition symptomatic of disorder either of the
liver alone (hepatogenous jaundice), or of the liver and the blood in
association (ha^mo-hepatogenous jaundice) ; characterised by yellowish
discoloration of the tissues Avith l)ile pigment, the excretion of bile
pigments in the urine with or without bile acids ; and by various general
symptoms referable, in simple cases, to disturbances of gastro-intestinal and
liver functions, in more severe cases, to disorder of the blood as well as of
the liver (fever, cerebral symptoms, haemorrhages). Caused by absorp-
tion of bile from the bile passages as the result of impeded obstructed
outflow.
52 SYSTEM OF MEDICINE
Introductory. — The subject of jaundice has long had a peculiar
interest alike for clinician and pathologist. It is one of the fe\v sub-
jects in connection with which a theory has long occupied a prominent
position in all treatises on medicine. In the present article it is pro-
posed to discuss its general ])athology in the light of much recently
acquired knowledge. It is interesting to note that another Avell-marked
disease, the general pathology of Avhich has excited a like interest, namely,
diabetes, like jaundice is connected with disorder of the liver.
The theory of jaundice has not been exempt from the liability to
change incidental to all theories. The changes it has iinderirone from
time to time are interesting in that they serve to denote for each succes-
sive period the extent of knowledge regarding the relations of the liver and
the blood. In its obstructive varieties one of the most easily understood
of conditions, in other varieties, apparently unconnected with obstruction,
it has long been a fruitful subject of speculation : by general consent,
however, the latter varieties have been ascribed to disorder of the blood
rather than of the liver itself.
That jaundice does arise in connection with certain disorders of the
blood is a very old observation. But it is only within the present century
that the association has been investigated. The connection of the two
disorders is indeed frequently referred to as far back as the time of Galen ;
but such observations indicate little more than the prevailing opinion of
ancient writers that disorder of the blood is the primary cause of most
diseases.
In later times, when this criticism does not so closely apply, —
at the end of last century and the beginning of the present, — it is to
be noted that the chief authors discuss the possibility of a form of
jaundice uncoruiected Avith obstruction in the liver, though they are very
far from admitting its probability. It is clear, however, that the jaun-
dice connected with blood disorder was clinically well known to them.
Thus Reil (1782) gave a long description of its chief features luider the
title " Polycholia," Avith rules for distinguisliing it from ordinary jaun-
dice. Saunders also (1809) recognised that jaundice might be associated
with a redundant secretion of bile and be independent of biliary obstruc-
tion ; as, for examj)le, the jaundice of yellow fever. He even Avcnt so far
as to admit that in certain morbid atates the blood might acquire a
bilious appearance independently of absorption or regiu'gitation of bile
from the liver, thus practically anticipating the later ha^matogenous doc-
trine of jaundice. But that he held such a mode of origin of jaundice to
Ijc unlikely is plain from his subseciuent conclusion, that "in every case
of jaundice bile miist be secreted and carried into the blood-vessels " ; in
other words, the jaundice is essentially of obstructive origin. And,
indeed, it would have been strange if the importance of obstruction as a
cause of jaundice had been overlooked l)y Saunders ; since he was the
first to demonstrate by experiment the channels l)y which, after ol)struc-
tion of the bile-duct, the absorption of bile takes place ; namely, the
lymphatics. He ligatured the bile-duct, and afterwards was able to trace
JA UNDICE 53
the lymphatics of the Hver distended with bile up to their junction with
the thoracic duct.
Still later (1827) Cullen also rejected any other mode of origin
of jaundice than that of absorption of bile already formed by the liver.
He distinguished two Avays in which jaundice might arise in this way :
namely, (i.) obstruction to the floAv of bile into the duodenum; and (ii.)
reabsorption of bile from the alimentary canal when it had accumulated
there in an unusually large quantity. How far this accumulation could
take place, and under what circumstances it occurs, he could not clearly
ascertain ; he considered, however, that jaundice was seldom produced in
this way.
Similarly most other writers about the end of last century taught
that the doctrine of jaundice from absorption was the only trustworthy
one ; jaundice was essentially obstructive in its nature. And it may be
stated generally that, up to the end of the first quarter of the present
century, the state of knowledge did not permit any further deduction.
It was recognised that there are certain forms of jaundice not clearly
traceable to obstruction, but difficult to account for on any other sup-
position.
I. Freriehs' hypothesis. — During the second quarter of the century the
view, hinted at by Saunders, that jaundice might arise from pure disorder of
the blood, independently of obstruction, began to take more definite form.
It Avas not, however, till 1858 that any serious attempt was made to
define more precisely Avhat such a view implied — to indicate Avhether the
fault lay in the blood or in the liA'er. The first attempt of this kind Ave
owe to Freriehs, Avhose results appeared to shoAv that the fault lay in
the blood, and that the jaundice Avas due to accumulation of bile pigments
imperfectly oxidised in the blood.
Freriehs distinguished tAvo possible causes which might lead to an
accumulation of bile constituents in the blood : (i.) increased absorption
of bile into the blood, Avhether from obstruction in the bile-ducts, or from
abnormal diffusion of bile into the blood capillaries of the liver under
conditions in Avhich the blood -pressure Avithin the liver Avas diminished ;
or (ii.) diminished consumption or metamorphosis of the bile constituents
absorbed into the blood under normal circumstances from the alimentary
canal. Chief among these constituents and the precursors of the bile
pigments he considered to be the bile acids ; for he found that, by the
action of sulphuric acid on bile acids, various pigments or chromogens
Avere formed resembling in many respects the pigments of the bile, especi-
ally in their behaviour towards Gmelin's reagent. On the basis of these
obserA-ations he conceived the normal fate of the bile acids absorbed from
the intestine into the blood to be that they underAvent a similar change
in the blood, and were converted into bile pigment ; and that this in turn
became oxidised within the blood into urinary pigment. Any interfer-
ence with this normal oxidising process Avould thus necessarily lead to an
excess of bile pigment in the blood ; and in this Avay a jaundice might
arise quite independently of any obstruction.
54 SYSTEM OF MEDICINE
Frerichs made certain other observations which seemed strongly to
siipport his views. For he found that if bile salts were injected into the
blood of dogs they disappeared, while bile pigment appeared in the
urine.
According to this view, then, the fault lay entirely with the blood,
which did not oxidise the bile pigment normally absorbed into it ; and
jaundice might arise either from increased absorption of bile into the
blood, or from diminished metamorphosis of bile absorbed in normal
(juaiitity.
II. Kuhne's hypothesis. — " Ucematogevous Jaundicfi." — Frerichs' import-
ant observatious on the appearance of bile pigment in the urine after the
injection of bile salts into the blood was soon confirmed by Kiihne (1858).
But so far from lending support to the views of Frerichs, Kiiline's obser-
vations led, curiously enough, to the establishment of a radically different
theory of jaundice. Kiihne showed that the explanation of the appear-
ance of bile pigment in the urine, after injection of bile salts, was very
different from that supposed by Frerichs. Kiihne found that if, instead
of bile salts, he injected haemoglobin into the blood, bile pigment still
appeared in the unne. He concluded, therefore, that the bile acids did not
liecome directly converted into bile pigment, as Frerichs had supposed,
but that they liberated the hasmoglobin of the corpuscles, and that this
was subsecpiently transformed into the bile pigment. On the groimd
of these observations he formulated the doctrine that all agents capalile
of liberating- an excess of hsemoglol)in in the blood were capable of in-
ducing icterus — at any rate to a degree sufficient to cause bile pigment to
appear in the urine.
The importajit point established by these observations of Kiihne was
that haemoglobin is the source of the bile pigments. It is not too much
to say that this observation marked a new era in the history of the sub-
ject ; later observations have but confirmed its truth. Very soon it
received supj)ort from A'irchow's discoA'cry, in and around- old extravasa-
tions of blood, of crystals of hsematoidin, a pigment closely resembling
bilirubin if not identical with it. As the haemoglobin of extra vasated
blood coiil<l undergo this conversion it Avas reasonable to suppose that
under certain circumstances it might undergo a like transformation in the
blood. Taken Avith the foregoing observation that bile 2)igment appears
in the urine after the injection of haemoglobin into the circulation or on
its liberation there, the evidence seemed, indeed, conclusiA-e that such a
transformation had taken place, and this, too, directly in the Ijlood Avith-
out the intermediation of the liver. The liver A\'as not concerned in the
process. Such jaundice must be purely " haematogenous " — in no sense
obstructive.
The doctrine of a ha'matogenous jaundice tlnis formulated very soon
received Avhat appeared to be strong suppuit fiom the clitiical side. Ley-
den's important observations (186C) appeared to confirm the view that
the blood, and not the liA-er, is the tissue at fault. He found that
in obstructive jaundice bile acids are ahvays jirescnt in the urine Avith
JAUNDICE 55
bile pigment ; whereas in the jaundice of pyaemia and allied blood dis-
orders they are not to be found. As the bile acids are formed by the
liver, their absence from the urine in such cases seemed to indicate
inaction of the liver and that the bile pigments present in the urine
had not been formed by the liver, and, consequently, that this jaundice
is not due to obstruction.
As a matter of fact the accuracy of Leyden's observation was very soon
called in question. But it fitted in so completely with Kiihne's doctrine
that his teaching soon gained a very general acceptance, and has held its
ground even up to the present time. The detection of bile acids in the
urine has been accepted as a sign of obstructive jaundice ; their absence
as a sign of so-called " non-obstructive " or " htematogenous " jaundice.
Chief among the supporters of the doctrine of a hsematogenous jaun-
dice at various times have been Leyden in Germany, Gubler in France
(1857), Budd (1845), and Harley (1865) in this country; and among
recent writers it has received qualified support from Bristowe (1890) and
Fagge (1891).
The class of diseases to which it was held to apply were such as
pyaemia, typhoid fever, pneumonia, and febrile jaundice generally ; the
jaundice following burns and scars ; that following the injection of
water, pyrogallic acid, or other destructive agents into the blood ; and
that of malaria, paroxysmal hsemoglobinuria, and other diseases marked
by blood-desti-uction.
The doctrine always failed, however, to gain acceptance from Frerichs
in Germany, or Murchison in this country (1868); and it was likewise
deemed insufficient by Wickham Legg (1880). It was indeed very
soon rejected as insufficient by the very observer to whom, in the first
instance, it owed its name, and who is often regarded as its founder.
Virchow it was who first suggested the name " hsematogenous " to describe
this kind of jaundice ; and, as we have seen, his o^vn observations lent no
little support to the doctrine. Yet, whatever his early views, his later
opinion undoubtedly was that a j^urely ha?matogenous origin of jaundice
in any form is extremely improbable. Even in such diseases as pyaemia
or pneumonia he held that obstruction, due, it may be, to catarrh of the
bile-ducts, plays a very prominent part.
It will presently be seen how fully this scepticism of the great patho-
logist has been justified by the most recent work on the subject. Before
considering this matter, however, it will be convenient to refer to another
hypothesis, having certain close relations to the haematogenous doctrine ;
namely, the theory of " jaundice by suppression."
III. The suppression hypothesis. — According to this hypothesis the
jaundice, unattended by obstniction, is due to a suppression of the biliary
secretion as the result of some morbid action of the liver itself. " The
biliary ingredients are not eliminated, and consequently accumulate in the
blood " (Harley). This is the oldest theory of all. At what time, indeed,
it took origin is not clear. A doctrine identical with it Avas expressed by
Boerhaave (1757) and by Morgagui ; but it is probably much older than
56 SYSTEM OF MEDICINE
their writings. Such a doctrine Av.as in strictest keeping with the early
knowledge of the functions of the liver, itr chief function being compared
to that of a sieve which strains off" the l)ile fioni the portal blood (Glisson,
1G59).
According to the modern version of this hypothesis, biliary secretion
can be retarded or even totally arrested, for instance by nervous influence,
without any structural alterations in the liver-cell. The liver can " strike
Avork " and refuse to secrete bile, and the result is jaundice. It is
claimed for this hypothesis that it rests on a basis of pathological facts,
and in support of its accuracy special importance is attached to certain
cases of obstruction described by ^loxon and others, where the gall-bladder
and larger bile-ducts behind the point of obstruction are found tilled with
coloiu'less mucus free from all trace of bile.
The class of cases to which it is applied by its supporters includes —
(i.) Those in which jaundice occurs as the result of sudden mental emotion
or other severe nervous disturbance ; (ii.) Most of the cases in which it
occurs in connection with disorder of the blood, such as tyijhus, enteric
fever and infective diseases generally, icterus gravis, yellow fever, acute
yellow atrophy, snake poisoning and phosphorus poisoning — cases of much
the same class, indeed, as those to Avhich the hematogenous doctrine
applies. And, indeed, at some points the two doctrines are closely related.
They diff"ei', it is true, in this respect, that Avhile according to the h?emato-
genous doctrine the whole fault lies with the blood, the only fault ascribed
to the liver being that it cannot dispose of all the hfemoglobin supplied
to it, according to the suppression theory, on the other hand, the fault
lies entirely with the liver, the function of which is arrested. Neverthe-
less the two views have this in common, that both assume the bile pig-
ments to be formed from haemoglobin within the blood, and merely to be
excreted by the liver ; and, consequently, that jaundice is liable to occur
if at any time there be an excess of haemoglobin in the blood on the one
hand (hematogenous), or an arrested activity of the liver on the other
(suppression theory). In disease, as it happens, both factors are often
combined, since the poison which acts injuriously on the blood also acts
injuriously on the liver. Hence it is impossible to separate the two pro-
cesses entirely ; since, but for the facts in support of the hematogenous
doctrine, the suppression theory would have little or nothing to recom-
mend it.
The theory of jaundice by suppression has received support from
Andral (1839), Budd (1845), Sir Thomas Watson (1867), Bamberger
(1857), Trousseau (1865), Liebermeister (1864), Ilarley (1880), and
Moxon (187.3). The last-named observer, indeed, Avent so far as to
ajjply the theory to obstructive foi-ms of jaundice no less than to those
where no obvious obstruction could l>e found. In obstructive jaundice
he considered the yellowness to be caused by suppression of the secretion,
and not by absorption of bile already formed ; unless as an unimportant
incident of the earlier stages of the jaundice. "We may deny that re-
absorption of bile is a cause of jaundice." In extending the doctrine of
J A UNDICE 57
suppression thus far, Moxon, I think, stands alone ; its other supporters are
content to apply it to the cases where no obvious obstruction can be found.
Consideration of foregoing doctrines. — Of the three doctrines just con-
sidered, the only one which has contributed definitely to our knowledge
is the haematogenous doctrine.
Frerichs' teaching has contributed nothing. The bile pigments are
not derived from bile acids as he supposed ; and the oxidation processes,
to the arrest whereof the accumulation of bile constituents in the blood
was ascribed, have as problematical an existence now as ever they had.
The suppression doctrine took origin at a time when the excretion of
bile was supposed to be the sole function of the liver. In this case, if the
liver cease to act, the bile constituents accumulate in the blood. We now
know that the chief constituents of the bile do not pre-exist in the blood,
but are formed by the liver.
The hematogenous doctrine, on the other hand, is based upon a fact
of definite importance, namely, that the bile pigments are derived from
haemoglobin, and not infrequently appear in the urine after a liberation
of haemoglobin in excess. Where this doctrine proved wanting was not
in facts, but in the interpretation of them. It assumed that the conver-
sion of hpemoglol)in into bile pigment takes place within the blood, and
upon this assumption the doctrine depended. Indeed, the occurrence of
jaundice in connection with increased blood-destruction was conversely
adduced by the physiologist as an argument in favour of the j^urely
hoematogenous origin of bile pigment.
VARIOUS FACTORS IN THE PRODUCTION OF JAUNDICE
A. Hsematogenous origin of bile pigment (" Hoematogenous jaun-
dice "). — Possibility of a hcematogenous origin of Ulepigment. — Even now it may
be said that, although the evidence against such a mode of origin largely
preponderates, a certain, albeit limited, amount of evidence is still
adducible in its favour. For there still remain a few observations which
lend support to the view that bile pigments may be formed independently
of the liver-cell. On the one hand it has been shown by the important
experiments of the two German observers, Minkowski and Naunyn
(1886), that increased formation of bile pigments (induced in their
experiments by exposing the animals to the fumes of arseniuretted
hydrogen, and thereby causing great destruction of blood) goes hand in
hand with the appearance of numerous pigment-holding cells in the
capillaries of the liver, some of them containing bile pigment. They con-
clude that within these cells, which, be it noted, are not liver-cells, but
ordinary leucocytes and connective-tissue cells lying in the capillaries of the
liver, the haemoglobin is transformed into bile pigment, which afterwards
is simply excreted by the liver-cells.
Similarly another observer, Lowit, finds that in frogs it is the
normal fate of red corpuscles to be taken up by cells of the blood (leuco-
58 SYSTEM OF MEDICINE
cytes), and that within these their haemoglobin becomes converted into
bile pigment in the liver, spleen and bone-marrow.
Lastly, Neumann has recently studied the mode of origin of hjema-
toidin — the crvstalline pigment, as Ave have already noted, identical
with bilirubin — and concludes that its formation from hiiemoglobiu is a
simple chemical process independent altogether of tiie activity of cells of
any kind, whether leucocj'tes or any other.
As the I'csult of my OAvn observations on formation of hssmatoidin in
extra vasated blood, I came to similar conclusions (1886).
Recently (1896) Dr. Auld concludes from his experiments that the
jaundice following the action of certain poisons (phenylhydrazin and
metaphenylendiamin) is due to pigments formed in the spleen and carried
through an inert liver into the general circulation.
These observations derive their importance in relation to jaundice, not
so much from their number as from their nature. If bile pigments, or
allied pigments like hsematoidin, can be formed directly from haemoglobin,
whether by the action of leucocytes or other non-hepatic cells, or even alto-
gether independently of cell action, there is no a priori ground wh}', as the
hematogenous doctrine contemplates, a similar transformation should
not take place in disease, and set up certain forms of jaundice otherwise
difficult to explain. The possibility of an extrahepatic origin of bile
pigments or allied pigments is thus not to be gainsaid. Nor is the signi-
ficance of this admission materially lessened Avheii it is argued that it is
uidikely in the highest degree that this formation should ever take place
to such an extent as to occasion any marked degree of jaundice ; for most
of the forms of jaundice with which the hsematogenous theory concerns itself
are not marked by their severity : they are often but slight in degree, as,
for example, in pysemia ; they are denoted by a slight yellowness of skin or
conjunctiva, together Avith the presence of bile pigment in the urine, rather
than by any pronounced discoloration. JMoreover, in that variety of
jaundice or j'^elloAv discoloration accompanying the absorption of large
extraA'asations of blood, and marked by the presence of much urobilin
pigment in the urine (" urobilin icterus "), it is possible from the small
quantity or entire absence of bile pigments in the urine that other colour-
ing derivatives of hsemoglobin may be the cause of the yellow discolora-
tion.
To sum up, then, it may be repeated that so far as the ha?matogenous
doctrine of jaundice is based on the possibility of the formation of bile
pigments, or allied coloured derivatives of lurmoglobin, directly from
ha.'nioglol)in Avithout the agency of tlie liver-cells proper, some basis for
this doctrine still remains.
The liver the chief scat of fm'walion of hiJc pigment. — On the other
hand, so far as it rests on the assumptions that the bile pigments are
normally formed Avithin the blood, and that the liver merely excretes the
bile pigment conA'cyed to it, the hcematogenous doctrine I consider to
have been depriA'cd by later observations of all basis Avhatever. For the
important experiments of Stern on })igeons (188D), and of MinkoAvski
JAUNDICE 59
and Naunyn on geese (1886), have conclusively shown, for warm-blooded
animals, what Kunde and Moleschott's experiments long ago showed for the
cold-blooded (frogs), that the removal of the liver under the precise con-
ditions which ought to favour a hsematogenous jaundice is not followed by
jaundice at all. These observers showed that, if in the healthy goose a
liberation of haemoglobin be induced by the inhalation of arseniuretted
hydrogen, bile pigments appear in quantity in the vuine ; not followed
by free haemoglobin unless the destruction be great. If, however
(under similar conditions), the liver be cut off from the circulation, either
by excision or by ligature of all its vessels, the haemoglobin appears
directly in the urine, without any bile pigments. In the absence of the
liver the haemoglobin was not converted into bile pigment as was the case
in health. If the bile pigments were normally formed from free haemo-
globin • within the blood, the removal of the liver ought not to have
appreciably affected their formation ; still less should their formation be
practically arrested. These results warrant the conclusion that, under
normal circumstances, it is within the liver, not within the blood, that
haemoglobin is converted into bile pigment.
This conclusion Avould lose some of its force and significance in the
present relation if, as Minkowski and Naunyn seem to think, it is the
leucocytes of the capillaries, not the liver-cells, that are chiefly concerned
in transforming the haemoglobin into bile pigments. But in my opinion
there is strong rea-on for doubting the correctness, not of their
observations, but of their interpretation of them. I have carried out
a large number of experiments, involving destruction of blood, both in
birds (pigeons) and in mammals (rabbits, dogs, cats), and paid special
attention to the significance and importance of pigment cells within
the capillaries of the liver. And my observations lead me to attach
little or no significance to these cells in respect of the formation of
bile pigment ; and for these reasons — (i.) In certain animals (rabbit)
the presence of pigment cells within the capillaries of the liver is the
exception, not the rule ; yet bile pigments are formed in normal quantity,
(ii.) If increased blood - destruction be induced by suitable agents
— as, for example, by distilled water or toluylendiamin — a largely-
increased formation of bile pigments occurs, without any pigment cells
necessarily appearing in the capillaries (rabbit), (iii.) Even if under
such circumstances pigment cells appear in the capillaries of the liver
(dogs, pigeons after toluylendiamin poisoning), their number is far too
few to be held accountable for the largely increased formation of bile
pigment which then occurs. This latter fact is admitted by Minkowski
and Naunyn themselves ; and it serves in itself to do away with much of
the special significance they have attached to the occurrence of cells,
admittedly few in number, containing what they regarded as biliverdin.
Further, they admit that they could not find any evidence of the formation
of biliverdin within the pigment cells of the spleen — a curious circumstance
if it be within such cells that haemoglobin is converted into bile pigment.
As to the actual significance of cells containing blood pigment within
6o SYSTEM OF MEDICINE
the capillaries of the liver, my ohservations lead me to very different con-
clusions. It is not the haemoglobin stored within such cells that is the
source of the bile pigments, but the haemoglobin Avhich passes into the
liver-cell itself. My observations point strongly to the conclusion that
in health the transformation of haemoglobin into bile pigment is a purely
hepatic function — that is, a function discharged by the liver - cell
proper.
The basis of facts on which the haematogenous doctrine rests is thus
narrowed almost to vanishing-point. The only basis it retains is the
somewhat slender one supplied by the observations above cited, namely,
that the formation of lutmatoidin from haemoglobin is a purely chemical
process independent of cell activity. On the ground of this observation
Neumann and Lowit remain firm supporters of the haematogenous
doctrine of jaundice. Slender as its basis admittedly is, this doctrine
would nevertheless remain the most reasonable explanation to be offered
of the obscure forms of jaundice connected with blood disorder, but for
another series of observations, throwing an entirely fresh light on the
whole suliject, that have next to be considered.
B. Jaundice produced by poisons. — StadelmanvUs observations — Hcemo-
hepatogenous jaundice. — The observations referred to are those of Stadel-
mann (1881-1883). They show, for the group of cases to which the
haematogenous doctrine was supposed specially to apply, cases, that is,
of jaundice accompanying an increased destruction of blood, that the
jaundice is due to obstruction caused by well-marked changes in the
character and consistency of the bile.
The action of ioliiylendiamin. — The study of one drug in particular,
toluylendiamin, has proved of special interest in this relation. This
drug, when injected into dogs, possesses the peculiar action, first noted
by Schmiedeberg, of causing intense jaundice. Stadelmann, at the re-
quest of Schmiedeberg, undertook its closer study. He found that its
action caused well-marked changes in the bile differing at different stages.
In the first stage (beginning about 2 hours after the injection, and lasting
1 2 hours) the bile is increased in quantity and very rich in bile pigments.
In the second stage (l)Cginning aboiit the 14th hour and lasting 60-70
hours) it becomes greatly diminished in quantity, gradually loses all the
characters of bile, and assumes those of an extremely viscid colourless
mucus. At the end of this time it begins gradually to assume its normal
character, :ind there is again an increased excretion of bile pigments.
The jaundice begins towards the end of the first stngc, becomes very
pronoiuiced during the second, and gradually passes off during the
third.
A notable feature of the jaundice thus occasioned is the behaviour of
the bile acids. During the first stage, when the bile pigments are in-
creased, the bile acids are diminished. Hence their appearance in the
iirine does not coincide with that of the bile pigments ; for while the
latter are present in quantity 15 to 20 hours after the injection, the bile
acids do not appear till about the 22nd, 31st, or -iSth hour; in the next
JAUNDICE 6 1
24 hours they reach their . maximum, diminish during the following 24
hours, and then disappear altogether,
Afanassiew supplemented these observations in one important
particular by showing, what Stadelmann at first failed to recognise, that
the drug exercises a markedly destructive action on the blood — an
observation which appeared to supply the missing clue tc the explanation
of the jaundice.
According to Stadelmann the secjuence of events is as follows : The
drug causes a destruction of blood ; the haemoglobin liberated leads to an
increased formation and excretion of bile pigments (polychromia) ; this
is attended by an increased viscidity of the bile, which, at the low
pressure at which the bile is excreted, causes a ternporary obstruction,
Avith reabsorption of the bile and jaundice ; and, finally, when the action
of the drug exhausts itself, the bile gradually loses its viscid character,
the flow of bile is re-established, and the jaundice disappears. A
jaundice which thus had every appearance of being essentially hsemato-
genous, even in respect of the absence of bile acids from the urine in the
first instance, at a time when bile pigments were present in quantity, was
thus shown to be really of obstructive origin, and to depend upon altera-
tions (increased viscidity) in the character of the bile.
The same observer found, moreover, that a similar explanation applies
to other varieties of jaundice associated with increased destruction of
blood.
Thus poisoning uith arseniurefted hi/drogen occasions a remarkable
concentration of the bile — the gall-bladder and bile -ducts being filled
with a thick, viscid bile frequently containing large quantities of amor-
phous sediment, as well as numerous crystals of bilirubin. The increase
of bile pigments in the bile is very marked ; absolutely it amounts to as
much as 3 1 times the previous amount ; and relatively is still larger
(20 times) as the quantity of bile is reduced 5|- times. Yet, notwithstand-
ing this striking increase in bile pigments, the bile acids are in no way
increased, indeed they are reduced to one-tenth their normal amount —
the same disproportion between bile pigments and bile acids being thus
shown as in the case of toluylendiamin poisoning.
In the case of this agent Stadelmann conceives that " the destruction
of the blood is the occasion of the jaundice — only, however, through the
agency of the liver, Avhich produces an abnormal bile in consequence of
the abnormal blood conveyed to it."
Lastly, a similar explanation would appear to apply to the jaundice
occasionally met with in conditions of hsemoglobinsemia, Avhether induced
by injection of free hfemoglobin or of distilled water. Stadelmann's
observations show that changes in the bile are induced thereby, namely,
increase of bile pigments, increased viscidity of bile and diminution of
bile acids — changes similar in character, although by no means so
marked in degree, as those produced by toluylendiamin or arseniuretted
hydrogen.
The obstructive nature of toxic jaundice. — For the whole group of cases
62 SYSTEM OF MEDICINE
of jaundico acconipjuiving increased destruction of blood, the foregoing
observations show conclusively that the jaundice is really obstructive in
its nature, albeit the obstruction be temporary in character, and dependent
upon an increased viscidity of the bile induced by the changes in the
blood. It is really then hepatogenous, not hajmatogenous ; but to signify
its dependence upon the preceding blood changes it might be described,
as Afanassiew has proposed, by the term hcemo-hepatogenous.
The importance of this conclusion in relation to the pathology of so-
called "non-obstructive" jaundice cannot well be over-estimated. For
it ^\^ll be obvious that the great majority of the conditions in which this
variety of jaundice is assumed to occur — blood-poisoning, pyaemia, acute
yellow atrophy, mcilaria, paroxysmal h3emoglol)inuria, and so forth, are
precisely those in which increased blood-desiruction is either obvious or
likely to be present.
Nor does their significance end here. The observations throw light
not only on the class of cases formerly described as hi^matogenous, but
also on those obscure forms of jaundice regarded as due to suppression.
The jaundice attending 'pliosiiliorus poisoning has long been adduced as
an exemplary instance of a jaundice due to suppression of the hepatic
function. And jet Stadelmann's observations appear to show that this
form of jaundice depends upon bile changes similar in character to those
above described, although much slower in production.
Ten hours after administration of phosphorus the bile begins to be
darker in colour ; the bile pigments are increased by one-half ; the bile
acids are diminished. For the next 24 hours these conditions persist,
and no jaundice is manifested. Then the bile begins to change its char-
acter ; it becomes clearer, more mucoid, and much diminished in quantity
(one - fifth) ; the bile pigments fall to one-half oi- one-third of their
normal amount, and the bile acids are even more reduced (0"1, 0*15, or
0*7 instead of the normal 1-96). At this stage jaundice appears and
slowly reaches its maximum about five days after the administration of the
poison. The jaundice then slowly disappears, its disappearance being
marked by an increased excretion of bile pigments doubtless derived by
reabsorption from the tissues. The bile acids still remain in defect for
some days longer ; and it is not till the tenth or eleventh day that they
once more regain their normal amount.
Cause of the obstruction. — The foregoing observations show that the
obstruction is due to increased viscidity of bile. And as this change
appears to Ite an important factor in all cases of jaundice connected Avith
l/lood disorder, it becomes a matter of importance to determine the precise
cause of it. The matter has been worked out more especially in connec-
tion with one flrug — toluylendiamin. The jaundice pioduced by this
drug has a peculiar interest ; so intense is it, and so regular in its occur-
rence. In lai-ge doses it reproduces all the features of a severe jaundice,
Avith fever, and swelling of spleen and liver ; such as we meet with
clinically, for instance, in severe forms of icterus gravis, Weil's disease, or
yellow fever.
JAUNDICE 63
Three different opinions . have been advanced to account for the
obstruction in the bile-ducts occasioned by this and similar poisons.
(ci) Afanassievv considers the chief factor to be the compression of the
smaller bile capillaries from without. As the result of the action of the
drug, he finds dilatation of the blood-vessels and lymphatics of the liver,
and a blocking of the capillaries with altered red corpuscles. He believes
that the drug exerts an irritant action on the liver, causing a hypersemic
and oedematous state of its tissues, and consequently a compression of the
bile capillaries. Of this view it may be said that the jaundice is out of
all proportion to the alleged mechanical cause, and that far greater
dilatation of blood-vessels is met with — in congestion of the liver, and
in other conditions, without the occurrence of any such obstruction.
Q}) According to Stadelmann the chief factor is undoubtedly the
increased viscidity of the bile, a change he conceives to be connected in
some way with the increase of bile pigments (polychromia). In his view
the jaundice might be most fittingly called " jaundice from polychromia."
Besides this polychromia, he considers that there is probably another
factor in some special action of the poison which leads to the secretion by
the liver-cell of a more concentrated bile, too thick to flow away. He
concedes to Afanassiew that possibly at the same time the liver-cells are
affected, press upon the bile capillaries, and cause absorption of bile.
He thus contemplates a number of possible factors ; but he attaches
the chief importance to one — the increase of bile pigments. It is clear,
however, as I have shown elsewhere (16), that this increase cannot be
the chief factor ; if it were, the obstruction ought to be proportional to
the increase of bile pigments. Stadelmann's own observations, indeed,
show that this is not so. Jaundice may be most intense with only a
slight (one-half) increase of bile pigments (toluylendiamin) ; while, on the
contrary, it may be slight or absent with a very great (three or four-
fold) increase (arsenious acid poisoning).
(c) The conclusion I draw from my experiments in this matter is that
the cause of the increased viscidity of the bile is an extensive catarrh of
the intrahepatic bile-ducts from their origin downwards. In severe cases
this catarrh may extend into the duodenum itself, and there cause the
most intense inflammatory swelling and congestion of the mucous mem-
brane, beginning definitely at the orifice of the bile papilla ; the viscid
catarrhal mucus which covers its surface being of the same character as
that exuding from the bile-duct itself. A duodenal catarrh is, however,
not necessary to this production. For the jaundice occurs even Avhen
the bile-duct is cut away from the duodenum (as in dogs with biliary
fistula). This catarrh is excited by the passage of bile containing the
poison itself, or irritant products of it, along the bile-ducts. I found
the poison in the bile increasing in quantity from the first hour onwards.
The catarrh causes, to begin with, an increased viscidity of bile (1st
stage) ; as it becomes more intense, catarrhal mucus fills the bile-ducts to
the exclusion of bile pigments (2nd stage) ; and it then passes gradually
off as the poison is eliminated (3rd stage).
64 SYSTEM OF .MEDICINE
The chief feature of this catanh in ordinary cases appears to me to
be not so mucli its high degree as its excretory origin ; beginning,
as it does, in the smaller bile-ducts. Under the low pressure at which
the bile is secreted, a very slight catarrh, set up hy the excretion of
an irritant through the liver, may from its widespread character easily
set up obstruction enough to cause some rcabsorption of bile and some
degree of jaundice. The jaundice so occasioned is, I conclude, propor-
tioned, not to the amount of the accompanying blood-destruction (ha-mo-
globinieniia), nor to the increase of bile pigments (polychromia), but to
the irritant character of the substance or substances excreted in the bile.
A poison (or its product.',) is likelf/ to cause jaundice in pvportion as it is capable
of exciting catarrh of the bile passar/es during its elimination by the liver.
Toxcemic as distinguished from duodenal catarrli of bile-dti(t.<. — According to
these observations, I recognise a " descending " as distinguished from
a duodenal or ascending catarrh as a cause of jaundice. This variety
of catarrh of the bile-ducts may, as I have suggested, be called
"toxaemic," to distinguish it from the ordinary duodenal origin of catarrh
of bile-ducts which is assumed to arise and travel up the bile-duct from the
duodenum. In this latter case the catarrh is supposed to create obstruc-
tion and to lead to jaundice by blocking the opening of the bile-duct Avith
a plug of mucus. Only in this sense is it s})okcn of by Murchison ; and
this teaching as to the mode of origin of catarrhal jaundice has gained
Avide and general acceptance. Stadelmann also seems to have considered
the duodenum to be the necessary starting-point of jaundice of catarrhal
nature ; for in his experiments, when the bile-duct was ligatured ott' from
the duodenum, and yet the jaundice still occurred, he regai'detl this result
as conclusive of the " non-catarrhal " nature of the obstruction. The
possibility of a catarrh spreading, not upwards from the duodenum, but
down the bile-ducts from their origin, seems not to have presented itself
to his mind. And 3'et such a catarrh Avould obviously be of the first
importance in the pathology of a jaundice connected with blood disorder
and set up by poisons. I consider, indeed, that in all probability this is
a more common origin of catarrh of the bile-ducts, and consequently a
more common cause of jaundice, than catarrh ascending from the duo-
demim. Both varieties of catarrh — the toxajmic and the duodenal —
imply the action of an irritant, the one exerted on the bile-ducts in the
course of its excretion with the bile from above downwards, the other
on the duodenum and the mouth of the bile-duct. Of the two the former
is the more likely, fi'om its widespread character, to produce an obstruc-
tion sufficient to cause jaundice. It is certain, at least, for the reason
already stated, that in the case of jaundice due to poisons a duodenal
catarrh is not necessary for the production of the jaundice. If it occur,
and it is only in the case of severe poLsons that it does occur, it is not
primary, but secondary to a previous catarrh set up in the bile-ducts
duiing the elimination of the poison.
C. The relation between jaundice and blood - destruction. — It
has been seen that in nearly every case a notable feature of the blood
JAUNDICE 65
disorder caused by these various ictcrogenetic poisons is an increased
destruction variously manifested, whether by morphological changes in the
blood, by increased formation of bile jiigments derived from hijemoglobin,
by presence of haemoglobin in the urine (haemoglobinuria), or by all these
combined.
The connection between increased liberation of haemoglobin (hfemo-
globini>imia) and jaundice appears so close that, as we have seen, it formed
in Kiihne's hands the basis of the hsematogenous doctrine. In his view an
excess of free haemoglobin in the blood sufficed of itself to cause bile
pigments to appear in the urine. And the later' experiments of
Tarchanoff and Stadclmann appeared to establish the connection more
closely : the former always found bile pigment in the urine of dogs after
injection of Avater or haemoglobin into the blood ; the latter found that
under such circumstances important changes occurred in the bile, such as
increase of viscidity, leading to temporary retardation in its flow and
consequent absorption of bile pigments into the blood.
As I have shown elsewhere, the connection between hsemoglobinaemia
and jaundice is neither so close nor so constant as at first sight appears.
On the one hand, there is some reason to doubt the constancy or frequency
with which bile pigment is to be found in the urine under such circum-
stances. The results on which Kiihne's view is based have been obtained
in one kind of animals only (dogs), and not invariably in them. Now,
experiments on these animals are open to this great source of fallacy,
that bile pigment is not infreqiiently present in the urine even of
healthy dogs. And the experiments of Naunyn, as opposed to those
of Tarchanoff, conclusively show that even in dogs marked hsemoglo-
biniBmia — sufficient to cause htemoglolnnuria — does not necessarily cause
bile pigments to appear in the urine. Naunyn caused hemoglobinuria
by injecting haemoglobin subcutaneously ; yet in only two out of six
cases did the urine react to Gmelin's test (bile pigment) ; and in both
these cases the urine had given the same degree of reaction before the
experiment.
In other kinds of animals, such as cats or rabbits, the most intense
hsemoglobinuria may be produced without any trace of jaundice
(Steiner, Legg, Brunton, Hunter) (16).
And the same rule applies to man. The most intense hsemoglobinuria
may occur without a trace of bile pigment in the urine, and without a
trace of jaundice (for example, paroxysmal hsemoglobinuria).
It appears to me, then, that the jaundice depends upon some factor other
than the mere amount of haemoglobin set free. The relation between it
and the bloofl-destruction is, in my opinion, no simple quantitative one as
Kiihne assumed. The jaundice may be absent even when the haemo-
globinsemia (with hsemoglobinuria) is intense ; as in paroxysmal hsemo-
globinuria, or in blood-destruction by injection of distilled water. It
may be extreme when there is no hsemoglobinuria, as in icterus gravis,
Weil's disease, or toluylendiamin poisoning in dogs.
Nor is the jaundice simply related to the increase of bile pigments
VOL. IV F
66 SYSTEM OF MEDICINE
due to the preceding hlood-destruction — simply a "jaundice from poly-
chromia," as Stadelmann has suggested. For here again I •would point
out that the relation is not constant. Jaundice may be slight or absent
Avhcn the increase of liile pigments is A'ery great, as in poisoning with
arseniurettcd hydrogen, or in pernicious anajmia ; or, on the other hand,
it may be extreme when the increase is only relatively moderate, as in
toluylendiamin poisoning.
Thus, neither as regards amount of haemoglobin liberated, nor as
regards l)ile pigments formed, is the relation a mere quantitative one.
The relation is clearly rather of a qualitative than of a quantitative
character.
Different agents present certain differences in their mode of action on
the l)lood, to which importance has been attached by certain observers
in this relation (Afanassiew, Silbermann). Some, such as glycerine
or distilled water, cause intense hagmoglobinuria, leaving but a small pro-
portion of h;Temoglobin to lie dealt Avith by the liver and other organs.
Others a])pear rather to break up the red corpuscles into fragments which
accumulate in the liver (and other organs), a portion only escaping
through the kidneys ; and the increased excretion of bile thereby
occasioned is liable to be attended with jaundice. To this class belongs
the chief jaundice-producing agent — toluylendiamin. A third group,
like pyrogallic acid, are intermediate in their action, causing both
hsemoglobinuria and a slight degree of jaundice.
Whatever interest such differences may have, they are, I consider,
insufficient of themselves to account for the great difference in the
action of the above-mentioned agents in producing jaundice (IG).
Doubtless they may serve in some degree to explain why one kind
of agent causes ha^moglobiniu-ia more than another ; but they quite
fail to account for the remarkable facts we have already observed
— why, for instance, one drug Avhich causes but a limited amount
of blood -destruction, without htemoglobinuria, is capable of producing
intense jaundice ; while another which causes a much greater blood-
destruction, and an intense hagmoglobinuria, fails to produce any jaundice
at all.
In addition to the haniiolytic changes in the Ijlood and increase of
pigment in the bile just noted, the foregoing observations have revealed
another change of more importance than any other in relation to this
sul)jcct of jaundice. This change is increased viscidity of bile, amount-
ing at the height of the jaundice even to a replacement of it by clear
viscid mucus free from bile. To this more than to any other change I
find the degree of jaundice related, and the degree of obstruction propor-
tioned. I have shown for the chief of these icterogenetic ])oisons that
this viscidity is due to extensive and widespiead catarrh of the bile-
ducts set up by the irritant action of the jioison (or of its products) in
course of its excretion in the bile — an irritant action so great that in
certain cases it may excite the most intense duodenitis.
It is not its destructive action on the blood, but the action of the
JAUNDICE 67
poison on the liver-cells and epithelinm of the bile-ducts during its
excretion, that appears then, so far as our observations go at present,
to be the chief determining factor in the occurrence or non-occurrence
of jaundice in disorder of the blood. The liability of a poison to produce
jaundice is, I consider, proportioned to its irritant action on the liver and
epithelium of the bile-ducts in the course of its excretion through the bile,
not to its power of causing blood-destruction. And to this variety of catarrh
the name " toxfemic" may be conveniently applied, to distinguish it from the
ordinary form of catarrhal jaundice of " duodenal " origin, from which
it is essentially distinct. The term " toxsemic " indicates the blood
origin of the condition ; that it is produced by excretion of poisons from
the blood through the bile. It also indicates the chief character of
the clinical features of these cases of jaundice, which are mainly of a
toxic character.
D. Jaundice by suppression; "letere hemapheique," "Urobilin
icterus." — In the class of cases hitherto considered it has been assumed
that the jaundice has been always marked by the presence of bile pigment
in the urine. There is a class of cases, however, to which reference must
now be made where this is not the case ; where, with a discoloration of
skin hardly distinguishable from that of jaundice and a high colour of
the urine reseml)ling that of jaundiced urine, the pigments in the urine
are not bile pigment, but other pigment derivatives of hciemoglobin of a
more or less obscure nature. The coloration of skin in these cases is
usually not so deep as that found in ordinary obstructive jaundice ; and
it is of a more dirty earthy tint.
This kind of jaundice has received various names at different times.
It constitutes one of the many forms of " jaundice by suppression " of
older Avriters ; it was named by Gubler (1857), and French writers follow-
ing him, " I'ictere hemapheique " : it is the " urobilin icterus " of more
recent writers, chiefly German. These names are by no means equivalent,
but they are conveniently considered together, because all three imply that
the cause of the discoloration is the presence of pigments circulating in the
blood as the result of some faulty excretion, or even of entire suppression
of function of the hepatic cell.
Of all the various opinions regarding the mode of origin of jaundice,
that of a jaundice hij sujjpression is both the oldest and the one most firmly
rooted. We have seen that the class of cases referable to this category
has been very greatly narrowed by recent observations. But even when
all the cases arising in connection with the action of poisons and with
increased blood -destruction are excluded, as now they must be, there
still remain the few cases that suffice to raise the questions : " What
is to be understood by suppression of liver function ? Does it occur ?
If it does, what part does it j)lay in producing jaundice ? " In other
words, is it possible for the liver-cell, Avithout undergoing structural
change, to cease to act altogether, to " strike work " (Harley) ?
I have said "Avithout structural change"; for this is the only point
on which any difference of opinion can reasonably exist. It is obvious
68 SYSTEM OF MEDICINE
thcat a livcr-coU structurally di.sorgauiscd, as is the case iu the later stages
of many liver diseases — notably in acute yellow atrophy — must fail in its
functional power. Moreover, there can be no doubt that many of the
poisons capable of inducing jaundice aflfect the liver-cells injuriously, both
in their structure — causing fatty parenchymatous degeneration — and,
presumal)ly, in their function also. Indeed the latter may be said to
have been shown beyond doubt ; for it has been found, experimentally,
that under the influence of poisons or other depressant factors, such as
injury of the liver, ha-mogloltin may pass through the liver-cell unchanged,
and be found free in the Ijile ; an occurrence which never takes place
otherwise. These facts may be admitted. But the theory of suppression
implies something more than mere functional disorder ; it implies that,
as the result of certain infliiences — nervous as well as toxic— the liver-
cell can dynamically be suddenly thrown out of action without any
necessary static change, and that the effect of this arrest of function is to
dam up within the blood the bile pigment which would otherwise have
been duly excreted.
It is this doctrine which meets us at every point when we consider
the pathology of jaundice, and which therefore must be considered in
more detail. In a more or less modified form it is still held to apply to
the jaundice of mental emotion, and indeed to some of the forms of
jaundice produced by poisons ; but the facts on which it is based are for
the most part exceedingly indefinite. So long as the view was held
that the bile pigments are formed in the blood, their mere retention in
the blood and tissues and appearance in the urine, especially when un-
accompanied by any bile acids, were deemed sufficient to point to sup-
pression of liver function. But, as I have shown, such a view is no
longer tenable. Bile pigment is not formed within the blood, but within
the liver-cell ; and its presence in the urine, even when unaccompanied
by bile acids, is quite compatible with excessive activity of the liver-
cells.
There remain three classes of facts which may be held to denote some
interference with the functions of the liver in certain cases of jaundice :
{a) Presence of pigments otlier than bile pigment in the urine in these
cases ; (ft) Changes in nitrogenous metabolism met with in the severest
forms of jaundice, for instance, diminished excretion of urea and the
appearance of Icucin and tyrosin in the lu'ine ; (c) Presence of colourless
mucus in the biliary passages, and absence of bile (Moxon).
(a) Evhlence of suppression derived from a study of pigments other than
hile pifjment. — In many severe cases of jaundice the urine presents a
depth of colour far in excess of what can be accounted for by the
(piantity of bile pigment present, and obviously denoting the presence
of abnormal pigments.
f lubler was led by observation of this fact to distinguish two forms of
jainidicc : Vidhe bilijiheiqnr^ due to the presence of bile pigment in the
tissues ; and Virthre hdmnpheiqve, due to the presence of a hypothetical
pigment, " hemaphcin." He considered that if the liver were thrown out of
J A UNDICE 69
action by poisons or other influences it could no longer transform
hajmoglobin into bile pigment ; the colouring matters in the blood
would accumulate there, and undergo various modifications before their
excretion in the urine.
Various organic diseases of the liver, such as cirrhosis and cancer,
could bring about a similar suppression. Indeed cases of ordinary-
obstructive jaundice, if unduly prolonged or intense in degree, would
lead to the same result.
This view of Gubler has now only a historical interest, inasmuch as
the pigment he termed liemaijhein had never more than a hypothetical
existence. So far as it conforms in its characters to any definite urinary
pigment, it approximates most closely, as Quincke has shown, to the
})igment urobilin. And since Gubler's time, more especially of late years,
the class of case to which his view referred has been most frequently
discussed under the title of " urobilin jaundice."
" Urobilin Jaundice."- — It is chiefly to this pigment urobilin, and
another urinary pigment urohsematoporphyrin, that most of our know-
ledge of the urinary pigments relates. First recognised as a normal pig-
ment of the urine by Jaff'e in 1863, urobilin was soon afterwards (1871)
shown by Maly to be identical with one obtainable by reduction from
bilirubin, the chief bile pigment ; and, subsequently (187-1), Hoppe-Seyler
succeeded in preparing it artificially from h^matin.
The later studies of MacMunn (1889), and the still more recent
and exhaustive studies, carried out on greatly improved methods, of
Garrod and Hopkins (1896), have added greatly to our knowledge of its
characters, and its affinities to the pigments of the bile. In particular,
since the important observation made by Midler (1892) that intestinal
micro-organisms possess the power of transforming bilirubin into urobilin,
evidence has steadily accumulated that this is probably the ordinary
mode of origin of urobilin ; although the possibility of a direct conver-
sion of haemoglobin into urobilin under certain special circumstances
cannot be altogether exchided.
Urobilin is a normal constituent of the urine, and especially abundant
in febrile urines ; but the conditions under which it is met with in excess
are those in which large extravasations of blood are being absorbed (ha?ma-
toceles), or an abnormal destruction of blood is occurring (pernicious
anaemia) ; conditions I have elsewhere shortly defined as " an excessive
destruction of haemoglobin unattended by hsemoglobinuria."
Its presence under such circumstances has a special interest in
relation to OTir present subject, as it is not infrequently associated with a
certain yellowish, apparently icteric tinge of skin and conjunctiva. It is
this association that has led some observers to apply to the condition the
title urobilin jaundice.
The precise conditions Avhich determine the amount of urobilin in the
urine in cases of jaundice are as yet but ill defined. Hardly any two
observers are agreed upon them. While according to Hoppe-Seyler an
increased excretion of urobilin is found at the very outset in obstructive
70 SYSTEM OF MEDICINE
jaundice, according to another author (Kunkel) it is most abundant
towards the end, lieing then derived from the bilirubin in the tissues ;
and yet a third (Hayem and Quincke) find tliat obstructive jaundice
may I'un its entire course with onh' a trace of urobilin in the urine.
The following are Quincke's conclusions with regaxxl to the relation-
ship of urobilinuria and jaundice : —
(i.) If much bile pigment be present in the blood a part is deposited
in the tissues, a second part is excreted unchanged in the urine, and a
third is excreted as urobilin.
(ii.) If less bile i)igment be present in the blood, less is deposited in
the tissues, the whole or the greater part being converted into urobilin.
The group of cases of severe jaundice in which there is abundance of
bile pigment in the urine, and only a trace of uroljilin, cannot be
accounted for on any view which implies that urobilin is formed from
bilirubin within the tissues. But in the light of the more recent
observations referred to, establishing the intestinal origin of urobilin from
bilirubin by the action of micro-organisms, this class of cases liecomes
clear. For in severe jaundice, M-ith no bile entering the intestine, we
might expect the formation of urobilin to be lessened or even to cease.
Conversely the conditions in which urobilin might be expected in
excess are those in which, along with some degree of jaundice, there is
also an increased secretion of Ijile pigments ; and it is precisely in such
conditions — tho.se of hcBmo-hepatogevous jauvdke already considered — that,
as a matter of experience, urobilin is usually found in excess.
"Whatever be the precise conditions which determine the amount
of urobilin in the urine, and these are probably chiefly intestinal, the
important point is that the title urohiliii jaundice is, under any circum-
stances, a misnomer. The staining power of urobilin is very small
compared Avith that of bilirubin ; and it is not its presence, in however
large an amount, that produces the jaundice with Avhich it is sometimes
associated, but the presence of bile pigment. Thus urobilin may be
present in the urine in the greatest excess without any trace of
jaundice, albeit the skin may have a lemonish yellow hue which at first
sight rescml)les jaundice. This is best oljserved in cases of pernicious
anaemia. I have described a severe case of this kind, lasting for months,
unaccompanied by any trace of bile ])igment in the urine, the urobilin
in which was so abundant that its band coxild be easily recognised after
sevenfold dilution of thcui-ine; its amount varying from time to time
with the pei'iodic exacerbations of the lucmolytic jirocess.
I find myself thus in entiie agreement with (j>uincke, Stadelmann, and
Chauffard as to the non-existence of a jaundice due to urobilin. And I
find no evidence that any other pigment possesses any greater jrowcr in
this respect than urobilin, though no doubt other pigments, modifications
of those of health, arc j)resent in such cases.
For the group of cases of so-called suppression jaundice, where the
suppression is ascril)ed to nervous influences, I find no evidence Avhat-
ever that the pigments excreted ditler in any way from those of ordinary
JAUNDICE 71
obstructive jaundice ; or that there is any " suppression " of excretory
function on the part of the liver.
In severe tox;eraic conditions — such as characterise the gravest forms
of jaundice, malignant jaundice, acute yellow atrophy, and the like —
where the liver is extensively disorganised, and the excretion through the
kidneys is interfered with owing to degenerative changes in the cells of
the tubules, it is probable that abnormal pigments may be formed, and
may give a special chai-acter to the coexistent jaundice. We know that
in septic conditions of the blood — and in all severe cases of jaundice
haemorrhages are almost a constant feature — the haemoglobin is more
unstaljle than in health. Thus, as Dr. Copeniau has shown, if a drop
of putrid serum be added to healthy blood under a cover-glass, crystals
of reduced haemoglobin appear in from 24 to 48 hours ; whereas normal
blood alone undergoes no crystallisation. On the other hand, in certain
toxic conditions — for example, cancnmi oiis, septicaemia, erysipelas,
pernicious anaemia ^ — the blood readily crystallises without addition of
any putrid serum. It is very probable that, in severe forms of blood
disorder marked by jaundice, abnormal pigment derivatives of haemoglobin
may be formed and be excreted in the urine. But their presence under
such circumstances does not necessarily indicate a suppression of the
excretory function of the liver, as the suppression theory of jaundice
implies. It is sufticiently accounted for by disordered function of the
liver consequent on the toxic condition of the Ijlood. For functional
disorder is a condition wholly distinct from total suppression of excretory
function.
Thus a liver-cell, under the influence of a severe poison, may have its
functions so affected that, instead of breaking up haemoglobin into normal
bile pigment, it produces abnormal bile pigments : such I consider cpiite
a permissible assinnption ; and this of itself is sufficient to account for the
presence of abnormal pigments. But that under tlie influence of mental
emotion, or the action of a severe poison, the whole of the liver, without
undergoing previous structural change, may cease to Avork, and that the
effect of such a suppression is to produce jaundice, damming up bile
pigment or allied pigments, finds, in my opinion, no suj^port whatever
from any facts concerning the character of the pigment, urinary or other,
excreted in such cases.
(5) Evidence, of mppression derived from a study of changes in mefabolism.
— The second class of facts adduced as evidence of suppression of liver
function in jaundice is the occurrence of marked changes in the nitro-
genous metabolism in severe cases of jaundice — for example, diminished
excretion of urea ; appearance of leucin and tyrosin in the urine.
Thus with regard to the jaundice produced by phosphorus— always
cited as an eminent example of a jaundice from suppression — in the first
observations made (Schultzen and Eiess, 1870), the urea a])peared to be
reduced almost to vanishing-point, and its place to be taken by other
products, lactic acid especially being very abundant. That such changes
should occur in the later stages when the liver -cells have become
72 SYSTEM OF MEDICINE
stinicturally disorganised, is easy to understand. But the ([uestion here
at issue is to what extent the metal )olic functions of the liver are sup-
pressed at the outset when jaundice first makes its appearance.
It is in connection with the jaundice of phosphorus poisoning that the
most exact and detailed observations hearing on this point have been
made within recent years; namely, those of Miinzer (1894). This
observer has estimated the total excretion of nitrogen in ten cases of
phosjihorus poisoning, determining at the same time the proportions of
urea, uric acid, ammonia, and extractives of which the total was made up
[i-'ule p. 89]. Miinzer's observations Ining out the remarhal)lc fact that,
so far from the excretion fif urea being diminished, after the first twenty-
four houis when the vomiting has ceased, the excretion continues up
almost to a few hours of death, in quantities approaching those of health ;
and far exceeding Avhat would be formed by a health}' liver in the
absence of food. Since all recent observations agree in pointing to the
liver as the chief seat of urea-formation, this excretion is such as to
denote that a very active metabolism is going on within the liver up to
Avithin a few hours of death.
This conclusion is broui:ht out still more clearly by some further facts.
As an indication of the degree of liver activity, even more imjiortant
than the actual amount of luea formed, is the proportion of urea to the
total nitrogenous excretion. The experiments of Schroeder have estab-
lished satisfactorily that the liver is the chief seat of the formation of
urea, and that it is formed there by a process of sjnithesis from
ammonia.
In health iirca constitutes about 85 to 90 per cent of the total nitrogen-
ous excretion, ammonia from 4 to 6 j^er cent ; the remainder being in the
fonu of exiradives.
If the liver be cut off from the circidation there is a marked fall in
the proportion as avcII as in the amount of urea, and a corresponding rise
in the proportion of ammonia.
Now, what is found in i:)hosphorus poisoning is, that the proportion
of urea is but little reduced (80 instead of 90 per cent), the corresponding
increase of ammonia being moderate (10 to 18 per cent instead of the normal
4 to 6 per cent). This alteration, slight though it be, might be held to
indicate that the functional activity of the liAcr is affected — is " sup-
pressed " to that extent ; but even this significance cannot be attached to
it. Apart altogether from activity of the liver, thoic is one condition
which more than any other influences the amount of ammonia excreted,
namelv, the degree of alkaliiiitv of the blood. Anvthiiig that tends to
lower the alkalinity (jf the blood below the normal standard tends to raise
the proportion of ammonia excreted in the mine at the expense of the
urea. Now such a tendency exists in phosphorus poisoning. An in-
crea.sed acifiity of the blood (as well as of tlie mine) has been shown by
von Jaksch to be a feature of ])hosphorus poisoning. And not Miinzer
only, but Starling and Hopkins also, who, before Miinzer, had observed
this slight increase in the proportion of ammonia in a case of johosphortis
J A UNDICE - 73
poisoning, are agreed in their opinion that the increase is to be referred
to this change in the blood rather than to any impaired activity of the
liver. Experiments conducted by Miinzer to test the question appear,
indeed, to be conclusive on this point.
To sum up, then, Avith regard to the jaundice of phosphorus poisoning,
the facts show that at the time at Avhich the jaundice makes its aj)pear-
ance the liver functions are by no means suppressed. On the contrary,
whether we have regard to the bile-forming functions, or the functions
concerned Avith nitrogenous metabolism, the activity of the liver is
hardly diminished. For not only is there an increased formation and ex-
cretion of bile pigments (Stadelmann), but, notAvithstanding the absence
of i'ood, urea also continues to be formed in large quantity up to the last
few hours of life, in amounts approximating those of health (Miinzer).
(c) Absence of bile from bile passages as an evidence of suppression. — The
fact that in certain cases of jaundice the bile passages are found filled
Avith an almost colourless mucus, instead of bile, has been much insisted
on by Moxon and others as an evidence of suppression of excretory
function on the jiart of the liver. But as pointed out, in my opinion
correctly, by Dr. Wickbam Legg, the presence of such mucus in the
large bile-ducts is only evidence that the obstruction is higher up — in
the smaller ducts. " These continue to receive the bile poured into
them by the loAver cells, but the bile does not reach the large ducts
because the smaller are shut off from the large either by plugs of
tenacious mucus or by gravel." Although the larger ducts are colourless,
the smaller ducts can be found stained Avith bile. Stadelmann's experi-
ments shoAv that in the jaundice produced by poisons the bile becomes
Aascid and mucoid at the time the jaundice is most intense. Examination
of the liver itself at this time shoAvs the smaller 1 tile-ducts and capillaries
to be filled AAdth thick, viscid, highly pigmented bile.
Conclusion. — Xeither the facts concerning the pigments nor those
concerning niti'ogenous metabolism appear to lend any support to the
hypothesis of jaundice by suppression Avithout structural change. There
is no conclusive evidence that a healthy liver can be suddenly throAvn out
of action, Avhether by nervous action or the action of a poison ; or that
jaundice can thus be caused. There is evidence on the contrary that a
liver so obviously diseased as the liver in phosphorus j^oisoning is,
continues to discharge some of its most important functions almost un-
impaired Avithin a fcAV hours of death.
Nor is my judgment as to this hypothesis affected by the modification
of it recently put forward by Liebermeister (1893). Liebermeister, one
of the oldest of observers on the subject of liA-er disease, considers that
in certain cases, under the influence of mental emotion or action of
poisons, there may be suppression of only one particular function of
the liver-cell. Apart from forming the bile pigments, he considers one of
the chief functions of the liA'er-cell to be that, notAvithstanding its close
relation to blood capillaries and lymphatics, it excretes its bile into the
bile capillaries, and prevents it from entering the blood. For the dis-
74 . SySTEJf OF MEDICINE
charge of this function the integrity of the cell is necessary. It is not
to he assumed that cells profoundly att'cctcd by nerve influence or poison,
as the case may be, will discharge this function properly. It is rather
to be supposed that under such circi;mstances they will no longer be
able to prevent direct diifusion of their contents into the blood and
lympli, just as in renal disease the living endothelium of the vessels can
no longer retain alliumin. Apart, therefore, from any obstruction,
jaundice, he says, might thus arise ; and all the more readily inasmuch
as it is precisely in such cases that degenerative changes are found in the
whole or in a large number of the liver-cells. He goes even fartlicr, and
conceives that the cell might be only partially aficctcd in its functions,
still being able to produce bile although no longer able to prevent its
diffusion into the blood ; or that the cells in one portion of the liver
might continue to produce bile, which afterwards comes into relation
with others that had lost their power of retention. Jaundice so caused,
by failure on the part of the liver-cell to retain its bile, he proposes to
designate " akathektic " jaundice {kathehUkoa = retentive). This view is
one capable neither of proof nor disproof ; one which, under any circum-
stances, could only be entertained when all other explanations fail.
E. Increased secretion, with excessive absorption of bile from the
intestine, as a cause of jaundice ; " Jaundice from polyeholia." —
The cases so described correspond for the most part with those desig-
nated ha?matogenous. Of the latter, indeed, a polyeholia was deemed
to be a distinguishing feature ; if the stools were free from bile, the
jaundice Avas of obstructive origin ; if they contained bile, its oi'igin
was huMiiatogcnous.
We now know, in the light of Stadelmann's ol)servations, that the
jaundice in these latter cases is no less obstructive than in the former ;
and that the cause of it is not the increase of bile (polyeholia) itself,
but the increased viscidity of bile which usually acconi]ianies the poly-
eholia. Indeed exception is taken by Stadchuaiui to the use of the term
"polyeholia" at all in this relation; inasmuch as lioth its Avatery
constituents and its bile acids are usually diminished. It is really a
"polycln-oniia," an increase of bile pigments.
E\en when this large group of cases arc excluded, as now they nuist
be, from the category of jaundice from polyeholia, Ave have still to in(]uire
Avhether, as Frerichs tauglit, jaundice can result from increased absorption
of bile from the intestine.
This teaching received the suppoi-t of IVIurchi.son. He considered it
to be the cxp];ination of jaundice in congestion of the liver; in many
cases of Avhich, as he jiointed out, the quantity of l)iie is increased.
" The A'cssels of the liver are distended, and the diffusing surface of
the Avails is consequently increased, and more than the noinud <iuantity
of bile is taken up into the lilood. . . . There is no obstruction of the
bile-ducts unless there be concurrent itiHamniation df the duoilcnuni and
ducts; and sometimes indeed there is l)ilious diarrha-a. If the bowels be
constipated, the jaundice from congestion of the liver Avill ])robably be
JAUNDICE 75
increased, as the bile instead of being cleared away will accumulate in the
biliary passage, and will be absorbed in all the larger quantity by the
distended vessels. A sluggish state of the bowels often contributes to
the development of jaundice, partly by impeding the portal circulation
and inducing congestion of the li\-er, partly by causing an accumulation
of bile in the biliary passages and duodenum, and thus favouring its
absorption into the blood."
It is clear from the foregoing that although Murchison had chiefly in
view an increased absorption from the bile passages, not directly from the
intestine, he had also in view in such cases a direct absorption of bile into
the blood-\'essels of the liver from increase of their diffusing surface. In
the light of more recent observations, it must, I think, be regarded as
exceedingly doubtful whether such a direct absorption ever takes place.
Saunders was the first to show (1815) that, after ligature of the bile-
duct, the chief absorption of bile takes place through the lymphatics.
Later Fleischl (1874), working under Ludwig, showed that if after such
ligature care be taken to prevent any lymph entering the general circula-
tion (by tying a canula in the thoracic duct and collecting the lymph
externally) no jaundice results. Under these circumstances no absorp-
tion whatever occurs directly into the blood.
More recently (1892) these experiments have been repeated and
strikingly confirmed by Vaughan Harley, also working imder Ludwig.
He found that under these circumstances not only does no immediate
jaundice occur, but also that jaundice remains absent for as long as
seventeen to twenty days later.
When it is remembered how close are the relations of bile capillaries
and blood capillaries, separated as they are only by the thickness of the
liver-cell interposed, the above results are very striking. That under
these favourable circumstances bile is not reabsorbed by the livei'-cells
and does not enter the blood directly, but continues to be excreted into
the bile capillaries and thence absorbed by the lymphatics, affords con-
vincing proof that absorption of bile is not a matter of extent of
diffusing surface between bile and blood capillaries respectively. Bile
once excreted is absorbed only by lymphatics, not by the blood-vessels
directly.
As regards congestion of the liver in particular, it is, I think, un-
necessary to call in the aid of any vinusual factor to explain its jaundice.
That is sufficiently accounted for by the prevailing condition of congestion
and catarrh, which favours temporary stagnation of bile in the bile passages
with or without increased secretion of Ijile.
The view of a jaundice from polycholia implies, however, more than a
mere absorption of bile within the liver, whether through lymphatics or
blood-vessels. It implies that such an absorption may take place from
the intestine ; that the absorption which normally takes place may become
so increased that the liver is no longer able to dispose of all the bile
jjigment conveyed to it, and that some of it escapes into the general
circulation and produces jaundice. This view assumes, first, that bile is
76 SYSTEM OF MEDICINE
normally absorbed fi-om the intestine into the portal blood ; secondly, that
this absorption may be so great that the liver cannot excrete all the
pigment conveyed to it; that is, there is a relative incompetence of the
liver.
The basis for this view is the hypothesis of " the circulation of the bile"
put forward by Schiff (1868). He observed that in dogs with biliary
fistula the secretion of bile diminished when the bile was withheld from
the intestine ; whereas it immediately became inci'cased if the bile were
allowed to How again into the intestine. The same thing was observed
if, instead of bile, bile salts were injected into the duodenum. He con-
cluded that the increase arose from absorption of bile into the portal
blood again to be excreted by the liver ; that what might be termed a
" circulation of bile " thus took place within the portal system.
Similar obser\'ations were made l)y Rutherford and Vignal in their
experiments (1876): injection of bile into the intestine was followed by
increased flow of bile. Together they aftbrd at least presumptive evidence
that a portion of the increase is actually due to the al)sorption and
excretion of the injected bile. But although later observations con-
clusively show (Tarchanoff, Wertheimer) that bile pigment injected into
the blood is without doubt excreted in part in the bile, the evidence
that increased al)sorption of bile from the intestine plays any part in i^vo-
ducing jaundice remains still little more than presumptive.
That the liver exercises an important excretory and destructive function
in respect of certain substances normally absorbed from the intestine
in the p(n'tal blood is beyond dispute. Interference with this function,
with the passage of such products into the general circulation, is probably
accountable for some of the more characteristic symptoms of liver dis-
order— intense depression of spirits, drowsiness, sense of giddness, head-
ache, pains on moving the eyeballs. And it may be regarded as equally
beyond dispute that whatever bile pigment is absorbed in the portal
blood is again excreted in the bile.
But what, in my opinion, is much open to question is the extent to
which such an absorption occurs in health, and whether it is ever a factor
in producing jaundice. Wertheimer's observations, striking as they are,
I cainiot regard as conclusive on the jDoint. The bile of the sheep contains
a pigment, with definite spectroscopic bands, not present in the bile of
the dog. After injection of sheep's l)ile into the circulation of the dog
Wertlieiinor was able to discover the pigment in the dog's bile.
Were jaundice produced in this way it would a})pear not only in the
one condition adduced by Murchison of congestion of the liver, Init in other
conditions also where the increase of bile is even moi"e marked ; namely,
under the action of hiemolytic ])oisons generally. But in all these cases,
where a polycholia exists, the conditions favouring an al)sorption of bile
into the circulation are created ])efore the bile reaches the intestine,
namely, within the liver itself .iml its bile-ducts, and have been brought
about by increased viscidity of bile. The jaundice is thus not of intestinal
but of hepatogenous origin.
JAUNDICE 77
F. The influence of the nervous system in producing jaundice. —
The nervous system has long been credited with a very direct influence in
the production of certain forms of jaundice.
According to some authors, indeed, disturbance of the nervous system
plays a part of considerable importance in nearly all forms of jaundice,
from the simplest " bilious attack " to the gravest form of all, namely,
acute yellow atrophy of liver. The former malady has been regarded as
an evidence of altered nerve function (Habershon) ; and in the latter,
deranged innervation has been considered to play a chief part (Lieber-
meister), either by causing perverted secretion in which the liver-cells
become broken up (Rokitansky), or by causing paralysis of the bile-ducts
(von Dusch). In a considerable proportion of cases (one-tenth, Thierfelder)
the only cause assignable for the disease has been the influence of fright,
or some depressing mental emotion.
Apart, however, from these cases, where the influence of the nervous
system in causing the jaundice is, I consider, more or less purely
speculative, the cases regarded as manifesting this influence more clearly
are those in which jaundice has followed sudden or severe mental emotion
or strain — such as fear, anger, or anxiety — either immediately or very soon
after. Of this character, also, is supposed to be the jaundice following
on concussion of the brain.
The cases may be divided into two classes —
(i.) In the one — an extremely small class — the jaundice is described as
following immediately, that is, in a far shorter time than ordinary obstruc-
tion could produce it. Of this nature are the two cases of Villeneuve
(1818) quoted by Murchison. A soldier, insulted in iKiblic, in a fit of
furious anger became suddenly jaundiced, soon afterwards delirious, and
died in convulsions. A priest had a sudden fright from the rush of
a mad dog ; he uttered a loud cry, fell down unconscious, and was taken
up yellow as saff'ron.
(ii.) The other class of case^comparatively common — is where the
jaundice occurs in the course of a few hours after anxiety or great
mental strain. Of this nature is the case of the youth quoted by Sir
Thomas Watson, who had an attack of intense jaundice apparently
traceable to nothing but overdue anxiety about an apjn-oaching examina-
tion ; or that of the doctor who, while attending a case of puerperal
haemorrhage, became deeply jaundiced in one night.
The mechanism of the jaundice in such cases is by no means clear.
And the features that aj)pear to suggest nervous derangement as distin-
guished from obstiniction, especially in cases of the first class, are, first, the
suddenness of onset of the jaundice — the skin becoming yellow almost in
an instant, whereas the jaundice from mechanical obstruction takes twelve
to twenty-four hours or more to develop ; and, secondly, the frequency
with which such cases are said to be marked by cerebral symptoms —
delirium, coma, convulsions.
(i.) Cases of instantaneous jaundice are admitted to be of great
rarity. Most of them date from the earlier history of the subject. But
78 SYSTEM OF MEDICINE
assuming such cases to occur, the}' raise points of interest as to the
possible part taken by the nervous system in producing jaundice.
Various views have been put forward : —
(rt) Like every other variety of obscure jaundice, it has been referred
to suppression of liver function. Under the influence of powerful emotion
the function of the liver-cell becomes temporarily arrested, and jaundice
results. We have seen, however, that there is no theory of jaundice so
luisatisfactory as this of suppression. If the jaundice in these cuses
were shown to be produced by pigments other than bile pigments, there
might be ground for assuming such a suppression ; but this is not so.
The jaundice is due to the presence of bile pigments, formed as Ave have
seen by the liver-cell ; and the problem is to account for their passage
into the blood : whether they pass into the blood capillaries directly or
indirectly in the usual way through the lymphatics.
The suddenness of onset would appear to point to direct absorption ;
and it has been suggested (Brunton) that this might be brought about
by some sudden fall of blood-pressure Avithin the portal system, such
as emotion might cause, followed by a sudden absorption of bile from
the bile capillaries.
(h) This view raises the question of the relation of the blood-pressure to
hile secretion under normal circumstances. The conditions within the liver
are so far peculiar, that it is from the venous blood-supply — the portal
blood, not the arterial — that the liver obtains the chief material for its
metabolism, including the formation of bile. The chief function of the
hepatic artery is to supply the tissue framework of the liver. The main
supply is through the portal system. It follows from this arrangement
that, to an extent cjuite unusual in the case of any other organ, the supply
of blood to the liver and its functional activity are independent of any
direct vaso-motor control. It is regulated rather in an indirect manner by
the amount of blood entering the portal system through the intestine.
Variations in the general l)lood pressure affect it little. Thus
Heidenhain found that a fall in the general pressure even so great
as one - half appeared to influence the secretion of bile but little.
On the other hand, vai-iations in the portal pressure do affect it
materially. Thus stimulation of the spinal cord, or of the sensory nerves,
by causing contraction of the splanchnic vessels and thus diminishing
the amount of blood entering the portal system, occasions a diminished
.secretion of bile. And, conversely, section of the splanchnic nerves, by
causing a dilatation of blood-vessels in the portal area, and tiuis increasing
the flow of blood through them, occasions an increased secretion of bile.
The secretion and flow of bile being thus chiefly influenced by the
flow of Ijlood within the portal system, the question arises whether
sudden and extreme variations in the direction of a fall of jiressure can
affect the flow of bile to such an extent as to arrest it altogethei-, and cause
its direct absorption into the blood. Now even in hcalih the pressure
within the portal sy.stcm is very low and, what is still more important, is
much lower (nearly two and a half times) than that at which the bile is
J A UN DICE 79
secreted. The conditions might thus appear to be permanently favour-
able to a direct absorption of bile into the blood-vessels. And yet, as we
have seen, so far is this from taking place that even after ligature of
the bile-duct the bile cannot be made to pass into the blood-vessels. It
is absorber I through the lymphatics. Whether, under the influence of
emotion or other powerful nervous shock, these conditions can be altered,
appears to me to be exceedingly doubtful.
(t) To account for the sudden onset of the jaundice in such cases
another possible factor may be suggested as the result of sudden emotion,
namely, spasm of the bile-chcds, at a time when the secretion and flow of
bile are in active progress.
Peristalsis of the walls of the bile - ducts and gall - bladder must, I
consider, play a more prominent part in the actual propulsion of bile into
the duodenum than is generally supposed.
The effect of sudden emotion on the peristaltic movements of the
intestine is well known. And it is conceivable that in rare cases — and,
after all, the cases now under consideration are of extreme rarity — under
the favouring conditions above described, sudden mental emotion of the
nature of fear and anger might occasion a spasm of the bile-ducts of
the nature here contemplated. Assuming that such cases occur, it is in
this direction, rather than in that of suppression, or direct absorption
into the blood-stream, that, as it appears to me, the most likely explana-
tion of the jaundice is to be found.
(ii.) The more common class of cases referred to nervous derangement
— those, namely, where the jaundice appears more gradually, albeit still
quickly — say in the course of twelve or twenty-four hours or more —
present less difficulty, and can be accounted for without calling in the
aid of such special factors. The effect of grief and anxiety in arresting
digestion, and in producing acute indigestion with all the symptoms of
gastric and duodenal catarrh, need not be dwelt on. In the case of a
medical man under my observation it led in the course of one night to a
condition just short of actual jaundice ; the stools were clay-coloured,
there was great distress in the region of pit of stomach and duodenum,
and the complexion was distinctly sallow ; but by urgent measures the
actual onset of jaundice was prevented.
In these cases the jaundice is doubtless of catarrhal origin — more
sudden in onset than usual, it is true, but pursuing subsequently the same
course and disappearing in about eight days.
Summary of the various factors. — As possible factors, other
than mechanical obstruction, in the causation of jaundice we have had to
consider : —
1. Hgematogenous origin of bile pigment (" Hsematogenous Jaundice ").
We have seen that the normal seat of formation of bile pigment is
within the liver-cell. A hsematogenous origin of bile pigment sufficient
in degree to cause jaundice does not occur.
2. Suppression of function ("Jaundice by Suppression").
8o SYSTEM OF MEDICINE
(a) Suppression of Biliary Function. Pigments other tliaii bile pig-
ment as a cause of jaundice ("L'ictere hemapheique," "Urobilin
Jaundice ").
There is no conclusive evidence of any such causation of jaundice.
Pigments other than bile pigment may be formed, and may in certain
cases produce some discoloration ; but this is totally distinct from jaundice.
In many cases of jaundice evidence of altered activity of liver-cells is
forthcoming; for example, diminished Bccrction of bile, increased formation
of bile pigments, diminished formation of bile acids : but such changes
cannot be regarded as indicating " suppression " of biliary function. On
the contrary, in the larger number of such cases the most marked feature
is an increased formation of bile pigments — evidence, therefore, of in-
creased activity rather than of suppression of function.
(b) Suppression of Metabolic Function. Diminished formation of
urea, appearance of leucin and tyrosin in urine.
Besides the formation of bile, the formation of urea may be taken as
an index of liver activity ; all evidence going to show that urea is formed
by process of synthesis from ammonia, and that the synthesis takes
place within the liver-cell.
In health urea constitutes about 85-90 per cent of the total nitro-
genous excretion of the urine, the remainder being made up of ammonia
and extractives.
In jaundice, even in the severest cases such as phosphorus jDoison-
ing, this proportion may remain unchanged, or at most slightly lowered ;
so that at the time the jaundice appears, no evidence is forthcoming of
any "suppression" of liver function, as regards urea-formatiun, in the
sense assumed by the " suppression theory " of jaundice ; namely, sup-
pression of function apart from structural alteration.
It is thus extremely doubtful whether total " suppression " of function
ever occurs apart from actual destruction of the liver-cell. Hence it is
oidy in the last stages of the severest forms of toxic jaundice — such as
acute yellow atrophy of the liver — that the functions of the liver can
rightly be said to be "suppressed."
3. Increased secretion of bile Avith excessive absorption from the
intestine ("Jaundice of Polycholia ').
Many cases of jaundice, those produced by poisons generally, are
marked at one stage or other by increased flow of bile and increased
excretion of bile pigment. There is no conclusive evidence that jaundice
may result from increased absorption of this liile from the intestine. The
jaundice met with under such circumstances is the result of absorption
of bile from the bile-ducts.
4. Deranged innervation ("Jaiuidice of Emotion ").
Deranged innervation plays a doubtful, and in any case quite a sub-
ordinate part in the production of jaundice.
(ii) There is no evidence that jaundice can be produced by extreme
fall of pressure within the portal system and absorption of bile direct
into the blood.
JAUNDICE 8 1
(i) Sudden mental emotion may conceivably cause spasm and
reversed peristalsis of the bile-duct, as of involuntary muscle generally.
The two important factors in producing jaundice are : — -
5. Increased destruction of blood with increased supply of haemo-
globin to the liver.
6. Action of poisons (" Ha^mo-hepatogenous Jaundice ").
Both factors are conveniently considered together, as they usually
operate together. The most common cause of increased destruction of
blood is the action of poisons on the blood. Although operating to-
gether these two factors are not of equal importance. Tlie, degree of
iaundice is dependent more v^xm the nature of the poison than the amount of
blood-dedruction. The most intense jaundice may be produced by poisons
that cause but little or at most a moderate destruction of blood ; for
example, phosphorus and toluylendiamin. ]\Iost of the severe forms of
jaundice met with in disease — " Icterus gravis," " INIalignant jaundice,"
"Weil's disease," are of this character, and illustrate this point.
On the other hand, intense destruction of blood may be attended with
little or no jaundice : for example, hsemoglobinuria experimentally in-
duced by injection of water, glycerine, or arseniuretted hydrogen ; in
disease, paroxysmal hsemoglobinuria or pernicious anaemia.
In both cases the jaundice is the result of absorption. It is caused
by changes in the liver and in the bile, and is thus in every sense hepato-
genous. Of most importance are the changes in the bile and smaller bile-
ducts. The chief of these are — {a) increased foi-mation of bile pigments
(polychromia) ; {h) diminished formation of bile acids ; {c) diminished
quantity and increased viscidity of the bile itself. The viscidity retards
tempoi'arily the flow of bile along the bile passages ; for a time it may
arrest it altogether, and is the proximate cause of the absorption. In the
case of the most notable jaundice-producing poison — toluylendiamin —
this increase of viscidity I have shown to be due to a catarrh of bile-
ducts, extending from above downwards {descending catarrh), produced by
the excretion of the poison through the bile.
Instead, then, of the two varieties of jaundice formerly described, one
hepatogenous or obstnirtive, the other hannatogennus or uon-ohtructice, it is
necessary now to recognise one class only. All jaundice is hepatogenous,
the result of absorption of bile formed and excreted by the liver. The
cause of the absorption may be obvious — mechanical obstruction {Simple
hepatogenous jaundice), or moi-e obscure and less easily demonstrable swell-
ing and catarrh of the lining epithelium of the bile passages, with conse-
quent increased viscidity of the bile {Hcemo-hepatogenous jaundice).
Causes of Jaundice
All cases of jaundice may be classed in two great divisions : —
I. Jaundice resulting from obvious mechanical obstruction independent
of changes in the blood or bile (Ol)structive Jaundice).
II. Jaundice dependent upon changes in the bloc 1 and bile ; the
VOL. IV G
82 SYSTEM OF MEDICINE
actual cause of obsti-uctiou being increased viscidity of bile, cousequent
on intrahepatic catarrh (Toxiemic Jaundice).
I. Obstructive Jaundice
The following table of causes is given by Murchison : —
A. Obstruction hy Foreign Bodies within tlie Dud.
1. Gall-stones and inspissated bile. 2. Hydatids and distomata. 3.
Foreign bodies from the intestines.
B. Obstruction bi/ Liflammatnrj/ Tumefaction of the Duodenum, or of
the lining membrane of the Duct with Exudation into its Interior.
C. Obstruction hy Stricture or Obliteration of the Duct.
1. Congenital deficiency or obstruction of the duct. 2. Stricture from
perihi'patitis. 3. Closure of orifice of duct in consc(|uence of an
ulcer in the duodenum. 4. Stricture from cicatrisation or ulcers
in the bile-ducts. 5. Spasmodic stricture 1
D. Obstruction hy Tumours closing the orifice of the Duct, or gromng into
its Literior.
E. Obstruction by Pressure on the Duct from loithout by —
1. Tumour projecting from the liver itself. 2. Enlarged glands in
the fissure of the liver. 3. Tumour of the stomach. 4. Tumour
of the pancreas. 5. Tumour of the kidney. 6. Post-peritoneal
or omental tumour. 7. An abdominal aneurysm. 8. Accumula-
tion of faeces in bowels. 9. A pregnant uterus. 10. Ovarian and
uterine tumours.
II. ToXiEMic Jaundice
The causes may be divided into three groups —
1 . Definite Poisons — Toluylendiamin, Phosphorus, Arseniuretted
hydrogen.
2. Poisons formed in various Sjjecific Fevers.
(a) Yellow fever ; (b) Malaria ; (r) Enteric fever ; (d) Relapsing
fever ; (e) Typhus ; (/) Scarlet fever.
3. Special Icterogenetic Poisons.
(a) " Epidemic Jaundice." (//) " Infectious Jaundice " (" "Weil's
disease"). (r) "Malignant Jaundice." ((/) "Acute Yellow
Atrophy of Liver,"
I. OBSTRUCTIVE JAUNDICE
For the symptoms, morbid anatomy, differential diagnosis, and treat-
ment of the several varieties of jaundice caused by mechanical obstruc-
TOXyEMIC JAUNDICE 83
tion, the reader is referred to the various articles dealing fully with the
diiferent causes of this condition, as detailed in the foregoing list,
namely —
1. Inflammatory affections of gall-bladder and bile-ducts (p, 212).
2. Cholangitis (p. 257). 3. Tumours of the gall-bladder and
bile-ducts (p. 226). 4. Gall-stones (p. 234). 5. Tumours of the
liver (p. 194). 6. Congenital obliteration of the bile-ducts (p.
249). 7. Cirrhosis of the liver (p. 170). 8. Tumours of the
pancreas (p. 272).
II. TOX^EMTC JAUNDICE
Synonyms. — Hcemo-hepatogenous jaundice (Afanassiew) ; Jaundice of poly-
chromia (Stadelmann) ; Non-obstructive jaundice.
Definition. — A form of jaundice connected with disorder of the blood,
met with in a number of conditions ; sometimes as a complication of
specific febrile conditions, sometimes as the prominent feature of con-
ditions of obscure, probably infective, natnre : it is characterised by
jaundice of varying severity in association with symptoms of more or less
general disturbance ; in severe cases by fever, delii'ium, epistaxis, black
vomit, alljuminuria, and other symptoms of blood disorder : it is caused
by the agency of various organic poisons, acting on the blood first and
subsequently excreted through the liver, leading to altered character
and viscidity of the bile, and in severe cases to degenerative changes in
the liver-cells.
Varieties, — The varieties of jaundice falling within the scope of the
above definition may be grouped in three classes —
1. Jaundice produced by the action of j)oisons, such as toluyl-
endiamin, phosphorus, arsenic, snake-bite.
2. Jaundice met with in various specific fevers and conditions, such
as yellow fever, malaria (remittent and intermittent), pyaemia, relapsing*
fever, typhus, enteiic feA^er, scarlatina.
3. Jaundice met with in various conditions of unknown but more
or less obscure infective nature, and variously designated as "epidemic,"'
"infectious," "febrile," " malignant " jaundice, "icterus gravis," "Weil's
disease," " acute yellow atrophy of liver."
General characters. — Although differing widely from one another in
severity and in individual character, there are certain general characters
common to all these forms of jaundice which seem to mark them off" as
a distinct group, conveniently described by the term " toxa?mic." In
all of them the jaundice appears to be independent of any obstruction to
the flow of bile, or at any rate no obvious obstruction can be found in the
larger ducts. In all of them the jaundice is associated at one time or other
Avith the px'esence of more or less bile in the stools, sometimes indeed
with an excess of bile (polycholia). In all of them bile acids are not
present in such quantity in the urine as in cases of jaundice of purely
84 SYSTEM OF MEDICINE
obstnictive nature ; they may indeed be absent altogether — a point of
dirterence to which, following Leyden's original teaching, it has been
customary to attach a signiticance altogether out of proportion to its
imijortance.
AVe now knoAv from Stadclmann's studies that in all these respects
the jaundice met with in disease agrees in its characters with that pro-
duced by drugs like phosphorus or toluylendiarain, so closely indeed as
to leave no room for doubt that in disease poisons are also at work. In
particular a diminished formation of bile acids appears to be a feature
of the action of all such agents — even when causing a largely increased
formation of bile pigments ; so that their absence from the urine or
their presence in diminished quantity in these cases is thus satisfactorily
accounted for. And so Avith regard to the. presence of bile in the stools
— the action of all these icterogenetic drugs is attended at one stage or
other by increased formation of bile pigments and increased flow of bile.
Turning from these pathological features to those of a more clinical
character, the jaundice met Avith in the foregoing class of cases presents
certain general points of resemblance distinguishing it fiom the
jaundice of purely obstructive origin. In the first place, the jaundice is
usually less intense in its character than that met with in obstruction,
being frequently evidenced by a slight yellowish or greenish-yellow dis-
coloration of skin and conjunctivae rather than the deep golden yellow or
green colour of obstructive jaundice. It appears to be due, as indeed
is the case, to the absorption of some, rather than to the retention of
all the bile pigment formed.
But while this is its character in general, it may, on the other hand,
be as intense as the jaundice of pure obstruction. Of this nature is the
jaundice of toluylendiamin poisoning. In severe cases it is as complete
and intense as if a ligature had been applied around the bile-duct ;
but it is only for the time being, for another feature of the jaiindice thus
caused is that it is of a more temporary character than that caused
by mechanical obstruction. It passes off" with the condition of blood
and bile on which it depends ; that is, in the case of jaundice of drugs, as
soon as the action of the poison has exhausted itself.
In the second place, this variety of jaundice is generally associated
with more constitutional distui-bance than is the case with oixlinary
obstructive jaundice. In the mildest cases, indeed, disturbance is hardly
observable. The mildest forms of catarrhal jaundice, occurring in the
course of an e])idcmic outl)rcak, and obviously, therefore, the result of
some more or less infective influence, may not be distinguishable from
cases of ordinary " catanhal " jaundice of duodenal origin, and may
present little constitutional disturbance, if any.
But in general some degree of general disturbance there is ; and in
the severe cases this is of so pionounced a character — dry tongue, fever,
delirium, subsultus, convulsions, cpistaxis, l)lack vomit, diminished excre-
tion of urine, and albuminuria, — symptoms of the "typhoid state,"
— that the jaundice becomes only one symptom of a general conditio))! of
TOXEMIC JAUNDICE 85
severe poisoning. Moreover, although the symptoms vary very greatly in
their intensity in different classes of cases, they have the same genei-al
character. At first sight it might appear necessary to distinguish between
the form of jaundice accompanying definite specific fevers, such as
malaria, yellow fever, typhoid fever, and the like, and that met with
apparently as an independent affection in "epidemic," "febrile," "in-
fectious," " malignant " jaundice, " Weil's disease," " acute yellow atrophy
of liver." And still more might it appear necessary to distinguish in this
last group of cases between forms apparently so widely diverse as mild
cases of catarrhal (epidemic) jaundice and severe cases of " Weil's
disease," " malignant jaundice," and cases of that rarest of all diseases,
acute yellow atrophy of the liver. But in reality, both from a clinical
and a pathological point of view, they all present certain features in
which they resemble each other, and no sharp line of distinction can be
drawn betwixt them.
The severest cases of an outbreak of catarrhal (epidemic) jaundice
may be marked by so much fever and constitutional disturbance as to be
indistinguishaljle from cases of Avhat is variously called " icterus gravis,"
" febrile jaundice," " infectious jaundice," " malignant jaundice."
Similarly, the condition named " Weil's disease," to which so much atten-
tion has been drawn of recent years by German observers, differs in no
respect from forms of icterus gravis described long ago by many observers
— Graves and others. And lastly, as I shall presently have occasion to
show, it is not even possible to draw any clear line of demarcation between
the severest forms of icterus gravis, or malignant jaundice, and the acute
yellow atrophy of the liver. In mode of onset, character of symptoms,
progress of case, and lastly, in character of post-mortem appearances,
cases have been observed and recorded as occurring in the course of
endemic outbreaks of jaundice which were not to be distinguished
from acute yellow atrophy of the liver, even in the minutest particulars
supposed to be characteristic of the latter disease ; such as atrophy
of the liver, diminished excretion of urea, and the discovery of tyrosin
and leucin in the urine and liver. So far, indeed, as the last-mentioned
points are concerned, identical changes — yellow atrophy of the liver,
presence of leucin and tyrosin in the liver and in the urine, diminished
excretion of urea — have been found by Frerichs, Murchison, and others in
severe cases of jaundice occurring in typhus, enteric, and relapsing fevers.
It thus appears that even in their clinical features all these forms of
jaundice have a good deal in common. Their symptoms have a generic
likeness, from the initial jaundice, with or without general disturbance,
common to all alike, to the marked cerebral and toxic phenomena which
characterise the severest cases. The differences in character manifested
by the special forms are doubtless due to differences in the character and
intensity of the poisons. The differences observable in the action of such
agents as phosphorus, arseniuretted hydrogen, toluylendiamin, show that
the power of inducing jaundice (icterogenetic power) is possessed by
poisons in very varying degree.
86 SYSTEM OF MEDICINE
But whalevcr the character of the other symi^toms, the icterogenetic
power is usually associated Avith three classes of changes — («) destructive
changes in the Mootl ; {h) alterations in the quantity and quality of
the bile ; ('•) changes, functional or parenchymatous, according to the
severity of the ])(jisonous action on the liver-cells, and, as the case of
toluylendiamiii illustrates, on the bile-ducts, and also on the renal cells.
In disease all these modes of action are manifested in varying degree,
especially in severe cases ; the degree of blood change being frequently
shown by the occurrence of bleedings from nose and stomach (black
vomit), and the action on the liver and kidneys by the occurrence of
extensive parenchymatous changes in both organs.
Etiolog'y. — As regards their etiology the above class of cases haA'e a
good deal in common. Their etiology, except in the first class, where
"we have to deal Avith the action of definite poisons, such as phosphorus,
is obscure. Age, sex, occupation, habits of life are without any definite
influence of themselves, except in so far as they favour the incidence of
disease of an infective character. For it is to this latter mode of origin
that the preponderance of evidence points, e^en in the isolated (sporadic)
cases. This infective character becomes most manifest when, as not 'in-
frequently happens, the jaundice assumes an endemic or even epidemic
character, aff"ecting those in the same household or district, or spreading
over larger areas. But the resemblance between the severe cases met
with under such circumstances and the isolated cases — for example,
icterus gravis, Weil's disease — where no definite infection can be proved,
suggests very strongh^ that these latter also have an infective origin.
In a in;ml)er of such cases, indeed, organisms of varying character
have been described as occurring in the liver, and within the last few
years much evidence of a similar nature has accumulated. Of the nature
of the infection nothing definite is known — whether bacterial or of even
lower forms of life (varieties of proteus have been described as the
accompaniment of certain severe cases of jaiuidice). There is hardly any
reason, however, to doubt its microbic origin ; and it is exceedingly
probable that it is of very varying character — that the power of forming
poisons, possessing more or less icterogenetic properties, is one possessed
by a number of different organisms. But the conq)arative rarity of forms
of infective jaundice indicates that the power is not one incident to the
ordinary microbes inhalating the intestinal tract. Moreover, the com-
parative rarity with which jaundice of this kind is met with, complicating
marked infective conditions of the intestinal tract, speaks to the same
effect. Thus jaundice is of very rare occurrence in entei-ic fever.
Murchison only met with it on four occasions ; Jenner never met with a
case at all.
We may take it then, I think, that in these forms of jaundice we
have to do Avith the action of organisms of specific natuic, Avhether
of a bacterial or other kind remains still to be shown ; organisms of
varying character and virulence; limited in their distribution, or even
rare, in this country and in temperate climates, but more widely distributed
TOXEMIC JAUNDICE 87
in trop.'cal climes (for example, the infection of yellow fever and of
malaiious disease, the remarkably endemic character of outbreaks of
jaundice in some parts of Southern Australia).
The seat of infection in most cases is probal)ly the intestinal tract.
Intestinal symptoms — for example, diarrhoea, more or less foetid in
character — form a prominent feature of a large number of such cases at
the outset of the illness. And it is extremely likely that in the lai'gest
numljer of cases the infection remains confined to this tract, and does
not S[)read to the blood ; the infection of the blood being limited to the
poisons absorbed. It is thus readily conceivable that in fatal cases no
organisms "would be found in the blood or in the liver ; and such cases
have been recorded by Dreschfeld and others in acute yellow atrophy.
In .other cases, however, the infection passes more directly into the
blood itself. Of this kind is the jaundice of pyaemia and of snake-bite.
After this general consideration of the characters and features of this
variety of jaundice as a whole, I shall now pass to the consideration of
the chief forms comprised within the group.
Jaundice of phosphorus poisoning. — The jaundice of phosphorus
poisoning is the best-known example of a jaundice produced by the
action of drugs. It was formerly comparatively common ; but since
legislative measures have been taken in this country and Germany to
enforce the use of the insoluble and non-poisonous form of the dnig in the
making of lucifer matches, it has become decidedly less frec^uent. In
Austria it is still very common.
The poison is usually taken in the form of an infusion of the heads of
lucifer matches, sometimes in the form of those rat poisons which contain
phosphorus.
Symptoms. — The symptoms vary considerably, according to the dose
of the poison taken and the rapidity of its absorption. Eut usually two
stages may be distinguished : one in which the symptoms are mainly those
of irritant poisoning, followed by a second in which more characteristic
symptoms of toxic poisoning make their appearance, ushered in with
jaundice. The duration of the first stage vai'ies according to the amount
of the poison taken. It usually lasts from some two to five days ; in
exceptional cases it may be as long as fourteen to twenty-one days, and
one case is recorded by Dr. West where the characteristic symptoms did
not make their appearance for six weeks.
The first symptoms usually begin a few hours after the poison has
been taken, and take the form of severe burning pain in epigastrium,
with intense nausea and vomiting. The vomiting continues almost
incessantly, everything taken being rejected, till in the course of twenty-
four hours or so the patient may be in a state of collapse. The respira-
tion is very rapid, the pulse small and weak, the tongue and lips dry
and red ; thirst is incessant. At this time there is great tenderness
over the epigastrium and the region of the liver ; but the latter is not
perceptibly enlarged.
88 SYSTEM OF MEDICINE
After a time there is a slight remission in the violence of the
symptoms. Then the vomiting returns -vith renewed severity, but
the character of the vomit changes. It now contains blood, dark or
chocolate -coloured, and the patient becomes jaundiced ; the pain and
tenderness over epigastrium and region of the liver continue, and the
liver dulness is increased. MoreoM'r, lun-vous symptoms become pro-
minent— intense headache, sometimes hiccup ; drowsiness ])a.ssing into
coma, varied with attacks of delirium and sometimes convulsions \ and
the patient rapidly sinks, dying either from exhaustion oi-, more sud-
denly, from heart failure, witliin twenty-four or forty-eight hours of the
onset of the graver symptoms.
Jaundice is a very characteristic feature. In severe cases it is usually
noticeable about the second or third day ; in milder cases not till the
sixth or seventh day. It shows itself at first as a slight icteric tinge of
conjunctiva, but is not fully manifested until the second stage of the
disease is entered. Although a characteristic symptom, it is bj^ no
means a constant one, nor is it necessarily proportionate to the severity
of the poisoning. A considerable number of eases of acute phosphox'us
poisoning without jaundice have been recorded. Hessler found it in
twenty-six only out of forty-eight cases. On the other hand, it Avas only
absent in one out of ten cases recorded by Miinzcr, and that case "was a
mild one which ended in recover3\ Even when preccnt the jaundice may
be slight throughout, although in most cases it is well pronounced.
It is marked as usual by the presence of bile pigments in the urine ;
bile acids are usually present also, although in greatly diminished quantity.
Temperature is usually normal or sul)normal throughout. It may be
raised in the second stage as much as 100° to 103° F. In rare cases it
has risen as high as 107° F. just before death.
Hivmorrhages are a constant feature, but they are not so prominent a
feature of the jaiindice of phosphorus poisoning as the)' are of the other
forms of se\ere jaundice ; for example, of icterus gravis or acute yellow
atrophy of liver. At least this is true of ha?morrhages under the skin.
The most frequent form the haemorrhage takes is that of l)lack vomit —
hffjmorrhage from the mucous membrane of the stomach. The urine is
usually free from blood, although in certain cases blood may be present
in quantity. Although thus not so prominent as a clinical feature, the
occurrence of haemorrhage is nevertheless a marked post-mortem feature
of the disease.
T/ie Liver. — The region of the liver is exquisitely sensitive to pressure
throughout. At first no enlargement of liver dulness is to be made
out ; but in the second stage the liver can be felt, projecting below the
costal margin. In some cases also the spleen is perceptibly eidarged.
The urine always shows marked changes. Its qnnniitii is usually
more or less diminished, sometimes throughout ; at other times it may
be diminished at first, but afterwards increased, agaiii to fall shortly
before death. At no time, however, is there ever any approach to
anuria. The quantity varies between 300 c.c. and 2000 c.c. — on an
TOXyEMIC J A UN DICE 89
average about 750 c.c. Its specific gravity varies from 1020 to 1037,
according to quantity ; its reaction is strongly acid, a marked feature.
The bile pigments and bile acids are nearly always present — the latter in
very diminished quantity. Albumin is frequently present, although not
invaria].)ly, and usually in small quantity. When present, fatty epithelial
cells and fatty cads are usually also to be found on microscopic examina-
tion. In some cases hlood is present also. Sugar is an extremely rare
constituent ; only three cases are on record.
The chief changes presented by the urine relate to its nitrogenous
constituents. The first observations made — those of Schultzen and
Riess, 1870 — appeared to indicate that the urea became reduced almost
to vanishing-point, and that its place was taken by other products; lactic
acid especially being very abundant. More recent observations have
shown that this is far from being the case ; that although at first diminished,
as compared with the normal, the excretion of urea is relatively much in-
creased, considering that the patient can take no food ; so much so as
to indicate a largely increased destruction of albuminous material as the
result of the action of the poison. This subject has recently received
most exhaustive study at the hands of a German observer — Miinzer
(1894). He has estimated the total nitrogenous excretion in the urine
in 10 cases of phosphorus poisoning, and determined at the same time
the proportion of urea, ammonia, uric acid, and extractives of which the
total was made up.
Tohd Niirdgcn. — His observations shoAv that in the first stage of the
poisoning there is an extraordinary diminution in the excretion of
nitrogen, the total amount falling as low as 2 to 5 grammes daily, instead
of the normal mean of about 1.5 to 18 grammes. These low figures
correspond closely to the excretion of nitrogen in starvation ; and they
are probaljly to be regarded as such. For in the fii'st stage of the
poisoning the patient is unal^le to retain anything on his stomach, either
fluid or solid.
This great diminution does not, however, last long. "While the
patient is still unable to retain anything there occurs a remarkable rise,
as high as 1 0 to 1 7 grammes per day ; and at or about this height the
nitrogenous excretion remains to the end. Usually Avhen these high
figures are reached the patient dies. In some cases, however, recovery
has still taken place. So large an increase occurring in spite of the
absence of food obviously represents a very largely increased destruction
of the albumin of the tissues.
Of this total amount the largest proportion continues throughout
to be made up of urea. But the proportion varies somewhat according
to the stage. In health, urea constitutes from 85 to 90 i)er cent of the
total nitrogen of the urine. In the first stage of the poisoning this pro-
portion is unaltered ; urea still forms about 9 1 per cent of the whole.
In the second stage it falls somewhat, namely, 70-80 per cent of the total
nitrogen. But the absolute excretion of urea is greatly increased, since
in this stage, as we have just seen, the total nitrogen rises so much.
90 SYSTEM OF MEDICINE
Corresponding to this fall in the proportion of urea there is a rise
in the proportion of ammonia and extractives, chiefly of the former. In
health, ammonia constitutes from 4 to 6 per cent of the total nitrogen of
the urine. In the second stage of phospliorus poisoning the proportion
rises considerably, 10 to 18 per cent.
In health, extractives constitute about 4 per cent of the total nitrogen.
In phosphorus poisoning they undergo a slight increase, 4 to 9 per cent.
The nature of these extractives is unknown — whether amido- acids
(leucin and tyrosin) or peptones. Peptones are found in the urine in a
few cases. They were not ])resent in any of ]\Iunzer's cases.
Leucin and tyrosin are sometimes found. In one case Miinzer found
crystals resembling those of tyrosin in the urine. In one case Fraenkel
found tyrosin but no leucin.
Uric acid. — In health about 1 to 2 per cent of the total nitrogen is
in the form of uric acid. In the first stage of phosphorus j^oisoning the
proportion of uric acid remains fairly normal (1*6 and 1*4 per cent). In
the second stage an absolute increase occurs corresponding to the increase
in the total nitrogen; but the proportions remain unaltered (TIG, r47,
and 1*37 per cent). If the patient live long enough a slight relative
increase appears (2 "45 per cent). On the whole it may be said that
in phosphorus poisoning there is a distinct increase in the excretion of
uric acid corresponding to the total increase of nitrogen ; but that its
proportions are unaltered.
Organic acids. — The organic acids include especially volatile fatty acids
and lactic acid.
Fattij acidti have been found by von Jaksch in the urine in a number
of liver affections ; and their appearance was thought by him to stand in
some relation to the diminished formation of urea, and thus to mark
the severity of the disease. This opinion cannot now be held. Fatty
acids were only found in one case out of five in Avhich they were looked
for by Miinzer ; and that was in a patient who recovered. Moreover, the
urea, so far from being diminished, was increased.
Lactic acid. — This or some allied acid must be present in most cases.
For the urine is extremely acid, notv\ithstanding that the alkaline value
of the ammonia present is more than sufficient, according to jNliinzer, to
neutralise all the acids present. The nature of these acids has not yet
been determined.
Inorganic omMitucnts. — Chlorides fall to a very low amoimt, under a
gramme daily ; and do not rise again until recovery sets in. This great
fall is doubtless due to the absence of food.
riwsphoric acid. — The phosphoric acid in the urine has two chief sources
within the body — the albumin of the tissues and lecithin — the latter a
prominent constituent of certain tissues (red corpuscles, liver, and neiwous
tissue). In health the albumin of the tissues is its chief source ; and
hence the amount daily excreted stands in a certain proportion to the
total nitrogenous excretion, namely, as IS : 100. This proportion rises
whenever there is any increased destruction of lecithin. In phosphorus
TOXEMIC J A UNDICE 91
poisoning there is a distinct absolute increase in the excretion of plios7
phoric acid during the first two or three days. But still more marked is
the relative increase lasting for two or three days, and only falling
towards the end, or when recovery occurs. Thus, instead of the above
proportion 18 : 100, the proportion to the total nitrogen rose in individual
cases as high as 27, 31, 57, and even as high as 83 per cent. In one
case it rose from 18 per cent on the day of poisoning to 97. These
changes in phosphoric acid excretion are probably to be referred,
not to any oxidation of the phosphorus taken, but to a great destruc-
tion of phosphorus-containing tissues — chiefly of the liver. Phosphorus
exercises no special destructive action on the red corpuscles, one source of
lecithin. On the other hand, it has been found by Heffter that the
lecithin o-f the liver after phosphorus poisoning is reduced by one-half.
Sulphuric mid. — The excretion of this acid in phosphorus poisoning
corresponds in the main to that of phosphoric acid. It is increased. A
large increase of the unoxidised compounds of sulphur was found in a
case recorded by Starling and Hopkins. A similar change was noted by
Goldmann in some cases of phosphorus poisoning.
As regards the ether sulphates they seem to vary ; sometimes they are
increased. In one case the proportion of ether suljahates to the inorganic
sulphates was 1 to 5-9, instead of 1 to 10 as in health. On the other
hand, they have been found diminished, for example, 1 to 20 (Starling and
Hopkins), 1 to 5-1-6 (Miinzer).
Morbid anatomy. — The chief changes found post-mortem are (i.)
jaundice; (ii.) hcemorrhages; usually small and punctiform, scattered over
the various serous membranes — pleura, pericardium, mesentery, and in
the mucous membrane of stomach and intestine, under the skin and
between the muscles ; sometimes of larger size, and met with in the
liver, and in the tissues of the neck and elsewhere.
(iii.) Fafti/ degeneration of liver and kidneys. — The liver is usually con-
siderably enlarged and remarkably fatty, presenting all the characters
of a fatty liver — doughy to the feel, greasy on section, its lobules in-
distinct and deeply bile-stained. Its colour is usually a uniform j^ale
yellow ; but in some cases there are portions here and there of a more
reddish yellow colour, due to congestion of the centres of the lobules.
On microscopic examination the liver-cells are found fattily degenerated,
their outlines indistinct, the nuclei refusing to stain, and the substance of
the cell converted into fine granular detritus, or filled with large fat drops,
especially in the outer zone of the lobule. The cells of the central zone
often contain biliary pigment. The connectiA'e tissue throughout the
liver is usually unaffected ; in a few cases it has been found in a state of
proliferation. In rare cases the liver may be found diminished in size
and shrunken, instead of increased. The increase of fat is very notable.
The normal liver contains about 3 per cent of fat, 76 per cent of Avater,
and 21 per cent of non-fatty substance. In phosphorus poisoning the
percentage of fat is as high as 30, water 60, and non-fatty tissue 10 per
cent. This increase of fat contrasts remarkably Avith what is found in
92 SYSTEM OF MEDICINE
acute 3'ellow atrophy ; namely, •4"2 per cent of fat, 80"5 per cent of water,
and 15'3 per cent of non-fatty substance.
The kidnei/s are usually swollen, soft, and enlarged ; the capsule strips
off easily ; the cortex is increased in thickness, and pale, contrasting with
more purple colour of the medulla. On microsco].iic examination the
epithelium of the convoluted tubules is swollen and fatty, or thrown off as
casts.
The heart is flaliby, and its muscle presents a more or less mottled
appearance from fatty degeneration.
The sjjieeii is usually enlarged, often to double its natural size, and full
of blood ; in other cases it is small and firm.
Nature of the jaundice. — This problem is one of peculiar interest.
Far more than any other form of jaundice, that of phosphorus poisoning
has long been held to establish the existence of a jaundice from sup-
pression independent of obstruction. The facts in favour of such a view
are that the bile-ducts, or at least the larger bile-ducts, are free from
obstruction, often indeed free from bile ; the 1)lood shows no evidence of
any special destructive action of the poisoii, such as we meet with in the
case of other icterogenetic poisons ; and, lastly, the intense fatty change in
the liver indicates that the poison acts specially on the liver-cell.
What more reasonable, then, than to conclude that the function of the
liver has been " suppressed," and that jaundice is one of the results.
Nevertheless the evidence addncible appears to me conclusively to
show (a) that at the time at which the jaundice occurs the functions of
the liver are by no means suppressed, however much they may be, and
doubtless are, injuriously affected ; and (b) that the changes in the bile
(increased viscidity and retarded flow) are such as sufficiently to account
for the jaundice (Stadelmann) — changes similar in character, though less
in degree than those produced by toluylendiamin.
So far as total suppression of function is concerned, the excretion cf
urea, and more especially the relative proportions of urea and ammonia
in the urine, afford an important index to the activity of the liver. If
the liver be cut off from the circulation, and its functions thus suppressed,
there is a great fall in the amount of urea, and a no less marked increase
in the ammonia of the urine.
In disease a suppression of its function, such as is assumed to occur,
ought to manifest itself in the same way, namely, (a) by a great fall in
the total excretion of urea, (h) by a large proportionate increase in excre-
tion of ammonia. Yet as a matter of fact the elaborate analyses of
Miinzer show that so far from urea being reduced to vanishing-point, urea
continues to be excreted in quantities approximating to those of health —
in quantities, therefore, which, when we consider the absence of food, greatly
exceed those of health.
Moreover, and still more significant of continued activity of the liver,
urea still constitutes about 80 per cent of the total nitrogenous excretion
(instead of the normal 90 per cent) — the increase in ammonia being only
moderate (10 to 18 per cent instead of the normal 4 to G per cent).
TOXEMIC J A UN DICE 93
This increase in the percentage of ammonia might be taken as an indi-
cation of some impaired activity of the liver in transforming amirionia into
urea. But even this significance cannot be attached to it. Both Starling
and Hopkins, who had previously described it, and Miinzer are in accord
in referring it rather to the increased acidity which is a feature of the
blood (as also of the urine) in phosphorus poisoning (von Jaksch) ; and
the experiments of Miinzer have confirmed the accuracy of this view.
Whether, then, we have regard to the increased formation and excre-
tion of bile pigments shown by Stadelmann's experiments to occur in the
first stage of the poisoning, or the continued formation of urea which
occurs throughout almost up to the last moment, there is at the time at
which the jaundice occurs absolutely no evidence of the total arrest or
suppression of function which the suppression theory contemplates.
On the other hand, there is at the time at W'hich the jaundice appears
evidence of marked fall in the cpiantity of bile — one-fifth its former
amount, with an increase of its viscidity siifficient of itself to retard
and temporarily to arrest the flow of bile in the small bile-ducts.
And indeed changes in those ducts have long been noted and described.
Thus Oscar Wyss (1867), in experiments on dogs, found the larger
ducts free from bile and unstained, while the smaller ones were filled
with thick mucus which prevented the flow of the bile downwards.
And similar appearances have been noted in man (Ebstein), although
others have failed to find them (Schiiitzen and Riess).
Considering the obvious effects of the poison on the liver-cell (swell-
ing and fatty degeneration), it is not diificult to understand how an
analogous injurious effect on the lining of the smaller bile-ducts may lead
to swelling; and increased secretion sufficient to retard or arrest the flow
of bile along them.
To sum up, then : the jaundice of phosphorus poisoning is essentially
obstructive ; it is hcBmo-hepatogenous in nature, and is due to obstruction
in the smaller bile passages set up by changes in its epithelium and in its
secretion.
The jaundice of yellow fever. — For a full description of yellow
fever the reader is referred to the article on the disease in the second
volume (p. 385). So far as the jaundice is concerned, the disease bears
a striking resemblance to cases of so-called idervs gravis observed from
time to time in this country. The symptoms of these maladies are closely
alike. Indeed, isolated cases of yellow fever are not to be distinguished
from cases of icterus gravis.
Yellow fever presents characters of acute yellow atrophy — the same
mode of onset, with fever and slight jaundice followed suddenly by the
severer symptoms of black vomit, haemorrhage, delirium, convulsions,
coma, and death. The close resemblance has been noted by all observers,
and a few have even gone so far ns to regard the two diseases as identical
(Liebermeister). However, the facts hardly bear out such a conclusion.
Although of the same generic character, the changes in the liver in the
94 SYSTEM OF MEDICINE
two diseases arc not quite identical. In both cases they indicate the
action of a severe poison ; but the characteristic atrophy found in acute
yellow atrophy points to the action of a more A'irulent poison than that
present in j'cllow fever. In the latter disease there is not the shrinking
of the liver which is so marked a feattu-e of the former.
In both diseases we have to deal with the action of poisons closely
similar in nature and action, although not identical. And the same
conclusion probabl}-^ applies to yellow fever and icterus gravis. The
resem1)lance is here absolute in all ])oints — both in the clinical features
during life, and in the post-mortem changes after death.
An isolated case of yellow fever occurring in this country would,
apart from any history of its importation, be almost certainly regarded
as a case of icterus gravis.
REFERENCES
1. Af.vnasstew. Zeitsehrift f. Idia. Med. vi. — 2. Idem. Vircli. Archir, xcviii. p.
465, 1884. — 3. Auld, A. G. " On Hsematogenous. Jaundice," ^rii. Med. Jour. i. 1896, p.
137. — 4. Bkunton, Lauder. Handbook for Plujsiolog. Labor. 1873, p. 499. — 5.
CH.\rFFAUD. " Maladies du Foie," Traitc dc mddecinc, 1892, p. 704. —6. Copeman.
" Tlie Crystallisation of Hemoglobin in Man and tlie Lower Animals," Jour, of Physiol.
xi. 1890 ; Lancet, i. 1887 ; JSrit. Med. Jour. ii. 1889, p. 190.— 7. Cullen. TVorks,
vol. ii. p. 656, 1827. — 8. Freiuchs. Diseases of the Liver, 1858. — 9. Gamgee. The
Physiological Chemistry of the Animal Body, vol. ii. 1893. — 10. Gakrod, A. E. "On
the Occurrence and Detection of Ha;matoporphyrin in the Urine," Jour, of Physiol, xiii.
1892. — 11. Gakrod, A. E., and Hopkins, F. Gowland. "On Urobilin," Jour, of
Physiol. XX. 1896. — 12. Harley. Diseases of the Liver. London, 1880. — 13. Hayem.
Du Sang. Paris, 1889. — 14. Hunter, William. Thesis, University of Edinburgh,
1886. — 15. Idem. "The Physiology and Pathology of Blood Destruction," Lancet,
ii. 1892. — 16. Idem. "The Action of Toluylendianiiu," Jour, of Pathology and
Bacteriology, vol. iii. 1895. — 17. Idem. "Excretion of Pathological Urobilin iu
Pernicious Anamia," Practitioner, 1889. — 18. Kuhne. Virchow's Archiv, xiv. p.
337, 1858 ; Lchrbuch d. j)hys. Chemie, Leipzig, 1868. — 19. Legg, Wickham. The
Bile, Jaundice, and Bilious Diseases. London, 1880. — 20. Leyden. Beitrdge zur
Palhologie des Icterus, 1866. — 21. Lowrr. " Beitnige zur Lehre vom Icterus,"
Ziegler and Xauwerk's Beitrdge zur 2>(if^iol. Anat. iv. — 22. MacMunn. "On
the Origin of Urohfeinatoporphyrin and of Normal and Pathological Urobilin in the
Organism," Jour, of Physiol, x. 1889. — 23. Minkowski and Naunyn. " Ueber
den Icterus durch Polycholie und die Vorgiingo in der Leber bei demselbeu," Archiv
f. cxp. Pathol. M. Pharinak. xxi. 1886. — 24. MuxoN. Trans. Path. Soc. Lond. 1873,
xxiv. p. 133. — 25. MuNZER. "Der Stoffwechsel des Menschen bei acuter Phosphor-
vergiftung," Z>. Archiv f. klin. Med. xxii. 1894. — 26. Mi-hchison. Diseases of the
Liver, London, 1868, 3rd edition, edited by T. Lauder Brunton. Loudon, 1885. — 27.
Nauxyn. " Beitriigc zur Lehre vom Icterus," Archiv f. Anat. «. Physiol. 1868,
p. 401. — 28. Neumann. " Beitriige zur Kenntniss der pathologische Pigmente,"
Firch. Archiv, Bd. ii. C. xi. — 29. Quincke. Firch. Archiv, Bd. xcv. — 30. Saunders.
I'he Structure, Economy, and Disorders of the Liver. London, 1809. — 31. Silber-
MANN. "Ueber Haemoglobinaemie," Zeitsehrift f. klin. Med. 1886, xi. p. 471.— 32.
StadelmaNN. Der Icterus und seine verschiedcnen Formen. Stuttgart, 1891. — 33.
Idem. " Zur Kenntniss der Galleafarbstotr Bildung," Archiv f. exp. Path. ii. Pharviak.
1882, XV. p. 337.— 33«. v. SloucK. " Beitrage zur Path, der Phosjilior Vergiftung," D.
Archiv f. klin. Med. xxxv. 1881. — 34. Starling and Hurkins. "Note on the Urine
in a Case of Phosphorus Poij;oning," Guy's Hosp. Hep. xlvii. 1890.— 35. Steiner.
" Ueber de hacinatog. Bildung des Gallenfarbstones," ^rcA./. Anat. u. Physiol. 1873. —
36. Stern. Arch, f e.cp. Path. u. Phamuik. x\k. y. 39.— 'S7. Tarchanoff. "Ueber
die Bildung von Gallenpigment aus Blutfarbstolf im Thierkorper," Pjlugers Archiv,
Bd. ix. — 38. ViRCHow. Virch. Archiv, i. ji. 1 ; Ibid, xxxii.
W. H.
WEIL S DISEASE 95
WEIL'S DISEASE
Synonyms. — Infectious jaundice ; Febrile jaundice.
In 188G, under the title of "A peculiar form of acute infectious disease
characterised by Jaundice, swelling of Spleen, and Nephritis," there
appeared a paper by Professor Weil of Heidelberg, describing four cases
of febrile jaundice presenting certain general features of resemblance.
He was in doubt whether to regard them as extremely rare modifications
of other v/ell-known forms of infectious disease, oi', on the other hand,
as a disease hitherto unrecognised. The paper excited much interest,
chiefly amongst German observers, who decided at once in favour of the
latter alternative, and gave it the title of " Weil's disease."
Since then a considerable discussion has sprung vip in connection with
the subject — almost exclusively amongst German writers. French ob-
servers have, for the most part, declined to see in the condition anything
more than what they had long been accustomed to descril:)e under the
title of icterus gravis, or infectious jaundice ; and, judging from the atten-
tion bestowed on it, the same \iew ai^jpears to have been taken by most
English and American observers.
Symptoms. — The character of the disease in Weil's original cases was
that of a sharp febrile attack coming on suddenly, Avith or without rigors,
followed on the second or third day by jaundice, swelling of liver and
spleen, and nephritis ; marked by severe nervous symptoms, and ending
gradually in recovery about the tenth or fifteenth day.
The disease begins with fever with or without rigors, extreme debility
and general makuse, painful sensations or violent muscular pains in back
and limbs, loss of appetite, thirst, usually diarrhoea, headache, giddiness,
and disturbed sleep. These symptoms increase in intensity for a day
or two, the weakness becomes more marked, and to the other nervous
disturbances there are added slight delirium and somnolence. On the
second or the third day jaundice appears, with marked swelling and
tenderness of the liver and enlargement of spleen ; and the urine becomes
albuminous, and shows the other changes characteristic of nephritis In
the digestive sj'stem the disturbances are very marked — furred tongue,
sometimes vomiting, diarrhceaj or constipation, sometimes abdominal pains
and uneasiness.
All these symptoms continue for two or three days more, and then
gradually subside, improvement setting in on the fifth to the eighth day.
The temperature, which has remained high, falls gradually to the normal
about the tenth day, the jaundice gradually disappears along with the
other symptoms, and convalescence begins.
The convalescence may be uninterrupted ; but in a certain number of
cases, after an apyrexial period of one to seven days, fever recurs, lasting
96 SYSTEM OF MEDICINE
five or six days, sometimes, though exceptionally, attended Avith
recurrence of jaundice, swelling of liver and spleen, and alhuminuiia.
Convalescence is in all cases slow, the patients being left much
reduced in strength for many Aveeks after.
The jaundice is the most striking symptom of the disease. It usually
shows itself about the second or third day, and rapiilly increases till,
in the course of twenty- four hours, the patient is quite yellow. It
lasts about fourteen days, and disappears slowly. Bile pigments are
abundantly present in the lu'ine ; bile acids are also sometimes present.
It is attended by awdUntj and tnidernrss of liver, corresponding in degree
to the degree of jaundice, and gradually disappearing with the latter.
In all cases there is also notal)le enlargement of spleen, recognisable at
the very outset of the fever even before the jaundice appears, and lasting
as long as the fever lasts.
The f ever is a constant symptom and is usually high, reaching 103°
or lOJ:^ F. in the course of the second or third day, and, with slight
morning remissions of about a degree, it remains high for several days.
Then between the fifth and ninth days it begins slowly to fall, and reaches
the normal about the ninth or twelfth day. In about three-fovu'ths of
the cases the temperature then remains normal. In the remaining fourth,
after a, few days' intermission, it rises again for several days, sometimes
even reaching its former height. It is only in exceptional cases that
this recurrence of fever is attended by jaundice, swelling of the liver and.
spleen, and albuminmia.
The pulse corresponds to the fever, is usually rajiid — 1 1 0 to 1 20, some-
times even 136. When jaundice appears it becomes slower.
Nervous symptoms are very prominent and constant. They include
headache, giddiness, great prostration, and more or less delirium. But
perhaps the most striking symptom of all are the muscular pains, especi-
ally in the calves of the legs ; these are sometimes so severe that they put
the other subjective symptoms into the background. The pains occur
spontaneously, and are greatly increased by movements and by pal])ation
of the muscles.
Nephritis is almost constant, and is evidenced by albuminuria, presence
of epithelial casts, and .sometimes blood. Its occurrence coincides with
the enlargement of the spleen, and it usually subsides with the latter.
Some albuminuria often persists for a long time during convalescence.
Occasional symptoms observed have been rashes, roseola, erythema,
pur]iura, herpes, and in a few cases epistaxis.
Etiolog'y. — The disease has been most commonly met with in men
between the ages of fifteen and thirty ; a few cases have occurred in
children between eight and fourteen. The greatest number have occurred
in the summer months lietween June and September, but isolated cases
have been met with in winter and spring.
It is not confined to any one class of society, but it is certainly most
common in working-men (thirty-eight out of fifty-three) whose occu-
pations or habits have exposed them to insaniUiry surroundings.
WEILS DISEASE 97
Infection undoubtedly plays the most important part in producing
it. Thus out of thirteen cases recorded by one observer (Fiedler), nine
■were in men engaged in the slaughter-house of Dresden, and two of the
others had eaten tainted sausage. Two cases described by another
observer (Stirl) Avere in workmen engaged in cleaning out a sewer, who
were taken ill with all the symptoms of the disease. Ducamp reports on
a slight epidemic outbreak of infectious jaundice in six Avorkmen who fell
ill after cleaning out a blocked sewer, three of them of gastric catarrh,
three of Weil's disease.
Lastly, a series of epidemic outbreaks of the disease have been
recorded, chiefly 1)y garrison officers in Germany.
Thus under the title of " infectious jaundice " an outbreak of jaun-
dice was recorded in 1866 by Weiss, — twenty-five cases observed by
himself, and fifteen others known to him, — presenting in all respects the
characters of "Weil's disease. In one instance the father and two sons
of a single family were attacked sxiccessiveh'. Similar outbreaks have
been recorded by Haas (18S7) and Weiss (1889), both in Prague; and
by Pfuhl (1888),"'Hueber (18'J0), and Jaeger (1892). The last observer
has reported nine cases — three of them fatal — occurring in garrison at
Ulm ; the source of infection Avas traced by him to bathing in a certain
pait of tlie river near the garrison. A similar outbreak in a garrison
Avas traced to bathing, and reported by Globig (1890).
Pathogeny. — As to the nature of the infection obserA^at ions are still
Avanting. In the outl)reak recorded by him Jaeger succeeded, in tAvo
out of three fatal cases, in discovering Avithin the organs of the body
a certain organism, with definite morphological and cultural characters,
Avhich he believes to be the cause of the disease. To this he gives the
name " Bacillus proteus fluorescens." He found the same organism in
the urine in four out of six of the patients Avho recovered, Avhereas he
failed to find it in a case of simple catarrhal jaundice. On further
investigation he ascertained that on the banks of the infected river
running past the garrison Avhere the disease Avas acquired by bathing,
the Avater-birds — ducks and geese — frequenting the river Avere subject
to a fatal disease marked by jaundice, and on examination he found the
same post-mortem changes and the same organism present in them.
In two fatal cases recorded by him NauAverck had already (1888)
found organisms in the intestinal Avail — partly Avithin the glands, partly
amidst the connective tissue — apparently Avithin Avidened lymphatics,
and forming zoogloea-like masses made up of small bacilli, AAnth rounded
ends deeply stained ; the middle portion being hardly stained at all.
Jaeger recognises in the description the same organism he also had found.
Morbid anatomy. — The disease is not usually fatal ; and hence only
a few records of post-mortem examination are available, ten in all — three
recorded by Sumbera, tAvo by NauAverck, one by Brodowski and Dunin,
three by Jaeger.
The following AA'as the condition obserA'ed by Sumbera in three fatal
cases. In all there AA-as jaundice Avith fatty degeneration of the heart-
VOL. lA' 'J.
98 SYSTEM OF MEDICINE
muscle, and numerous punctiform liamiorrhagcs cither under the skin, the
pericardium, the j^leura^, or the nuicous membrane of intestine.
Case 1. — Liver deeply bile-stained; lobules indistinct; liver -cells
sho\\nng cloudy swelling ; fatty infiltration of periphery of lobule ; con-
nective tissue not increased.
Spleen : not enlarged.
Kidneys : large and soft ; numerous punctiform hsemorrhages in cortex ;
epithelium degenerated.
Duodcnnni: mucous membrane swollen and studded with lucmorrhages.
Dura milter : inner surface covered with a ha^morrhatric membrane.
'&'
Case 2. — Lirer large, firm, deeply jaundiced; liver- cells cloudy;
nuclei considerably increased.
Gall-bladder and hile-duds : mucous membrane swollen and hypergemic.
Spleen: large, soft.
Kidneys : parenchymatous nephritis.
Bladder co'.itained urine and blood.
Stomach ami intestine : mucous membrane throughout hjqaerKmic and
catarrhal, and studded Avith haemorrhages.
Case 3. — Intense jaundice. Changes in heart, liver, spleen, kidneys,
stomach, and intestine same as in Case 2.
Blood and organs Avere examined for organisms but with negative
result.
Three fatal cases have been recorded by Jaeger. The chief changes
Averc jaiuidice; fatty degeneration of liver Avith indistinctness of lobules, and
small cell infiltration of connective tissue ; fatty degeneration and cloudy
swelling of epithelium of kidney and acute parenchymatous nephritis ;
minute haemorrhages in diH'erent organs ; sAvelling of spleen ; intestinal
changes, observed in one case only but in this one very fu)tal)le, namely,
marked vascularity, numerous htemorrhages, and superficial erosions of
mucous membrane throughout Avhole intestinal tract. No trace of typhoid
lesion ever observed. In tAvo out of the three cases Jaeger found a definite
organism in the tissues as already noted. Similar changes Avere descriljed
in the two cases by NauAverck (1881). The changes in the liver are
described l)y him as resemljling those of acute yelloAv atrophy in many
respects ; liver-cells reduced to a granular fatty detritus ; the epithelium
of bile-ducts fattily degenerated to a high degree. In the intestine
nothing special Avas noted. In both cases he found an organism in Avail
of intestine.
Nature and relation to other forms of jaundice. — The infective
nature of the disease can hardly be doubted. The sudden onset and the
character and course of the symptoms suggest this ; and its occasional
occurrence in epidemic or endemic outbreaks seems to establish it conclu-
sively. In one instance the father and the two sons of one family Avere
attacked successively. Beyond this its etiology is quite obscure ; how
WEIL S DISEASE 99
much so may best be judged from the different names given to the
condition by different observers.
Weil gave it no name at all. He was not sure whether to regard it
as a special disease, a form of " bilious typhoid," or as a form of aliortive
enteric fever. And on these points the opinions of German observers,
among whom, as I have said, the condition has received most attention,
appear greatly divided — " Infectious or septic jaundice " (Fraenkel) ;
" Febrile jaundice " (\Yagner) ; " Infectious jaundice " (Wassilieff, Weiss) ;
" Icterus typhosus " (Heitler); " Abortive enteric fever " (Haas) ; " Typhus
biliosus nostras " (Weiss).
The term " bilious typhoid " has been given to it on the ground that
its characters agree generally with those formerly described by Griesinger
under the name " typhus biliosus." Moreover, it has been thought to be
identical with the disease described as " typhus biliosus or icterodes "
met with in Alexandria and Smyrna. The name appears to me, however,
to be particularly inapplicable. For later observers have shown that the
disease described by Griesinger was really relapsing fever ; in which
disease jaundice occurs in a large proportion of cases (over 37 per
cent) [vol. i. p. 943]. And there are important differences between it
and the Smyrna disease ; in the latter the spleen is usually normal,
parotitis is common, and over 27 per cent of cases prove fatal.
The disease cannot be regarded as an abortive form of enteric fever.
Jaundice is one of the rarest complications of enteric fever. Murchison
met with only 4 cases; Jenner never with one; Liebermeister with 26
out of 1420 cases ; Griesinger with 10 out of 600 cases. Moreover, when
jaundice does occiu- it is not, as in the condition now under consideration,
at the outset of the disease.
Lastly, in the necropsies recorded typhoid lesions have not been noted.
These possibilities being excluded, there remains only the cjuestion
whether the condition is to be regarded as a special disease, or as
one form of " infective jaundice." The evidence appears to me to be
against the former and in favour of the latter view.
The closest relations of the disease appear to be with other forms of
" infective " jaundice such as are met with sporadically or endemically
both in this country and abroad, and more especially with sporadic
forms of yellow fever in America. And it is of interest to note that I
find no mention of Weil's disease by physicians in America, where febrile
forms of jaundice are so common ; or by physicians in Australia, in certain
parts of which (Broken Hill) febrile jaundice appears to be almost
endemic.
Neither in the symptoms nor in the morbid changes described as
Weil's disease is there anything essentially characteristic. They are
those of a scA'ere icterogenetic poison, more severe than that found in
epidemics of ordinary catarrhal jaundice, and in most cases not so severe
as that observed in cases of " malignant " jaundice (icterus gravis). Its
relations to both these varieties of jaundice are, however, manifest. Thus
I find four cases recorded (von Fetzer, 1SS2) amongst soldiers, three in
loo SYSTEM OF MEDICINE
August and one in September, in certain rooms of a barrack in Avhich
there had been an outbreak of epidemic (catarrhal) jaundice from
February to June of the same year ; one of those attacked in August
having suffered from " catarrhal " jaundice in June. On the other hand,
the symptoms and post-mortem appearances in severe fatal cases are
absolutely indistiuiruishable from those of severe cases of icterus gravis.
In two of Jaeger's cases even tyrosin crystals were found in the urine.
It appears to me, then, that until the nature of the infecting agent can
be determined, no advantage is to be gained from regarding a condition
which probably OAves its origin to different infective agents in different
localities as a special disease, or in giving to it the name of any one
observer.
The older name of " infectious jaundice " serves sufficiently to de-
scribe it.
As regards the character of the jai;ndico itself, it remains to point out
that there is a striking' similarity between it and that producible experi-
mentally in dogs by toluylendiamin. Great swelling of sjjleen and liver
and nephritic changes are constant features of the action of this drug.
When large doses are given I have found that considerable fever is also
present.
Post-mortem the changes are identical, the bile-ducts being distended
with bile ; and, most striking of all, the duodenum shows in certain cases
the marked congestion which I have described as characteristic of the
action of toluylendiamin.
REFERENCES
1. Bkodowski and Dunin. " Ein Fall der sogen. "Weils'clien Krankheit iiiit
lethaleni Ende," D. Arehivf. klin. Med. xliii. — 2. Fiedler. " Zur Weils'chcn Krank-
heit," D. Arehivf. klin. Med. Bd. xlii. 261. — 3. Fraexkel. "Zur Lchre voa
der sogenannten \yeirschen Krankheit," Berl. klin. Tfoch. 1889, No. 33. — 4.
Goi.denhorn. "Zur Frage ueber die Weils'clien Krankheit," Bcrl. klin. li'och.
1889, No. 33.-5. Goldschmidt. D. Archiv/. klin. Med. Bd. xl. S. 238.-6. Jdnn.
"Ein Beitrag zur neuen Infection-skrankheit Weils." — 7. HErrLER. "Zur Klinik
des Icterus Catarrh," JFien. vied. U'och. 1887, No. 30. — 8. M.\thieu. "Typhus
hepatique henin," Revue de m6d. 1886, ii. 633. — 9. Nauwerck. "Zur Kennt-
niss der fieberhaften Gelbsucht," Munch, med. JFoch. 1888, No. 3.'). — 10. Wagner.
"Zwei Fallc von fieberhaften Ikterus," D. Arehivf. klin. Med. Bd. xl. p. 421,
1887.— 11. Wassilieff. "Ueber infektiosen Ikterus," Jl'eiucr A'linik, 1889.-12.
Weii,. "Ueber eine eigentliiiniliche, niit Milztumor, Ikterus und Nephritis eiu-
hergehende akute Infectionskranklieit," D. Arehivf. klin. Med. xxxix. 1886. — 13.
Weis.s. "Zur Kenntniss und zur Geschichte der sogenannten Weils'chen Krank-
heit," JFie7i. med. JFoch. 1890, Bd. xl. 425, 470, 516, 557, 611. — 14. Windt-
SCHEIDT. "Zwei Fiille von Weils'chen Krankheit," D. Archiv/. klin. Med. Bd.
xlv. S. 132, — 15. Young, E. H. "Notes on a Case of Weil's Disease," Lancet, 1889,
ii. 1109.
W. H.
ACUTE YELLOW ATROPHY OF LIVER loi
ACUTE YELLOW ATROPHY OF LIVEE
Synonyms. — Idlre grave, Icterus typhoides (Lebert), Acute parenchymatdse
Hepatitis (Foerster), Icthe hdmorrhagique essentiel (French authors),
Parenchymat'Ose Degeneration der Leber (Liebermeister).
Definition. — An acute disease, probably of toxic origin, characterised
by jaundice in association with severe cerebral symptoms, black vomit, and
haemorrhages ; and by marked diminution in the size of the liver due to
parenchymatous degeneration.
History. — The disease was probably not unknown to earlier writers,
but only a few cases, and these of doulitful nature, are recorded until
early in the present century. According to Dr. Wickham Legg, no
record of any case is to be found earlier than 1616. One of the first to
record cases presenting the features of this disease was Morgagni. Early
in this century ol-servations were made by the Diiblin physicians,
Cheyne (1818), O'Brien (1818), and Marsh (1822); and in Edinburgh by
Abercrombie (1828). One of the earliest and fullest accounts of the
disease, however, was that given by Bright (1836) ; he described it as
a diffuse " inflammation " of the substance of the liver affecting the gland-
ular substance more than the connective tissue, leading frequently to
marked diminution in the size of the organ, causing jaundice associated
with severe nervous symptoms, and a special tendency to heemoxThage.
Bright's account must be regarded as the earliest recognition of the disease
as a definite symptom group. He regarded it as a " diffuse inflammation."
The history of the disease, under the title it now bears, dates from
1843, in which year Eokitansky, basing his description mainly on the
naked-eye appearances presented by the organ, described it under the
name "acute yellow atrophy."
It was not till a few years later that the characteristic microscopic
appearances, significant of degeneration of the liver -cells, were de-
scribed; first of all by two English observers — Busk (1845) and Hand-
field Jones (1847).
In France the first full account of the disease was given by Ozanam
(1849), under the title of a "forme grave de I'ictere essentiel."
From this time onward oltservations accumulated. Lebert's account
of the disease (1854) was based on a study of seventy-two recorded
cases of icterus gravis, many of them of doubtful nature. He regarded
the condition as a general disorder rather than as a special disease of the
liver, and preferred to name it icterus typhoides ; this view was propounded
about the same time by Buhl also.
In the first edition of his well-known work on Diseases of the Livel
(1858), Frerichs gave an account of the disease based on a study of
I02 SYSTEM OF MEDICINE
thirteen cases which had come under his own obsei'vation, and thirty-one
recorded cases.
Later important contributions to the study of the disease were made
by Wunderlioh (1860), Wagner (18G2), Liebermeister (18G4).
The remarkable similarity between the morbid changes found in the
liver aTid kidney in this disease and those produced by phosphorus
poisoning was first pointed out by Rokitansky (1860). "Wagner was the
first to suggest that many cases of tte disease miiiht really be unrecog-
nised cases of phosphorus poisoning.
Liebermeister's contribution was an important one. He described ten
cases observed by himself, and made a study of all the cases of idems
graris on record (177 in number recorded by eighty-two authors), fitted
to throw any light on the relation between that condition and acute
yellow atrophy.
Amongst more recent accounts the two fullest and best are those
given by Wickham Legg (1880) and Thierfelder (1880) ; the latter based
on a study of 1-43 cases recorded up to the year 1876, the former on 100
cases recorded up to the same date (1876-77).
The present account is based mainly on fifty cases which I have
collected in the records from 1880 to 1894 inclusive.
Etiology. — Acute yellow atrophy must be ranked amongst the rarest
of diseases. It is seldom met with even in the largest hospital practice.
Out of 25,700 cases admitted during nine years into the London Fever
Hospital at a time Avhen a brown tongue and delirium constituted a sure
passport to admission, Murchison states he only met with one case.
Wickham Legg found only one case in the course of nine years at St.
Bartholomew's Hospital. Thierfelder estimates with some probability
that the total number of recorded cases up to the year 1880 does not
exceed 200.
Since then, betAveen the years 1880 and 1894 inclusive, I have been
able to collect some fifty additional cases, thus bringing the total up to
250. As regards the rarity of the disease Liebermeister's experience
must be regarded as exceptional. No fewer than ten cases, confirmed by
autopsy, came under his observation in a comparatively short period, and
he stands alone in regarding the disease as one comparatively common.
It is probable that amongst this number were some which ought to be
grouped as cases of icterus gravis rather than as acute yellow atrophy.
This appears the more likely, as Liebermcister considered the chief
criterion of the existence of the disease to be the occurrence of " parench}'^-
matous degeneration " of the cells of the liver, a pathological condition
by no means confined to acute yellow atrophy.
Age. — Acute atrophy is most commonly met Avith betwixt the ages
of 20 and 30 (50 per cent), but no age is exempt. It is very rare in
childhood below the age of 10; 8 cases out of 143 collected by Thier-
felder, 7 out of 100 collected by Wickham Legg, - out of 63 collected
bj' Lebert, 4 out of 37 collected by myself occurred in patients under 10
years of age.
ACUTE YELLOW ATROPHY OF LIVER 103
The earliest age recorded is that of an infant taken ill four days after
birth (Politzer),. Of the four recent cases I have collected, one was aged
1\ (Goodhart, 1881), one aged 7 (Venn, 1884), one aged 6 (Eoss, 1888),
and one aged 10 months (Yeoman, 1892).
One-half of the cases have occurred between the ages of 20 and 30,
more than four-fifths between the ages of 10 and 40. Below 10 and
above 40 the number rapidly diminishes.
Sex. — The influence of sex is undoubted; one of the few facts
definitely established as regards the etiology of the disease is that females
greatly preponderate among those attacked. Between the ages of 20 and
40, when the liability to the disease is greatest, the proportion of females
to males attacked is exactly double. This greater liability is connected
with the occurrence of pregnancy. Out of 49 cases recorded by Thier-
f elder in women, 18 occurred in pregnant or lying-in women. Out of
Frerichs' 31 cases, 22 were women and 11 of these Avere pregnant. Out
of 69 cases in Avomen collected by Wickham Legg, 25 were in pregnant
women. Out of 42 recent cases collected by nwself, 24 Avere in
women ; and of these 1 2 Avere pregnant, or suckling. It occurs in every
stage of pregnancy except the first three months, but is most common
about the middle period. The greater disposition to the disease thus
shoAvn by pregnant Avomen is probably related to the fact first observed
by VirchoAV (1848), namely, that a certain degree of parenchymatous
defeneration of the liver and renal cells is a common condition in
pregnancy. Even in pregnant Avomen, hoAA'ever, the disease is of very
rare occurrence — only 1 in 28,000, according to one observer (Braun),
or 2 in 33,000 (Spaeth). Pregnant and suckling Avomen show a similar
liability to be attacked by other severe forms of jaundice — notably that
occurring in epidemics.
Seasons. — Season of the year is Avithout any influence. It is met
with alike in extremes of heat and of cold.
Constitution. — The majority of cases occur in those of robust con-
stitution, a certain number in persons Aveakened by excess ; this latter
number is not so great as to suggest any special relation betAveen Aveak-
ened constitution and liability to the disease.
Syphilis. — No definite relation can be traced betAveen syphilis and the
disease.
Alcohol. — Nor can any definite part in the causation of the disease
be assigned to alcohol. A certain number — in Thierfelder's cases 13 out
of 143 — occurred in patients who Avere or had been heavy drinkers;
and in some cases — 6 out of the foregoing 13 — the attack had folloAved
a period of unusually heavy drinking. As pointed out by Liebermeister,
the habitual use of alcoholic drinks favours a certain degree of par-
enchymatous degeneration of the liver.
Other hepatic diseases. — The disease occurs not only primarily, as an
acute process in persons previously in good health, but also secondai'ily in
persons already the subject of liver disease. A certain number of cases are
recorded in Avhich it occurred secondarily to, or was superadded to cirrhosis
104 SYSTEM OF MEDICINE
of the liver, long persistent biliary obstruction, or chronic fatty de-
generation. Amongst more recent cases, as in one recorded by Dr. Cayley,
it supervened on a chronic cirrhotic process, the result of free drinking ;
in a case of somewhat doubtful nature, a child aged 7, it followed hyper-
trophic cin-hosis.
There is no evidence, however, that these morbid conditions — which
after all are relatively very common — have any special causative relation
to the disease, except in so far as they induce an unhealthy state of the
liver-cell.
Mental emotion. — That an antecedent morbid condition of the liver-
cell is not necessary for the occurrence of the disease is in no wise more
clearly evidenced than by the fact that in the great majority of cases, as
I have said, it attacks people prcviousl}^ in robust health ; and in a con-
siderable j)roportion of these cases the only cause assignable has been
the influence of fright or some depressing mental emotion. Out of
Lebert's 72 cases, 13 were assigned to the latter cause; IG out of 100
cases collected by Wickhani Legg ; and one-tenth of the cases according
to Thierfelder. Most of these cases were in women. It is on the basis
of such cases some authors have surmised that acute yellow atrophy is a
nervous disease (von Dusch), or at any rate that dejiressing emotion
plays a pre-eminent part in its causation (Liel)ermeister). Among recent
cases I find only two ascribed to mental shock, — one in a pregnant
woman aged 24 (Hayward, 1890); one in a man aged 41 recorded
by Duckworth. This man saw his own child run over in the street ; on
the following day he became jaundiced, and four weeks later the acute
svmptoms set in. Such an ascription has, however, but little in its
supi)ort.
Tone influences. — It is when we come to discuss the relations of acute
yellow atropliy to other forms of severe jaundice that we find some light
thrown on the probable etiology of the disease. The condition of
liver and kidney in acute yellow atrophy, as first pointed oxit by
Ilokitansky, closely resembles that induced by phosphorus poisoning.
Moreover, certain symj^toms are cunimou to the two affections, those
which are constant in the one being constant in the other; Avhile the
constant symptoms occur in both with alx)ut the same relative frequency.
It has been suggested, accordingly, that some cases of the disease under
discussion may really be obscure cases of phosphorus poisoning ; by some
writers, iiideed, it has been urged that all cases have this oi-igin.
The resemblances — namely, the parenchymatous changes in liver and
kidney attendL'd liy jaundice and severe nervous syinptums — are untloul)t-
edly so striking as to suggest that the one disease like the other has a toxic
origin ; yet there are certain differences which appear no less clearly to
denote that the two diseases are not identical. Thus, as regai-ds the size
of the liver, ont of 15 cases of plios])horus poisoning, collected by Lewin,
in which the condition of liver was noted, in no case Avas it diminished ;
in 4 it was normal, aii<l in no fewer than 11 it was actually enlarged.
Moreover, even as regards the prominent feature — jaundice — recorded
ACUTE YELLOW ATROPHY OF LLVER 105
experiences are rare. Out of 20 cases collected by Liebermeister, in only
one was it missed. On the other hand, Lewin found it present in a
minority of cases only — 1.5 out of 44 ; and Ehide, likewise, in 8 cases
out of 2.3. And there are minor difterences between the two con-
ditions ; especially as regards the characters of the urine and the general
character of the nervous symptoms.
On the whole, then, taking the most liberal interpretation of the
relationship between acute yellow atrophy and poisoning by phosphorus,
we should have to conclude that the former must be an anomalous form
of poisoning by the drug — a conclusion, I need hardly say, somewhat
different from the allegation that the two affections are identical. The
resemblances between the two conditions, such as they are, nevertheless
lend strong support to the view that acute yellow atrophy, if not due to
phosphorus, is due to some toxic agent.
Further support is lent to this opinion when we consider the close
affinities between the disease and other forms of severe jaundice, where
the action of specific poisons is less doubtful ; such, for example, as yellow
fever and severe cases of icterus gravis. The resemblance between yellow
fever in particular and acute yellow atrophy are many and striking, so
many as even to suggest to some observers that the latter may be
nothing more or less than sporadic cases of the former.
And so it is with regard to other forms of severe jaundice — icterus
gravis — whether occurring sporadically or in epidemic form. Many such
outbreaks of icterus gravis have now been recorded, sometimes widespread,
sometimes limited to one single household ; and the more severe of these
cases present many of the features of acute yellow atrophy, including
the nervous disturbances, the haemorrhages, and so on. Thus Budd
observed several cases of severe jaundice on board a ship : one fatal case
showed parenchymatous degeneration of the liver-cells ; in another, where
recovery eventually took place, severe nervous symptoms and bloody
stools were present. Three very striking cases of the same kind, and oc-
curring in one family, I find recorded by Graves in his Clinical Lectures.
The first case was a girl aged 17, who was suddenly seized with vomiting
and jaundice ; on the fifth day she became comatose, liad convulsions, and
died on the day following. Nine months later her sister aged 1 1
suddenly fell ill, became jaundiced on the third day, vomited black
matter, became insensible and convulsed, and died on the fourth day.
The liver was found of normal size, but soft in consistence, the cut surface
presenting a peculiar crimson-orange colour. Three months after this
another sister, aged 8, also fell ill with jaundice and vomiting ; on the
second day headache and restlessness appeared, on the third day she
began to recover.
In an epidemic outbreak of jaundice amongst convicts reported by
Carville there Avere 11 fatal cases out of 47 attacked; and in no
fewer than half of the cases haemorrhages occurred.
A further point of resemblance between such severe cases of jaundice
and acute yellow atrophy is that in such epidemics the disease is
lo6 SYSTEM OF MEDICINE
pcculitarly fatal amongst pregnant and suckling Avomen. Thus in the
epidemic which occurred in IMartinique in 1858, reported by Gallot, the
only severe cases occurred amongst pregnant women, of whom no fewer
than 20 died after abortion.
Now, it is noteworthy, in the same relation, that amongst the 44
recent cases of acute yellow atrophy collected by m}''self, no fewer than
9 (all in pregnant women) are recorded by three observers, and all of them
Australian ; from districts where epidemic outbreaks of jaundice seem
comparatively common (Broken Hill Proprietary). Two of these cases,
carefully recorded by Creed and Scot-Skirving (1889), are especially
worthy of note, inasmuch as they presented all the clinical features of
acute yellow atrophy, including diminution of liver dulness, yet ended in
recovery. In one leucin and tyrosin were present in the urine, in the
other the symptoms included severe nervous phenomena, ])etechia} over
limbs and trunk, and coffee-ground vomiting. Both occurred in pregnant
"women about the eighth month (8 and 8^ respectively), and they occurred
in the same neighbourhood. In each case there was premature delivery
on the seventh day. The five cases reported by one observer (Hardie,
1890) are closely alike ; all of them ended fatally. In three the liver
Avas found diminished in size during life, the observation being confirmed
after death (30, 30, and 32 oz.) In two the urine contained both leucin
and tyrosin, in one leucin without tyrosin. Six cases, indeed, are
recorded by Hardie ; but one of these (the third) I have not included, as
it appears to me of doubtful nature.
The resemblance between acute yellow atrophy of the liver and
severe fatal cases of icterus gravis is thus exceedingly striking. It ex-
tends not only to the clinical features and course and morbid anatomy,
but also to the occasional endemic characters of the former disease.
The resemblance is so striking as to render it probable that, in the one
as in the other, toxic influences or agencies are at work ; this presump-
tion is the stronger in icterus gniris on account of its comparatively
frequent occurrence in endemic and even in epidemic form. Of what
nature these toxins may be, whether miasmatic or bacterial, we know
as yet nothing.
In arriving at this conclusion, which appears to be most in conson-
ance with the facts, it is not necessary to press it so far as to assume
that the toxic agencies are specifically the same, and different oidy in
degree. On the contrary, acute yellow atrophy is probably a specific
variety of icterus gravis. Its occasional occurrence in endemic form, as
in the cases above described, undoubtedly lends much support to the
view that toxic influences of specific nature play the most important
part in its etiology.
Symptoms. — At the onset of the disease there is nothing in the
features of the mahidy to distinguish it from an ordinary attack of
jaundice. The disease is ushered in with the same symptoms — loss of
appetite, malaise, nausea and vomiting, and epigastric discomfort, followed
in the course of a day or two by the appeai'ance of jaundice. The only
ACUTE YELLOW ATROPHY OF LIVER 107
feature that may possibly mark it off from a simple attack of jaundice is
the occurrence of some rise of temperature at the outset. This stage lasts
on an average some five to six days ; but it varies considerably. During
this time the physical signs are in no sense obvious. The tongue is
coated, the bowels constipated ; the pulse averages 60-70 beats per
minute, the respiration is unaffected ; and, beyond perhaps some slight
degree of epigastric tenderness on pressure, nothing abnormal is presented
by the abdomen. There are in addition the usual signs of jaundice,
both in the skin and in the urine.
Suddenly a marked change occurs, ushered in usually by severe and
repeated vomiting. In a few hours the patient passes into a condition
of drowsiness and semi-consciousness, followed by great restlessness and
delirium ; occasionally he screams out loudly, or attempts to get out of
bed, or even becomes maniacal. Simultaneously the jaundice assumes a
deeper and more of a greenish hue, the tongue becomes dry and brown, the
pulse rapidly rises in frequency (120-140) and loses in strength, the respira-
tion is quickened. The temperature, which in the first stage may have
been considerably raised, now becomes subnormal. The vomiting, hither-
to perhaps intermittent, again recurs with greater severity than ever,
it becomes almost continuous ; the vomited matter frequently contains
blood ; blood may also be passed by the bowel, making the stools dark
and offensive ; haemorrhages also occur under the skin or from the nose
and mouth ; in women severe metrorrhagia sets in, and in pregnant
women abortion or premature delivery ensues.
The most notable physical change, however, is that presented by the
liver, rapid diminution in the area of hepatic dultiess, so that instead
of the usual area from the fifth rib to the edge of the costal arch, it may
be reduced to a finger's breadth ; or in severe cases it may disappear
altogether.
Next to the liver the most marked changes are presented by the
urine. Contemporaneously with the changes in the liver the urea is
diminished, and its place is taken by abnormal constituents — notably by
tyrosin and leucin. Not infrequently also albumin is present, although
only in small quantity.
The second stage, marked by the above severe symptoms, is of short
duration. Under the combination of them all the patient rapidly
passes into a muttering delirium, with or without convulsions, and dies in
from two to three days.
If, passing from the above general description of the ordinary course
of the disease, w^e consider the more prominent featm-es in detail, the
most notable, and that which gives the name to the disease, is un-
doubtedly the peculiar change in the liver.
The diminution in the area of hepatic dulness usually does not become
manifest until after the onset of the severe nervous symptoms, and often
not till within a few hours of death. Within this period of time it
proceeds so rapidly that in the course of forty-eight hours the vertical
io8 SYSTEM OF MEDICINE
dulness in the right mammary line may be reduced from the normal 5 or
6 inches to 1 or 1 i inch. The diminution first becomes manifest in the
left lobe, and subsequently in the right. If the liver has been pre-
viously enlarged from any cause, as by cirrhosis, fatty infiltration, gall-
stones, or syphilis, the diminution may be scarcely evident if at all ;
but, in unconi^jlicated cases, it is easily made out towards the end of life,
all the more readily because of the absence of meteorism or any other
abdominal distension. As subsequent examination shows, the diminished
dulness is due partly to diminished volume of the organ, but also in part
to a falling back of the tiabby and greatly shrunken organ from the
anterior abdominal wall.
As regards the condition of the liver in the earlier stages of the
disease, observations are, unfortunately, but scanty, and for the most part
those that exist are at variance. In the majority of cases the condition
of the liver was not noted until the onset of the severe nervous symptoms
directed attention to the true nature of the case. By this time the
diminution in size has usually begini. In a certain number of cases,
however, in Avhich earlier observations had been made, the stage of
diminution Avas found to have been preceded by one of enlargement.
In one such case the hepatic dulness on the first examination was
found normal ; two days later it was increased ; and two days later still
it was reduced below the normal size.
In a case recently recoided by Sir Dj^ce Duckworth (1892), in a man
aged 41, the liver dulness at the time of the first observation was found
to extend from the 6th rib to just above the level of the umbilicus in the
nipple line, the edge of the liver being palpable. On the following day
the edge Avas no longer palpable ; and two daj^s later it had disappeared
altogether over the back and axillary region, and in the nipple line it
extended only li inch downwards from the 6th rib. After death the
liver was found to weigh 28 oz. (instead of the normal 50-60 oz.)
The position in which the remaining dulness is to be detected is usually,
as in the above case, in the neighbourhood of the 6 th rib, extending an
interspace or a little more downwards.
In a case of a man, aged 28, who died in four days from the first onset
of symptoms, and two days after he had l)een walking aliout, the liver
dulness was reduced to 1 i inch below the 5th intercostal space ; and in
another case, a man aged 25, it extended from the 6th rib to the lower
border of the 7th.
In a case of a Avoman aged 26, on the fourth day the area of hepatic
dulness was only one inch deep ; and on the next day it had disappeared
altogether.
The diminution in aica of dulness is usually the more marked,
inasmuch as Iti gcneial there is an entire absence of meteorism.
In l)ut few cases is the liA'cr dulness normal, and they are usually
cases in which the liver has been chronically enlarged. Even in these,
however, the dulness is reduced, although it does not fall below the
normal.
ACUTE YELLOW ATROPHY OF LIVER 109
As regards the frequency with which this change occurs, the records
are unfortunately imj^erfect. Thus out of 44 recently recorded cases
collected by myself, in only 24 is mention made of the condition of the
liver during life. In the great majority of these, shrinking was detected
(21 out of 24).
In some cases there is sensitiveness on pressure over the liver, some-
times to a very high degree ; especially during the second stage. But
this is not constant ; more usually there is merely dull pain over
epigastrium.
Gastro-intestinal symptovis. — The gastric symptoms are prominent in
all cases ; they include nausea, sickness, coated tongue, and above all
vomiting. This is often met with in the first stage as one of the earliest
symptoms ; but it is a constant feature of the second stage, and is of a
particularly urgent and severe character. The vomit soon tends to
assume a dark colour from presence of altered blood, and resembles
treacle in appearance ; sometimes it contains bile.
The bowels are usually constipated, and may be so throughout ; but
in some cases, especially in the second stage, they are loose, and the
motions very offensive. They often contain bile, and sometimes altered
blood.
The jaundice is in the great majority of cases one of the earliest
symptoms, making its appearance a few days after the first feelings of
illness. At first it differs in no respect from that due to simple catarrh,
the urine giving the usual Gmelin's reaction of bile pigment. It may
vary somewhat in intensity during the first stage ; but, as a rule, it
steadily increases till the second stage, when, with the onset of the
nervous symptoms, it suddenly deepens and at the same time alters in
character, the discoloration of the skin assuming a greenish tint.
With this change there may also be a change in the character of the
pigments in the urine. The urine may still be dark and give a yellowish
foam, as if from much bile pigment ; but, on testing, Gmelin's reaction
may be faint or even entirely absent. Bile acids have been found in
many cases.
In a few rare cases presenting all the features of the disease^
including atrophy of the liver, jaundice has been absent, or has been
confined to the liver. But these must be regarded as quite exceptional
instances.
Fever. — A certain degree of fever is usually met with in the first
stage at the outset ; it then falls to normal or subnormal again, usually
rising during the second stage. But there is no general rule.
In the first stage the temperature may be normal or even subnormal
(96°); then, with the onset of nervous symptoms, it may rise to 102°
or 103°, sometimes becoming hyperpyrexia! just before death, attaining
105° to 106° F. (3 out of 16 recent cases). In other cases the tempera-
ture may never rise above 99° F. ; or may remain persistently below the
normal 96° to 98° F. (8 out of 16 cases). In other cases, again, the
temperature may be high to begin with (103° F.), and then, Avith the
no SYSTEM OF MEDICINE
onset of the second stage, fall below the normal (97"5° F.) (3 out of IG
cases). In other cases the temperature may not rise till the last twenty-
four hours before death, when it may become hyperpyrexial (105° F.) (2
out of 16 cases).
Ilaniwrrhages are very common : they are met with in more than one-
half of the cases.
Hfematemesis is most common : melrena (one-fourth of the cases),
petechife, and ecchymoses under skin, are not infrequent : less frequently
epistaxis occurs, and in a few cases hcematuria ; in women metrorrhagia is
common.
Haemorrhages are a feature of the second stage.
The Urine. — The urine is usually slightly diminished in quantit}^
varying in specific gravity from 1015 to 1030; it is deeply bile-stained,
and sometimes throws doAvn a heavy deposit of urates. It usually gives
a well-marked reaction to Gmelin's test for bile pigments. But other
pigments are obviously present ; for sometimes, notwithstanding bilious
colour, this reaction is not given. It is probable that urobilin is greatly
increased in such cases ; but on this point information is much required.
In one recent case indican was much increased.
Albumin is often present, but seldom in any quantity. Out of 24
recent cases in Avhich the urine was examined, in only one was much
albumin present.
Sugar is not found.
Urea is usually much reduced — sometimes to a mere trace ; that it
should be greatly reduced is not at all surprising Avhen we consider that
in health the amount excreted depends mainly on the quantity of food
taken ; and that, in the second stage of this disease, owing to the constant
vomiting, no food is retained. Information is greatly wanted as to the
extent of the reduction met with. Among recent cases, 44 in number,
there are only 24 in which information as to urine is forthcoming; and
out of these 24 I find only 7 in which the urea Avas estimated. '
In a case recorded by Dr. Cayley, the urine four days before death
was found to contain only 0'7 per cent of urea, instead of the normal .
2 per cent. Neither leucin nor tyrosin was present. The liver weighed
33 oz.
In a case recorded by Dr. Cullingworth, in which the urine Avas
investigated by Professor Gamgee, the amount of urea in twenty-four
hours was 6*67 grammes instead of the normal 30 grammes. In this case
there was no trace either of leucin or tyrosin in the urine, although
these substances were present in the liver. The liver weighed 24 oz.
(the normal weight being about 50 oz.)
In a case recorded by Dr. Ralfe the percentage of urea was 1'9;
leucin and tyrosin were present. The liver weigheil 34 oz. He refers
to another case observed by him in which the urea was but slightly
diminished.
In a case recorded by Sir Dyce Duckworth the percentage of urea,
on the day before death, was found to be TG, and next day 1*5. The
ACUTE YELLOW ATROPHY OF LIVER in
liver weighed 28 oz. On the first examination tyrosin was found, with
doubtful leucin ; in the last neither leucin nor tyrosin was present.
Leucin and Tyrosin. — The presence of these bodies constitutes the
most characteristic feature of the urine in this disease. The latter is
sometimes thrown down in crystals on cooling ; the former appears on
evaporation of the urine. Frerichs found them in every case in which
he looked for them ; later observations, however, show they are by no
means constantly present.
Out of 34: cases collected by Thierf elder, in which the urine Avas
examined in this relation, in 7 the result was negative; in 17 both were
found ; in 3 tyrosin only ; in 7 leucin only.
Out of 2.3 recent cases collected by myself, in 9 neither was found ;
in 1 0 both were found ; in 3 tyrosin only ; in 1 leucin only.
In one of the cases in which neither was found (Gamgee), it is
interesting to note that both were found in the liver; as much as 10
grains of leucin and over half a grain of tyrosin were found.
Duration. — The duration of the disease from start to finish varies
considerably, according as it attacks one previously healthy, or supervenes
on some other aff'ection of liver. In the majority of cases it does not ex-
ceed 14 days, and rarely does it exceed three weeks.
Duration of Disease.
Thierfelder.
102 Cases.
Days. Cases.
2-4 5 )
5-7 18 V54 5-7 3 > 15
8-14 31 )
15-21 22
3- 8 weeks. 26
Among recent cases collected by me, in only one did it exceed 31
days, namely, 57 days (Glynn).
The relative duration of the two stages of the disease varies within
wide limits.
In certain cases, indeed, where the disease supervenes on some other
morbid condition of liver, such as cirrhosis, it is not possible to determine
when the disease commences.
First stage. — In 24 recent cases in which information on this point is
forthcoming, the duration of the first stage, from the first onset of
symptoms to the appearance of the nervous disturbances ushering in the
second, varied from two days to three or four weeks. In two cases it ex-
ceeded four weeks ; namely, over six weeks (Cayley), two months (Glynn).
Second stage. — Of greater interest is it to ascertain the duration of the
second stage, when the true nature of the disease is recognised.
Thus in 26 of my cases, in which information on that point is
Hunter.
29 Cases
•
Days.
Cases,
2-
- 4
4)
5-
- 7
4
8-
-14
8)
15-
-21
5
3-
- 8
weeks.
9
112 SVS TEM OF MEDICINE
given, I find the duriitioii of the second stage varied from one to seven
days, and on an average was from two to three days.
Duration of Second Stage in twenty-six Cases.
Days. Cases.
1-2 12
3-4 12
5-7 2
These results agree with those of Thierfelder, obtained from 118
cases ; namely : —
Days. Cases.
1- 2 56
3- 4 43
5-7 15
9-14 4
According to their severity it has been proposed by Thierfelder to
divide cases into three groups: peracute, subacute, and protracted. It ap-
pears, however, hardly worth while to distinguish relative degrees of acute-
nes3 in a disease which, once it has manifested itself, is usually so acute.
The disease, however, is not invariabl}'' fatal. A considerable number of
cases are now recorded in which recovery has taken place. Two such cases
are recorded by Creed and Scot-Skirving. The first Avas that of a woman
aged 24, in the 8th month of pregnancy, who was attacked with severe
jaundice, and was delivered spontaneously on the 7th day. Hej)atic
dulness was greatly lessened, and leucin and tyrosin were found in the
urine. She recoA'ered in the course of six weeks, the area of hepatic
dulness being then found normal.
The second case was that of a woman aged 23, between the 8th and
9 th months of pregnancy. She suffered from moderate jaundice lasting a
week, and then urgent symptoms set in — including coffee-ground vomiting
and petechias on limbs and trunk — and she was delivered prematurely of
a jaundiced child on the 7th day. The extent of liver dulness was re-
duced to three fingers' breadth. In this case no leucin or tyrosin was
discovered in urine.
Morbid anatomy. — The chief change is presented by the liver. This
is greatly reduced in size, and is found lying collapsed, with smooth surface
and wrinkled capsule, fallen away from the ribs in the right hypochondrium.
Both on surface and on section it shows a number of orange - yellow
pitches of varying size and irregular outline, distributed irregularly
throughout its substance ; the remainder of the liver is of reddish colour,
of uniformly soft consistence, and its lobules much smaller than normal.
In the yellow portions the lobules cannot be distinguished.
On microscopic examination the liver-cells are found extensively
degenerated ; they are swollen with .indistinct nuclei, and the cells are
filled with fat granules. In parts they have entirely disappeared, and
ACUTE YELLOW ATROPHY OF LIVER 113
are represented by masses of fat granules held together by the liver
stroma.
The appearances differ somewhat in the yellow and red portions. In
the latter, in addition to fatty degeneration, there is in some cases a
small-celled infiltration around the portal vessels and throughout the
lobule ; the interlobular bile-ducts being numerous and prominent, their
epithelium tinged with bile, and their lumen filled up with small
masses of bile pigment. The larger bile-ducts are usually free from
bile, and contain mucus only ; but the gall-bladder often contains some
bile.
The reduction iti size is variable, but amounts on aii average to one-
third or more. Among forty-four cases collected by me the weight of
the liver is given in twenty-eight cases occurring in adults. In five of
these the weight was below 30 oz. (the average normal weight being 50
oz.) ; namely, 24, 25, 23, 23, and 28 (Cullingworth, Suckling, Tomkins and
Dreschfeld, Moore, Duckwoith, respectively). In nineteen the weight
varied between 30 and 38 oz. In one the liver Avas enlarged — 66 oz. —
from old-standing fatty disease (Dreschfeld). Leucin and tyrodn have been
found in the liver in a considerable number of cases : out of thirty-four
cases examined in this res]3ect, in fourteen both were found ; in six,
leucin alone ; in four, tyrosin only ; in twelve, neither substance (Thier-
felder). Among recent cases only three, appear to have been examined
in this respect ; in two both substances were foimd (Cullingworth,
Pincherle) ; in the other neither was found (Suckling). Dr. Culling-
Avorth's case is of special interest, as one of the most fully investigated
cases on record (1881); the histological investigation was carried out by
Professor Dreschfeld, and the chemical investigation by Professor Gamgee,
who determined the actual amount of leucin and tyrosin in the liver ;
namely, 10"8 grains of leucin, and 0"56 grains of tyrosin. Curiously
enough, no trace of these bodies was found in the urine.
Micro-organisms have been sought for in a few cases, but usually Avith
negative results. Bacteria and micrococci have been described by Klebs
in three cases ; they Avere present in the large and small bile -ducts,
as well as in the interstitial connective tissue. Among recent cases
three have been carefully examined by Dreschfeld (1881); in tAA^o of
these the result Avas negative. Koch's method for detection of micro-
organisms Avas applied to numerous sections Avath negative result. In a
third case (that of Tomkins), examined half an hour after death, numerous
large micrococci Avere found in the portal canals filling the arteries
and capillaries ; sparingly distributed in the yelloAvish portions, but more
numerous in the reddish portions, chiefly in the peripheral part of the
lobules and interlobular spaces : they Avere found only in those parts of
the lobules Avhere the liver-cells Avere either intact or only beginning to be
diseased.
The spleen is usually more or less enlarged, soft, and diffluent ; and
sometimes this enlariiement is recoiinisable durino; life. Amons; recent
cases collected by me I find the Aveight recorded in six only ; it varied from 5
VOL. IV I
114 SYSTEM OF MEDICINE
to 10 oz. : ill two it is stated to have been enlarged ; in other two it is
statetl to have been not enlarged.
The Hdncijs show fatty degeneration of the epithelium of the con-
voluted tubules.
Hu'inorrhaiies are present not only under the skin, lint scattered
throughout the mesentery, the pericardiac and pleural surfaces, the mucous
membrane of stomach, the pelvis of kidney and the bladder.
Pathogeny. — The nature of this rarest of diseases is still for the
most part wrapt in mystery. It may be (i.) a general constitutional
disease to Avhich the atrophy of the liver is only secondary ; or (ii.) a
primary disease of the liver — an acute inflammation leading to destruction
of the secreting structure ; or (iii.) a form of phosphorus poisoning; or
(iv.) a rare form of infective disease, having its relations, not with con-
stitutional disease, but with other forms of jaundice produced by infective
agents.
(i.) In favour of the first proposition, it has been pointed out that not
the liver only, but other organs — the kidneys and the heart — are also
found fattily degenerated.
(ii.) In favour of the second proposition, it is pointed out that the
changes are undoubtedly most marked in the liver ; and that the more
characteristic symptoms of the disease appear to be directly related
to the liver changes rather than to those in any other organ.
Are the liver changes of an inflammatory nature, or only degenerative ?
In favour of their inttaramatory character a small-celled infiltration in
and around the lobules is pointed out by several observers ; this, how-
ever, has been found in a few cases only, and limited to the red portions.
The degeneration is often as marked in the yellow where there is no
evidence of inflammation.
(iii.) In favour of its being a variety of phosphorus poisoning is
that in phosphorus poisoning, as in acute yellow atrophy, fatty de-
generation of the liver is the chief morbid change, and that the symptoms
of the two conditions are closely alike, even to the appearance of leucin
and tyrosin in the urine.
(iv.) Lastly, in favour of the fourth alternative — that we are dealing
wnth a rare form of infective disease — is the fact, already pointed out in
discussing the etiology of the disease, that cases indistinguishable from
acute yellow atrophy of the liver have been met with during outljreaks
of severe epidemic jjunidice ; and that generally the s3'mptoms and course
of the disease, even in the minutest particulars, are practically the same
as those met Avith in the severest forms of what is termed " malignant
jaundice." Thus among recent cases I find no fewer than nine recorded
by three observers in Australia, from districts where cases of infective
jaundice are common.
An extensive epidemic outl)rcak of jaundice which occurred in Saxony
and Dresden in the autumn of 1889 has been recorded by Meinert ; no
fewer than 5 1 8 persons were attacked. There Avere two stages in the
diseai^c : an initial f('])rile stage with rigor, sickness, headache, but Avithout
ACUTE YELLOW ATROPHY OF LIVER 115
jaundice ; and a second stage of jaundice without fever, the fever fall-
ing on the second or third day, and the jaundice appearing on the fifth
or sixth day, and lasting on an average about eleven days. Of these
cases thirteen died, and two of these with all the symptoms of acute
yellow atrophy.
The evidence in favour of acute yellow atrophy being a rare form
of malignant jaundice of obscure infective nature appears to me far to
outweigh that in favour of any other of the propositions I have cited.
The resemblance between the disease and phosphorus poisoning is
important, in that it shows that certain poisons do possess the power of
producing degeneration of the liver with profound disturbances of its
metabolic functions, such as we meet with in acute yellow atrophy. But
this resemblance is by no means so close as to justify the proposition
that acute yellow atrophy is but an obscure form of phosphorus poisoning.
On the contrary, there are many important points of difference between
the two conditions. In the first place, we are apt to forget that, although
in both there is a fatty degeneration of the liver, in phosphorus poisoning
this change is, in the great majority of cases, attended by enlargement
of the liver, not by atrophy. It is this atrophy, indeed, which constitutes
the special feature of the disease before us ; and herein it differs not
only from phosphorus poisoning, but from other forms of jaundice due
to jjoisons ; as also from other forms of severe jaundice occurring in
disease — the usual result in such cases being swelling and enlargement
of the liver. Thus I always found toluylendiamin, whicli may be regarded
as the most intense icterogenetic poison we are acquainted with, produce
marked swelling of liver and of the spleen (in dogs). So also in the
jaundice of yellow fever, of malarial fever, and of Weil's disease, enlarge-
ment of the liver is the rule.
It has been suggested that the size of the liver depends upon the
length of time the disease has lasted ; that the liver is large if the disease
ends early, and small if the disease lasts long. The facts, however, in my
opinion lend no support to this view. Even in the bodies of patients
who have died four days after being ajDparently in perfect health, the
liver has been found much reduced.
Thus in a case recorded by Dr. Church the total duration of- the
disease from start to finish was only five days, the second stage lasting
only twenty-four hours ; the liver was found reduced to 33 oz.
The atrophy of the liver is in my opinion one of the most character-
istic features of the disease. On the other hand, a certain degree of
enlargement, or at any rate no notable reduction, is no less a character-
istic feature of phosphorus poisoning.
Although fatty degeneration occurs in both, yet in phosphorus
poisoning it appears, in its earlier stages at least, to have invariably the
character of a fat infiltration ; whereas in acute yellow atrophy the
change appears to be a necrobiotic one from the outset : the cell breaks
down into fatty detritus at once.
Chemical analysis confirms this diff"erence in the character of the
ll6 SYSTEM OF MEDICINE
changes in the two diseases. As I have pointed out (see the article on
"Phosphorus Poisoning"), the percentage of fat in the liver of phosphorus
poisoning is very greatly increased — some tenfold — fiom 3 to 30 per
cent ; while in acute yellow atrophy it is only slightly increased to 4 or
5 per cent.
While, then, the resemblances between phosphorus poisoning and
acute yellow atrophy are so close as to lead us to suppose that in
the latter case, as in the former, we are dealing with the action of
a severe poison, there are nevertheless differences between the two
which appear to indicate clearly that the poison is not the same in
both cases.
On the other hand, the resemblances between acute yellow atrophy
and the severest cases of malignant jaundice are even closei-, and extend
likewi.se to the production of degeneration of the liver- cells and to
destruction of their functions ; as evidenced by the occasional appearance
of such products as leucin, tyrosin, peptones, and the like in the urine.
Yet here again there are certain differences — notably the essentially
degenerative character of the liver change in acute yellow atrophy — which
appear to me to indicate that the poison is not the same in both diseases.
It can hardly be doubted, however, that it is of the same character ;
in both we have to do with a virulent organic poison jDrobably formed
within the intestine, and acting on the liver (as also on the blood and
kidneys and other tissues) after absorption. It is possible that in certain
cases this may be followed by an actual invasion of the liver by the
organisms themselves, as in Professor Dreschf eld's case, where he found
micrococci in the A-essels and capillaries of the liver half an hour after
death. But it is probable that such an invasion is not essential ; that the
absence of organisms, as in the two other cases examined by the same
observer, is the more common condition. The Avidespread character of
the liver change, and the rapidity with which it usually occurs, both
suggest the action of a circulating toxin rather than a local ■ invasion by
micro-organisms
As to the nature of the infection, the extreme rarity of the disease
indicates that it must be of altogether exceptional origin. The compara-
tive rarity of ordinary epidemic (catai-rhal) jaundice strongly suggests, as
it appears to me, that in this case we have to do with a " mixed infection."
And the fact that the severest cases of this kind so strongly resemble
acute yellow atrophy — in the mode of onset ; in the character of symptoms,
in the appearance of leucin and tyrosin in the urine ; in the changes in
the liver, including even diniinutiun in size, and in the couise of the train
of symptoms — appears to suggest that in acute yellow atrophy we are also
dealing vvitli an cxcei)tionally raie form of mixed infection.
Nature of the jaundice. — No ol)stnKtion is to be found in the
larger bile-ducts ; and the jaundice has long ])een regarded as a striking
example of javnidice independent of obstruction. It has been variously
ascribed to suppression of liver function, to htcmatogenous oiigin of bile
pigment, to paralysis of bile-ducts, and to sjiasm of bile-ducts ; in its
ACUTE YELLOW ATROPHY OF LIVER 117
production nervous disorder has been thought to play an important part
(Liebermeister) ; and, finally, it has been ascribed to poisoning with biliary
acids.
These surmises may, one and all, be regarded as no longer tenable,
for reasons which I have fully discussed elsewhere. Bile pigments are
not preformed in the blood ; and at tlie time the jaundice appears
there is no evidence of suppression of biliary function. On the contrary,
even to the very last, bile continues to be formed ; sometimes, indeed,
there is actual polycholia during the second stage. In the majority of
cases bile is to be found in the gall-bladder, sometimes in normal
amount.
Although the larger bile-ducts are unobstructed, and usually contain
only colourless mucus, the same does not apply to the smaller intra-
hepatic bile-ducts. These, on the contrary, are found bile-stained, and
usually filled by desquamated and fatty epithelium. The condition pre-
sented is, in fact, precisely the same as that found after poisoning with
toluylendiamin or phosphorus ; larger bile-ducts free from bile ; smaller
bile ducts filled with inspissated bile, due to obstruction high up. The
jaundice is due to catarrh, going on subsequently to complete fatty
degeneration of the epithelial lining of the finest bile-ducts.
The striking resemblance between the disease and that producible by
poisons leaves, in my view, no room for doubt, that in it we have to do
with that variety of catarrh of the bile- ducts which I have called
"toxsemic" — that is, a catarrh produced by the excretion through the
bile of the injurious products which cause extensive degenerative changes
in the liver-cells.
The view, originally put forth by Buhl (1854), that the cause of the
jaundice is mechanical obstruction of the smallest bile-ducts by degenerated
epithelium, a view subsequently supjoorted by Bamberger and Cornil,
has thus received strong confirmation.
William Hunter.
EEFEREIsTCES
1880-1886.— 3. Armitage, J. Bt. Bart. Hosp. Rep. 1881, p. 264.-4. Bowen, J.
Arch. Med. N.Y.l^M, 175-179.— 5. Garuingtox, R. E. Trans. Path. Soc. 1884-5,
vol. xxxvi.— 6. Cavafy, J. Ihid. 1882-3, vol. xxxiv. p. 122.— 7. Cayley. Brit. Med.
Joura. 1883, i. p. 62.3.-8. Chew, S. C. (With P.M. exam.) JV.Y. Med. Bee. 1883,
xxiv. p. 369.-9. Church. Brit. Med. Journ. 1884, i. — 10. Clubbe, C. P. B.
Lancet, 1883, ii. p. 96. — 11. Cui.lixgworth. Med. Times and Gaz. 1881, ii. pp.
263, 291.— 12. Dre.schfeld. (Morbid Histology.) Jr. Anat. and Physiol. 1880-81, xv.
422-430.-13. Glyxn. Liverpool Med.-Chir. Journ. 1882, ii. p. 364.— 14. Goodhart.
(A child aged 2.) Trans. Path. Soc. 1881-2, xxxiii. p. 170.— 15. Vax Harex Noman.
ArcJi. f. path. Anat. 1883, Bd. xci. p. 334.— 16. Hlava. Prag. med. JFoch. 1882,
vii. p. 421. — 17. Joxes, H. (In a young man.) Med. Times ami Gaz. 1880, i. p. 477.
—18. Kahler. Prag. med. JFochensc. 1885, x. p. 213.— 19. Le Ruy, G. La7icet, 1885,
ii. p. 155. — 19a. Legg, Wickham. Bile, Jaundice, and Bilious JDiseases, 1880. — 20.
Looms, A. L. New York Med. Journ. 1880, xxxi. p. 31.— 21. M'Dowall, J. W.
Following rotheln (?) in a melancholiac (with tern, chart). Jour. Ment. Soc 1881-2,
xxvii. p. 541.— 22. Mader. TFien. med. Bl. 1885, viii. p. 294.-23. Marsh, E. F.
Xew York Med. Eec. 1885, xxvii. p. 203.— 24. Mus.ser, J. H. Phil. Med. Times,
1 1 S SVS TEM OF MEDICINE
18S2-3, xiii. p. 43 ; Amer. Journ. Med. Soc. 1884-88, p. 166.— 25. Ossikovszky.
(Identity with Phosphorus Poisouiiii;.) JFien. mcd. Woch. ISSl, xxxi. p. 937. — 26.
PiNCHEKLE. (A case.) Wien.vicd. JTocA. 1886, xxxvi. p. 1022. — 27. R.vlfe. Lancet,
1881. i. p. 780. — 28. Salkow-ski. (Chemistry of the subject.) Virch. Archiv, Ixxxviii.
1882. p. 394.-29. Suhkling. Brit. Med. Joiirn. 1884, i. p. 3.'')8. — 29rt. Tiin-.n-
FELDER. Ziemssen's Cyelopcudia, ix. 1880. — 30. Tomkins. y>.J/./. 1883, i. p. 818 ;
Lancet, 1884, i. p. 606.— 31. Ven.n. Lancet, 1884, ii. p. 191.
1887. — 32. .MooKE. (2 cases.) ^«s/ra^. J/crf. J(y?ir. 1886, viii. p. 446. — 33. John.son,
C. W. Brit. Med. Juurn. 1886, ii. p. 1031. — 34. Redtenbacher. (A case.) Wicn. mcd.
Bl. 1886, ix. p. 1439.— 35. El.sner. Austral. Mcd. Gaz. 1886-87, vi. p. 224.-36.
Holt, A. F. Boston Mcd. and Surcj. Journ. 1887, cxvii. p. 374.
1888. — 37. Ross, J. C. Lancet, 1888, i. ]i. 972.-38. Api'Lkyahi). Med. Press, and Cir.
18SS, xlv. 659.-39. RoiiMANX. (Chemistry of the subject.) Bcrl. klia. Woch. 1888, 861.
1889.— 40. Baur. Med. Xe^vs, PhUad. 1889, liv. 540.— 41. Rosenheim. Xeit. f. liin.
Med. 1888-89, xv. p. 441.— 42. Foltanick. Wicn. klin. Woch. 1889, ii. p. 294.-43.
Creed and Scot-Skirving. (2 cases with recovery.) Austral. Med. Gaz. 1888-89,
viii. p. 259.-44. Haywai-.d. Ihid. 1889-90, ix. p. 17.
1890.-45. Bu.ss. Bcrl. liin. Woch. 1889, xxvi. p. 977.-46. Madek. ("Without
atropliy of liver or jaundice.) Ber. der k. k. Krank. zu Wicn. 1889, 387. — 47.
.Srni<"KHAKr>T. Munch, mcd. Woch. 1889, xxxvi. 756. — 48. Dokfi.eii. (Etiology.)
Munch, vied. Woch. 1889, xxxvii. 878. — 49. Hai'.die. (In pregnancy.) Austral.
Mcd. Gaz. 1889-90, ix. p. 179.— 50. Muet.ler. Ilnd. 211.
1892.-51. Duckworth. Lancet, 1892, i. p. 630.-52. Yeoman. Lancet, 1892, ii.
p. 422.-53. Gairdnek and Coats. Glas. Med. Journ. 1892, xxxviii. 287.-54. Keinert.
Ccntralb.f. klin. Med. 1891, p. 270.
W. H.
PERIHEPATITIS
By this name we understand an inflammation of the peritoneal
capsule of the liver. It may be acute or chronic, but the acute form,
being but an unimportant part of some other acute process, such as
acute peritonitis, hepatic abscess, or acute pleurisy, is of little interest.
Chronic perihepatitis is either universal — over the Avhole liver, or
scattered in patches on its surface ; in the lattei- case it is usually called
local perihepatitis. This variety has many causes which will readily
suggest themselves to the reader ; as instances, I may mention the local
peritonitis over the liver which is merely part of a tubercular or cancerous
peritonitis ; that which is seen around the gall-bladder in some cases of
gall-stones ; the thickening of the hepatic capsule seen in the neighbour-
hood of a gastric ulcer which has become adherent to the liver ; the
local peritonitis which may occur over a hepatic cancer, and the local
peritonitis which i-adiates from a gumma or a syphilitic scarred depression
on the surface of the liver. Local perihepatitis occurring in patches is
very common when there is marked Ijackward pressure in pulmonary or
cardiac disease ; among eighteen examples of it, in ten there was either
cardiac or pulmonary disease. Capsulitis of the spleen is very commoidy
associated with local perihepatitis. Probably it hardly ever becomes
universal.
The thickened capsule cannot readily be peeled from the surface of the
PERIHEPATITIS ^ 119
liver, save in quite exceptional cases ; and it commonly shows several
little pits on its surface, which give it a meshed appearance. Usually
no symptoms can be detected, but a rub can occasionally be felt or heard
over the liver ; and perhaps local perihepatitis may sometimes explain
the hepatic pain of which sufferers from diseases of the heart and lungs,
or cirrhosis of the liver, often complain.
General op univepsal perihepatitis is a very different condition ; in
it the whole capsule becomes thick, opaque and white. This white jacket,
which may be a quarter of an inch thick, easily peels off the subjacent liver,
the surface of which is smooth ; and for some unexplained reason it is quite
common to find the inferior edge of the liver folded up on to the anterior
surface of the organ. Fagge mentions a case in which the lower margin
of the liver touched a point on the anterior surface that should have been
4^ inches distant from it. As a result of the folding, the lower edge of
the liver cannot be felt at all ; and, if the liver can lie made out by
tactile examination, the surface, at first taken for the lower edge,
feels particularly thick and rounded. The upper and lower folds of
peritoneum which form the posterior ligament of the liver become so
thick that they are approximated. Often little pits are to be seen on
the surface of the thickened capsule. Occasionally the early stage of
perihepatitis is met Avith in the post-mortem room, in patients who have
died of some other affection; then the liver is simply covered with a
thin layer of white lymph which easily peels off.
Writers express different opinions ujoon the condition of the liver
in universal perihepatitis. Murchison states that perihepatitis leads to
atrophy of the liver, and that " fibrous bands also pass from the thickened
capsule into the interior of the liver, which on section presents a dense,
smooth, uniform surface with the outline of the lobules more or less
obliterated " ; but, as he goes on to say that this is especially seen in
syphilis and long-standing backward pressure from heart disease, there is,
I think, little doubt that he is describing extreme cases of the patchy
perihepatitis to which I have just alluded. Fagge, on the other hand,
says the hepatic " tissue is commonly soft, and is very often loaded with
fat. It is seldom cirrhotic, but there is sometimes an excess of white
fibrous tissue in the coui'se of the large portal vessels." This description
certainly agrees with what I have observed for myself; and among twenty-
two consecutive cases of universal perihepatitis that have occurred at
Guy's Hospital I find the liver was never markedly cirrhotic ; its tissue
was nearly always soft. In two instances in which the patient had had
syphilis it was lardaceous ; and in some cases where in the heart or
lungs there was any cause for increased venous pressure it presented
the nutmeg appearance.
The liver Avith its thickened capsule generally Aveighs about the same
as a healthy liver ; from this Ave may conclude that the organ is a little
atrophied. The thickened capsule hardly ever exercises sufficient pi-essure
in the transverse fissure to compress the bile-duct ; jaundice is extremely
rare in perihepatitis, and I ncA'er heard of the gall-bladder being dilated.
I20 SYSTEM OF MEDICINE
Many authors assume that, as ascites is xary common in perihepatitis,
the flow through the portal vein is impeded either by the pressure of
the thickened capsule on the jiortal vein in the transverse fissure, or hy
its pressure on the liver as a whole ; but against this view stands the
fact that jaundice is so rare, and it is difficult to believe that the increased
pressure would always fall upon the portal system and never on the bile-
ducts. Then, again, in a case of perihepatitis in which the ascites had
been so severe that, at various times, nearly 800 pints of fluid had been
withdrawn from the abdomen, I carefully dissected the portal vein, and
could not find any e-\-idence that it was dilated ; or that it was constricted
by the thickened capsule of the liver as it passed through it at the trans-
verse fissure of the liver.
The consideration of pressure on the portal vein naturally leads us to
that of the conditions associated Avith perihepatitis ; for I shall show that
this universal perihepatitis, as it is almost always associated Avith a chronic
general peritonitis, should ho regarded merely as a part of it ; in this
fact we have an explanation of the frequency of ascites and the rarity of
jaundice. I took quite indiscriminately from the post-mortem records at
Guy's Hospital forty consecutive cases of perihepatitis ; eighteen were
examples of partial and twenty-two of universal perihepatitis. Of the
eighteen cases six were instances of peritonitis due either to tuljcrcle
or cancer, and the thickening of the capsule of the liver appeared to
be merely part of the general peritonitis ; of the remaining tAvelve only
one is stated to have had peritonitis, and, of the eleven left, eight are
distinctly stated not to have had any peritonitis ; in the remain-
ing three the peritoneum is not mentioned. Turning now to the
twenty-two cases of universal perihepatitis, in only two is it stated that
there was no peritonitis ; in seventeen it is distinctly stated that there
was peritonitis, and in the remaining three no mention is made of the
peritoneum. The peritonitis was always chronic, and was never clue
to tubercle or growth ; it was always of that well-known variety in which
the peritoneum becomes thickened and opaque ; the omentum is puckered
up towards the colon, where it forms a transverse ridge often nu'staken
for the lower margin of the liver ; the mesentery becomes shortened so
that the intestines arc dragged back to the spine, and in an extreme
case they may become so matted together that they can be removed as
one mass, fi'om Avhich it may take an hour to dissect them : they may
even be puckered up parallel to their long axis, so that the distance from
the duodenum to the ca?cum is much lessened. .Sometimes the material
Avhich mats the intestines together can be stripped off, leaving their
smooth serous sui'face exposed ; and thus we see the similarity between
this chronic peritonitis and universal jicrihcjjatitis.
Ascites is a very frequent symptom of simple chronic peritonitis, and
I would argue that, as we have just seen, constriction in the portal
venous system being improbal)le, we ought to regard the ascites Avhich
accompanies perihepatitis as the result of the associated chronic peri-
tonitis. This view is strongly supported by the fact that in the only
PERIHEPA Tins 1 2 1
tAvo cases I haA'c come across in which universal perihepatitis occurred
without chronic peritonitis there was no ascites.
In the twenty-two cases of universal perihepatitis, capsulitis of the
spleen was stated to be found in fourteen, and in only two Avas it said to
be absent. It AAas ahvays universal, and should, like the perihepatitis,
be looked upon merely as part of the general chronic peritonitis. By far
the most important association is that in nineteen of the tAventy-tAvo
cases the kidneys Avere granular. There seems but little doubt that uni-
A'ersal perihepatitis should usually be regarded as a sequel of interstitial
nephritis, for it is Avell knoAvn that the chronic peiitoiiitis of AAdiich it is
a part is a complication of this disease. As might be expected, in several
of the nineteen there Avas some evidence of failure of the lieait or lungs,
and consequently sometimes the liver AA'as luitmeg ; in one case in which
the cardiac failure Avas very marked there Avas jaundice, but this Avas the
only instance of jaundice in perihepatitis. In four cases there was
gout ; in one more it aa'rs douljtfully present ; in tAA'o others there Avas
a strong family history of it ; and in six cases there Avas a history of
alcoholic excess : but it is particularly noteAvorthy that in none of these
cases Avas there any marked cirrhosis, — in fact, in many of them it is
distinctly stated that the liver Avas soft. In three instances SA^philis Avas
a very prominent feature in the case, and this disease Avas probably the
cause of the perihepatitis in those tAvo patients in whom no chronic peri-
tonitis Avas present.
The average age at denth in the cases of universal perihepatitis Avas
47^ years; the youngest Avas 29, the eldest 68. The proportion of males
to females Avas as 13 to 8.
Hie sijmjitoms of universal perihepatitis need not detain us long.
In the first place, Ave nearly ahvays find albuminuria and other evidence
of chronic interstitial nephritis ; secondly, the liver is rarely enlarged,
and the edge, if it can be detected at all, is thick, uniform, and felt just
under the ribs ; thirdly, there are the signs of chronic peritonitis, the
most conspicuous being the formation of an elongated tumour lying
transversely across the abdomen above the umbilicus distinct from the
edge of the liver, and made of the thickened puckered omentum ; perhaps
also other peritoneal thickenings may be felt in other parts of the abdo-
men. The accumulation of ascitic fluid quickly makes the abdomen
dull to percussion, even at the umbilicus, if the shortening of the
mesentery draAvs the intestines back to the spine. The ascitic fluid
is sometimes loculated betAveen the matted intestines, and then the
diagnosis may be very difficult ; but commonly it presents the ordinary
signs of ascites, and it is particularly characteristic of it that it re-
accumulates quickly after paracentesis : thus the abdomen may be tapped
several times, usually three or four times, before the patient dies from
exhaustion. A remarkable case Avas under my care eight years ago in
Gny's Hospital. The patient Avas a sailor Avho had had syphilis ; from
25th December 1885 to 4th August 1887 he was tapped thirty-five
times, and the total amount of fluid AvithdraAvn Avas 790 pints; the largest
122 SYSTEM OF MEDICINE
quantity taken out at any time was 31 i pints, and the average was about
23 pints. He ultimately sank and died in August 1887, and was found
to have perihepatitis, chronic peritonitis, interstitial nephritis, and general
lardaceous disease. As is usually the case, the Huid was clear and straw-
coloured.
The common diagnostic difficulty at the bedside is to distinguish
between perihepatitis and cirrhosis with ascites. If jaundice be present
the patient almost certainly has cirrhosis ; if the signs of chronic peri-
tonitis or those of interstitial nephritis are well marked, the presumption
is much in favour of perihepatitis ; but both chronic peritonitis and
interstitial nephritis may be associated with cirrhosis. The main distinc-
tion lies in this, that in cirrhosis the ascitic iluid generally collects quickly,
and the supervention of ascites — at any rate in sufficient quantity to
require tupping — almost always means that the end is not far off; so that
in cirrhosis the patient rarely lives long enough after the first tapping
for a second to be necessary, while in chronic peritonitis with perihepatitis
he does not usually sink till after the abdomen has been tapped two or
three times or oftener. I have published a series of thirty-four cases
illustrating these jDoints. Ten suffered from cirrhosis Avith ascites and
died before ta])iDing was necessary ; they show very well how the super-
vention of ascites in cirrhosis heralds death, for the average duration
of life after the abdomen was first noticed to be enlarging was only eight
weeks. There were fourteen undoubted cases of cirrhosis in which para-
centesis was performed. Here also the average duration of life after
the abdomen was first noticed to be enlarging was eight weeks ; in
some of the cases the patient was dead within a month, and in only two
was life prolonged beyond three months : in not one did the patient
survive the first tapping long enough for a second tapping to be neces-
sary, and in not one was there any evidence that the tapping was beneficial.
The lemaining ten of my cases were those which were regarded during life
as having cirrhosis, but were tapped oftener than once ; of these, in four
the post-mortem examination proved the diagnosis to be wrong, one turn-
ing out to be a case of colloid disease of the peritoneum, and each of
the other three had chronic j)eritonitis and perihei)atitis : the i-emaining
six had peritonitis more or less chronic associated with the cirrhosis.
Since I collected these cases I have seen two undouljted cases of un-
complicated cirrhosis in which life continued long enough to render a
second paracentesis necessary ; but I have also seen several cases,
diagnosed as cirrhosis, which had been tapped several times, but in
which it was found that the diagnosis was incorrect, for they had no
cirrhosis, but chronic peritonitis with pei-ihepatitis. Cirrhosis of the
liver is often found in persons who have died from accident or from
some disease which is quite unconnected with the liver ; but it seems to
me that all persons with cirrhosis, although for years it may produce no
symptoms, are liable at any time to the rapid development of symptoms
which (juickly increase in severity, and show that life will soon come to
an end. The chief of them are ascites, jaundice, a general feeling of
SUPPURATIVE HEPATITIS 123
illness, drowsiness, and swelling of the feet. Chronic peritonitis and
perihepatitis, on the other hand, are very rarely found in those dead of
diseases other than interstitial nephritis, of Avhich it is a complication;
from this, as Fagge observed, we may infer that it is a progressive
condition, and one which is ultimately fatal. He states there is one
fatal case of ascites from perihepatitis to every five fatal cases of ascites
from cirrhosis \yide art. "Cirrhosis," p. 177].
Treatment is of little avail. Paracentesis must be performed when
necessary ; perhaps iodide of potassium is the best drug to use. In one
case I tried leaving a tube for some time in the abdominal cavity to let the
fluid run out as it formed, but this method did not prove of any benefit.
W. Hale White.
REFERENCES
Fagge. Guy's Hospital Hejjorfs, -vol. xxxv. pp. 196, 202. — Murchison. Diseases
of Liver, 2nd edition. — White, W. Hale. Guy s Hospital Reports, vol. xlix.
SUPPUEATIVE HEPATITIS
Suppurative hepatitis presents itself under four forms : (I.) Pycemic
hejxdUis, occurring as part of a general infective process in Avhich the
liver, along with other organs, becomes the seat of metastatic abscesses ;
(II.) Portal pycemia, in which the pyaemic process resulting in multiple
metastatic deposits has its point of departure in the portal tract, and is
limited, as a rule, to the liver, which acts as a barrier to the passage of the
pyogenetic micro-organisms into the general circulation; (III.) Pyosepticmnic
multiple abscesses, following the spontaneous or surgical opening of tropical
liver abscess, due to the introduction of septic organisms into the abscess
cavity ; (IV.) Tropical or endemic hepatitis, restricted mostly to tropical or
subtropical countries, associated with or independent of dysentery, giving
rise to one or several large abscesses, and (V.) Cholangitis (vide p. 257).
In the pycemic forms we have to do Avith abscesses in the liver ; in
the tropical form with abscess of the liver. The liver, at the outset, is
presumably soixnd in pyaemia ; oi% if diseased, this fact has nothing to do
with the process or its results. In tropical hepatitis, on the other hand,
the nutritive and functional condition of the organ is always more or less
impaired ; hence a diminution of its disease-resisting power, which is an
important factor in the evolution of the abscess. The pyaemic and
pyosepticsemic forms are common to all latitudes, while endemic hepatitis
is above all other diseases, dysentery ziot excepted, a malady peculiar to
warm climates.
It has been lately shown that suppurative hepatitis in warm climates
is not infrequently a complication of amoebic dysentery, and that amoebae
are also found in a certain number of cases of liver abscess in which
124 SYSTEM OF MEDICINE
dysentery is absent. Whether the amoebae in either case are the direct
agents of suppuration, or simply act as the bearers of pyogenetic bacteria
has not been finally settled ; nor have Ave the means of deciding with any
degree of precision to what extent tropical liver abscess is of amoebic
origin. It appears probable that most cases of the so-called idiopathic
liver abscess, and perhaps a majority of those associated with dysentery,
are not of the amoebic variety, but directly dependent on the presence of
the ordinarj^ micro-organisms of suppuration. The amcebic form of liver
abscess is treated of elsewhere (p. 153), but in the sequel I shall take a
general view of the etiology and pathology of tropical suppurative hepa-
titis, whether associated with dysentery or independent of it.
I. Pyemic liver abscess. — Etiology. — The etiology of this form of
suppurative hepatitis resolves itself into that of pyaemia. A woimd is
invaded by pyogenetic micro-organisms ; the veins involved in the primary
lesion are frequently, but not alwaj's, thickened, ulcerated, or occupied by
adherent and more cr less decomposed coagula. Minute infective particles,
or fine zoogloea masses, find their way into the systemic circulation,
become arrested in the hepatic capillaries, cut off" the blood-sujDply from
the impacted areas, and thus mechanicall}^ and by their toxic secretions
cause necrosis of circumscribed patches of the hepatic substance.
Pyjemia is thus found to follow Avounds and injuries, especially re-
section, amputation, and gun-shot wounds ; or it is consecutive to suppura-
tion in connection Avith bone, as in comminuted fractures and otitis ; or
arises in connection Avith suppurative processes in the bladder, prostate,
or urethra ; or in the uterus after parturition. It is also occasionally
met Avith in ulcerative endocarditis and aortitis. It has been observed to
folloAV trifling operations such as phlebotomy, local inflammations such as
carbuncle and Avhitlow, and general diseases such as typhus, typhoid,
rheumatism, and small-pox.
Bacteriology. — There is no evidence of the existence . of a specific
microbe of metastatic liver abscess, nor, indeed, of any form of suppurative
hepatitis. Posenbach found the streptococcus pyogenes in five out of six
cases of pyaimia ; twice associated Avith staphylococcus pN'ogenes aureus,
and in one case, Avhich ended in recovery, the staphylococcus Avas dis-
covered alone (3). In pyaemia associated Avith ulcerative endocarditis or
osteomyelitis, staphylococci (aureus and albus) have been demonstrated.
Morbid anatomy. — The liver is studded Avith small alisccsses con-
taining thick pus of a Avhite, yelloAV, or greenish colour. The abscesses
may be disseminated, or arranged in clusters in diflTerent parts of the liver ;
but are often most numerous towards the surface of the organ. The
abscesses are generally surrounded Avith a zone of congestion ; their Avails,
in most cases, being formed by the hepatic substance and dcA-oid of any
limiting membrane. When the abscesses are few in number the inter-
vening hepatic substance may be healthy. More frequentl}' the liver is
enlarged, softened, and friable ; and it may be remarked that in pyaemia
the liver is often enough found enlarged, softened, and of an oily
SUPPURATIVE HEPATITIS 125
appearance ; it may even contain pyogenetic micrococci without being the
seat of suppuration — death having anticipated this result. Coming to the
formation of these abscesses, we find that the infective agents reach the
capillaries of the liver through the hepatic artery, and ultimately invade
the finer veins. The lumen of the affected vessels is obliterated, the
supply of blood to the corresponding hepatic territory is cut off, and, as a
result, we have cloudy swelling of the hepatic cells, disappearance of their
nuclei, and breaking down of their protoplasm ; the destruction of tissue
being doubtless furthered by the chemical action of the products of the
microbes.
While these changes are in progress small-celled infiltration makes its
appearance in connection with the finer veins — interlobular and central.
Pus forms and, mixing with the necrosed hepatic tissue, gives rise to an
abscess.
In its nascent stage the abscess appears as a buff-coloured patch of
normal consistence, but somewhat swollen, so that the parenchyma in
which it is seated is slightly prominent. Each necrotic patch corresponds
to a group of lobules related to one of the smaller divisions of the portal
vein, on which they are placed like leaves on a twig. After a time these
patches soften from the centre, forming spheroidal abscesses vaiying in
size from a millet seed to that of a walnut ; these, in number, corre-
spond to the microbic emboli impacted in the liver, and in their
stages of growth to the successive dates at Avhicli the impactions have
occurred.
While the multiple abscess affecting various organs is eminently
characteristic of the i)y£emic process, it occasionally happens that the
liver alone is the seat of suppuration after surgical operations ; and in such
instances it is not unusual to find one or more large abscesses present.
A case of this kind is recorded by Vedrenes, in which repeated chills
occurred on the twenty-first day after a sword-wound of the head. This
was followed by j^ain in the region of the liver, the formation of a
fluctuating tumour, the evacuation of half a tumblerful of pus, and
eventual recovery. Trousseau, again, relates the case of a man who died,
with all the symptoms of purulent infection, fifteen days after an opera-
tion for comminuted fracture of the humerus. At the autopsy enormous
abscesses were found in the liver, apparently without any deposits in
other organs, or any discoverable inflammation of the veins leading
from the stump. Still more rare is it to meet with a solitary liver
abscess when other internal organs are the seat of metastatic deposits.
Guthrie relates a case which appears to have been of this nature : the
patient was a soldier who had been wounded in the battle of Waterloo,
in whom amputation of the right arm had been performed. He died
after exhibiting pronounced febrile symptoms and a tendency to delirium.
The pleura pulmonalis on both sides was covered with a thick layer of
coagulated lymph ; a quantity of serum occupied the left side of the
chest, and the pericardium was distended with fluid. The liver, enor-
mously enlarged, pushing up the diaphragm and displacing the lung, had
126 SYSTEM OF MEDICINE
in its substance a large abscess containing at least a quart of pus (7). But
in p3^<iemia the liver is seldom the only or even the most common seat of
metastatic suppurations. According to Sedillot's figures, the lungs are
aft'ected in 91) per cent, the liver and spleen in 8 '3 per cent, the muscles
in 6 "6 per cent, and the heart in 5 per cent of the cases of pysemia.
Symptoms. — AVhcn it follows surgical operations, pyaemia may appear
at any time from Avithin a few days of the operation until the wound
is thoroughly healed. After parturition it usually manifests itself
between the third and fifteenth days. The wound assumes an unhealthy
appearance, the discharge becomes scanty, foetid, or otherwise changed
in character ; in puerperal Avomen the lochia become oifensive, scanty,
or arrested. The distase declares itself by rigors— repeated, it may be,
two or three times daily— followed by hyj^erj^yrexia, rapid defervescence,
and profuse sweating. These attacks are renewed at irregular intervals,
while metastatic deposits take place in the lungs and other internal
organs ; or in the joints, muscles, or subcutaneous tissue.
These deposits are further announced by symptoms special to the
organ affected. The deposition of pus in the liver is indicated by pain
in the hepatic region — a symptom, however, which is sometimes absent
or only elicited by pressure — and by a uniform enlargement of the
organ, which, in most instances, may be detected by careful palpation
and percussion if the patient survive the attack for a few days. The
general aspect of the patient betrays the serious nature of the malady
from which he is suffering. The countenance undergoes a change expres-
sive not so much of pain as of oppression. Emaciation proceeds rapidly.
The heart's action is hurried and feeble ; the respiration shallow and
accelerated ; the skin assumes an icteric or subicteric tint even in cases
in Avhich the liver is not the seat of abscess ; the urine contains bile
pigment ; albumin in small amount may be present, and the urea is
increased. Diarrhoea almost invariably supervenes, and vomiting is fre-
C{uently present. The mind may remain clear until the end, or .the patient
sinks into a typhoid condition marked by drowsiness, muttering delirium,
subsultus tendinum, and, ultimately, coma. Death generally occurs
between the third and twelfth days.
Diagnosis. — The presence of a wound or injury, or the history of a
recent confinement, gives pathognomonic significance to the rigors, fever,
and sweating. The sudden, tiunultuous, febrile outbiu'st, the in-cgularity
of the accessions, the violent constitutional and local symptoms, which so
speedily follow, will make the pyteraic nature of the case sufliciently
obvious ; l>ut at the same time they may divert attention from the liver
complication. Pain, sharp or obtuse, uneasiness or a feeling of weight
or tension in the region of the liver, i)ain or tenderness on pressure, and
more or less enlargement of the organ should lead us to suspect that the
liver is attacked. Icterus and enlargement alone, without pain, are of
less diagnostic significance, inasnnich as they are frequently present in
pya:;niia when sup])urative hepatitis is absent.
Prognosis. — Pyiemia with diiiuse visceral metastatic deposits has
SUPPURATIVE HEPATITIS 127
almost invariably one termination — death. The recorded instances of
recovery refer mostly to cases in which the localisations were wholly or
mainly confined to external organs. Occasionally Avhen the liver alone
of internal organs has been the seat of abscess -formation, and the
abscesses have been few, or have coalesced into one collection, recovery
has taken place ; but cases of this nature are extremely rare.
Tpeatment. — The treatment of pyaemic suppurative hepatitis is
mainly that of pyaemia, for which the reader is referred to the article on
the subject [vol. i. p. 586]. Should it happen that one or more large
abscesses are formed, surgical interference becomes practicable.
PORTO-PY^MIC LIVER ABSCESS — PYLEPHLEBITIS. — Etiology. — Portal
pyaemia is characterised anatomically by having for its cause a lesion
situated within the portal tract, and by the restriction of the metastatic
process to the liver. These peculiarities involve important modifications
in the clinical phenomena of the disease which we shall have afterwards
to describe. ■ ,
The frequency Avith which metastatic abscesses are met with in the
liver in connection with unhealthy suppuration within the portal territory
is less than might have been expected, considering the liability of the
gastro-intestinal canal and its annexes to suppm-ative processes, and the
constant presence of pyogenetic micro-organisms in the digestive canal.
Nor, as might have been expected, is it the pyajmic form of suppurative
hepatitis that is most frequently observed when abscess of the liver com-
plicates tropical dysentery. The doctrine of Budd — that abscess of the
liver, arising during the progress of dysentery, is always of pyeemic
origin — is opposed to the fact that the autopsies in such cases reveal
more frequently one large abscess than two ; and two large abscesses
more frequently than the multiple, small, disseminated deposits character-
istic of pytemia. In two instances in which I have had an opportunity of
examining the liver at quite an early stage of abscess-formation, secondary
to dysentery, I found the solitary, large, necrotic focus present in both.
Similar observations have been recorded by Kelsch and Kiener (9) and by
Morehead. But if, in the face of such facts, we cannot concede that
important part to portal pyaemia in connection with suppurative hepatitis
secondary to dysentery which some have claimed for it, we must not, on
the other hand, overlook the tendency of disseminated abscesses, dis-
tributed as they sometimes are in grovips, to coalesce so as to form large
abscesses. It cannot be doubted that in a considerable number of
instances the larger multiple abscesses associated with dysentery are of
pyaeraic origin. The proof of this is sometimes found in the traces of the
outlines of smaller cavities on the walls of a large abscess. But allowing
for this process of coalescence, it may, we think, be safely affirmed that
the pya?mic liver abscess does not form more than ten per cent of the
cases of suppurative hepatitis associated with dysentery.
The existence of phlebitis and the presence of pus and decomposing
clots in the veins have been demonstrated in a certain number of cases of
I2S SYSTEM OF MEDICINE
portal pyjemia, and if carefully sought for they would doubtless have been
foutul in more. In most cases of abscess in the liver associated with ulcer
of the stomach or dysenteric lesions erf the large intestine, phlebitis of the
radicles of the portal vein has been assumed rather than proved. I
failed, after careful dissection, to find any trace of thrombus or pus in the
veins in a case of multiple liver abscess, associated with sloughing
dysenteric lesions of the sigmoid Hexurc and rectum and general ulcera-
tion throughout the colon. It must be confessed, however, that negative
results, especially when the possil)le points of inflammation of the veins
are so numerous and widely scattered, have little value. Phlebitis may
exist without being discovered, and pyipmia may exist without phlebitis.
Thierfelder, referring to the numerous observations " in which the
development of abscesses in the liver is, from the condition of the case,
in all probability traceable to the formation of pus in some parts of the
roots of the portal vein, although a broken-up thromluis is nowhere to be
found in the portal system, ' suggests as an explanation that the remains
of the thrombus may already have been destroyed at the time of exam-
ination. How far this explanation is applicable to the class of cases
under consideration I do not venture to decide, but loolving upon the
mass of ulceration and sphacelation in which, in dysentery, the vessels
are often involved, we find no ditiiculty in understanding the entrance of
infective micro-organisms into the portal circulation without exciting
spreading inflammation of the veins and the formation of septic coagula.
Of sixty-one observations selected with the greatest care and detail
from those described, and tabulated to serve as a basis for our descrip-
tion of the disease, Ave find that phlebitis of the portal vein or its
branches was demonstrated in nine instances. The points of departure
of the pya?mic process in these cases were : sloughing of the ciecum or
appendix vermiformis, abscess of the spleen, ulceration originating in the
mesenteric glands and involving the vena porta, ulceration of the common
bile-duct extending to the vena porta and its larger branches, and inflam-
mation of the umbilical vein in infants.
Of tift3'-two cases in which inflammation of the veins was not demon-
strated, the pysemic suppuration of the liver Avas referred in fifteen
instances to various lesions of the gastro-intestinal canal and its annexes.
Amongst these Avere simple and cancerous ulceration of the stomach,
ulceration and obstruction of the Inle-ducts or gall-bladder, lithotomy (in
which the rectum Avas Avounded), operations for fistula in ano, and
cauterisation and excision of cancerous groAvths of the rectum. In a case
of colotomy recorded by Mr. Bryant, ulceration had extended to the
submucous cellular tissue and to the veins in the neighbourhood. Forcible
replacement of a prolajjscd anus Avas the cause of the disease in three
instances ; and an operation for strangulated hernia, in Avhich an irreducible
mass of omentum suppurated externally, in one case.
Thiity-.seven of the tabulated cases Avere consequent on dysentery.
It is important to observe the chai-acter of the lesions when small abscesses,
disseminated through the substance of the liver, are associated with
SUPPURATIVE HEPATITIS 129
dysentery. In seventeen cases the autopsy reA'ealed sloughing or gan-
grenous ulceration of the large intestine, and in a great majority of these
the caecum was the part chiefly aftected. In two of the cases large
portions of the mucous membrane of the bowel had been passed by stool.
In others, the large intestine was ulcerated throughout and often thickened.
In one case only did the ulcerative process in the large intestine appear
to have been of a minor grade. We may conclude, therefore, that
unhealthy suppuration in any portion of the portal tract may give rise
to pysemic abscess in the liver ; and that sloughing of the submucous
connective tissue of the bowel, in which the radicles of the portal vein
are necessarily involved, is the foi'm of lesion most frequently observed
when the pysemic process is consequent on dysenter3\
Pathology. — The pathology of portal pyaemia differs in no respect
from that of general jjyoemia. In the former, as in the latter, we have to
do with a process of capillary embolism resulting from the impaction of
masses of pyogenetic mici'o-organisms, or of infected particles leading to
necrosis of the hepatic cells and proliferation of the connective tissue
elements with suppuration.
Morbid anatomy. — When the vena porta contains decomposing clots,
the abscesses are invarialjly numerous or innumerable, and devoid of any
limiting membrane. In a case recorded by Marston, arising from a semi-
gangrenous condition of the appendix vermiformis and caecum, the liver
was enhu'ged, full of small abscesses from the size of a millet seed to that
of a walnut, ^' spreading out from the branches of the portal veins like
twigs from a tree." They were destitute of a limiting membrane, and
the lobules were surrounded by dark rings of congestion at the parts
least affected. The pus in these cases is thick, and white, sometimes
with a tinge of yellow or green, rarely red-coloured and sanious.
When the disease arises from limited points of ulceration in the gastro-
intestinal canal, in the bile-ducts, or gall-bladder, Avithout the presence
of clot or pus in the larger vessels, the abscesses vary much in number.
In some instances seA^en or eight only have been found ; in other cases
from forty to fifty ; frequently they ai'e to be reckoned by hundreds.
They are generally found in both lobes, although seldom to the same
extent, and they are often most numerous towards the surface. Occasion-
ally they are distributed in clusters in limited portions of the hepatic
substance. Along Avith these purulent foci Ave frequently meet A\dth
sharply-defined pale yelloAv patches, from three to tAventy lines in diameter,
some of Avhich are consistent throughout — perhaps even move firm than
the healthy liver substance — Avhile others are softened in the centre.
Some of them are surrounded Avith rings of congestion, others are Avithout
a ti-ace of hyperemia. When the abscesses are few in number, the
intervening liver sii])stance is microscopically healthy ; but if the deposits
are numerous, the liver is more or less congested. Whether fcAv or many,
the organ, as a rule, is enlarged. When the deposits are limited to one
lobe, it is enlarged and more or less congested ; AA'hiie the other lobe may
be healthy or only slightly congested. Hoav completely confined to one
VOL. IV K
130 SYSTEM OF MEDICINE
lobe the disease may sometimes be, will be seen by referring to the
beautiful plate given b}^ Annesley (Diseases of India), illustrating case
Ixxvii., in which the left lobe appears of normal size and perfectly
healthy ; the lobules being distinct and well marked, while the right lobe
is much enlarged and of a deep purple colour.
When the disease sujjervenes on chronic dysentery, the liver through-
out, or in certain areas, is more or less diseased — often softened and
easily broken up, or firm but friable, and of a pale drab or yellow
colour. When the pysemic suppuration appears during the course of
acute dysentery the hepatic substance often presents a healthy appear^
ance ; but there ai-e many exceptions to these mles.
When the patient has survived the attack for some time the abscesses
become encysted. Louis, in one of his cases, found the cavities lined by
a membrane half a millimetre thick, which was soft yet susceptible of
removal by traction (11). In a case associated with dysentery, recorded
by JNIorehead, the history of Avhicli did not extend beyond sixteen
days, " the liver Avas studded with abscesses about the size of walnuts,
each within a membranous bag" (17).
Tlie spleen is generally healthy. In some instances it has been found
smaller than normal and firm ; or, on the other hand, much enlarged and
softened. But the morbid appearances found in this organ are not, as a
rule, causally related to the hepatic disease.
Although it is distinctive of portal pysemia that the liver acts as a
barrier to the passage of the infective micro-organisms into the general
circulation, so that metastatic abscesses of other organs are seldom met
with in this form of pyaemia, nevertheless instances do occur in which
the disease becomes generalised. Dance records an interesting case of
this kind in which ulceration and disorganisation of the common bile-duct
extended to the portal veins, penetrating their cavities by small openings,
and thus allowing the bile (probably along with other matters) to enter
into the circulation. The portal veins contained clots and pus. In
addition to nixmerous abscesses of the liver there were petechia?, pustules,
and gangrene of the skin, with numerous metastatic abscesses in the lungs,
muscles, and parotid gland (5).
Symptoms. — The symptoms of liver abscess due to portal pyaemia
vary according to the presence or absence of phlebitis, the organ which
is the seat of the primary lesion, and the extent to which the liver itself
is involved. I shall, therefore, briefly particularise the symptoms met
with in certain groups of cases, illustrating special features from my own
experience and that of others.
It is excei)tional for the advent of jiortal pyemia to declare itself by
an array of symptoms so obtrusive and distinctive as those that usher in
the general pyaemic infection. It is mostly when the disease is associated
with decomposing clots or pus in the portal vein, or some of its larger
branches, that sevei'e rigors and sweating are observed. In a case observed
by Busk (2), in which a suppurating mesenteric gland had burst into
the trunk of the portal vein, there were frequent rigors followed by
SUPPURATIVE HEPATITIS 131
profuse sweating, a sense of sinking and general distress, pain in the
epigastric region and jaundice. Rigors, hyperpyrexia and sweating are
also occasionally observed when phlebitis of the portal vein or its affluents
has not been demonstrated ; but these symptoms are then less severe and
persistent. Except in the cases just referred to, the onset of portal
pysemia is marked by irregular chills, fever and moderate perspiration ;
and these febrile accessions are soon followed by the symptoms which
we are accustomed to call " typhoid." Occasionally fever without rigors
or sweating may be the initial symptom; and in not a few cases the
preliminary febrile stage is altogether wanting, and the sudden accession of
typhoid symptoms, pain and more or less enlargement of the liver are
the leading features of the malady.
When portal pyaemia is dependent on ulceration of the stomach there
will usually be a history of gastric troubles pointing towards ulceration.
The liver complication generally begins with the milder train of symptoms
just enumerated, and are often somewhat ambiguous in their nature.
In a case recorded by Louis the liver disease set in with jaundice, head-
ache, pains in the limbs and loins, anorexia, great thirst, and a dull pain
in the epigastrium. There was a feeling of resistance or fulness in the
right hypochondrium, the pulse Avas rapid, and the skin hot and dry.
Then followed severe pain in the region of the gall-bladder, and during
the last eight days of illness there were diarrhcea, nausea and prostration.
There were no rigors throughout the whole course of the disease. On
examination the liver was found enlarged, softened and ecchymosed at
points, and contained a great number of encysted abscesses from four to
five lines in diameter. In a case which came under my own observation
the symptoms were much more distinctive. Symptoms of chronic ulcera-
tion of the stomach were followed by irregular chills, fever, and moisture
.of the skin, with marked pain in the hepatic region — especially in the
right hypochondrium — slight enlargement of the organ, vomiting, diarrhoea,
and great prostration. There were about thirty small, non- encysted
abscesses scattered through the right lobe, from the size of a hazel-nut to
that of a walnut, and a few smaller points of suppuration in the left
lobe.
"\Mien ulceration of the gall-bladder or obstruction of the bile-ducts is
the primary lesion, the symptoms — other than those of a typhoid type —
are by no means uniform. We may expect in these cases a history of
biliary colic. Gall-stones or suppuration in the gall-bladder may lead to
multiple abscess in the liver in two ways — (i.) by extension to the portal
vein, the bile-ducts being healthy; (ii.) by setting up suppurative
cholangitis (vide art. "Cholangitis," p. 249). Suppuration is frequently
announced by irregular febrile accessions and sweating. Sometimes fever
alone, without rigors or sweating, is present. Pain is generally com-
plained of, but is often referred at the beginning to the epigastr-ium, less
frequently and distinctly to the right or left hypochondrium ; although
at a later stage of the disease pressure over the hepatic region seldom
fails to elicit signs of pain. Enlargement of the organ will be made
SY'STEAf OF MEDICINE
out by palpation and percussion. Vomiting and jaundice are often
present in this form, but have little pathognomonic significance. Upon
the whole, fever, pain in the hepatic region, and enlargement are the
symptoms which point most directly to suppuration. The pysemic nature
of the disease nuist be inferred from the accompanying constitutional
symptoms, which we have spoken of as "typhoid." The patient's
features become suddenly shrunken ; prostration, oppression, cold sweats,
and diarrhani set in. The mind may remain clear until the last, but
in many cases stupor and delirium set in before death. One or more
of the initial symptoms may be absent ; the typhoid condition never
fails to make its appearance.
Febrile symptoms may usher in py?emia when it follows operations
on the rectum, or disease of this part ; but in some instances the sudden
supervention of typhoid symptoms has been the first indication of the
disease. There may be little complaint of pain in the region of the liver
in such cases, and the invasion may consequentlv be overlooked unless
sought for ; but a careful examination of the organ will usually reveal
the presence both of pain and enlargement. After repeated and violent
attempts to reduce a prolapsed anus, Cruveilhier observed the expression
of the patient to change on the same da}- (an important indication of
pyaemic mischief). The pulse became small and frequent ; the patient
tell into a state of prostration, with cold skin, vomiting, hiccup, and
stupor, but without much pain, and died on the fifth day after the
operation.
When pyaemic abscesses in the liver occur during the course of
dysentery, the symptoms of hepatic suppuration will, in most cases, be
recognised, unless indeed the attention be absorbed by the iirgency of the
primar}'' disease. The supervention of fever, during the progress of
dysentery, or its marked increase should suffice to direct attention
to the liver. If suppuration is detected, its pyaeniic character will be
inferred from the uniform enlargement of the organ, the absence of
bulging or localised pain, and, above all, from the rapid development of
the train of symptoms which we have already described. Should the
dysenteric .sym])toms point to sloughing of the large intestine, this will
naturally give increased significance to the other phenomena indicative of
pyamiia.
Diag-nosis. — Tf we compare the symptoms of portal with those of
general py;e:iiia, two features become apparent at once. Those symptoms
of the general infection which dejiend on localisations in the lungs, spleen,
kidneys, heart, joints, and connective tissue are absent in portal pyaemia.
In most instances also, as we have seen, rigors and sweats are less fre-
quent, less severe, and persistent, or even altogether Avanting. The other
symptoms significant of a general pyoseptica^mic infection of the system
are present, and pretty much alike in both forms. The patient's features
become pinched, anxious, and pale ; he is dull and diowsy or restless and
agitated, there is a feeling and appearance of great oppression, the skin
and conjunctivae become sallow or jaundiced, there are cold sweats,
SUPPURATIVE HEPATITIS 133
thirst, hurried, feeble and irregular action of the heart, rapid emaciation
and diarrhcea ending in exhaustion or coma. These symptoms appearing
during the progress of a disease associated with ulceration or sloughing
within the portal tract, accompanied by the usual signs of hepatic sup-
puration, indicate the formation of pyaemic abscesses in the liver.
Kelsch and Kiener, who have not recognised the distinction between
portal and general pyaemia on the one hand, or between the pytemic and
tropical form of liver abscess associated with dysentery on the other,
have nevertheless drawn attention in a very particular manner to the
frequency with which the train of symptoms I have just enumerated are
found related to multiple and small abscesses of the liver. " Our in-
quiry," they say, " has shown us the frequent correlation between acute
hepatitis accompanied with more or less marked typhoid symptoms and
the multiplicity and smallness of the purulent foci. This correlation is
affirmed by facts sufficiently numerous to warrant our bringing it into
I'clief " (10). The facts lead us farther, and justify the distinction here
made between portal and general pyaemia, and between portal pyaemia
and the liver abscess usually associated with tropical dysentery. Typhoid
symptoms, similar to those met with in pyaemia, appear in connection
with the formation of the multiple pyosepticiemic deposits following the
opening of a tropical abscess ; and also as a result of purulent absorption
from an unopened abscess. In neither case can the symptoms be mistaken
for those of portal pyaemia.
Prognosis. — It is unnecessary to say that the prognosis is always
highly unfavoural)le. Recovery, no doubt, occasionally takes place by
absorption when the abscesses are few, or by the fusion of a group of
smaller purulent foci into a single abscess and its subsequent spontaneous
or operative evacuation.
Treatment. — Our chief hope in this disease clearly lies in prophylaxis.
The mildest forms of inflamujatory action in any part of the portal tract
should be looked upon as serious from their possible results ; and the
appropriate remedies should be sedulously employed. Asepsis of the
intestinal canal should also be maintained so far as possible by the
means indicated in the article on Dysentery (vol. ii. p. 43o). When, not-
withstanding these precautions, the disease has arisen, the medical treat-
ment will be that of pyaemia, and the surgical treatment that of liA'er
abscess.
Secondary pyoseptic.^mic abscess of the liver.— This form of
hepatic suppuration is always secondary to the opening — spontaneous
or operative — of an abscess of the liver, and the consequent entrance of
infective micro-organisms from without. It is thus met with as a sequel
of the bursting of an abscess into the lung or bowel ; but much more
frequently it follows the opening of an abscess externally. Notwith-
standing the use of antiseptics, secondaiy pyosepticaemia is still th(?
danger which the surgeon has most to dread in operating for liver abscess.
The anatomical character of pyosepticaemia is the appearance in the
IJ4 SYSTEM OF MEDICINE
immediate vicinity of the primary abscess — occasionally, also, in other
parts of the organ — of small abscesses from the size of a pea to that of a
walnut, or even larger. They are often surrounded by a ring of con-
gestion, and are destitute of pyogenetic membrane. Their contents may
be either a "white pus or a reddish serous fluid. Sometimes small Ijufi-
coloured circumscribed nodules are also met with in various stages of
abscess-formation.
Symptoms. — The external wound often assumes a sloughy gangrenous
appearance. The discharge from the abscess may become scanty, serous,
and of a red colour ; in some cases it remains free from odour, in others
it becomes fcetid. The walls of the abscess cavity are sloughy or
necrosed.
The constitutional symptoms are similar to those of pyaemic abscess —
pinched features, febrile accessions, sweating, diarrhoea, rapid loss of
strength and collapse.
REFERENCES
1. Bryant. Atlas of Pathology, ^jd..&0Q. ]}\&tQy.-s.\x. — 2. BroD, Diseases of the
Liver, Lond. 1845, p. 189. — 3. Cheyne. Microparasitcs in Disease, Sj^d. Soc. 1886,
p. 432. — 4. Ckuveilhier, quoted by Bl'DD, o}). eit. p. 56. — 5. Dan'ce. Archives gin.
de med. vol. xix. p. 40. — 6. Davidson. Hygiene aiul Diseases of Warm Climates,
Edin. 1893, p. 631. — 7. Guthrie's Commentaries, 5tli ed. p. 63. — 8. Hewett.
Year-Book, Syd. Soc. 1862, p. 210. — 9. Kelsch and Kiener. Traite des malad. dcs
pays chauds, Paris, 1889, j). 187. — 10. Ihid. p. 249. — 11. Louis. Mem. ou Ilccherches
anatom.-paih. Paris, 1826, Obs. iv. — 12. Marston, in Cooper's Surgical Diet. vol. ii.
p. 503. — 13. Morehead's Clin. Researches, 2nd ed. p. 331, case 97. — 14. Sedillot.
De Vinfect. purulente ou Pyohemie. Paris, 1849.^ — 15. Trous.seau. Clin. Med. vol.
V. p. 262. — 16. VEDRfeNES. Rec. de mim. de med. mil. 1869. — 17. Waring's Enquiry
into the Path, of Liver Abscess, Trevandrum, 1854, p. 36. — 18. Wilks' Report on
Pyaemia, Guy's Hosp. Reports, Series III. vol, vii. 1861.
Tropical suppurative hepatitis. — Definition. — Clinically, tropical
hepatitis j^resents itself as a febrile hypersemia associated with dysentery,
or independent of it, and terminating in resolution or suppuration. In
cases which do not end in resolution, it is anatumicalhj characterised by the
formation of one or more large foci of microbic necrosis, at first diifuse,
afterwards limited by a pyogenetic membrane. Eiiologically, it is the
expression of hepatic insufficienc}", the result of the imperfect adaptation
of the liver and associated organs to the physiological conditions — climatic
and other — imposed upon them, leading to functional and nutritive
changes which determine the invasion of limited areas of the hepatic
parenchyma l)y pyogenetic bacteria.
Etiology. — (JeograpJikal distribution. — One of the most striking features
in the etiology of this form of suppurative hepatitis is its practical
restriction to tropical and subtropical regions. The large liver abscess,'
except as the result of injury, counts, as Hirsch remarks, among the rarest
of diseases in temperate and cold climates. It is only in tlie extreme
south of Eurojic that it becomes endemic in a mild degree. The relative
SUPPURATIVE HEPATITIS
135
frequency of liver abscess in certain geograpliical regions is approximately
measured by tlie death-rates from hepatitis among the troops stationed in
them. The figures in the following table refer to the four years 1888-91,
except for Bengal, China, the Straits Settlements, and Egypt. For the
first the average is for the three years 1888-90 ; for the second and
third, 1889-91 ; and for the fourth, 1888 and 1889 only.
Death-rates from Hepatitis per 1000 of the troops stationed in India
and other British Possessions.
Country.
Death-
rate.
Country.
Death-
rate.
Country.
Death-
rate.
Bengal
Madras
Bombay
Ceylon .
Straits Settlements
1-35
1-78^
0-96
0-88
0-00
China .
Mauritius ,
South Africa
Egypt .
Malta .
0-24
1-48
0-23
1-18
0-43
"West Indies
Bermuda
Canada . ,
Gibraltar
0-23
0-00
0-00
0-11
The fact that no death from liver abscess occurred in the Straits
Settlements during the years included in this table sufficiently proves,
what is otherwise well attested, that under ordinary circumstances these
Settlements enjoy as marked an immunity from hepatic abscess as they do
from malaria and dysentery. The experience of campaigns in the Malayan
Peninsula has shown, however, that these diseases are rather latent in
the nosology of the Straits than absent from it. Hepatitis, dysentery, and
remittent fever were found by Conwell to be the reigning maladies among
the European troops in the Island of Penang in the early days of its
occupation. No satisfactory explanation has been given of the greater
fatality of liver abscess in India, Ceylon, and Mauritius, as compared with
the West Indies, where the climate is eminently tropical. It has been
thought that the insular and more equable climate of the West Indies, and
the mitigating influence of the sea-breezes on the temperature, go far to
account for the lesser prevalence of suppurative hepatitis in these islands.
Among the negro population, too, of the West Indies the disease must
be exceedingly rare ; for Dr. Macnaught did not meet with a single case
of liver abscess in a negro during a residence of twenty-two years in
Jamaica.
A brief notice of the distribution of liver abscess in other tropical
countries must suffice as supplementary to the table given above.
In Africa, abscess of the liver is endemic in a mild degree both in
Algeria and Tunis. The mortality from this cause in the hospitals of
Philippeville and Bougie (1867-78) formed from 12-4 to 9-6 per 1000 of
the deaths from all causes. The British troops in Egypt, as we have seen,
sufTer to a considerable extent, but Dr. Sandwith, whose long residence in
136 SYSTEM OF MEDICINE
the country lends weight to his observations, informs me that abscess of
the liver is only met with among those of the natives Avho are addicted to
the use of alcohol ; while the orthodox Mussulman, who restricts himself
to water, although ho may suHer from hepatic enlargement is seldom the
subject of suppurative hepatitis.
In Senegal, abscess of the liver is one of the most fatal diseases of the
European residents, causing one-third or more of the total mortality ; l)ut
here, too, it seldom aticcts the natives. In the French Soudan and the
Upper Congo it is rarely met with except in connection with dysentery
and diarrhnea. Along the east coast and inland rt-gions of Africa, where
dysentery is conuuon and fatal, abscess of the liver is said to be compara-
tively rare. As regards the island of Zanzibar, in particular, Ave have the
recent and explicit testimony of Drago to the efiect that hepatitis and
abscess of the liver are almost unknown there. Dysentery and liver
abscess are alike prevalent in Mauiitius, and the latter is by no means
restricted to the white population. Here in a large proportion of cases
these two diseases run their course independently of each other. In the
Seychelles group, again, malaria is unknown, dysentery exceedingly fatal,
and abscess of the liver only moderately prevalent.
Turning to Asia, it may be noted that suppurative hepatitis is not
severely endemic in Cochin China, where it furnished (18Gl-G-i)a propor-
tion of one in fifty-four deaths. In Tonkin it gives rise to about 3
per cent of the total mortality among the French troops.
Our accounts of the extent to which liver abscess prevails in the low-
lands of Mexico and Central America are far from precise, but they justify
the conclusion that it forms a much less important element in the pathology
of the Western than of the Eastern Hemisphere. In Bi'itish Guiana sup-
purative hepatitis is not, upon the Avhole, of frequent occurrence. Out of
457 consecutive autopsies made in the Georgetown hospital, we find no
more than two cases of liver abscess mentioned ; and the disease furnished
only 21 admissions during the four years 1886-89, out of nearly 30,000
patients. Xor does it appear to be more common in the neighbouring
countries of Surinam and Cayenne. The statements respecting Ih-azil
seem to point to its somewhat frequent occurrence in certain districts,
but it does not appear to be severely endemic in any part of the
country.
In contrast to the comparative immuin'ty from liver abscess which
these regions enjoj', is its marked fatality along the shores of Peru and
Chili. About 2 I per cent of the subjects sent to the anatomical theatre
in Valparaiso were found to have liver abscess. This points to its extreme
frequency at any rate among the pooi'cr classes in that cit}''. In the
more temperate disti'icts of Chili south of latitude 3J°, abscess of the
liver ceases to lie endemic.
A review of the geographical relations of h(>patic abscess appears to
warrant the following conclusions : {a) AKscess of the liver is piactically
restricted to, and is everywhere more or less pievalent in tropical and sub-
tropical regions, {b) Its frequency in warm climates does not bear a strict
SUPPURATIVE HEPATITIS 137
relation to latitude or mean temperature. Those tropical countries, such
as the Straits Settlements and Guiana, in which liver abscess is compara-
tively rare, are distinguished by an equable and moist climate ; while many
of the regions in which suppurative hepatitis is severely endemic are char-
acterised either by great ranges or sudden transitions of temperature. In
Senegal, for example, where liver abscess is so fatal, the temperature
during the day may reach from 95° to 104° F., falling at night to 64° or
60°. (c) Liver abscess exists in countries where malaria is unknown, as
in the Seychelles group, the island of Kodrigues, and also in Chili and
Mauritius, in both of Avhich malaria has only appeared in quite recent
times. On the other hand, it is never absent from the pathology of a
tropical country in which dysentery is endemic ; although the facts, so far
as they are ascertained, do not support the sweeping conclusion of
Chauifart that " the more frequent, grave, and persistent dysenteiy is in
a country, in the like proportion will suppui'ative hepatitis be frequent,
persistent, and grave." {(I) In tropical countries ordinarily exempt from
the malady it will appear in a severe form among Europeans subjected to
unusual exposure and fatigue, {e) Dysentery and hepatic abscess may
be prevalent in a given region, but, nevertheless, be to a large extent
independent of each other.
Ilelaiion to altitude. — The occasional occurrence of hepatic abscess
in Europeans transferred from a coast to a hill station is no more incon-
sistent with the fact that the disease becomes less frequent (other things
being equal) in proportion as the increase in altitude reduces the temjDcra-
ture to that of higher latitudes, than its occasional occurrence in those
who have returned to England is inconsistent with the proved immunity
of temperate climates from liver abscess. Rouis states that in Algeria
abscess of the liver is unknown or rare in localities such as Medeah,
Milianah, etc., the altitude of which reaches or exceeds 1000 metres.
Jourdanet likewise found the disease to be rare at the higher elevations
in Mexico. A moderately elevated spot may, however, from local circum-
stances, be more productive of hepatitis than the sea-coast. Liver
abscess is undoubtedly less fatal in the more elevated and colder districts
of the North- West Provinces of India than in Lower Bengal. The death-
rate from hepatitis in the Presidency district of Bengal (1881-88) was
1'85 ; in Peshawar, at an elevation of 1110 feet, it was 0*80 per 1000.
Meteoviilofiical conditions. — Hiffh temperature. — A careful consideration
of the latitudinal and altitudinal relations of hepatic abscess points very
conclusively to the influence of a high mean temperature as an im-
portant factor in its etiology. That the high temperature of the tropics,
more than any concurrent meteorological element, is the chief climatic
factor in determining the geographical distribution of liver abscess, is
confirmed by the observation of Rouis that in Algeria those years when
the heat was unusually severe, such as 1843, 1847, 1853, and 1849,
never failed to furnish an increased number of cases of liver abscess, and
that the disease is, upon the whole, most prevalent in localities where
the temperature is excessively high. Budd ascribes the prevalence of
T38 SYSTEM OF MEDICINE
abscess of the liver in the tropics to the greater frequency of dj^sentery
in warm climates. But if heat plays no important part in the causation
of tropical abscess, it is difficult to explain Avhy it should become to such
a large extent divorced from the dysentery of temperate climates. The
objection lU'ged by this distinguished authority against the influence of
heat as a factor in the genesis of liver abscess, namely, that men employed
in japanning, and other processes in the arts, are exposed to heat much
greater than that of India, but do not sufler in consequence from liver
abscess, is based, I venture to think, upon a defective appreciation of
the conditions of life in the tropics. Nor is it to be admitted that those
subjected to constant and great heat in temperate climates in connection
with manufacturing processes never suffer from liver abscess. A tj'pical
case of the disease is recorded by Graves as having occurred in a robust
man, by trade a glass-blower — an employment in which the workmen
are subjected to intense heat. A closer examination into the history of
the comparatively rare cases of idiopathic abscess met Avith in temperate
climates must be made before Budd's statement, that those who are ex-
posed to great heat in temperate climates do not suffer from liver abscess,
can be accepted. In short, as Maclean has remarked, " it is impossible to
overlook the influence of a continued high temperature in causing suppiu-a-
tive inflammation of the liver, although some esteemed authors have made
light of it." I am incliiied to place exposure to a constant high
temperature in the first rank as a predisposing cause of tropical liver
abscess ; and clinical observations seem to show that, in exceptional in-
stances, temporary exposure to excessive heat may also act as an exciting
cause of the disease (9).
Vicissitudes of temperatvre. — In our review of the geographical dis-
tribution of liver abscess we have already observed its prevalence in
regions where there are great, frequent, and sudden transitions of tempera-
ture. Clinical facts point clearly in many instances to a chill as the
exciting cause of the disease in those ■whose constitution has been
impaired by trojiical heat. I may mention one case which came under
my own observation in which the facts could bear one interpretation
only. A young man belonging to the Indian population of jMauritius,
who had previously enjoyed good health, and had never suffered from
diarrhoea or dysentery, presented himself with an abscess in the right
lobe of the liver. His account was that, being employed as a night
guardian, he had spent the afternoon and evening drinking arrack with
his companions. He fell asleep at night on the damp ground, and awoke
next morning Avith severe pain in the right side, which persisted, and
was soon followed by fever, and terminated in abscess. Instaiices of this
nature are within the experience of all who have had occasion to see
much of the disease.
Sir liiinald Martin states that he frequently observed acute inflamma-
tion of the liver follow exposure to a cold north wind in ])eoj)le issuing
from heated ball-rooms in Calcutta (Maclean). Larrey, in his account of
the French campaigns in Egypt and Syria, gives it as the result of his
SUPPURATIVE HEPATITIS 139
experience that suppression of the perspiration by a chill was one of the
most frequent causes of liver abscess among the troops.
Personal influences. — Age. — Hepatic abscess is chiefly a disease of
adult life. Among 23,850 soldiers' children in India, three deaths were
caused by liver abscess — a ratio of 0'13 per 1000; which is about a
tenth of the mortality of the army.
Sex. — Of 11,413 soldiers' wives, for which data are available, 8 died
of abscess of the liver, or 0'70 per 1000, which is about one-half of the
death-rate of the men. It may be assumed that among Avomen of the
higher classes liver abscess is still less common. The rarity with which
women are attacked in Egypt has been noticed by several authors (7), and
is confirmed by the testimony of Sandwith.
Race. — It is everywhere remarked that the natives of tropical countries
are much less liable to suppurative hepatitis than Europeans. The death-
rate per 1000 of the European troops from abscess of the liver in 1890
Avas 1'05, while that of the native army Avas 0"03 — the death ratio of
Europeans being thus thirty-five times higher than that of the natives of
India. For the two preceding years the European death-rate was twenty-
five times higher than that of the natives. AVe shall be the less disposed
to exaggerate the admitted importance of dysentery as a factor in the
causation of liver abscess if Ave bear in mind that dysentery is quite a
common and fatal disease among the native races of India. No doubt
the habits of tlie tAvo races count for much in this connection.
CouAvell states that " the native domestics who acquire European
vices are equally or more subject to hepatitis than the Europeans." It
may at least be said that their immunity from the disease is much less-
ened by contracting drinking habits. I may remark that liA^er abscess
is by no means rare among the coloured Creole and Indian populations
of Mauritius. Respecting the comparative liability of Europeans of dif-
ferent nationalities to contract liver abscess on being remoA'ed to the
tropics, Ave have the A^aluable but narrow experience of Haspel, Avho had
charge of a foreign legion in Algeria. He found the Italians, Spaniards,
and natives of the south of France to resist the diseases of Algeria (in-
cluding hepatitis) infinitely better than the natives of the north of Europe.
They proA^ed, he says, physiologically better adapted to the country.
Acclimatisation. — Length of residence in the tropics does not diminish
but rather tends to increase the liability of Europeans to suppuratiA^e
inflammation of the liA'er ; as Avill be seen from the folloAving figures, by
Brydon, relating to the European army of India (1873-76), and shoAving
the proportion of deaths from liver abscess to 100 deaths from all causes
at different periods of service : — ■
First four years. Fifth to seventh year. Above seven years.
14-0 18-9 16-0
Food and Drink. — Free liA'ing, and an excessive use of animal food,
when combined Avith Avant of exercise, haA^e been looked upon as a cause
of the disease. This may be true, perhaps, in respect to Europeans, but
I40 SYSTEM OF MEDICINE
experience proves that it is seldom the penalty attached to errors of this
kind in the case of natives who abstain from alcohol. The abuse of
alcohol in any of its forms is one of the most potent of the remote causes
of liver abscess. " We seldom," says Cayley, " meet with cases of hepa-
titis or liver abscess among total abstainers, except the p} semic form
directly associated ^^'^th dysentery, but moderate drinkers are liable to
suffer." I would only add that alcohol is also to be reckoned among the
causes of liver abscess associated Avith dyscnter3\
Seasonal prevalence. — Hepatitis is everywhere most frequent after the
heats of summer have exerted their depressing influence on the body,
and the colder weather, with greater thermometrical fluctuations, sets in.
Relation to dysentery. — No point in connection with the etiology
of liver abscess has given rise to so many conflicting statements and
h3'potheses as that of its relation to dysentery. I shall here confine
my attention solely to matters of fact. The frequency of dysentery
as a complication of liver abscess is a matter of contention. Waring
found ulceration of the large intestine in 147 out of '10 i autopsies
of persons Avho died of liver abscess — a ratio of 72 "16 per cent. This
agrees almost precisely "with an analj^sis I have made of 111 cases
reported by English and French authors. Kelsch and Kiener, on the
other hand, found that 260 out of 314 cases, or 86 per cent, Avere
comj)licated Avith dysentery, and they add that this proportion Avould
have been still greater if they had taken into account 22 cases in which,
according to the symptoms, dysentery had very probably occurred (15).
It is upon these figures that the existence of liver abscess, not associated
Avith dysentery, is declared by the French school to be quite an excep-
tional occurrence ; and upon them is based the proposition that both are
due to one microbic cause. To this school, indeed, liver abscess is but
an incident in the course of dysentery. The latest figures bearing x;pon
this problem, derived from the reports of the Sanitary Commissioners
Avith the GoA^ernment of India for the year 1892-93, shoAv that the deaths
from liver abscess numbered 137 ; and that of these only 58, or 42 3 per
cent, Avere found associated Avith dysentery. If Ave are prepared to accept
these figures as cA'cn approximately correct, Ave shall ha\e to admit that
the so-called idiopathic form is of much more frequent occurrence in
India than the estimates derived from reported cases had hitherto led us
to suppose ; and if Ave l>ear in mind that most of the cases successfully
operated on belong to the class of those not associated Avith d^'sentery, it
Avill be evident that the proportion of cases treated in Avhich the disease is
indejjcndent of dysentery must be higher than the ratio given above, Avhich
is based upon necropsies. The frequency of a dysenteric complication in
fatal cases of liver abscess doubtless varies in diH'erent countries and cir-
cumstances, but the view that uncomplicated cases form a quite unim-
portant residuum of the Avhole cannot be maintained.
What is, then, the frequency of hepatic abscess as a complication of
dvsentery ? According to a very complete table compiled by Hirsch of
2377 autopsies of tropical dysentery, hepatic abscess Avas present in
SUPPURATIVE HEPATITIS 141
the ratio of 19 '2 per cent, wliicli agrees closely with the estimates
arrived at from a much smaller number of autopsies made in Algeria.
It is usually the severer cases of dysentery that become complicated
with hepatitis. In forty-five autopsies of dysentery recorded by
Moreheacl, four only were complicated with liver abscess, and in each
of these sloughing lesions were present in the bowel (cases 59, 65,
72, 81).
When Ave turn to temperate climates, it is rare to find dysentery com-
plicated with liver abscess. Thierfelder informs us that in 231 autopsies
of persons who had died of dysentery in Prague between February 1846
and September 1848 no instance of abscess of the liver was found. The
same was true in the eighty cases of ej)idemic dysentery observed by
Niemeyer in the military hospital at Nancy and examined after death.
Dr. Marston states that of the great number of soldiers from the Crimea
suffering from dysentery who came under his charge in the Malta
hospital, only tAvo were subjects of liver abscess. Baly, again, did not
meet with a single case of abscess of the liver in the many hundreds
who died of dysentery at Millbank. It appears, however, to have been
somewhat more common as a complication of the famine dysentery of
Ireland ; but accurate statistics of this epidemic are wanting.
As regards the priority of the diseases when found associated in
tropical countries, we may state that, out of fifty-six observations bearing
upon the point before us, the liA'er abscess and dysentery arose
simultaneously in seventeen instances ; the hepatic symptoms appeared at
some time during the course of dysentery in twenty cases, and in four of
these the dysenteric symptoms ceased or diminished as the hepatic disease
appeared. In seven cases there had been a history of a previous
dysenteric attack dating from six to twelve months before the onset of
symptoms of liver disease. In twelve cases the hepatic symptoms had
preceded the advent of the dysentery.
It is obvious from the facts before us that liver abscess often occurs
as an uncomplicated disease, and that when complicated with dysentery
it not infrequently precedes it. Yet on the other hand, if we bear in
mind that in a varying, but still large, proportion of cases suppurative
hepatitis is associated with dysentery ; that, to a considerable extent, the
two diseases are endemic in the same localities, and rise and fall in
frequency synchronously, and that the one is often preceded or followed
by the other, Ave shall be compelled to admit that the doctrine of simple
coincidence is inadmissible. The nature of the relation betAveen the tAvo
Avill be considered in the sequel.
Morbid anatomy. — In about 75 per cent of the cases the abscess is
solitary, in 1 1 per cent double; Avhile in about 14 per cent the number
of abscesses exceeds tAvo. These facts have an important bearing both on
the pathology and prognosis of the disease.
In considerably more than half of the cases some portion of the right
lobe — frequently its convex, upper, or outer surface — is affected. In its
initial stage the abscess is generally seated at a greater or less depth
142 SYSTEM OF MEDICINE
•within the substance of the liver ; but in a certain number of instances
(according to my observations, 6 to 9 per cent) it is superficial from the
beginning.
The pus is generally thick and white, or tinged yellow or green ;
more rarely it is dark red or chocolate-coloured, and of the ordinary con-
sistence or serous. Reddish serous contents are rather frequently found
in the superficial abscess.^ The quantity varies in amount from a few
drachms to many pints. "\A"hen the abscess enters its surgical phase
the contents vary in amount from four to thirty ounces, or more.
In its first stage the abscess is diffuse ; that is, it is limited only by
the hepatic substance, which may be dense or softened ; in the latter case
it is found projecting in shreddy masses into the pus. At a later period
the pus becomes limited by a capsule, which varies extremely both in
thickness and consistence, and often presents internally a flocculent
appearance. This membrane is formed of a granulation tissue, more or
less highly organised, which makes its appearance at the line of demarca-
tion between the dead and living hepatic substance.
The abscess thus limited, if small, may cease to extend. The pus
becomes absorbed and the ca^'ity undergoes obliteration, its site being
marked by a white puckered cicatrix ; or the contents may be reduced to
a pul^jy or chalky mass surrounded by a thickened capsule.
Much more frequently a liver abscess follows the course of an abscess
in any other tissue, enlarging and making its way towards the surface by
the disintegration of the intervening liver substance, and by the formation
of minute points of suppuration in its walls which subsequently open into
its cavity. During this process the vessels and ducts become obliterated ;
so that haemorrhage or extensive extravasation of bile into the abscess
cavity seldom occurs.
The patient may die before the abscess opens spontaneously, or is
evacuated by operation. "When spontaneous opening occurs, it will easily
be understood, from what we know of the usual seat of the abscess, that it
will generally make its way into the right lung or pleura. Very rarely,
indeed, does it open into the pericardium. Rupture into the peritoneal
ca^^ity is a more common termination, and would be still more so if
inflammatory adhesions of the abdominal viscera did not frequently
circumscribe the pus and prevent its effusion. The transverse colon,
again, gives issue to the pus in a certain number of cases. Less frequently
the abscess opens into the stomach or duodenum ; and the instances are
quite exceptional in which the pus evacuates itself through the bile-ducts,
the hepatic veins, the vena cava, or the pelvis of the right kidney.
Before the evacuation of the pus the liver, in nine cases out of ten, is
enlarged, and this enlargement is looked for as one of the surest signs of
abscess-formation. Rouis found, however, that when the pus had been
^ I am unable to offer any explanation of the serous character of the contents of the
abscess in certain cases. Bacteiiological research may, perhaps, throw some light on the
matter. The point is deserving of investigation. To say that it is accidental explaius
nothing.
SUPPURATIVE HEPATITIS 143
got rid of, the volume of the liver was normal in about 63 per cent of
his observations.
According to Waring, the substance of the liver, apart from the abscess
and the immediately surrounding tissue, is generally congested, softened,
or otherwise altered in colour or consistence. In only a few instances
was it found to be perfectly healthy. Out of twenty -five observations
recorded by Kouis, in which the state of the hepatic substance outside the
abscess zone is minutely described, it was found to be more or less dis-
eased in nineteen, and apparently healthy in six cases. Kelsch and
Kiener's observations lead them to the conclusion that the integrity of
the rest of the hepatic parenchyma is the rule and not the exception.
My own observations point to the extreme rarity of a healthy state of
the liver when abscess has followed repeated or long-continued attacks of
dysentery. In these circumstances the parenchyma is manifestly diseased
— often of a pale colour and friable, the lobulation being indistinct. In
uncomplicated cases the liver substance is not infrec^uently healthy,
except in the immediate neighbourhood of the abscess. Nor are we to
assume that in every instance in which the hepatic parenchyma is found
diseased on autopsy, it was so from the beginning of the suppurative
process. The circumscribed nature of the lesion, and the frequency
with which the liver proves capable of performing its functions after
spontaneous or operative evacuation of the pus, point rather to the con-
clusion that the suppurative process in tropical abscess is a localised one
dependent on nutritive conditions affecting primarily a limited area of the
hepatic substance ; exposing it to be surprised, as it were, by a microbic
invasion which it was, perhaps only temporarily, unable to resist.
The lesions met with in other organs are someAvhat numerous, but do
not call for detailed description. The proximity of the advancing abscess
on neighbouring organs and tissues, or its pressure upon them while it is
making its way in the directions already mentioned, gives rise to adhesive
inflammation of the plem-al, pericardial, or peritoneal membranes ; more
rarely, to serous effusion into their cavities. Inflammation and ulcera-
tion of the intervening tissues, the rupture of pui'ulent collections into
one of the closed sacs or hollow viscera, and limited or diffuse abscess of
the right lung are among the more common of the morbid conditions
resulting from the spontaneous opening of a liver abscess.
The spleen, as a rule, is healthy ; sometimes it is abnormally small, at
other times enlarged ; in either case its parenchj^ma may be softened or
firm. Various morbid conditions have been observed in the kidneys, but
none of them, except those mechanically pi-oduced, has any etiological
significance.
Two special forms of abscess require brief notice : the fibrous abscess
of Kelsch and Kiener, and the areolar abscess of Chauffart. The first is
multiple — numbering from three to twelve — the abscesses varying in
size from a hazel-nut to that of a pigeon's egg, of a gray or whitish
colour, and containing a grumous, semi-solid purulent matter. These
small abscesses are characterised by their encapsulation in the midst of
144 SYSTEM OF MEDICINE
a stratified fibrous tissue Avhich is traversed by numerous vessels with
embrvonic ■walls. The wall of the abscess is firm and coriaceous. The
second form, advancing towards the surface of the liver, presents on
section a series of unequal areolae, isolated or communicating Avith each
other so as to form a sort of cavernous structure. Each areola is lined
with a pyogcnetic membrane, and contains a muco-purulent fluid. This
form is l^elieved by Chauftart to be connected Avith inflammation of the
l)iliary canals.
Nature and evolution of the lesions. — Side by side \dl\i a formed
abscess we occasionally meet with the circumscril)ed buff-coloured patches
or nodules already described in the section on pyaemia. Such a nodule,
when softened at the centre, may be taken to represent the initial
stage of a hepatic abscess ; it is, in fact, an abscess in miniature. It is
important to observe that, although in some cases the nodule is bounded
by a hypersemic zone, it happens quite as often that no such zone of
congestion is present. We have before us, then, a group of lobules in a
state of necrosis, the capillaries blocked, the hepatic cells in a state of
cloudy swelling, or of advanced fatty and granular degeneration, with
small-celled infiltration of the finer veins. The formed abscess, dysenteric
or idiopathic, is in its earliest stage no more than a magnified necrotic
nodule. As generally met M-ith, an abscess at an early stage of its foi'ma-
tion varies in size from that of a plum to that of an orange. On section
the central portion is of a grayish yellow colour, and more or less diffluent.
This central part is surrounded by a buft'-coloured zone, the periphery of
which is bounded by an area of congestion, from a quarter of an inch to
an inch in breadth. This hypersemia, as was pointed out long ago by
Dr. F. N. ]\Iacnamara, who was one of the first to give an accurate
account of the pathology of hepatic abscess, is secondary — a result of
reaction. The process is essentially necrotic, not inflammatory. A
microscopic examination of the fluid contents of the central portion con-
firms this view, for they are found to consist of broken-down liver-tissue —
fat globules mixed with only a few scattered pus corpuscles.
To what is this process due 1 It has not yet been demonstrated for
the tropical, as it has been for the pyemic form of abscess, that the
capillaries of the necrosed portions aie impacted with micrococci. Yet the
anatomical identity of the lesions in both speaks strongly for an identity
of cause. In the abscess itself pyogcnetic cocci have been frequently
demonstrated. Macfadyen satisfied himself at once of the absence of
amoeba? and of the presence of staphylococcus aureus in a case of tropical
liver abscess contracted in India. In four out of nine cases of non-
dysenteric liver abscess Kartulis isolated the same micro-organism, and in
one case he demonstrated the S. albus. The same observer out of
thirteen cases of dysenteric liver abscess demonstrated the S. aureus twice,
the S. albus once, and the Bacillus pyogenes foetidus once. The two
staphylococci have also been found by Bertrand in liver abscess. That
a considerable number of results have been negative does not prove that
these microbes had not been present at an earlier stage. Thus it is
SUPPURATIVE HEPATITIS 145
in the highest degree probable that, when liver abscess is not associated
with amosba;, the impaction of pyogenetic micrococci in the capillaries of
the necrosed area is the sole cause of tropical liver abscess ; whether
associated with dysentery or independent of it.
There is not much difficulty in accounting for the entrance of these
organisms into the liver Avhen the large intestine is the seat of dysenteric
ulceration. The cylindrical epithelium, which forms the first line of
defence from their inroads, is removed, and the exposed and injured vessels
seem to invite their entrance. The difficulty of explaining their
presence in the liver will appear at first sight to be greater when dysentery
is absent. Birch-Hirschfeld recognises the probability of idiopathic liver
abscess being a cryptogenetic infection, and suggests that the pyogenetic
bacteria may obtain an entrance into the portal vessels through small
excoriations in the intestinal tract ; and we know how frequently a
catarrhal condition of the intestinal canal, Avhich must be accompanied
by loosening and descjuamation of the epithelium, is present at the
beginning of suppurative hepatitis ! But the assumption of wounds,
large or small, is not at all necessary. It is well known that staphylo-
cocci have a considerable power of penetrating healthy tissue, and a still
greater power of finding theii- way to diseased tissues. The biliary
ca,nals are normally aseptic up to a point near the entrance of the
common bile-duct into the duodenum. If, however, obstruction of the
common bile-duct be established by any extrinsic or intrinsic cause, the gall-
bladder and biliary canals are speedily invaded by micro-organisms, and,
amongst others, by staphylococci which, according to Netter's investiga-
tions, may penetrate into the liver and blood-vessels, and produce
abscess of the liver and other organs (Macfadyen). \yide art. "Cholan-
gitis."] The unhealthy condition of the bile -ducts caused by the
obstruction determines the immigration of the micrococci, and the
absence of a wound does not prevent their access to the diseased tissues.
There can be little doubt that these organisms, always present in the bowel,
do from time to time enter the portal radicles and find their way into
the liver ; but there, if in small number and the liver functionally and
structurally sound, they will be promptly destroyed. All the more
certainly will they make their way into the organ if its vitality is impaired,
and the greater will be their chance of establishing themselves in a given
area if the endothelium of the vessels in that locality has from any cause
become diseased. The importance of a lesion in disposing the part to the
reception of infective agents has been demonstrated by Orth and Wysso-
kowitsch, who, according to Fliigge (10), were able to set up endocarditis
in rabbits by "first causing tiivial lesions of the cardiac valves, and then
injecting cultivations of staphylococci. The infection did not succeed
when the cultivation was injected without simultaneous injury to the
valve."
We have to bear in mind then, on the one hand, that a diseased con-
dition of the liver, apart from wounds opening the lumen of the portal
radicles, may determine an immigration of pyogenetic cocci ; and, on the
VOL. IV L
146 SYSTEM OF MEDICINE
Other hand, that an impairment of the vital energy of the endothelial cells
of the capillaries is essential to the lodgment and increase of these
organisms. The prevalence of liver abscess in the tropics, its com-
parative absence from temperate regions, and the singular fact that
tropical abscess is a disease of the liver only, and not of any other
organ or tissue, Avill become intelligible as soon as we can show in
what manner and to what extent the transference of the European to
warm climates gives rise to functional, nutritive, and structural disease
of this organ.
The organs of the European have become adapted to work under
the conditions which obtain in temperate climates. This is shown
by the difficulty of rearing European children in India, and the con-
stitutional degeneracy which results when they are not removed at an
early age to their native country. In addition to this hereditary want of
adaptation between European man and tropical surroundings, we have, in
the case of those who are transplanted from a temperate to a tropical
climate after reaching manhood, acquired habit to reckon with. Both of
these elements vary greatly in different individuals. Some are better
able to accommodate themselves to the new conditions of life than others.
Without entering upon the vexed cpiestion of the additional work thrown
upon the liver as the result of alterations of the respiratory function in
warm climates, we may point out one respect in which the physiological
balance is notably upset. The skin, which in temi)erate climates is com-
paratively inactive, is mainly related, vicariously, to the respiratory
system. Hence a chill results in a catarrh of the respiratory tract.
In the tropics, on the other hand, the functional activity of the skin
is enormously increased, and it is now brought into close compensatory
relationship to the portal system. A chill under the new conditions
induces a congestion of the liver or an intestinal catarrh. Pathologically,
this s^vitching off of the skin from its connection ^-ith the respiratory
and placing it in relation with the portal system (taken with correlated
changes, of course), manifests itself in a complete altei'ation of the
cadre of disease on transference to a tropical climate. The number of
admissions from diseases of the respiratory organs falls from 57 to 32,
while that from diseases of the digestive system rises from 101 to 143 per
1000. More particulai-ly hepatic aff'ections, mostly congestive, give rise
to six times, and diarrhrea and dysentery to nearly ten times the number
of admissions in India that they do in England. Congestion of the liver
gives rise mechanically to congestion of the intestinal tract, and this
mechanically caused congestion of the ])Owel is furtlier aggravated b}'' the
physiological consequences of liver congestion. The circulation through
the capillaries of the liver is slowed, the secretion of bile is consequently
lessened, and the contents of the intestine, partially deprived of their
antifermentative fluid, undergo fermentation, which in turn induces catarrh
of the intestine already mechanically congested. One of the functions of
the liver, which is l)elieved to be closely allied to its glycogcnetic function,
is the transformation of toxins. These are the direct or indirect products
SUPPURATIVE HEPATITIS 147
of the bacteria which inhabit the bowel in the proportion, according to
Vignal, of twenty millions to a decigramme of intestinal matter. The
amount of toxins thrown upon the oppressed liver is augmented in
intestinal catarrh and their character altered. This still fui^ther increases
the strain upon the organ, and, a vicious circle being thus established, it
matters not whether the liver or bowel be the starting-point of the mis-
chief ; the one acts and reacts upon the other, the result being disordered
nutrition and impaired function in both, which disorder or defect, in
some cases, runs on to structural change. The nexus, therefore, as we
conceive it, between the dysentery of the tropics and liver abscess is
to be looked for in the physiological and pathological relations between
the two, rather than in any unity of pathogenetic germ. In a small but
still considerable number of Europeans residing in tropical countries
hepatic insufficiency exists, and all the more surely is this established if
alcohol be taken to excess. The toxins, acting upon the tissues of
the disabled liver, diminish their vitality, especially in parts in which
previous congestions, or other causes, have already established an area of
less resistance. It has been shown, as Fliigge remarks, that, " under the
influence of ptomaine poisoning, the same bacteria which formerly quickly
died in the endothelial cells, and never caused disease in the animals,
are now able to multiply with extreme rapidity and cause the death of
the animals previously immune." There can be no difficulty, then, in
understanding in what way residence in a warm climate causes hepatic
insufficiency and, in so doing, favours the settlement and growth of pyo-
genetic organisms in the liver, quite apart from any dysenteric complica-
tion ; and also in what way and to what extent dysentery comes in as
a powerful accessory cause of liver abscess. An attack of dysentery in
temperate climates increases, it is true, the strain upon the liver, but the
organ is sufficient for its work ; in a certain proportion of cases of tropical
dysentery, however, the organ is unfit for the additional work thrown upon
it. Dysentery at once favours the establishment of a point of less re-
sistance, and, by the intestinal lesions it causes, facilitates the entrance of
pyogenetic bactei'ia into the vena portse. The attacks of febrile congestion
of the liver, on the other hand, which are so frequently premonitory of
abscess, determine, in the manner already indicated, a catarrhal or
dysenteric inflammation of the large intestine, which in its turn aggravates
the liver disorder.
Just as in temperate climates a blow over the liver, by impairing the
vitality of the organ, furnishes the opportunity for an invasion of
micrococci, so the want of adaptation of the organs of the European to
the new conditions imposed upon them by transference to a warm climate
frequently results in functional and nutritive changes in the liver which
prepare it for the reception of the pathogenetic agents.
In tropical hepatitis pathological change in the liver is primary and
determines the microbic infection. In pyaemic abscess, on the other
hand, the impaction of minute infective emboli, derived from a local
focus of unhealthy suppuration, in certain capillary areas to which
148 SYSTEM OF MEDICINE
chance may liappcn to direct them, is the primaiy lesion ; and thus the
further chanujes the liver suhstaacc may undergo arc determined.
Symptomatology. — Acute Hepatitis. — Abscess of the liver is gener-
ally described as one of the terminations of acute hepatitis. The con-
stitutional symptoms of hepatitis are fever, a coated tongue, constipation,
scanty and high-coloured urine, gastric disturbance, and, in some cases,
slight jaundice. The local sj'mptoms are pain, tenderness, or simply a
feeling of weight or uneasiness in the hepatic region, usually increased
on pressure. Pain in the right shoulder occurs in relatively few cases,
but when present it is an important sign of hepatic mischief. A
uniform enlargement of the liver is the only other local sign of
importance. If these symptoms do not subside spontaneously, or as the
result of treatment, suppuration is to be feared. This event is announced
by rigors and sweating, and by a bulging, painful enlargement in some
part of the hepatic region.
Hepatitis thus clinically portrayed is not a fatal disease ; 86 per cent
of the cases treated by Morehead ended in recovery.
It may be safely affirmed that the A'ast majority of cases returned as
hepatitis are febrile congestions of the liver due to malaria, having little
or no tendency to end in suppuration. Hence it was that a free
use of the lancet and mercury seemed so frequently to succeed in pre-
venting this misfortune.
It must be admitted, however, that a form of hepatitis of a graver
type, etiologically related to liver abscess, does occur. The patient suffers
from an attack characterised by the constitutional and local symptoms
described above, and often in a severe form. In a few days it passes off,
recurs, and again subsides. After, it may be, many such fugitive
attacks the same train of symptoms reappears, not to pass off as before,
but now as premonitory of liver abscess. In many instances this non-
malarious hepatitis occui's in connection Avith recurrent dysenteric or
diarrhceal attacks, and these should alwaj's excite sus])icion ; or it may
appear as a primary disease. In either case it may be regarded as a
febrile congestion resulting from the absorption of some ptomaine from
the bowel. It points, in short, to toxic vulnerability, and is not to be
regarded with indifference. It alwaj's indicates a state of things that
may be followed by grave consequences, although it does not necessarily
imply that an invasion of the liver by pyogcnetic micrococci — the first
step to abscess -formation — has actually taken place. This form of
hepatitis, the only one relevant to liver abscess, has hitherto been very
imperfectly distinguished from other foi-ms, and it is very important that
its nature and symptoms should lie recognised and iniderstootl.
Liver Absreffs. — The most distinctive symptoms of liver abscess are
fever, pain, and irregular cidargemont of the organ, followed by a train of
phenomena secondary to suppuration, and significant of ))urulent absor])tion
— emaciation, hectic, ccjld sweats, diarrhd-a or dysentery, and occasionally
delirium. It sometimes happens that all the symptoms, primary and
secondary, are absent. In making autopsies one comes now and again quite
SUPPURATIVE HEPATITIS 149
unexpectedly upon an abscess which had not betrayed its presence by
any symptom during life.
The evolution of liver abscess is so irregular that it is impossible to
delineate the clinical features of the disease in such a way as to represent
more than a few of its protean forms. I shall content myself, therefore,
with a brief review of the individual symptoms, indicating, at the same
time, the way in which they are usually found associated.
Fever. — In a very large number of cases fever is the initial symptom,
and this may be accompanied from the beginning by pain in the region of
the liver, and followed after a week or a fortnight by enlargement. In
other cases the fever lasts for a period vaiying from a few days to a
month or more before pain supervenes or distinctive enlargement can be
made out. The fever sometimes assumes a quotidian type, or the acces-
sions occur t^Wce daily ; but irregular evening exacerbations are most
frequently observed, and these are usually followed by perspiration. The
fever often subsides as the swelling appears, or even earlier ; and may
recur from time to time during the progress of the disease. The
irregularity of the fever should excite suspicion of its non- malarial
origin. Towards the end, fever of a hectic type is frequently present.
It is important to observe that in a few cases liver abscess makes its
appearance suddenly with severe rigors, high fever, and urgent vomiting ;
and often enough Avithout pain or tenderness in the hepatic region. An
instance of this kind came under my observation which I mistook for
and treated as a severe paroxysm of malarial fever. The diagnosis
seemed to be justified by the disappearance of the symptoms within a
few days. About eighteen months afterwards, during my absence, the
patient was seized with all the symjDtoms of liver abscess and died. The
autopsy revealed, in addition to a recent abscess, an old one, the size of a
pigeon's egg, in the substance of the right lobe, advancing to cure. When
we read of abscess being found in fatal cases of bilious remittent it means
that a similar mistake in diagnosis has been made.
Pain. — In many cases pain is the first symptom to attract notice.
If its onset is sudden and severe it will be accompanied with more or less
fever, otherwise it often persists for days or weeks without much fever
or any enlargement. The pain is generally situated in the right or left
hypochondrium or epigastrium ; more rarely in the right slioulder, when
it is generally found to be associated with abscess in the right lobe. If
the disease be limited to the parenchyma the pain is usually dull and
tensive, but when the serous capsule is involved it is acute and increased
by superficial pressure.
Enlargement is one of the most common and distinctive characters of
liver abscess. As a rule it follows the symptoms already mentioned.
When the disease has made some progress it will frequently be
possible to detect a bulging in some direction — upwards, downwards,
or outwards — according to the seat of the disease and the direction it is
taking. When it pushes up the diaphragm and encroaches on the thoracic
cavity it often gives rise to a short, dry cough, dyspnoea, and oppression,
I50 SYSTEM or MEDICINE
■with the physical signs of basal pleurisy or pneumonia ; much more rarely
does it cause hydrothorax. If the enlargement be downwards, the tumoiir
will be felt below the margin of the )-i])s or in the epigastrium. By its
pressure on the stomach, nausea, vomiting and other gastric symptoms
may be caused. When the abscess comes into relation with the costal
walls, more or less vaulting, with widening and effacement of the inter-
costal spaces, Avill l)e manifest.
Flnduation can generally be made out when the abscess nears the
sui'face.
Decubitus. — The patient is seldom al)le to lie on cither side without
suffering. In many cases he finds most ease by lying on his back with
his shoulders raised.
Si/m2)toms connected with the spontaneous opening of an abscess. — When the
contents of an abscess are poured into the peritoneal cavity symptoms
of acute peritonitis will speedily ensue. Pain in the region of the heart,
a sense of suffocation, and the physical signs of pericardial efllusion in-
dicate rupture into the pericardium. Should the abscess 1)urst into the
right pleural sac, pain, dyspnoea, and the signs of pleuritic effusion will
be present. If it burst into the lung, the sudden expectoration of brick-
red puriform matter, sometimes tinged wnth bile, preceded and accom-
panied hy the physical signs of pneumonia of the base, will he observed.
Kupture of the abscess into the stomach is often preceded by gastric pain
and irritation, and announces itself by purulent vomiting ; or the pus,
more or less changed, may pass off by the bowels. In case of rupture
into the colon, pus Avill be detected in the stools, and a coincident sub-
sidence of the tumour "wall be observed. The opening of the abscess into
the pelvis of the right kidney can only be known by the discharge of
pus by the uix'thra.
Duration, Diagnosis, Prognosis. — Duration. — Hepatic abscess
running an acute course and ending fatally from seven to twenty-
one days from the beginning of the disease is generally to be
referred to portal pyaemia. Instances are occasionally observed, however,
in which the tropical form proves fatal Avithin a week or two. A case of
this kind is ix'corded by Kclsch and Kiener as occurring in a patient M'ho
had been ailing for a few days only, and died six days after his admission
to hospital. Tropical abscess, as a rule, runs a subacute or chronic
course. The mean duration of fatal cases complicated with dysentery
M-as found by Kouis to be ninety-five days, and that of those not so
complicated eighty-five days. The cases ending in recovery ran a still
more protracted course. The average stay in hospital of twenty fatal
cases of which I have notes averaged forty-two days.
Diiif/nosis. — Hydatid cysts may be distinguished from liver abscess
by their slow and painless growth ; besides, they do not present the con-
stitutional .symptoms proper to liver abscess. A suppurating hydatid
tumour will generally be recognised by the history of a previously
existing painless and slowly increasing tumour ; but in case of doubt
an exploratory puncture should be resorted to.
SUPPURATIVE HEPATITIS 151
An inflamed and distended gall-bladder has been mistaken for a liver
abscess. The situation, the pear-like form, the mobility of the tumour,
which, as Frerichs remarks, scarcely ever contracts adhesions to the
abdominal wall, the absence of inflammatory oedema of the tissues over
it, the history, in some instances, of biliary colic, and the fact that the
tumour has been soft from the beginning, sufficiently indicate its nature.
Serious difficulty can scarcely arise in establishing a diagnosis between
a deep abscess of the abdominal parietes and one ,of the liver. Should
any doubtful case occur, the suggestion of Sachs to introduce a iinc
needle into the cavity of the abscess may be borne in mind ; if the aliscess
be seated in the abdominal wall the needle will remain motionless during
inspiration.
It is hardly necessary to do more than mention the possibility of a
chronic liver abscess with hectic symptoms being mistaken for phthisis.
The history of the case, the absence of the physical signs of tubercular
deposit in the apex of the lung, the enlargement of the liver, and the
local pain, are the points to be attended to.
The prognosis in liver abscess must always be guarded. Out
of ninety-five admissions in the army of India in 1893, no fewer than
sixty-two patients died. The coexistence of dysentery, the plurality of
abscesses, a history of alcoholism, or the coexistence of severe constitutional
disease all increase materially the gravity of the prognosis.
Treatment. — Our primary object must be the prevention of the
disease. Much success in this direction has already been attained. The
death-rate per 1000 in the European army of Bengal for the decennium
1860-69 was 3-31, and it had fallen to I'OO in 1893. The efi'ects of
a constant high temperature can be largely mitigated by attention to the
dwelling. The rooms should be large, airy, but not di^aughty. Needless
exposure to heat should bo avoided, and the clothing should be adapted
to the climate. Care should also be taken to avoid exposure to chills,
especially when heated, and to change the clothes as soon as possiljlc
when they have become damp with perspiration. Exercise, always short of
exhaustion, should be taken regularly at proper hours. Excess of food
and a diet below the requirements of the system are alike harmful. The
habits and tastes of the individual are not to be ignored in advising the
Eiiropean respecting his regimen in the tropics. Some find themselves
better on a diet chiefly animal, and have a difficulty in digesting food
composed mainly of rice and vegetables. What is most easily digested
will be found the best ; but excess of animal food, rich sauces, and
pastry should be strictly avoided. In some constitutions the lighter
wines, taken in moderation and along with the meals, will not only be
harmless but even beneficial. Ardent spirits in any form or amount are
injurious, and ought to be shunned by every one who wishes to enjoy
length of days and health in the tropics.
Attention to the regular action of the bowels will be looked upon as
a matter of the first importance by those who share our views respecting
the etiology of liver abscess. Constipation and looseness are alike to be
152 SYSTEM OF MEDICINE
guarded against. It should never Le forgotten that, when eitlier con-
dition has become habitual, the patient is already in a state in which
something more than a routine purgative or astringent is called for.
There is something -wrong in the food, drink, work, exercise, habits, or
suri'oundings of the individual that must be looked into and set to
rights.
A consideration of the important relations between dysentery and
liver abscess will indicate the necessity of treating the mildest attack,
especially mild recurrent attacks, of tropical dysentery as serious.
Care must be taken to distinguish the malarious from the non-
malarious form of hepatitis. In the former there will usually be a
history cf previous attacks of ague ; the spleen "will probably be found
enlarged, and the malarial parasite or pigment may be detected in the
blood. The non - malarious form, as already stated, is frequently
associated with recurrent diarrhoeal or dysenteric symptoms. This form
demands special treatment. The patient is to be confined to bed, his
diet restricted to milk, and ipecacuanha given in full doses, whether
diarrha>a or dysentery be present or not. Benzo-naphthol, or other
appropriate antiseptic, should be administered in the intervals between
the exhibition of the ipecacuanha. An occasional purgative dose of
calomel or blue pill may sometimes be given with advantage, a practice
often followed by a manifest improvement in the patient's feelings and
the state of his excretions.
When the acute symptoms have passed or moderated, resort shotild
be had to the chloride of ammonium in fifteen to twenty grain doses,
three or four times daily, and persisted in for a considerable time ; the
action of the bowels must be regulated l)y cascara sagrada, a combination
of euonymin and rhubarb, or an alkaline saline, as the special features of
the case may suggest. If pain or uneasiness in the region of the liver
persist, successive applications of lii]Uor epispasticus at various points
over the seat of the pain will often give relief. p]ut, above all, the
habits of the patient as regards food, drink, and exercise' should be
regarded. If nothing in these respects seems amiss, and the hepatic
symptoms persist, a change to a temperate climate must be made.
When abscess has formed, its treatment enters the domain of surgery.
The earlier the existence of an abscess is ascertained, the greater will be
the hope of successful surgical treatment. An exploratory puncture in
case of doubt is all the more justifiable that the best results have been
observed to follow its use, even when no abscess could be detected.
Andrew Davidson.
references
]. BiRCH-HiRSCHFELD. Path. Anal. Bd. xi. 2 Htilfte, Leip. 1895, p. 716.— 2.
Brillsh Guiana Aiinual. Geor<.,'eto\vn, 1892. — 3. Brui). Disarscs of the Liver, Lond.
ISi.'i, p. 72. — 4. Cayi.ey. Davidsons iri/f/ienc ami Diseases of Warm Climates, Edin.
1893, p. 615.— 5. CuArFFAUT. Charcot's Traitd de 7)i(d. t. iii. Paris, 1892.— 6.
CuNWKi.L. A Treatise on Functiomtl and Structural Chamjes of the Liver, Lond.
1835, p. 72. — 7. De Cahtko. Des abcts du foie. Paris, 1870. — 8. Dkago. Arch.
AMCEDIC ABSCESS OF THE LIVER 153
demM. nav. 1890. — 9. Fayrer, Sir J. Tropica?, Diseases, p. 204. — 10. Flugge. Micro-
organisms, Syd. Soc. 1890, p. 751.^—11. Giiaves. Clin. Med. lect. liii. — 12. Haspel.
Malad. de I'Algerie. Paris, 1850. — 13. HiRscH. Handbook Geo. and Hist. Path. Lond.
1886, vol. iii. p. 412. — 14. Kartulis. Arcliiv f. path. Anat. u. Phys. T. cxviii. — 15.
Kelsch and Kiener. Maladies des pays chauds, Paris, 1889, p. 285. — 16. Ibid. p. 209.
— 17. Macfadyen". Davidson's Hyg. and Dis. of Warm Climates, Edin. 1893, p. 660.
—18. Macnamara, F. N. Ind. Ann. of Med. 1862. — 19. Macnaught. Cyclop.
Anat. and Phys. vol. iii. p. 190. — 20. Marston. Med. Times, Sept. 1856. — 21. Rouis.
Sur Us suppurations endem. du foie, Paris, 1860, p. 203.^22. Pachs. Aixhiv f.
klin. Chir. Berlin, 1867. — 23. Thierfelder. Ziemssen's Cyclop, vol. ix. p. 111. —
24. Waring. Enqu.irti into the Stat, and Path, of Abscess in the Liver, Trevandruni,
1854, p. 134.— 25. Ibid. p. 137.
A. D.
AMCEBIC ABSCESS OF THE LIVER
Definition. — Abscess of the liver, single or multiple, occurring in associa-
tion with dysenteric ulceration of the bowel, active or latent, in which the
amoeba coli is found bearing a relation to the hepatic lesions analogous
to that which it bears to the intestinal lesions.
Etiology. — In 1887, Kartulis of Alexandria described the occurrence
of living motile amoebce in the contents of an hepatic abscess. He had
already noted their presence in sections of the walls of such abscesses in
certain fatal cases of dysentery, in the stools and in the dysenteric ulcers
of which the same organism was also present. These observations have
been repeatedly conlirmed in America by Osier, Councilman and Lafleur,
Musser and others ; and more recently in Egypt by Kruse and Pasquale,
in their extended investigation of amoebic enteritis and hepatitis. [Vide
art. on "Amoebic Dysentery," vol ii. p. 753.]
In abscesses involving the liver and lung, which discharge themselves
spontaneously through the air -passages, the amoebae are found in the
sputum also (Councilman and Lafleur).
A detailed description of the amoeba has already been given in
another portion of this work, to which reference may be made [fide art.
"Amoebic Dysentery," vol. ii. p. 754].
The amoebae found in abscesses of the liver and lung differ in no
essential respect from those present in the -^ tools and in the intestinal
lesions of this form of dysentery.
The bacteria associated . in the lesions with the amoebae are many.
Of thirteen cases of dysenteric liver abscess, examined bacteriologically by
Kartulis, the staphylococcus aureus was found in two, and the staphylo-
coccus albus, bacillus pyogenes foetidus, and the proteus vulgaris in
one case each. The remaining eight cases were sterile in this respect.
The sterility of the pus is explained by Kartulis on the supposition that
the bacteria in closed abscesses of long standing are not so resistant as
the amoebae and quickly perish. Kartulis adopts the classification of
154 SYS TEA/ OF MEDICINE
tropical liver abscesses into "idiopathic"^ (those due to bacterial infection
from the gastro-intestinal tract) and dysenteric (those due to infection of
the liver through the portal s^'stem by the intervention of am«bai Avhich
contain bacteria — microbenhaltigen).
Kruse and Pascjuale investigated fifteen cases of abscess of the liver,
of which nine were idiopathic, and six in association Avith dysenteric
ulceration of the bowels. Araoebc'e were found in the latter, but not in
the former. In the idioj^athic abscesses bacteria Avere found by
cultiA'ation in six cases, and in the dysenteric abscesses in Aa'C. Of the
various species of bacteria, streptococci Avere found in three dysenteric
abscesses and in one idiopathic abscess ; staphylococci in tAVO dysenteric
abscesses and in one idiopathic abscess; bacilli resembling that of
typhoid fever in four abscesses of both sorts ; the bacillus pj'^ocyaneus in
three idiopathic abscesses. None of these organisms AA^as found in large
numbers except the bacillus pyocj^aneus. Councilman and Lafleur in
two cases of dysenteric abscess found the Bacillus coli communis in one,
and no bacteria in the other. Pansini (quoted by Kruse and Pasquale)
obtained typhoid-like bacilli in three dj^senteric abscesses.
The relative importance of the amoebae and of the seA'eral other
micro-organisms in the production of the lesions in the liver has been
A'ariously estimated by different observers. Kartulis considers that the
amoebae play the principal, but not the sole part ; that they serve as the
vehicles of the bacteria, Avhich may then complete the morbid })rocess ; that
by their active movements the amoebee cause rupture of the capillaries, but
that the bacteria AA^hich accompany them are the pus-producing agents. He
does not believe that the amojbse alone are capable of causing suppuration
in the liver.
Kruse and Pasquale lean to the opinion that none of the bacteria
found is sufficiently constant to be considered specific ; but, nevertheless,
that the bacteria cannot be considered as absolutely non-pathogenetic, for all
of them can be experimentally shoAvn to possess pathogenetic properties ;
some of them are the common pyogenetic organisms. They belicA^e in
a direct co-operation of the amoebce Avith the bacteria in the process of
disintegration of the liA'er tissue and pus-formation.
Councilman and Lafleur think that the amoebse alone are the active
agents in the production of the abscesses. In the smallest abscesses, in
Avhich the lesions can best be studied in their inception, they found no
bacteria, but the amcebae Avere ahA^ays many. Again, even in the
larger abscesses examined by them, the bacteria were not numerous, and
the lesions in the liver Avere in general of a different character from those
produced l)y bacteria. \J^ide section on pathological anatomy.]
It may bo said, at least, that in the idiopathic abscesses — that is, in
those Avhich are not accompanied, preceded, or foUoAA'ed by dysentery —
no amnobre, but A'arious forms of bncterin only ;irc found ; Avhile in the
dysenteric cases — that is, those in Avhich there is cither an actual
' The word iiliopathic i^ ore whicli T do not readily take into use. In the present
article, however, it m.iy be serx iceaUlc if accepted only iu its negative bearings. — Ed.
AMCEBIC ABSCESS OF THE LIVER 155
dysentery with amoebae in the stools, or a history of such an attack —
amoebae are constantlj^ jDresent, and may or may not be accompanied by
small numbers of bacteria similar to those found in the idiopathic
cases.
In all the recorded cases amoebic abscess of the liver has arisen
secondarily to an attack of amoebic dysentery. It is not necessary,
however, that the dysenteric idceration of the bowel should ]je active, or
even that any dysenteric symptoms should coincide with the abscess : on
the contrary, the dysenteric process in the boAvel may be latent and, until
disclosed post-mortem, even unsuspected
Whether an amoebic abscess can form in the liver independently of
any intestinal lesion is a question that is still undecided. There is no
recorded case which may be accepted without reserve as evidence on this
point. Kruse and Pasquale mention two cases, but admit that they are not
conclusive. In one there were slaty-pigmented scars in the large bowel,
suggestive of prior dysenteric ulceration ; in the other were ulcers in the
stage of healing, though the patient had not suffered from dysentery until
after the development of the abscess in the liver. The latter case is un-
doubtedly an example of latent amoebic dysentery, with exacerbation
following abscess-formation ; and can in no wise be addiiced as evidence
of primary amoebic abscess. It is possible, indeed, to suppose a primary
infection of the liver through the bile passages, but there is no recorded
examjile of such an occurrence. Amoebic abscess of the liver must, for
the present, be considered as invariably secondary to active or latent
amoebic dysentery, or, in other words, as a complication of this disease.
With the so-called idiopathic — non-amoebic — abscesses the case is
entirely different. Such abscesses usually, if not always, appear in-
dependently of intestinal affection, and are not followed by it.
To explain their occurrence one must take into account the general
etiological factors that dispose persons in the tropics to inflammatory
diseases of the viscera in general, and of the liver in particular. It does
not seem probable that these factors can of themselves cause suppuration,
but rather that they prepare the tissues for the invasion of one or more
species of the ordinary pyogenetic micro-organisms. Through what
portals these micro-organisms gain access to the liver is not quite clear,
though in a few cases Kartulis has found lesions in the mucous membrane
of the stomach.
To discuss whether tropical liver abscess in general is or is not
dependent upon dysenteric ulceration of the intestines appears to me to
be futile. The intimate association of abscess of the liver Avith one form
of dysentery is quite clear ; and what is needed is a more accurate
etiological investigation to determine in individual cases Avhich are of
dysenteric and which of non-dysenteric (idiopathic) origin. Whether,
as a rule, the dysenteric liver abscesses are jDroduced by amoeba?, or
whether in tropical countries there are dysenteries, commonly followed
by liver abscesses, which are due to some other agent, are also questions
that invite further investigation.
156 SVSrE.V OF MEDICINE
The amoebce found in liver abscesses come from the large intestine,
and must necessarily gain access to the liver by way of the blood, by
way of the lymph -channels, or by Avay of the peritoneum. Infection
through the l)ile i)assages has already been referred to as an hypothetical
but not very probable occurrence.
In the case of multiple abscesses in the interior of the liver, it is
probable that the amoebte reach the liver through the radicles of the
portal vein. They are often found in the capillaries about the base and
sides of the intestinal ulcers. Again, it is possible that secondary
abscesses in the liver may be produced by a backward infection of the
portal veins from a primary single abscess (Kruse and Pasquale).
Though amu3bie are very often found in the lymph spaces and lymph
capillaries of the intestine, it is not probable that infection occurs through
the lymph -channels, for before reaching their destination the amoebse
would have to pass through a long series of intervening lymphatic glands
and channels ; they are very rarely found in any of these glands, nor do
the glands present any changes characteristic of the action of amoebae.
Infection by way of the peritoneal cavity undoubtedly occurs. In one
case there was found peritonitis with amoebae in the exudation over the
intestinal coils and the surface of the liver (Councilman and Lafleiu-).
Such a mode of infection explains in a satisfactory manner the frequent
situation of the abscesses at the extreme upper portion of the right lobe
close to the diaphragmatic attachment, and the early extension of the
mischief to the lower lobe of the right lung. It also explains the
occurrence of the multiple superficial abscesses, ai\d of abscesses of the
under surface of the liver adjacent to the hepatic flexure of the colon.
It is difficult to form an estimate of the frequency of amoebic
abscess, for the statistics in which this etiological factor is taken into
account are as j'et too scanty. Kartulis states that of some 500 liver
abscesses which had come under his observation, 55-60 per cent were
of dysenteric origin ; but he does not state the proportion of cases of
dysentery in Avhich abscess supervened. Kruse and Pasquale found
abscess six times in 57 cases of amoebic dysentery, and Councilman and
Lafleur six times in 15 cases.
The extensive statistics of British and French physicians relating to
dysentery and liver abscess in India and other eastern countries are not
directly available for purposes of comparison, as no mention is made of
the etiological factor, and the various kinds of abscess are not dis-
tinguished. It is highly suggestive, however, that the collective
statistics of liver abscess and dysentery in the tropics show an average
of one case of liver abscess for every four or five cases of dysentery.
These figures lend a proliability to the supposition that a large proportion
of the cases Avere of amoebic origin, for it cannot be questioned that in the
diphtheritic and in catarrhal dysenteries of temperate climates abscess
of the liver is a rare complication.
Pathological anatomy. — («) Lesmis in the lirer. — Leaving the abscesses
out of account, the liver is generally of normal size, sometimes enlarged :
AMCEBIC ABSCESS OF THE LIVER 157
in some cases it is congested, in others pale. There are areas of local
peritonitis Avhere the larger abscesses reach the surface of the liver, and
when an abscess is situated in the uppermost part of the right lobe close
to the diaphragm, the latter is bound to the liver over the periphery
of the abscess by very dense adhesions. The abscesses may be one or
more : in the latter case there is usually one which is larger and evidently
of longer standing than the others. Sometimes, in the same liver,
abscesses of all ages are to be seen, from the smallest and mo.st recent
with no definite walls to the oldest with dense fibrous walls. The smallest
visible abscesses are from 1 to 5 mm. in diameter ; the largest may attain
the size of a large orange or even, in rare cases, of an infant's head.
As a rule the right lobe of the liver is the seat of the large abscesses,
and certain portions of the lobe are especially prone to be affected, namely,
the under surface adjacent to the hepatic flexure of the colon, and the
dome of the liver close to the diaphragmatic attachment. The small mul-
tiple abscesses are commonly superficial, or at any rate near the surface ;
l)ut in a few instances they are found scattered throughout both lobes of
the liver.
The general shape of the abscesses is spherical or ovoid, liut there
are often irregularities in outline, especially in the larger ones, due to
unequal extension in difi'erent directions.
AViih regard to the naked-eye appearance the abscesses may be
divided roughly into three varieties : small, very recent abscesses ;
abscesses of larger volume, with walls partly necrotic and partly fibrous,
which are evidently still extending ; and old abscesses, apparently
stationary, Avith firm and thick fibrous walls.
The contents vary with the kind of abscess. In the smallest they can
scarcely be called fluid, for they do not empty themselves on section ; a
little glairy translucent fluid exudes, leaving a yellowish -gray spongy
mass behind. In the larger and older abscesses the contents are more
liquid, of a grayish, a yellowish -gray, or a mottled yellowish -red or
brownish-red colour (which indicates admixture of blood) ; and frequently
numerous yellowish or grayish shreddy fragments of necrotic liver tissue
are mixed with the more fluid portions. Even in these larger abscesses
the contents are very viscid, and do not resemble ordinary pus.
Under the microscope the contents of the abscesses are seen to
consist mainly of a finely granular detritus, containing fragments of
cells, a few leucocytes and red blood corpuscles, ha^matoidin crystals,
necrotic or fattily degenerated liver-cells, and amoeba which, if the
autopsy had been performed a few hours after death, will still exhibit
active movements. The amoebse are most numerous and active in the
very small abscesses.
Bacteria are very sparingly found in cover-glass preparations, and at
times only by cultivation in suitable media. The species found have
already been stated.
The absence of large numbers of leucocytes, such as constitute the
bulk of the cellular elements in ordinary pus, is especially noteworthy.
158 SYSTEM OF MEDICINE
When the contents are removed it is seen that the walls of the
abscesses are irregular, and covered with a dirty, grayish-yellow necrotic
shreddy material, which extends to a variable distance into the liver.
This is more marked in medium-sized and rapidly extending abscesses
than .in the older ones. The latter may have smooth well-defined
fibrous walls, with fragments only of necrotic liver tissue adhering to
them here and there. The fibrous wall varies very much in thickness ;
in some instances it is more than a centimetre thick, and is of a firmness
almost cartilaginous. In the smallest abscesses there is often no definite
wall at all, the necrotic tissue passing insensibly into normal liver tissue.
The pathological histology and mode of formation are best studied
'n the smallest abscesses, as sections can be made including the whole of
the abscess and a portion of the surrounding tissue. Hardening in
alcohol and staining with methylene blue is most useful for general
purposes ; for more minute study Flemming's solution, followed by deep
staining with safranin, is the best. In sections so treated the abscess
contents are pale and finally granular Avith small brightly-stained par-
ticles, the result of nuclear fragmentation. There are present also darkly-
stained circumscribed masses, some of which are isolated and others
connected with the wall of the abscess ; these are fragments of liver
Avhich have resisted the j^rocess of disintegration, and are composed
of fibrous connective tissue with areas of round-cell infiltration. They
contain an artery, a vein, and one or more bile-ducts, the latter being
lined with low cuboidal epithelium, and thus resemljling newly-formed
bile-channels. Around these vessels are liver-cells more or less necrotic
It is evident from their histological structure that these masses are
remains of the portal system of the liver. A study of the periphery of
the small abscesses shows that the interlobular areas are always the first
to become disintegrated ; and to this process is due the irregular con-
tour of the abscess Avail, the periportal areas persisting until they are
detached from the Avail by the confluence of the foci of interlobular
necrosis.
In addition to finely granular detritus, and the fragments of liver
tissue above mentioned, the abscess contains a fcAv red blood corpuscles
and leucocytes, fibrin filaments, and necrotic liver-cells. The latter are
often elongated, with pointed ends, or they may be of irregular shape
and contain vacuoles. They refract light more than normal liver-cells,
and contain no nucleus.
In the foci of necrosis around the abscess caA^ity the capiliarios
are dilated and filled Avith blood or, Avhen near the caAdty, with granular
contents like the abscess. There is a dissociation of the capillary Avail from
the tral)ccul;e of liver-cells, and the latter are thiinied, highly refractive,
and vacuolated, many of the vacuoles containing fat. A i)ecidiar refrac-
tive reticulum, similar to that found at the bases of the intestinal ulcers,
is often seen around the borders of the abscess and the isolated fragments
of periportal tissue.
In most instances there is no accumulation of leucocytes either in
AMCEBIC ABSCESS OF THE LIVER 159
the necrotic tissue or in the capillaries. This absence of inflammatory
reaction on the part of the tissue is characteristic of amoebic abscess.
Numerous amoebae are found in the tissues, chiefly in the periphery
of the abscess, where they occupy the capillaries, and around the portal
tissue fragments. They are but seldom found beyond the zone of
necrosis.
The larger chronic abscesses present some differences in structure from
that of the small abscesses — diff"erences that are explicable on the sup-
position that the amoebae are fe^yer in number, and that the necrosis of
the liver tissue is less diff"use. They usually have a definite wall of
connective tissue. Sections of this wall show at the innermost part
more or less granular necrotic material, beyond this the refractive
reticulum mentioned above, then a zone of granulation tissue of varying
width composed of uninuclear round cells, and, finally, a zone of fibrous
connective tissue which contains spindle-shaped cells and small -celled
infiltration both diffuse and circumscribed. In the connective tissue
zone, which is highly vascular, there are numerous, often branching, bile-
ducts. In the outermost part of this zone liver-cells are found, singly
or in groups of two or three at first, then in larger agglomerations.
They are much swollen and fatty, but still possess a nucleus. Still
further outward in the liver tissue, which shows strands of connective
tissue rich in round cells, the capillaries are engorged and small hsemor-
rhages are common. When the abscess is large there is evidence of
pressure, the adjoining liver-cells for a considerable distance being flattened
and spindle-shaped. Amoebse are much less numerous in the chronic
abscesses than in the small acute ones, but are found chiefly in the same
situation, that is, in the necrotic zone of the abscess just at the edge of
the round -celled infiltration. In the connective tissue zone they are
scanty and occupy the blood-vessels and the spaces of the tissue.
Abscesses of the under surface of the liver, which are connected with
the bowel, more frequently show a true purulent infiltration of the
tissues, owing to the invasion of pyogenetic bacteria ; the conditions being
analogous to what is seen in some of the intestinal ulcers where there is
a mixed infection.
In addition to the formation of abscesses there is another very
important change in the liver, which consists in a widespread necrosis of
the cells around the central vein of the lobules, and is most marked in
the vicinity of the abscesses but is not confined to such parts. These
foci of necrosis never contain amoebae, and, as they are not the result
of pressure or of a local anremia, the most plausible explanation of their
occurrence is to assume that the amoebse produce some soluble toxic
substance that induces these changes. Though not due to the direct
agency of the amoebse the necrotic areas are more vulnerable than the rest
of the tissue, and it is by the softening of these patches that the abscesses
extend.
Tlie changes in the liver may be summed up as follows :- — 1st, a wide-
spread necrosis of the liver-cells, due most probably to soluble chemical
i6o SYSTEM OF MEDICINE
products of the amoebae ; and, 2nd, the formation of abscesses, due
to the direct action of the amoeba?, Avhich cause disintegration and
liquefaction of the necrotic tissue. It is to be particularly noted that
reaction on the part of the tissues in the form of su{)puration — leuco-
cytic infiltration of the tissues, and the presence of leucocytes in the
abscess contents — is as a rule absent, there being no moi-e leucocytes
found than those normally present in the vessels of the tissue involved
in the abscess.
(6) Ledoiis in the lung. — Abscess of the lung is always secondary, and
arises by the direct extension through the diaphragm of an abscess at
the extreme upper portion of the right lobe of the liver. The abscesses
are never metastatic, and it is always the lower lobe of the right lung
that is involved. The diaphragm is intimately adherent to the surface
of the liver, and usuall}'^ also to the under surface of the lung ; but in
some instances a collection of pus in the pleural sac separates the
diaphragm from the lung. The inferior portion of the lower lobe and
often a portion of the middle lobe are consolidated, and there are
adhesions between them and the parietes.
On section an abscess cavity is disclosed in the interior of the con-
solidated portions, extending from the diaphragm to a variable point
upwards, but not usually reaching the surface of the lobe. It is thus
centrally situated in the base of the right lung. There is usually an
opening in the diaphragm, but of smaller size than the diameter of either
the hepatic or the pulmonary abscess. In some instances the diaphragm,
though much thickened, shows no visible solution of continuity.
The consolidated lung tissue adjoining the abscess is very dense, of
a whitish opaque colour near the abscess, grayish and translucent
beyond. The cut surface is quite smooth and cedematous.
The bronchi contain either a purulent or a serous fluid.
The abscess cavity may or may not be empty, according as there
has or has not been evacuation through the bronchi. As in the hepatic
abscess, the contents consist of a viscid yellowish-gray or yellowish-red
fluid, which does not resemble ordinaiy pus, and contains Tuunerous shreddy
necrotic fragments. Under the microscope are seen granular detritus,
round lymphoid cells, some leucocytes, many red blood corpuscles, fat
globules, amceb.ne, and elastic tis.sue fibres from the lung.
The walls of the abscess are even more irregular than those of the
hepatic abscess, and are covered with ragged sloughy material, which
often projects in tag-like pieces into the abscess cavity. In some places
the abscess wall may be smooth and formed of dense connective tissue,
and in others soft and cedematous, without a definite fibrous capsule.
Sections of the wall of the al)scess show next to the cavitv a trranular
mass containing cellular elements and iniclear fragments. Farther aAvay
there are small pieces of lung tissue, chiefly elastic fil)res, but sometimes
also distinct groups of air-cells, mostly necrosed. Beyond this is the
connective tissue zone, which shows round-coll infiltration, and may be
quite thick; or where the abscess is extending rapidly there may be no
AMCEBrC ABSCESS OF THE LIVER i6i
definite fibrous -wall, so that the granular necrotic zone extends directly to
the luns: substance. Both fil^rin and the hyaline reticulum above men-
tioned are found in places at the border of the abscess.
In the portions of the lung adjacent to the abscess the interstitial
tissue is much increased at the expense of the alveoli, which are small, of
irregular shape, lined with a cuboidal epithelium, and resemble rather
glandular than pulmonary tissue. Nuclear figures are frequently seen
in these epithelial cells. The alveoli near the abscess are rilled with
large round fatty cells Avhich bear a close resemblance to amoebae ; they
also contain numerous granulation cells and a few leucocytes. The
more distant alveoli contain fibrin, or bud-like projections from the
proliferating interstitial tissue.
The walls of the bronchi are thickened and infiltrated with numerous
round cells. Their contents are either pus cells, fibrin, or lymphoid cells.
Amoebae are found in these abscesses, and are especially numerous
Avhere the abscess is extending rapidly. They are present also in great
numbers in the alveoli adjoining the abscess ; more sparingly in the
remoter ones and in the bronchi near the abscess cavity. "When present
in the fibrous connective tissue zone they occupy the blood-vessels and
spaces in the tissue.
In the main, making dvie allowance for the difference in the tissues
affected, the changes produced by the amoebae in the lung are similar to
those seen in the liver — necrosis followed by liquefaction of the tissues ;
and there is the same absence of the products of suppurative inflammation.
((■) Lesions of the peritoneum. — Peritonitis, local or general, is some-
times found. It is fibrinous, the exudation being pale and translucent,
and containinoc a s-ood deal of fluid. The cellular elements found in the
exudation are lymphoid cells, a few leucocytes perhaps of other kinds,
and cells from the endothelium with OA'al nuclei in great numbers.
Amoebae were present in two out of three cases.
Symptomatology. — Amoebic abscess of the liver may seem to occur
as a primary condition without any evident disturbance of the intestinal
tract, or again as a complication of a well-marked dysentery at some
period of its course. The latter case is the more frequent. Even in the
former case the iiidependence of the hepatic condition is more apparent
than real, for by careful inquiry a history of some trivial diarrhoea,
occurring, it may be, weeks or even months before the unequivocal signs
of abscess-formation in the liver, is often elicited ; and examination of the
formed stools in such cases may show actively motile amoebae. Moreover,
that dysenteric ulceration may be latent — that is, unaccompanied by any
symptoms or signs pointing to ulceration of the bowel — is amply proved
by the discovery of unhealed intestinal ulcers in patients who have
suffered during life from suppurative hepatitis apparently primary.
Whether apparently primary, or associated with an undoubted dysen-
teric attack, the course of the illness is practically the same in both cases.
The onset is insidious, and, as a rule, owing to the usually deep-seated
position of the abscess, the fix'st indications of the implication of the liver
VOL. IV M
1 62 SYSTEM OF MEDICINE
are derived from the subjective rather than from the physical signs.
When abscess occurs in the course of a dysentery of moderate severity it
is usually at some date between the fourth and twelfth weeks of the
intestinal affection. In chronic dysentery, however, there is no such
limitation of time, and abscess may arise after an intestinal flux had per-
sisted for months, or even for years. In gangrenous dysentery death
usually occurs before there is time for the liver to become infected.
The illness begins most frequently with pain, fever, and sweating ;
the pain being usually in the region of the liver, or near the lower part
of the scapula. The patient loses appetite, emaciates more or less
rapidly, and becomes progressively weaker and more anaemic. The skin
assumes a moderate icteroid hue, but pronounced jaundice is not common.
There is sometimes much gastric distress with attacks of vomiting, but
hiccough is more usual. On the Avhole, the general features of the
disease are those of septic absorption from an internal focus of suppiu-a-
tion. If the abscess be not evacuated, spontaneously or by surgical
intervention, death occurs sooner or later from exhaustion.
In a consideral)le luimber of cases there are sjmptoms pointing to the
extension of the disease to the lower lobe of the right lung. It is certain
that implication of the lung is more frequent in amoebic abscess than in
abscess due to other causes, Avhether of dysenteric origin or not ; and
this is attributable to the frequent situation of such abscesses at the ex-
treme upper part of the right lobe of the liver. In such cases symptoms
of pulmonary disease are apt to occur early and to predominate through-
out the illness ; the clinical picture, indeed, is often rather one of a de-
structive lesion of the lung than of hepatic suppuration. (A well-marked
example of this condition is seen in the case illustrative of Amoebic
Dysentery given in vol. ii. of this Avork, p. 769.) The chief symptoms are
early stitch-like pains in the right side of the chest, dyspnoea, and cough,
at first hacking and ineffectual, but later, when the aliscess is evacuated
through the bronchi, paroxysmal, and accomjianied by muco-])urulent
blood-stained expectoration containing amoebaj. Abscesses of this course
show little tendency to heal, and in my experience they progress as a
rule to a fatal termination, notwithstanding the seemin<rly free evacua-
tion of the abscess cavity. Kecovery may ensue after the patient has
been .spitting muco-pus for weeks or even months, but convalescence is
very tedious and may be interrupted by exacerbations of the cough and
expectoration.
The duration of fatal cases is about two or three months.
With the progress of both hepatic and hepato-pulmonarj' al)scess
there is either an aggravation of an existing dysentery, or this condition
makes its appearance ; even in cases in which the hepatitis appeared to be
primary.
ylmdi/sis of symptoms. — Pain is one of the earliest .sj'mptoms ; it
occurs at some period of the illness in all cases. It may be dull and
aching, or sharp, lancinating and tearing in character. The former kind
of pain is usually felt earlier, and is possibly due to the distension of the
AMCEBIC ABSCESS OF THE LIVER 163
liA-er by the abscess contents : the latter in all probability indicates
implication of the peritoneum — visceral or parietal — or of the pleura ;
and is certainly more frequent and more severe in those cases in Avhich
the lung becomes involved. In the latter case it is aggravated when tha
patient breathes deeply, and during paroxysms of cough. The pain is
modified by the movements and position of the patient, the easiest de-
cubitus being the right dorso-lateral, with the body slightly raised and
the thighs flexed. The site of the pain varies in different cases. It
may be in the epigastrium, the right hypochondrium, or the lower axillary
space ; posteriorly it is usually referred to the right scapular region, or
to the shoulder-joint itself. From any one of these points it not infre-
Cjuently radiates with increasing intensity over the whole of the right
side of tlie chest and the upper abdominal zone. Discharge of the
abscess, by surgical intervention or by evacuation through the bronchial
channels, is followed by an abatement of the suffering.
Fever of an irregular . remittent or intermittent course is the rule in
amoebic abscess. The pyrexia does not differ "nddely from that observed
in cases of dysentery uncomplicated by abscess ; but the range is higher,
varying between 100° and 103° F., and the remissions are more pro-
nounced. The remission usually occiu's in the morning hours, the
exacerbation towards evening ; but a reversed temperature curve may
be seen occasionally, as in other diseases characterised by a septic
temperature curve.
At the earliest period of abscess -formation the prevailing fever is
continuous or slightly remittent ; but, as the infection progresses, the
remissions become greater, and ultimately complete intermissions occur at
some time in the twenty-four hours.
The temperature falls when the abscess is evacuated, through the
bronchial tubes or otherwise ; but irregular fever may persist until the
abscess cavity is completely healed.
Sweating is invariably present, and is often profuse and drenching.
It does not appear to be more frequent at night than during the day, it
is very irregular in its occurrence, and is independent of the course of
the temperature. In any case of amoebic dysentery the appearance of
this symptom should at once suggest infection of the liver ; for as a rule
the skin in dysentery uncomplicated by liver abscess is dry and rough.
An exception may be made in the gangrenous form, but even then only
in the later stages. Moreover, in these cases it is rather a continual
clamminess of the skin than periodical and profuse sweating. There is not
often a definite rigor, but a chilly feeling before and after the sweating
is not uncommon.
The 'pii-he and I'esjnrations are both accelerated. In the earlier stages
the pulse ranges from 80 to 100, and has the usual characters observed
in febrile affections, being full and regular. Tow^ards the end of fatal
cases it becomes rapid, from 120 to 140, small and easily compressible.
The respirations are increased most obviously in the cases of hepato-
pulmonary abscess, and may range from 24 to 40. The breathing is
i64 SVSTE.V OF MEDICINE
often more rapid and shallow at the beginning of the lung infection than
at a later period of the disease. This is due to the pleurisy that in every
case precedes the extension of the process into the lung itself. In fact
the attitude of the patient, and the character of the cough, the pain, and
the breathing, imnu'diatcly suggest this event.
When a purulent effusion takes place, or the pleural surfaces become
adherent — and this is the more frequent result — the dyspnoea is much
less, and is still further relieved by a free evacuation of the abscess con-
tents through the bronchi.
In hepato-pulmonary abscess coxuih and e.rpedorntion are constant and
often very distressing symptoms. During the earlier part of the illness
— that is, before any definite plwsical signs in the lung — the cough is
frequent, hacking, and usually accompanied by pain in the right side,
right hjqiochondrium, or epigastrium. It suggests diaphragmatic pleurisy,
and is no doubt due to it. At this stage there is either no expectoration,
or a scanty clear mucoid or muco-purulent si)utum, occasionally tinged or
streaked with blood. Then after a variable lapse of time the cough
becomes more severe and paroxysmal, and during one of these paroxysms
the patient brings up a large qiiantity of reddish or reddish -brown
muco-pus, sometimes mixed with pure blood. This usually gives a good
deal of relief for a time, and the paroxysms of cough become less severe
and frequent. The sputum in such cases was described many years ago
by Budd, and was considered by him to be characteristic of the disease.
" When this happens (evacuation of an hepatic abscess through the
bronchi), it is marked by the sudden expectoration of a dirty red or
brownish puriform matter. The peculiar colour arises from the pus in
its passage through the lung becoming mixed with blood and broken-
down pulmonary tissue. There is no matter like it expectorated in any
disease of the lung itself, and I believe that its appearance is ]iatho-
gnomonic of al)scess of the liver, or at least of abscess perforating the
lung. I have been led b}^ it to detect an abscess of the liver, of which
I had previously no suspicion."
The following description of the sputum in cases of hepato-pulmonary
abscess, given by myself some time ago, maybe quoted here in illustration
of those cases in which ama?bpe are present : — " The expectoration is partly
diffluent, partly tenacious, and partly frothy, its viscidity being proportional
to the amount of mucus present. It is at first often bright red owing to a
large admixture of blood, and subsequently of a dull bi'ick-red, brownish-
red, or rusty brown colour, and occasionally bile -stained. Intimately
mixed with the muco-purulent mass are more or less numerous small
yellowish -white fragments of a friable or cheesy consistency. After
exposure to air for some time the whole mass liquefies into a thin syru])y
or oily homogeneous fluid, Avhich has frequently been compared to anchovy
sauce. Such a fluid was as])irated from an abscess of the liver Avhich had
not perforated the lung. The sputa are alkaline in reaction, and have
a faint sweetish odour. At a later period they become more puiulent,
sometimes nummular, reddish-yellow, and contain less blood. If the
AMCEBIC ABSCESS OF THE LIVER 165
patient progress toward recovery, the expectoration becomes more fluid
and frothy, and contains less pus, Avhich is slightly Ijlood-stained. On
settling, it separates into an upper frothy layer, a middle layer of slightly
turbid fluid, and a thin bottom layer of muco-pus. The quantity expec-
torated daily varies from 25 c.c. to 400 or 500 c.c. Even more than this
may be coughed up at the time the abscess first discharges itself.
" Microscojncul characters. — The cellular elements observed are red
blood corpuscles, leucocytes, round alveolar epithelial cells, oral epithelium,
and irregular polyhedral fatty degenerated elements, which look like liver-
cells, but do not show a nucleus. In the early sputa I'ed blood corpuscles
predominate, and in the later sputa leucocytes ; while swollen and de-
generated alveolar epithelium is present in al)Out the same projiortion in
all the sputa. Elastic tissue fibres from the lung, single or in groups,
showing the characteristic wavy or curled appearance, are frequently
found, more especially in the later stages. Orange-red rhombic crystals
of hfematoidin, needle-shaped crystals of tyrosin, single or in fan-shaped
groups of the same colour, and Charcot's crystals, are occasionally seen,
with various bacteria and particles of food. The -small cheesy fragments
consist entirely of an amorphous granular material and oil globules.
Amcebse are constantly j^resent. They occur indifferently in all portions
of the expectoration more or less abundantly, but on the whole they
are not so plentiful as in the stools. The number observed from
day to day is very variable. They vary in size and activity, but are
generally larger than those seen in the stools, and very frequently con-
tain red blood corpuscles. For their detection the same precautions should
be taken as in the case of the stools, that is, the sputa should be kept at
a temperature of 30'' to 35° C, and examined as soon as possible."
Disturbance of the gastro - alimentary tract is apt to occur with
abscess of the liver. The most constant and persistent symptom is
anorexia, which is often absolute, even the blandest food being distasteful.
On the other hand, thirst is increased, owing to the drain of the tissue
fluids caused by the profuse and recurring sweating.
Nausea and romtting occur in those cases in which the lung becomes
engaged, and are induced chiefly by the violent fits of coughing.
When the lung is not engaged these symptoms are not frequent or
severe.
Jaundice is occasionally present, but the hue is not deep as in the
obstructive icterus ; it is rather an aggravation of the sallow icteroid
tint seen in cases uncomplicated by liver abscess, and the stools still
contain bile pigment.
Phijsical signs of hepatic and hepato-pidmonary cd)sce^s. — (a) The physical
signs of an hepatic abscess develop slowly, and for a time are often obscure
and inconclusive. If the abscess occupy the left lobe or the anterior
and lower part of the right lobe, direct evidence of its presence occurs
earlier than if it be situated centrally in the right lobe, or toward the
convexity of the liver.
Inspection aff"ords no clue until the abscess has reached considerable
l66 SYST£J/ OF MEDICINE
dimensions. AVhon this is the case the lower ribs and cartilaires on the
right side may be more prominent than those on the left, and the expan-
sion of the right lower thoracic zone is diminished. The epigastric hollow
may be obliterated, and the costal margin on the right side indistinguish-
able. Very seldom is there any obliteration, still less any bulging of the
lower intercostal spaces.
The measurement of the thorax below the mammilla sometimes shows
the right side of the chest to be larger than the left.
The edge of the liver is often palpable below the costal margin,
und to a lower point than usual in the epigastrium ; but as there is
often sensitiveness to pressure in these situations, it may be impossible
properly to carry out the manipulations necessary for this investigation.
Sensitiveness to pressure may occasionally be elicited also by firm
palpation over the lower ribs and cartilages. AVhen the abscess points
towards the abdominal wall it may be possible to feel an irregularity in
the outline of the hepatic margin, and sometimes to detect deep fluctua-
tion, especially if the abscess be in the left lobe.
Percussion of the hepatic area usuall}' affords the first definite evi-
dence (in conjunction with the rational signs) of amoebic abscess. The
zone of liver dulness is enlarged, the direction and degi'ee of the enlarge-
ment depending upon the seat and the size of the abscess. With abscess
of the left lobe, or of the anterior portion of the right lobe, the liver
dulness is increased chiefly downward ; Avhile an extension of the upper
margin of liver dulness is observed when the abscess occupies the centre
of the right lobe, and more especially the dome of the liver close to the
diaphragmatic attachment. In the latter case, however, the physical
signs are usually very indefinite, and are late in appearing.
Auscultation reveals nothing if the abscess involve the liver alone,
unless, indeed, it be of very considerable size, and encroach upon the
area of normal pulmonary sounds, which are then enfeebled to a corre-
sponding degree. Occasionally a peritoneal rub may be heard over the
lower ribs and cartilages anteriorly.
(ft) In liefato-imlmonary abscess the physical signs arc at fii-st even
more indefinite, and may remain so for a longer time than in hepatic
absces.s. It is surprising in some cases to find extensive lesions of the
liver and lung after death, where physical examination (including
exploratory aspiration) had afforded but inconclusive evidence of sup-
puration in these organs.
The deep situation of the lesions, and the comparatively early evacua-
tion of the abscess contents through the bronchi, are answerable for this
discrepancy ; though, it may be added, the rational signs in all such cases
are sufficiently suggestive, if not conclusive.
Although tlie liver is in every case affected lieforc the lung, it is
in the latter, as a rule, that the first definite j)hysical signs are found.
Very little information is elicited by inspection and palpation. The
expansion of the right side of the chest is less marked than that of the
left, but bulging or enlai-gement of the right lower thoracic zone is
AMCEBIC ABSCESS OF THE LIVER 167
either not seen at all, or only at an advanced stage of the illness.
Friction fremitus may occasionally be felt in the lower mammary or
axillary areas, and some tenderness is elicited liy firm pressure in the
same situation and below the margin of the ribs, or in the right
epigastrium.
On percussion there is noted a gradual increase in the area of hepatic
dulness, chiefly upwards, the area of lung resonance being correspond-
ingly decreased. There is also an extension of liver dulness in the
abdomen, but this appears later and is not so pronounced as the upward
extension, Avhich may reach the fifth or even the fourth rib in the
mammary line, and extend posteriorly to a point considerably above the
inferior angle of the scapula. Above the hepatic dulness there is a more
or less Avell-marked zone of high-pitched or even sub-tympanitic reson-
ance (collapse of lung), which j)asses insensibly into normal pulmonary
resonance above.
On auscultation it is found that the breath-sounds at the base of the
right lung, in the lower axillary space and below the nipple are almost
inaudible or entirely absent. Over the zone of the high-pitched or sub-
tympanitic resonance they are enfeebled, have a faintly bronchial char-
acter, more especially behind between the scapula and the vertebral
column, and are accompanied on inspiration by muffled crackling rales,
particularly in the interscapular region. A friction rub may be heard
in the lower mammary and axillary spaces. Vocal resonance is slightly
diminished^ and the voice has a nasal quality. Over the upper portion
of the lung the respiratory murmur is enfeebled, but not altered in
C[uality.
On the whole the physical signs have a close resemblance to those
found in limited pleural effusions.
A marked change in these physical signs is observed when the
abscess has emptied itself through the air-passages. The edge of the
liver may now no longer be felt below the costal margin, and the area of
hepatic dulness is less than before ; the change being most evident in the
mammary and axillary areas. Over the zone of high-pitched resonance
the respiratory murmur has become frankly tubular, especially a;bout the
inferior angle of the scapula and the posterior axillary space ; and coarse
bubbling or even gurgling rales are heard on inspiration and coughing.
These rales have the consonating quality which is characteristic of cavity
formation. Vocal resonance is now increased over this zone, and the
voice-sounds are articulate and nasal. The whispering voice may be dis-
tinctly heard, usually most intensely in the lower interscapular space.
The above signs gradually disappear if recovery follows ; but an
enfeebled respiratory murmur, with more or less numerous crackling
rales at the base of the right lung, may persist for many weeks.
Diagnosis. — The diagnosis of amcebic hepatic or hepato-pulmonary
abscess is based on a history of a previous or actual attack of amoebic
dysentery, and on the rational and physical signs of aliscess-formation in
the liver and lung. The stools should be carefully examined for amoebae.
168 SYSTEM OF MEDICINE
If there be diarrhwa, these are readily found ; but wlieu the stools are
formed, as sometimes happens, there is some difficulty in detecting them.
In the latter case the mucus adhering to the faeces may contain a few
ama'b;\3.
Sometimes the ama-bic nature of the abscess is first demonstrated Ijy
finding actively motile amoebjB in the sputum Avhen the abscess has
evacuated itself throu"h the l)ronchi.
Definite information may also be obtained, before spontaneous
evacuation, by exploratory puncture of the liver •with a long and large-
sized aspirating needle. I have often been disappointed, however, in
this procedure, even when the physical and rational signs were apparently
quite conclusive. Failure to obtain pus is usually due to the deep
situation of the aljscess and to the great viscidity of the contents of
it. Exploratory aspiration, if unsuccessful at first, should be re-
peated from time to time, a different portion of the dull zone being
selected each time ; in this way a positive result may be obtained, and if
amcel);e are found in the material withdrawn the diagnosis is established.
It is practically impossil)le to diagnose multi})le al)scesses, or a small
abscess in the concavity of the liver due to direct infection from the
hepatic flexure of the colon.
The only diseases that are likely to be mistaken for amciebic abscess
are non-amrebic liver abscess, pya^mic abscess, sub-diaphragmatic abscess,
empysema, and possibly basic tuberculosis of the right lung. In non-
amoebic abscess there is very often no history of any intestinal disorder,
and the abscess appears to be idiopathic. IMoreover, the abscess is
usually large and single, and an exploratory puncture readily aflbrds a
rather thin pus which contains no amoebai but usually one or more species
of the pyogeuetic cocci. The j^us may, however, be entirely sterile, and
in such cases the disease pursues a much more benign course than is the
rule with amoibic abscess. There is not the same tendency to implica-
tion of the lung in non-amcebic as in amtebic abscess.
Pysemic abscess, which is usually multiple, is distinguished by its
more rapidly fatal course, and can generally be traced to some localised
abdominal or pelvic focus of sup])uration.
In the case of the three otht^r conditions mentioned which may
simulate the hepato-pulmonary form of amcebic abscess, an error in
diagnosis can occur only before spontaneous evacuation through the
bronchi ; or when the stools, whether formed or diai'i"h(v;d, do not contain
amteljie. After rupture of the abscess amtebaj will in\ariably be present
in the sputa, and the doubt at once dispelled.
Prognosis. — The prognosis of amoebic abscess of the liver, and
especially of the liver and lung, is A'ery unfavoui'able. These secpu'ls are
responsible for a large j)ercentage of the mortality from this form of
dysentery, and in many cases, l)oth of dysentery of moderate severity
and of chronic dysentery, are the final events.
Even when the dysentery is latent, that is when there are no actual
intestinal symptoms, the outlook is not very much better ; for an
AMCEBIC ABSCESS OF THE LIVER 169
exacerbation of the intestinal condition is very apt to occur with the
development of the hepatic complication.
Surgical intervention, moreover, is not as a rule followed by such
satisfactory results as in the case of non-amoebic abscess. In a series of
eleven cases of liver abscess observed in Baltimore, of which seven were of
amoebic origin, and four non-amoebic, one of the former and three of the
latter ended in recovery. Three of the amoebic cases were operated on,
and all died, the only recovery being a case of hepato-pulmonary abscess
which emptied itself spontaneously through the bronchi. All the non-
amoebic cases were subjected to operation, the result being three recoveries
and one death.
Treatment. — Notwithstanding the slender hope of recovery after
operation, the treatment of amoebic abscess of the liver and lung must
be surgical. The choice and time of operation are questions for
the surgeon to decide. It is usual to perform the operation in two
stages : the liver is first exposed and siitured to the anterior abdominal
wall, and a few days later, when adhesions have formed, an opening into
the abscess cavity is made with the thermo-cautery. Free drainage is
essential. It is of some advantage to irrigate the cavity with a solution
of quinine, which readily destroys the amoebae.
Unfortunately there are often secondary abscesses of small size
adjacent to the main abscess which are only discovered after death.
In hepato-pulmonary abscess which is discharging itself spontaneously
and freely it is questionable whether surgical intervention is at all likely
to advance the recovery of the patient. The abscess is usually so deep-
seated, and efficient drainage is so difficult to establish, that unless the
physical signs be very definite and localised, it is probably more prudent
to abstain from operation.
The medical treatment of abscess of the liver and lung differs in no
essential respect from that of the intestinal disease which accompanies
and has given rise to these conditions. The chief symptoms requiring
the aid of the physician are pain and cough. For the relief of the
former morphia, administered preferal)ly by hypodermic injection, is
usually required ; the latter may be alleviated by the same means or by
codeia. When spontaneous rupture through the bronchi has occurred it
is well to reserve the use of the morphia for the night-time, in order to
secure some rest and not to interfere with the cough necessary to the
emptying of the abscess cavity.
Henri A. Lafleur.
REFERENCES
1. Councilman and Lafleur. " Amcebic Dysentery," The Johns Hopkins
Hosjntdl Beports, vol. ii. 1891. — 2. Kartulls. " Zur Aeticlogie der Leberabscesse ;
lebende Dysenterie-Amoeben im Eiter der dysenterisclien Leberabscesse," Cent./. Bakt.
Bd. ii. 1887. — 3. Idem. " Ueber tropische Leberabscesse und ilir Verhiiltniss zur
Dysenterie," Virdiow' s Archiv, 'iid. axviii. 1889. — 4. Kruse and Pasquale. " Unter-
sucbungen liber Dysenteric und Leberabscesse," Zeitschr. f. Hygiene tend Infections-
krankheitcn, Bd. xvi. Hft. 1.
H. A. L.
I70 SYSTEM OF MEDICINE
CIRRHOSIS OF THE LIVER
General considerations. — The term " cirrhosis " comprises a group
of diseases of the liver which, though they diller Avidely in their
causation and clinical importance, have this feature in connnon, that the
organ becomes permeated to a greater or less extent by a ne\vly-de\'eloped
fibrous tissue. The word " cirrhosis," which, from the tawny yellow
colour assumed by the hepatic tissue, was originally given to a common
form of the disease (Laeiniec), is now in general use to denote any fibroid
change in the li^-er ; and it is not infrequently apj^lied to a similar morbid
change in other oi'gans.
This nswly - developed fibrous tissue in the liver is distributed in
various ways ; and a classification of the different forms of ciri-hosis might
be based upon its arrangement and distribution, though it is not to be
supposed that such anatomical -varieties are absolutely distinct. In the
most common variety of the disease it forms a coarse network which
permeates the whole organ, and encloses in each mesh a number of the
hepatic lobules (inultilobular). In a less common variety a fiiKM- network
of wmw fibrous tissue tends to sm-round individual lobules (unilobular) ;
and in this form a plexus of bile-ducts, apparently newly formed, is often
present around the lobules. In another form the new tissue is found
to penetrate the lobules themselves, often surrounding and isolating
individual cells or groups of cells (intraloljular or pericellular). In a
fourth variety, which is usually considered under the head of cirrhosis,
dense bands of cicatricial tissue traverse the whole or a lai'ge part of the
liver, cuttuig it up into irregular masses, and producing by their con-
traction considerable deformity of the surface of the organ (gummatous
or syphilitic cirrhosis).
Classification. — To classify the various forms of cirrhosis according to
these anatomical characters is not, however, clinically useful, inasnuich as
the points of distinction between them are seldom recognisable during life.
On the other hand, a classification based on the causation and mode of
origin of the disease cannot, in the imperfection of our present knowledge,
be thoroughly carried out. But, notwithstanding its scientific imper-
fection, such a scheme is practically useful ; and it will be ado])ted hei-e
.so far as oui- knowledge permits, as follows : — (A.) Alcoholic cirrhosis, (c)
Multilobular form ; (//) Unilobular form, to which is appended an account
of the foiiu comnmnly known as "biliary cirrhosis." (B.) Malarial
cirrhosis. (C.) Sypliilitic cirrhosis. And mention will be made of
certain minor forms of cirrhosis which are rather of pathological than
of clinical interest.
Etiology. — The excessive use of alcohol is by far the most common
cause of cirrhosis of the liver in all countries ; by its side all the
other causes together arc insignificant. As regards the form of alcohol,
CIRRHOSIS OF THE IIVER 171
statistics show that spirits of some kind are in most cases answerable for
the disease ; but it is certain that the more dilute forms of alcohol, beer
and wine, are capable of producing a like result.
The amount of alcohol which is necessary to produce the disease is
found to vary greatly. When a patient first comes under observation
Avith the signs of cirrhosis, there may be a history of many years of
slight daily alcoholic excess, to which the name of intemperance is given
only after the appearance of symptoms of alcoholic poisoning ; or he may
be an habitual drunkard ; or there may have been a short period of
indulgence, not amounting to more than a few months, in a person
previously temperate. The degree of cirrhosis has no constant relation
to the total amount of alcohol taken. A history of great habitual
alcoholic excess may sometimes be obtained from patients who present
no evidence of cirrhosis. It is possible that this variation in the result
may depend on such factors as the degree of dilution of the alcohol, or
the relation of its ingestion to the taking of food ; moreover, it is not
improbable that individuals differ greatly in their susceptibility to the
poison.
The disease, as produced by alcohol, is chiefly met Avith in males, in
whom it is three or four times as common as in females. It occurs at
almost any age. Cases, undoubtedly due to alcohol, have been recorded
as occurring at the extreme ages of six and ninety ; but the chief incidence
of the disease, as might be expected, is in middle and late life, and
statistics show that in about two-thii'ds of fatal cases death occurs between
the ages of thirty-five and fifty.
As will be subsequently described, two forms of cirrhosis — the multi-
lobular and the unilobular — must be recognised as due to alcohol. At
present our knowledge is not sufficient to determine whether this
anatomical difference depends on the form of the alcohol, or on the mode
of taking it, or on some other factor. There is, however, some evidence to
connect a large and highly fatty variety of multilobular cirrhosis (sometimes
called fatty cirrhosis) rather with beer than with other kinds of stimulant.
Syphilis, both hereditary and acquired, stands next to alcohol in
importance as a cause of cirrhosis. The form of disease commonly pro-
duced by hereditary syphilis is truly a cirrhosis or general fibroid condition
of the organ. The results of acquired syphilis must also be considered
under this head, although it leads rather to a localised fibroid change or
scarring of the liver, to which the name cirrhosis is not so strictly
applicable.
Further, it may be accepted that a cirrhotic condition of the liver may
supervene as the direct result of chronic malarial poisoning (Kelsch and
Kiener). The cirrhosis may be looked upon as a secjuel of the chronic
congestion of the liver which is apt to ensue in patients who have been
the subject of repeated attacks of intermittent fever ; but in some instances
the possibility of the association of alcoholic excess must be borne in mind.
Certain minor forms of cirrhosis occur under other conditions ; but in
such cases the change rarely reaches such a degree as to produce recog-
172 SYSTEM OF MEDICINE
nisable symptoms. Thus a deposit of tubercles in the liver may be
accompanied by a definite though slight degree of hyperplasia of the inter-
stitial tissue in the portal canals ; and this event is most common in
association with a chronic tubei'culous peritonitis (Hanot and Gill)crt).
The common enlargement of the liver in rickets has been occasionally found
associated with a similar slight increase in the portal connective tissue.
Finally, a cirrhosis, sometimes of a high degree, may result from the
absence or atresia of the common bile-duct, which is occasionally met
Avith in new-born infants {ride p. 253). Life, in such cases, is seldom
prolonged beyond a few months, and death occurs from the jaundice
rather than from the cirrhosis ; yet the latter may be sufficient to give
rise to ascites.
In conclusion, it may be safely stated that in nearly all patients who
present definite signs of cirrhosis the disease has arisen as a consequence
of alcoholic excess, syphilis, or chronic malaiial infection.
Still, when these three causes have been duly considered, a certain small
proportion of cases of cirrhosis will remain in w'hich there is room to
doubt whether any one of the three has been in operation. It must be
remembered herein that it is not always easy to elicit a history of alcoholic
excess — there being sometimes a purposeful, and more often an unconscious
tendency on the part of the adult patient to I'eticence in this matter. In
the case of young children it may be found that spirits or beer have been
administered to them occasionally by their parents, but it may be impos-
sible to ascertain exactly to what extent this pi'actice has been pursued.
It has been suggested that cases of cirrhosis, in which there is no history
of alcoholic excess, may be the outcome of a previous fever, such as scarlet
fever, measles, typhoid fever, or pneumonia ; inasmuch as in many specific
fevers slight inflammatory changes in the portal tissue may be found after
death (Botkin, Klein, AVelch). The connection of such changes with a
later development of definite cirrhosis is not proved, but it is at any rate
probable that some factor in the causation of this disease is still missing.
It is frequently stated that long-standing obstruction of the hepatic or
common bile-ducts may result in the development of cirrhosis. It has,
indeed, been repeatedly shown that ligature of the connnon duct is
followed in some lower animals by a remarkably rapid development of a
cirrhosis of luiilobular distribution (W. Legg, Charcot and Gombault).
It is true that a slight hypei'plasia of the portal connective tissue may
certainly be observed with the microscope in some instances of
obstructive jaundice in man, especially when the obstruction has been
due to carcinoTiia in the head of the pancreas. There may be
increased cellularity of this tissue, and there is sometimes evidence
of an acute and, it may be, of a suppurative inflammation in it. And as
has been already nii'iitioned, congcMiital aljsence or atresia of the conmion
duct in children may undoubtedly be associated with a high degree of
cirrhosis. Yet notwithstanding this positive evidence, it is established by
the overwhelming negative testimony of the post-mortem room that biliary
obstruction in man does not result in any degree of cirrhosis sutiicient to
CIHRHOSIS OF THE LIVER 173
produce symptoms. The discrepancy between experimental and clinical
evidence on this point may be explained by the difference in the condition
which causes the biliary obstruction in the two cases. There is no event
in man which is comparable to the drawing of a ligature round the outside
of the common duct and its sheath of connective tissue.
Finally, a cirrhosis has been described as accompanying the congestion
of the liver which results from chronic cardiac and pulmonary disease.
The liver, in this condition, is often finely granular on section, owing to
the sinking of the centre of the lobule below the general level of the cut
surface. But though there is sometimes a slight hyperplasia of the con-
nective tissue in the centre of the lobule, nothing Avorthy to be called
cirrhosis is pi-oduced in this way.
A. Alcoholic cirrhosis. — It is now generally recognised that two
forms of cirrhosis of the liver are induced by the excessive use of alcohol.
These two forms are separated by differences both in their morbid anatomy
and in their clinical features, and they must be separately considered.
In the first form (a), which is by far the most common, the newly-
developed fibrous tissue tends to surround large groups of hepatic lobules,
and it is therefore spoken of as " multilobular." This form is commonly
associated with ascites, but seldom with jaundice. In the second and less
common variety of alcoholic cirrhosis (/>), the new tissue is developed for
the most part around single lobules, and- it is consequently described as
" unilobular." In the latter case there is but little tendency to ascites,
while jaundice is a common event. In this unilobular form a number of
bile-ducts, apparently new formed, are generally found in the interlobular
connective tissue. This appearance gave origin to the hypothesis of a
cirrhosis starting around the small bile-ducts — a " biliary cirrhosis " —
and the question of such an origin in some cases will be presently con-
sidered.
The terms "atrophic" and "hypertrophic," as applied to the multi-
lobular and unilobular forms respectively, are scarcely worth retaining.
The term atrophic has lost much of its fitness, now that statistics show
that the hobnailed liver, to which it was originally applied, is not neces-
sarily small, but is often increased both in size and weight. And the
phrase hypertrophic cirrhosis has become so complicated by the postulate
of a biliary cirrhosis that its significance is vague and uncertain.
(rt) The multilobulap form. — {Synonyms: Laennec's cirrhosis, hob-
nailed liver) —
Morbid anatomy. — This variety includes the great majority of the
cases of cirrhosis met with in practice.
The liver, as found in a fatal case, is often reduced in size, but this
reduction is not invariable, as was at one time supposed. In many
instances it retains its normal dimensions, and sometimes it is moderately
enlarged, so that its free edge may be felt during life. "When thus
enlarged, it is generally found that the hepatic tissue is in a highly fatty
condition. It is often stated that the liver in this form of cirrhosis is
174
SYSTEM OF MEDICINE
commonly enlarged at the outset of the illness, and that it becomes
reduced in size during its course. Though this progressive reduction in
size is intelligible on general pathological grounds, and, indeed, clear
instances of it (mostly in children) have been recorded, yet tliere is no
evidence to show that such a change is of frequent occurrence. It is
possible that the liver may be enlarged in the early stage of the illness,
during which the symptoms are so slight that the patient does not come
under medical ol)servation ; but if a patient be seen with the recognised
symptoms of cirrhosis, and the liver be large enough to be felt in the
abdomen, it is exceptional at any rate for any diminution in its size to
be observed at a subsequent period.
The weight of the hepatic tissue is increased by the cirrhotic process ;
thus, though the liver is often diminished in bulk, its weight is seldom
below that of the healthy organ (50 to 60 oz. in the adult). Its weight
may, however, fall to 30 oz. or even less ; on the other hand, it may rise
to 80, especially if its tissue be fatty. A series of 100 consecutive cases
in adults taken from the records of St. Thomas's Hospital shows a mini-
mum of 32 oz., a maximum of 74 oz., and an average of 52 oz.
Owing to the contraction of the new fibrous tissue there is commonly
some alteration in the shape of the liver, especially Avhen there is much
diminution in size. Its sharp edge becomes blunter, or the whole organ
may tend to become globular ; the left lobe is often more affected
than the right, and may be reduced to a small triangular appendage.
The peritoneal covering is usually much thickened, and is often fixed
to the diaphragm, and perhaps to adjacent organs, by close adhesions or
tough fibrous bands. There may be evidence also of the extension of this
chronic inflammatory process over the whole or a large part of the peri-
toneum, which may be found Avhitened, thickened, and opaque.
"Whether the liver be of normal size, or small, or enlarged, both the
natural and the cut surfaces of the organ in this form of cirrhosis are cither
covered with minute granulations, or studded Avith nodules varying in size
from a pin's head to a pea. The cut surface especially presents the
appearance of rounded islets of yellow or ycllowish-broAvn hepatic sub-
stance surrounded by gray or grayish-red bands of fibrous tissue, both of
which elements can be easily recognised Avith the naked eye. The sub-
stance of the organ is always exceedingly tough and hard, and the
induration is greater than in any other form of cirrhosis.
Owing to the compression exercised upon the portal branches by the
new fibrous tissue, there is considerable obstruction to the How of blood
in the portal vein. In rare cases the stagnation is such that thrombosis
has occurred in its main trunk and l^ranches. A far more common mani-
festation of this portal obstruction is the dilatation of some or all of the
vessels, which form the points of communication between the portal and
the general venous systems. This compensatory dilatation will be sub-
sequently described.
Microscopical examination of a liver in an early stage of cirrhosis
shows clear evidence of infiammatory change in the tracts of connective
CIRRHOSIS OF THE IIVER 175
tissue which support the ramification of the portal vein throughout the
whole organ. These so-called portal canals are seen to be packed with leuco-
cytes and connective tissue cells in a state of active proliferation. Here
and there columns of such fibrifying tissue may be seen advancing
between the hepatic lobules ; and by the junction of such columns a wide-
meshed network of developing fibrous tissue comes into being throughout
the whole organ. In the late stage in which the examination is commonly
made, this network is seen to consist of dense fibrous tissue which may
be still richly nucleated in parts, but has generally lost the highly cellular
character seen at an earlier period. At the same time- the main portal
branches, which at an early stage are often widely dilated, become
narrowed and compressed by the contraction of the new tissue in which
they run. This new tissue, however, is by no means ansemic ; for it
can be shown, by injection from the hepatic artery, that it is richly
supplied with capillaries in connection with that vessel ; and it is probably
due to this accessory blood-supply that the functions of the liver are
so little interfered with. In some cases there is an apparent development
of a few new bile-ducts in the strands of the fibrous tissue. The origin
of these will be considered in connection with the second or unilobular
variety of ciri-hosis, in which they form a more frequent and conspicuous
feature.
The nodules of hepatic tissue, which are contained in the meshes of
this fibrous tissue, consist of many lobules compressed together. But
owing to this compression the lobular arrangement is obscured, and it is
difficult to say how many lobules each node comprises. Here and there
also a single lobule or a single group of pigmented hepatic cells may often
be seen as an islet in a broad fibrous strand.
In advanced cirrhosis the liver-cells are invariably degenerate ; they
are finely granular or filled with coarse pigment granules, and their nuclei
do not readily stain. They are also often filled with large fat globules,
and this is especially found to be the case when the liver is of normal or
of increased size.
As regards the interpretation of these morbid changes, it may be
taken as certain that they are produced by the action of alcohol entering
the liver by the portal vein. But these morbid changes are twofold.
There is both a degeneration of the hepatic cells and a development of
new fibrous tissue ; and it is bv no means certain whether either of these
changes is dependent on the other, or whether both changes are con-
comitant effects of the alcoholic poison. It has been argued that the
hyperplasia of the connective tissue is consecutive to a primary degenera-
tion of the hepatic cells and dependent upon it ; that it is such a hyper-
plasia, in fact, as is known to occur around degenerate and disiised
structures in all parts of the body. And in favour of this view, that the
cell-degeneration is the exciting cause and not the effect of the fibrous
overgrowth, it is pointed out that, although there is undoubtedly a high
degree of pressure exerted upon the liver-cells, yet, inasmuch as the
development of new vessels from the hepatic artery takes place step by
176 SYSTEM OF MEDICINE
step Avith the growth of the new fibrous tissue, the blood-supply is still
ample, and there is not that mechanical anaemia present which would be
likely to cause such an extreme cellular degeneration. On the other
hand, if specimens of early cirrhosis are examined from cases in which
death has occurred from some other cause, no doulit can be. entertained
that the interstitial change is essentially an inflammatory one, and that
it has its starting-point around the main branches of the portal vein at
a time when the appearance of degeneration of the hepatic tissue proper
is either scanty or absent.
Consequently, though it is possible that the cell-degeneration may in
part be a primaiy change, and the direct result of the action of alcohol
upon the cell, and though it is possible that this cell-degeneration may
play some part in the production of symptoms, yet it is quite out of propor-
tion to the vast overgrowth of fibrous tissue. The balance of evidence
is strongly in favour of the fibrous overgrowth being a primary
morbid change, and it is certainly responsible for the chief symptoms of
the disease.
Si/mptoms. — It can be readily understood, from what has been said
as to the morbid process in the liver, that the symptoms attending the
early stage of cirrhosis are usually slight and ctjui vocal. The more
severe and distinctive symptoms do not appear until the neAV fibrous
tissue has begun to compress the branches of the portal vein.
In this early stage the patient is liable to dyspepsia with nausea or
vomiting, especially in the morning. The appetite fails, being often
better in the later than in the earlier half of the day; the tongue becomes
furred ; there is a sensation of heaviness or distension after meals, and
gaseous eructations are of frequent occurrence. The bowels become
irregular, at one time costive, at another time loose ; there is often a
tendency to htemorrhoids ; and perhaps slight j'cllowness of the con-
junctivcB may be noticed from time to time. Such symptoms may, of
course, be merely the direct effect of alcoholic excess upon the stomach
and intestinal canal ; but their occurrence and persistence in a person
who has been addicted to alcohol for some considerable time are sufficient
to suggest the presence of cirrhosis in an early stage. This suspicion
would be strongly confirmed if at the same time some palpable enlarge-
ment of the liver should be detected.
As the morbid process in the liver continues, the obstruction to the
portal circulation increases in degree. A very definite train of signs and
symptoms ensues, some of which are the direct result of the portal
obstruction, while others are the consequence of the impairment of the
hepatic function. It is in this stage that the disease is commonly
recognised for the first time.
One of the direct results of the portal obstruction is the appearance
of ascites. It is not invariably present, but it occurs in at least 80 per
cent. The portal system is not completely isolated, but has communica-
tion at many points with the general venous system, and by the opening
up of these channels of communication, in the manner that will be
C//?J?ffOS/S OF THE LIVER 177
described, so much relief may be afforded to the obstructed portal system
that in some few cases little or no ascites may arise.
The ascitic fluid is clear, straw-coloured, and alkaline, with a specific
gravity varying between 1010 and 1 0 1 5 ; it contains from O'l: to 2"0 per cent
of proteid, and it either has no power of coagulation or it deposits a very
light clot very slowly. If there be any coexistent peritonitis, as is often the
case, the percentage of proteid and the power of spontaneous coagulation
are thereby proportionately increased. A trace of sugar is occasionally
found in it. The amount of fluid varies greatly, but if it be not removed
by paracentesis it may reach the enormous quantity of four or five
gallons. It may accumulate so slowly that many months may elapse,
after its first recognition, before pai^acentesis becomes necessary ; or it
may accumulate so rapidly that as much as thirty-four pints of fluid may
be removed within five weeks of a jirevious tapping by which the abdomen
had been emptied as far as possible. The relation between hepatitis, peri-
tonitis, and hepatic cirrhosis in the causation of ascites in these cases is
not yet fully understood. Dr. Hale White {tide, art. " Perihepatitis ")
is of opinion that the ascites proper to cirrhosis is a late event for
which more than one tapping is rarely I'equired ; and that in the cases of
ascites which admit of many tappings, the effusion is due rather to
peritonitis.
Another result of the portal obstruction is the state of passive hyper-
semia in which the stomach and intestines are maintained ; upon this
there follows a very constant and persistent catarrhal condition of the
mucous membrane. Digestion is imperfect, gastric fermentation and
flatulence are common, and there is often a marked tendency to nausea
or vomiting in the morning, which is probably attri1)utable to the mucus
accumulated in the stomach durina; the night. The action of the bowels
is also irregular ; the motions are often pale and unformed, and diarrhoea
is at times profuse and uncontrollable.
Further evidence of portal obstruction may be obtained from the
direct and indirect results of the opening up of the anastomoses between
the portal and the general venous system.
The vessels by which anastomosis is effected become dilated and even
varicose, and the results are of considerable importance. There are three
important points where this effect is produced.
(i.) The plexus of veins at the caixliac end of the stomach communi-
cates with a similar plexus in the lower end of the oesophagus, the vessels
of which open into the azygos veins. Consequently in many cases of
ciri-hosis there is extreme dilatation of the veins in the lower three or
four inches of the oesophagus ; and longitudinal submucous vessels, up to
a quarter of an inch in diameter, may be readily demonstrated there by,
means of injection or inflation with air.
(ii.) One or more small veins (parumbilical) constantly run from the
left division of the portal vein in the round ligament alongside of the
obliterated umbilical vein to the umbilicus, where they communicate Avith
the epigastric sj^stem. It is common, as a result of the portal obstruc-
VOL. IV N
I7S SYSTEM OF MEDICINE
tion, to fiiul a large vein developed here, which often reaches the size of
a crow(juill. A much larger size has indeed been recorded.
(iii.) Finally, there is a variable degree of communication between
the inferior mesenteric and hsemorrhoidal veins.
Other less imi)ortant communications exist by which some of the
blood may be diverted. There are the minor accessory portal veins of
Sappey, which lie in the areolar tissue and peritoneal folds around the
liver, and communicate on the one hand with the portal system, and on
the other with the phrenic veins. In some cases enlarged vessels are
visible after dealli on the under surface of the diaphragm, and this means
of relief to the portal system may be aided when the liver is firmly adherent
to the diaphragm. There i.?, moreover, some slight communication between
the veins of the pancreas, duodenum, colon and rectum, and the retro-
jDcritoneal veins.
A direct consequence of the passage of blood fi'om the portal vein,
by the parumbilical vein, to the epigastric system is the occasional
appearance of a network of dilated superficial veins around the umbilicus.
]\Iore commonly a few large vessels are seen running from the neighbour-
hood of the umbilicus downwards to the inguinal regions, upwards to the
costal margin, and perhaps extending to the lower part of the thoi'ax.
The subsidence of ascites is sometimes coincident with the ajjpearance
of these vessels. In connection with the dilatation of this })ar-
umbilical vein, it may be mentioned that a continuous venous murmur
may occasionally be heard with the stethoscope immediately below
the ensiform cartilage. The sinuous line of small distended venules,
which is often seen round the lower ribs along the line of attach-
ment of the diaphragm, may be equally present in health ; it has no
special significance in this connection. The formation of haemorrhoids,
again, is a common phenomenon resulting from the communication
between the engorged portal system and the htemorrhoidal veins ; but it
is too common a malady to be of great diagnostic importance.
Indirectly related to the portal obstruction is the common occurrence
of haematemesis, or melsena, or both. It is possible that a general oozing
from the congested capillaries of the stomach may be the source of the
smaller quantities of altered blood which are sometimes vomited ; but
it is proljaljle that the larger htemorrhages are due to ulceration or
rupture of one of the varicose veins already described as lying in the
walls of the cardiac end of the stomach, and more especially in the
lower end of the o'sophagus. In the former situation punched-out ulcers
have been found conmiuiucating with a vein, but the latter is probably
by far the most frecpient site of j^rofuse ha3morrhage. The ha3moirhage
may be very profuse and may be quickly fatal, as may be understood from
the size of these (esophageal varices. ]\Ioi-e than four ])ints of venous
blood may be lost in this way, and the bleeding may recur at intervals
of a day or two until death results. In most cases, however, the
htcmatemesis, though fairly profuse, is not so alarming ; and, as it is
usually the first grave symptom, many months or even years may elapse
CIRRHOSIS OF THE LIVER 179
before death occurs. Melsena has been known to result from an ulcer in
the bowel, but in most cases the hasmorrhage either springs from the
stomach, whence the blood is passed on into the bowel, or from the
rupture of distended capillaries in the intestinal mucous membrane.
It will be understood, from the origin of these dilated anastomotic
veins, that they form a compensatory mechanism for the relief of the
overcharged portal system ; and, consequently, it may be surmised that
when they are much developed and are likely to give rise to severe
haemorrhage, there is not much tendency to ascites. Clinical evidence
agrees with this anticipation, and profuse haemorrhage is actually not
common in cases of considerable ascites ; on the other hand, a sudden
haemorrhage has proved fatal in cases where ascites is absent.
The spleen, which is nearly always found in the post-mortem room
to be enlarged and indurated, and commonly Aveighs from 10 to 15 oz.,
may sometimes be felt during life ; but in most cases it is obscured
by the presence of ascites, Occasionally it escapes all change, even when
the portal obstruction has been severe ; and this is probably attributable
to its extensile structure.
The liver may often be felt below the ribs, and its edge may project
downwards for one or two inches, so that its hardness, and possibly
its nodular character, may be recognised. More commonly, however,
it is masked by the ascites ; though even then it may often be felt by a
sudden dipping movement of the hand, which displaces the overlying
fluid. The recognition of a small liver is a matter of greater difficulty ;
and generally speaking, considering the frequent flatulent distension
of the bowels, not much stress can be laid on a resonant note at the
right costal margin. Attacks of pain over the liver, and more frequently
over the spleen, may occur from time to time ; and these are doubtless
to be attributed to attacks of local peritonitis \yide art. on " Perihepatitis,"
page 118]. Tympanites is often a troublesome symptom, Avhich may
materially add to the gravity of a case by the production of collapse of
the basal parts of the lungs.
Jaundice is ordinarily absent throughout the entire illness ; there
is nothing more than a yellowness of the conjunctivae, and a sallow,
icteroid complexion. If present it is usually slight, and it may subside
and disappear. The urine is often diminished in amount, and
presents abundance of urates and sometimes bile pigment. If albumin
be present, it is generally due to coincident disease of the kidneys. Even
at an early period the feet and shins may become slightly cedematous,
but the oedema is not marked unless the ascites be so considerable as to
aid in its production by pressure on the inferior vena cava. GEdema of
the abdominal wall may also be noticed occasionally, and is presumably
due to that disturbance of the venous circulation in it which has been
already described. Often in a late stage there may be eflfusion of fluid
into one or both pleurae ; this may be of simple origin, but often it is
found to be due to a tuberculous pleurisy. As a rule there is no fever
in this form of cirrhosis ; but if a patient be under continual observation
I So SYSTEM OF MEDICINE
for a long period, avo may often observe an occasional rise of two or three
degrees for a few successive evenings.
The distended cajHllaries on the chcelvs, the so-called "venous
stigmata," which are attributal)le to alcoholic excess, are commonly
visible in cirrhosis at a very earl}^ period. By the time that ascites has
arisen the face has usually altered and has begun to assume a very
characteristic apj^earance. It is thin and wasted, and the malar bones
are prominent ; the eyc?> are somewhat sunken ; tlie conjunctivre are
yellowish, and the complexion is sallow and unhealthy. The process of
digestion is impaired, and absori)tion of nutritive material from the
intestinal canal is diminished, so that there is a progressive loss of bodily
strength Avith emaciation. The trunk and extremities are ill nourished,
and at a late stajjc the attenuated frame offers a marked contrast to the
swollen abdomen.
As the illness wears on, with progressive emaciation and increasing
feebleness of voluntary and cardiac muscle, the patient is apt to show
signs of poisoning, which are probably attributable to the increasing
interference with the function of the liver. He becomes liable to epi-
staxis, to bleeding from the gums, and to purpuric eruptions on the trunk
and extremities. Uncontrollable diarrhoea is also a common event, as in
ur;i3mia. Digestion is at a standstill, and he may thus sink from sheer
asthenia, or may be hurried off by pulmonary intlammation. Often
for some time before the end his mind may Avander at night, perhaps
also in the daytime. Occasionally a noisy delirium sets in ; l)ut more
commonly the end is marked by apathy and increasing feebleness of
body and mind, passing into drowsiness, coma, and death.
Course and Prognmis — Owing to the obscurity of the early stages
of the disease no accurate estimate of its total duration can be given. It
is Avithout doubt an extremely fatal disease, but evidence has been
recently adduced to show that it is not so uniformly fatal as was formerly
supposed ; and many instances of recovery are alleged. The character
of these alleged cures must be closely scrutinised. As regards some
of them, it may be said that doubt attaches to the nature of the disease ;
in some the affection Avas probably of syphilitic origin, and the ascites
on Avhich the diagnosis of alcoholic cirrhosis Avas mainly based had sub-
sided on the absoriition of the gummatous tissue in the liver.
At the same time it may be admitted that some patients suffei-ing
from undoubted alcoholic cirrhosis do lose their ascites, and do recover
and preserve a fair measure of health for a considerable number of years.
In one recorded case, Avhere the diagnosis Avas confirmed l)y the sujier-
A'ention on separate occasions of mental symptoms and of periphei-al
neuritis, 1)oth cleai-ly of alcoholic origin, the ])atient was in good health after
repeated tappings, the first of Avhich A\'as performed scmie six years before
(Bristowe). In another instance the patient Avas in good health after
fourteen tappings, the first of Avhich AA-as more than three years before
(BristoAve). A striking example is affordcfl by the case of a ])atient Avho
recently died Avith contracted granular kidneys and pericarditis in St.
CIRRHOSIS OF THE LIVER i8i
Thomas's Hospital. Twelve years before he had been a patient in the
same place under the care of Murchison, suffering from alcoholic cirrhosis
and ascites. From that date the patient, who had previously drunk
freely, became a teetotaller, and during these twelve years he had been in
fair health. At the post-mortem examination the liver Avas found to
weigh 59 oz., its caj^side was much thickened and adherent to the dia-
phragm, the cut surface was that of a hobnailed liver, and the microscope
revealed the usual appearances of a nudtilolmlar cirrhosis. Further
evidence on this point is perhajis afforded by the fact that cirrhosis of
the liver is sometimes found unexpectedly in autopsies on patients who
have died from some other cause.
It is clear, then, that in some few cases health may be restored after
the appearance of symptoms of an alcoholic cirrhosis ; but we must
nevertheless believe that a positive cure is im]30ssible. So far as present
knowledge goes, the new fibrous tissue developed in the liver must persist
in spite of all drugs and diets. The disease, however, may remain
stationary, and if it be recognised at a very early stage, and alcohol from
that moment be eschcAved, the liver may undergo no further increase or con-
traction. The essential conditions of recovery in any degree are that the
functions of the liver should be performed in a manner adequate to the
maintenance of health, and that the portal blood should have free means of
exit into the general circulation. Given these two conditions, it is probable
that a fair degree of health maybe maintained indefinitely, provided that
no intercurrent disease, such as tuberculosis or renal disease, step in. But
OAving to the tendency of this hcav fibrous tissue to a steady and destruc-
tive contraction, long after the poisonous cause of its development has
ceased to act, the conditions necessary for the restoration of health must
be very rarely attained.
{h) The unilobular form. — Morhid anatomy. — This form of cirrhosis,
which, though equally due to alcohol, is far less common than the other,
is a very distinct disease, and presents many points of marked conti^ast
Avith the preceding kind.
The liver is increased in size ; as a rule it reaches a size and Aveight
far beyond anything met Avith in the multilobular form. A Aveight of
fiA'e to seven pounds is common ; over ten pounds has been met with.
The right lobe may measure thirteen inches in an antero-posterior direc-
tion, and may be more than six inches in thickness. During life its edge
is commonly found to extend at least to the IcA'el of the umbilicus ; it
may descend much lower, and it often also stretches across the abdomen
into the left hypochondriac region.
The natural surface is smooth, and herein is a great contrast Avith the
preceding form. The capsule is often somcAvhat thickened, but there is
seldom the degree of thickening, or of perihepatitis, met Avith in the
multilobular form. Its normal shape and its sharp anterior edge are
commonly retained, and there is no appearance of any tendency to con-
traction. The cut surface is also smooth. It may be of a mottled broAvn
and Avhite colour, due to the presence of a netAvork of fibrous tissue
iS2 SYSTEM OF MEDICINE
throughout the oipin wliich encloses the iiidivichial loliules of hepatic
tissue. In many cases, liowcver, where, as usually happens, jaundice has
been present, the whole surface is of a yellowish or olive green
colour. In consistence it is tough and hard, but it does not present the
leathery hardness that is met with in the multilobular forin previously
described.
Microscopically a new development of fibrous tissue is seen through-
out the organ ; and this, with considerable uniformity, surrounds the
individual lobules. It is for the most part, therefore, " unilobular " in
distribution. Further, in many cases it may be seen to invade the lobules
to some extent from the periphery, separating peripheral cells from each
other and from the lobule, so that they come to lie stranded in the new
tissue. It is richly or poorly nucleated according to its age and the
activity of its development.
In nearly all cases a remarkable plexus of bile-ducts is seen embedded
in the new tissue. In the neighbourhood of the portal vein, that is, in
the centre of the triangular interlobular space where in health may be
seen one or two small bile-ducts in tT'ansverse section, there are noAv seen
one or more large irregularly-shaped spaces lined Avith columnar epi-
thelium. Nearer the margin of the lobule, and more especially in the
new fibrous tissue occupying the interlobular fissures, lie a series of
smaller ducts which tend to l)e arranged around and parallel with the
edge of the lobule ; and of these ducts the lumen is much smaller and the
epithelium lower and more ciibical. From this system short lengths of
duct commonly arise which come off at right angles, pass straight
to the edge of the lobules, and apparently become continuous M-ith
columns of hepatic cells. These short ducts may have a Avell-f<jrmed
cubical epithelium, but the lining cells usually show a tendency to become
oval and to lie in the axis of the duct ; moreover, the lumen of the duct
is usually packed Avith detached cells, of a similar character, in a state
of active pi'oliferation. That all these epithelium-lined canals are in fact
bile-ducts — not mere double rows of hepatic cells stranded in the new
tissue — is shown by the fact that they can be readily injected from the
hepatic duct, and they often (especially the smaller ones) show masses of
inspissated bile in their interior.
The mode of origin of these neAV bile-diicts is somewhat obscure, and
the matter has not been rendered clearer by its association Avith the prob-
lematic " biliary " form of cirrhosis. It is possible, though not likely,
that they are a Avholly ncAv formation. Such a process Avould have no
parallel in disease of any other organ. It has been maintained, again, that
these ducts represent, and indeed are columns of liver-cells derived from
the peripheral part of the lol)ule Avhich is iuA'aded by the neAv fibrous
tissue ; that their epithelium consists, in fact, of liver-cells degraded and
converted into duct-cells. This view receives some sui)])ort from the
arrangement of the ducts, especially of the short ducts Avhieh run up to
the margin of the lobule, Avhere their cells become merged in those of the
hepatic columns. On the other hand, if this Avere the true explanation,
CIRRHOSIS OF THE LIVER 183
we sliould expect that a transitional stage would be met with, in which
the process of conversion of the highly-organised liA'er-ccll into the lowly
duct-cell would be seen. But this is not the case. At the junction of
lobule and duct there are liA^er-cells and duct-cells, but there are no cells
in process of change from one form to the other. The explanation
suggested by Cornil is perhaps the most satisfactory ; his hypothesis
may be briefly stated in these terms : — Where the liver tissue wastes
from any cause, and the lobule thus grows smaller and its margin recedes,
the biliary canaliculi, which in health lie inside the lobule, between
adjacent rows of hepatic cells, are laid bare to view. In health these
canaliculi are minute tubes formed only by a basement membrane ; and it
is to be supposed that, as they are left bare by the recession of the margin
of the lobule, the epithelium of the extralobular bile-ducts multiplies and
groAvs up into them, and tends to afford them a regular epithelial lining.
In this way many facts are explained. In the first place, the usual
arrangement and pattern of these ducts, which have been described above,
become intelligible ; secondly, these ducts, though far more common in
this form of cirrhosis, occur under other conditions : they are not un-
common here and there in the multilobular form ; they are common in the
periphery of syphilitic scars ; they may be seen around tubercles in the
liver, and even in the lymphoid masses associated with leucocythsemia.
The condition common to all these affections appears to be the destruction
of the margins of lobules by the pressure of some kind of ncAv formation.
And it is clear that the development of these ducts has no relation to a
previous biliary obstruction, as was formerly supposed ; for they may be
present in abundance in cases where there has been no suspicion of
jaundice at any time. Finally, from the brilliancy of their staining
capacity, we may conclude that the cells lining these ducts are in active
life and growth, and in this respect they stand in marked contrast with
the degenerate liver- cells into which they seem to merge. These epi-
thelial cells are usually in a state of active multiplication, and, by their
numbers, they may even occlude the lumen of the smaller ducts.
In conclusion, it may be stated that the difference between the multi-
lobular and the unilobular form of cirrhosis appears to depend on the part
of the portal system upon which the injurious influence of the alcohol
first makes itself felt. In the former the morbid change may be
clearly seen to aiise around the main portal veins which lie in the tri-
angular interlobular spaces or portal canals. In the latter there
is evidence to show that the brunt of the damage falls rather on
the small portal branches which approach each lobule from all jjoints
of its periphery ; consequently the resulting new fibrous tissue is
developed around each lobule, and by its encroachment upon the edge of
the lobule an appearance of newly-developed bile-ducts may be produced.
Finally, in view of the packing of the smaller of these new ducts with
epithelial cells, it is possible to suppose that the common occurrence
of jaundice in this form of cirrhosis is due to their occlusion by this
means.
i84 SYSTEM OF MEDICINE
The problem of biliary cirrhosis. — It has l)ecn maintained that
the appearances above described — namely, the unilobular development of
a fibrous network which has nnmerous bile-ducts embedded in it — should,
in some cases at any rate, be explained on the hypothesis that the primaiy
disease lies in the bile-ducts, and that, as a consequence of this disease,
the fibrous tissue is secondarily developed around them. In other words,
a form of cirrhosis has been described, mainly by French observers, as
"hypertrophic cirrhosis with chronic jaundice," or more shortly, as "biliary
cirrhosis"' as opposed to a " portal cirrhosis."' There is considerable doubt,
at any rate in this country, whether there be any ground for believing in
the existence of a form of cirrhosis having a " bile-duct origin " as distinct
from a " portal vein origin " ; and, if an opinion is to be formed, a brief
summary of the facts is necessary.
Laennec's cirrhosis, the alcoholic multilobular form here described,
was well understood early in this century, and no other form was then
recognised. So firm Avas the belief in the truth of Bichat's positive state-
mctit, " cet etat (cirrhose) ne se complique jamais du volume extra-
ordinaire du foie, au contraire il diminue," that if a cirrhosed liver were
found increased in size it Avas supposed to be but an early stage of
the small hobnailed liver. In 1859 Charcot and Luys pointed out
that in some cases of cirrhosis, Avhere the liver is large, the new fil)rous
tissue penetrates into the lobules and becomes " intralobular " ; and this
communication heralded the recosmition of a form of cirrhosis distinct
from the small granular form of Laennec. In 1874 Hayem published
two cases of cirrhosis with enlargement, in which the individual lobules
were similarly invaded by the new tissue ; and in the same year Cornil
described the appearance of new bile-ducts lying in the fibrous tissue. A
year later Hanot pul)lished a thesis which established the existence of a
form of cirrhosis, with pei-manent enlargement of the liver, which differs
widely in its clinical and pathological features from the far more com-
mon small-sized form which, up to a few years before, had alone been
accepted.
This form was described by Hanot as being characterised by a great
enlargement of the liver, constant at all periods of the illness, by its
smooth surface, and by the a])sence of evidence of contraction of the new
fibrous tissue. He distinguished it, microscopically, by tlu; unilobular
and sometimes intralobular arrangement of the new tissue, and by the
appearance in it of a plexus of small bile-ducts. He described its clinical
features as a ])ermanent jaundice without ascites, and without any evidence
of portal obstruction, and a fatal progress due to the severity of the jaundice.
In the cases which had come under his observation he was unable to
trace any one definite exciting cause. Some ]>atients liad resided in
Algeria and had contracted intermittent fever. Other cases occurred in
hard drinkers, but in others, again, no history of alcoholic excess could be
elicited. No evidence was obtained of any connection with syphilis.
A^'hilc allowing that residence in a hot climate, malaria, and alcohol
might play a part in the causation, he Avas inclined to attribute the dis-
CIRRHOSIS OF THE IIVER 185
ease to the spreading of an inflammatory process from the smaller bile-
ducts, which he believed to be in a catarrhal state of unknown origin.
Charcot confirmed this clinical account and this view of a " biliary "
origin. He was influenced by the identity between the anatomical
appearance of this unilobular form of cirrhosis and that of the experi-
mental form, which has already been mentioned as the result of the
ligature of the common bile-duct in some lower animals. His train of
reasoning led him to the conclusion that in the experimental form the
cirrhotic process started around the small bile-ducts, and w^as due to the
catarrh excited in them by the stagnation of the bile ; and he applied
this conclusion to explain this form of cirrhosis in man.
The evidence on which this theory of a biliary origin of thece cases
was based has failed on further investigation. It is known now that the
results of experimental ligature of the common bile-duct cannot be
applied to man, and that little or no cirrhosis ever follows prolonged
obstructive jaundice. The appearance of new bile-ducts, on which so
much stress was laid, is now known to be a phenomenon of common occur-
rence in many forms of liver disease which are unattended by jaundice.
And the microscopical evidence of the catarrhal condition of these ducts,
on which the theory was partly based, is exceedingly doubtful.
The account of the morbid anatomy and of the clinical features, as
given by Hanot and Charcot, is in the main identical wuth that of the
unilobular form of alcoholic cirrhosis already detailed. In nearly all (if
not in all) such cases occurring in this country there is a history of hard
drinking. Osier in America states that all the instances he has met Avith
have been in hard drinkers. And the undetermined point at issue is
whether any cases of unilobiilar cirrhosis own any cause other than alcohol,
or possibly malaria ; and whether any of them can be referred with prob-
ability to a primary morbid change in the bile-ducts.
Syviptoms. — The clinical features of this form of cirrhosis are very
different from those of the multilobular form {a) already described (p. 173),
and this difference depends partly upon the anatomical arrangement of
the new fibrous tissue. It may be said generally that in this form
there is a great tendency to severe jaundice and little or no evidence
of portal obstruction.
It is probable that the disease maj' be well adA'anced before the
patient comes under notice. Some sudden disorder usually brings him
under examination, and the liver is then found much enlarged. The early
symptoms do not amount to more than some general failure of health,
loss of appetite, slight weakness, and perhaps a sensation of weight in
the right hypochondrium. Sometimes the patient has va^juely noticed
that his abdomen is grooving larger. Of the duration of this early
period we have no certain knowledge ; but it is probable that a year or
more may elapse before such patients come under observation.
In many cases it is the onset of jaundice which causes alarm ; and in
most instances jaundice is present, sooner or later. It may, however, be
entirely absent, but patients in whom this has been noted have usually
iS6 SYSTEM OF MEDICINE
died at an early period of the disease. The jaundice is commonly intense,
but there is some doubt -whether bile is ever entirely absent from the
stools. Wlien once established it commonly persists till death.
Ascites is either entirely absent or so slight as not to need inter-
ference ; and there is no direct or indirect sign of portal obstruction in
the form of dilated veins or hsematemesis.
The spleen is either normal or but slightly enlarged. The large, hard,
smooth liver is readily recognised, as it occupies a large part of the
abdomen, and often produces a visible enlargement of it and also of the
lower thoracic region on the right side ; its edge is to be felt at least on
a level with the umbilicus, and it may extend into the right iliac fossa.
An important feature of this disease is the occurrence of fever. There
is often an evening rise of temperature, and this occurs far more com-
monly than in the multilobular form. In man}^ cases, however, the fever
is high: it may range from 102° to 104° for considerable periods,
especially towards the termination of the illness, and it may also assume
a hectic course suggestive of hepatic abscess or pylephlebitis.
The urine is said commonly to show diminution of urea ; certainly
this is not always the case. Leucin and tyrosin have occasionally been
found in it. Diarrhoea is common and towards the end may be uncon-
trollable, resembling that met with in chronic urjemia. The facial aspect
of the patient lias something of the appearance seen in the multilobular
form ; and in long-standing cases there is progressive emaciation and in-
creasing feebleness. The ending is often sudden and acute : the tempera-
ture rises, the tongue becomes dry, the pulse rapid, petechia? may
appear on the skin, the condition during the last few clays of life has a
close resemblance to that observed in acute yellow atrophy of the liver,
and the patient dies comatose.
The duration of life after the first recognition of the malady is very
variable. In many instances the patient dies Avithin the first year ; but
cases have been recorded where life had been prolonged for five and even
seven years
Complications of aleoholie cirrhosis. — Other affections due to
alcoholic excess, such as delirium tremens, chronic alcoholic insanit}^, or a
peripheral neuritis, may coexist Avith cirrhosis of the liver.
Slight albuminuria is of common occurrence, being sometimes attribut-
able to the pressure of ascitic fluid on the renal A^eins. A chronic inter-
stitial nephritis is found in about 15 per cent of patients dying from
cirrhosis ; a chronic tubal nephritis in a much smaller proportion.
Thrombosis of the portal vein is a rare complication Avhich adds
materially to the rkpidity of accumulation of ascitic fluid and to the
gravity of the illness.
An important complication, which is probably an indirect result of
the alcoholic excess and the attendant loss of resisting power, is the super-
vention of tuberculous infection. Occasionally a definite tuberculous
phthisis arises, recognisable during life. Sometimes old caseous foci,
cavities, or scarring are found at the apex of a lung at the autopsy. But
CIRRHOSIS OF THE IIVER 187
the tubercle is more commonly of the gray miliary form, affecting the
peritoneum, or the pleura, or both membranes. In not a few cases an
abundant crop of gray tubercle is found on the peritoneum and on the
surface of the liver ; and a j^leuritic effusion occurring on one side, especi-
ally if the fluid on withdrawal is found to be blood-tinged, is always
strongly suggestive of a tuberculous origin.
B. Malaeial cirrhosis. — The connection between cirrhosis of the
liver and malaria is generally admitted ; but, looking at the frequency of
occurrence of the various forms of malaria in diff"erent countries, a cirrhosis
of this origin cannot be said to be common. In this country, although
the victims of chronic malarial cachexia are fairly numerous, a pure
malarial cirrhosis is very rarely met with. The evidence derived from
countries where malaria is endemic is seldom precise as to the anatomical
details of the hepatic change. And, further, it must be remembered that
in many reputed cases of malarial origin, due to residence in hot climates,
the history of the patient cannot be cleared from the suspicion of alcoholic
excess ; it is not improbable, therefore, that even in such cases alcohol
does often play an important part in originating the disease.
There is evidence, however, to show that a cirrhosis may supervene
upon that condition of the liver which is commonly describee! as chronic
engorgement. Hypersemia of the liver is a general and important
feature of malarial fever. Repeated attacks of such fever, while leading,
on the one hand, to a general malnutrition o\ -fialarial cachexia, tend also
to produce a state of chronic congestion of the liver, or, to use the term
employed by Kelsch and Kiener, of " hyper^mie phlegmasique." In this
condition the liver is enlarged, it commonly extends downwards to the
level of the uml^ilicus, and is found to Aveigh four or five pounds. It is
of firm consistence, dark red in colour, and bleeds freely on section. The
natural and cut surfaces are smooth. Microscopically such a liver shows
an intense and general hyperaemia, to which probably the increase in
size is largely due ; and in the connective tissue which supports the
portal veins an increase in the number of nuclei is to be observed.
This stage, which is of common occurrence, is Avell within the limits
of recovery. In a small proportion of instances, however, it is the fore-
runner of a definite cirrhosis. Of the cirrhosis thus induced both the
multilobular and the unilobular kind are met with. Each form, moreover,
is attended by the same train of symptoms in the malarial as in the
alcoholic disease, and no special description is needed.
On the one hand, the patient may present all the symptoms of the
common form of alcoholic cirrhosis, and the liver may turn out
to be of the small hobnailed variety. It is in such cases more
particularly that the possibility of alcohol as an important additional
factor cannot be excluded altogether. On the other hand, many cases of
the unilobular kind have been recorded which are of much purer malarial
origin. The liver remains enlarged; it is firm, and resistant; there is
little tendency to contraction of the delicate fibrous network which ma^:
T S8 5- YS TEM OF MEDICINE
be seen to infiltrate it, and ascites is according!}'' absent or slight.
Consideral)le enlargement of the spleen is nearlj' a constant coincidence.
Jaundice is comparatively uncommon, but it may appear and may assume
great severity. Finally, in these cases there is a tendency to lardaceous
degeneration of the liver which has no parallel in the corresponding
alcoholic affectioiL
C. Syphilitic cirkhosis. — Of all the abdominal viscera the liver
is most liable to syphilitic affections. The gumma and its resulting
cicatiicial tissue are met with both in acquired and in hereditary syphilis ;
but in the hereditary form of the disease there occurs also a peculiar
form of cirrhosis, which is probably not developed under any other con-
ditions, and which requires separate description. It is extremely doubtful
whether syphilis is ever responsible for either of the two anatomical
varieties of cirrhosis already described. Syjihilitic changes are as a rule
quite distinctive and easily recognisable.
Morbid aiiatonii/. — The starting-point of the fibroid change associated
with acquired syphilis is undoubtedly the development of the gumma,
though gummata do not in all cases lead to anything Avorth}- of the name of
cirrhosis. The gumma may occur singly, but commonh" there are many ; and
a score or more, varying in size from a pea to a Tangerine orange, may
be found scattered throughout the length and breadth of the organ. They
may occur in any ])art of the liver, superficiar or deep, but there is a clear
tendency to their development at the junction of right and left lobes,
beneath the suspensory ligament and in the iieighbourhood of it. They are
often recognisable during life in this situation, and they are also often
found unexpectedly in the post-mortem room. "When seen in this way
they are usually dead-white or gi-ayish white in colour, according to the
degree of caseation ; they are roughly spherical, find often fused together
into large lobulated masses. Microscopically the ceiiti-al part shows
nothing but caseous material, and it is rare to find much trace of the
original cellular structure of the gumma. Around the central caseous
area there is a zone of ncAv cicatricial tissue Avhich has a degree of ccllu-
larity var\nng with its age, and from this zone short fibrous bands may
be seen to radiate for a short distance into the liver tissue. In this stage
the gumma is of no great clinical importance, and, as a rule, grave results
do not ensue unless certain subsequent changes set in.
The natural end of the gumma is caseation with complete or incomplete
absorption, and replacement by fibrous scar tissue. And it can be under-
stood that the final result upon the liver will vary greatly according to
the position, extent, and number of the gummata A\hich undergo this
change. Two extremes must be considered, between which all grades of
severity may be met with. In the mildest degree of the afioction, when
the gummata have been small and superficial, a few scars puckering the
surface of the liver, and perhaps a little thickening of the peritoneum
around, may be the only marks of this occurroiice. Each scar, on vertical
section, will show a wedge-shaped area of cicatricial tissue extending into
CIRRHOSIS OF THE LIVER 189
the liver substance for a depth of one-third or half an inch, and perhaps
also microscopical examination will reveal in it a small central speck of
unabsorbed caseous material. As I have already stated, Avell-formed bile-
ducts are often seen in such scars. In the opposite extreme, in which
the affection is far more grave, the liver is grossly deformed. In these
cases there have been numerous gummata scattered throughout the whole
or a large part of the organ^ — some separate, some fused into large masses,
some superficial, some deep. And it results from their invariable ending in
caseation and cicatrisation that the Avhole or a large part of the organ is
seamed and traversed in all directions by broad fibrous bands, which on
section are seen to separate large irregular masses of liver tissue. Accord-
ing to the stage at which the process has arrived, these bands may or may
not still enclose caseous foci visible with the naked eye. In consequence
of their contraction the surface of the liver may be scarred and furrowed,
or it may come to present rounded eminences separated by deep depres-
sions ; or it may become largely lobulated, so that its appearance has been
compared to that of the kidneys of young animals. Sometimes the
depressions on the siu'face are so deep and close that the intervening and
protruding portions of liver tissue become almost polypoidal in form.
There is also commonly, but not invariably, some degree of general inflam-
matory thickening of the peritoneal covering of the liver, which may be
firmly adherent to the diaphragm and surrounding structures.
Before this severe degi'ce has been reached there has been, undoubtedly,
considerable destruction of liver tissue by the compression of these con-
tracting fibrous bands. But, with the exception of the local atrophy thus
produced, the bulk of the tissue of the organ shows no change ; the
vessels are free, and the connective tissue of the portal canals is unaltered.
There is a tendency, however, to the supervention of lardaceous degenera-
tion ; and cases have been met with Avhere both alcoholic excess and
syphilis have been in operation, so that gummata and this localised
fibroid change have been found in coexistence with a genuine granular
cirrhosis.
Such gummata, with scarring and lobulation of the liver already
descril)ed, are also met with, though rarely, as a result of hereditary
syphilis, and need no further description.
Another form of disease, distinctly due to hereditary syphilis, is a
diffuse interstitial hepatitis, often found in still-born children, sometimes
in children who have survived their birth for weeks or months ; rarely in
children beyond this period. The liver is uniformly enlarged, heavj^, and
hard, smooth on the natural and on the cut surface, exsanguine, and pale
or reddish gray in colour. Its lobular structiu-e is indistinct ; to the
naked eye it may show no resemblance to liver tissue. It ma^^- be mis-
taken for a lardaceous liver. It is found microscopically that some stage
of an interstitial hepatitis is in progress. The whole organ from end to
end is packed with formative cells and developing or fully-de^'eloped
fibrous tissue, which affects not onl}'- the portal canals, but invades the
individual lobules, not only separating the columns of hepatic cells from
I90 SYSTEM OF MEDICINE
each othei-, but even separating the )ndi\ idual cells from their neighbours.
So that in an advanced example there M-ill be seen single liver-cells or
groups of cells, still recognisable as such, scattered about in a matrix of
developing or fully-formed fibrous tissue ; and no trace of the normal
lobular arrangement may remain. Rarely miliary gummata arc also found
to be present, and sometimes a lardaceous change may be displayed by
suitable staining methods.
The syiiqdoins. of the interstitial hepatitis due to hereditary syphilis
are not clearly known, and the condition is scarcely recognisable during
life. But the liver may be recognised as enlarged ; and jaundice and
some degree of ascites have been observed.
On the other hand, the recognition of gummata in the liver, -whether
in children or in adults, is of the greatest importaiace. The liver is often
slightly enlarged, either as a whole or more particularly that part of it Avhich
presents in the epigastrium. In many cases the projection of one or several
gummata may be felt in this region upon the surface ; and occasionally one
large gumma as large as a Tangerine orange may be palpable. .Sometimes
no symptoms whatever are produced, and the hepatic condition is discovered
accidentally. There may, however, be a sensation of weight in the right
hypochondrium, or even some degree of pain, presumably due to implica-
tion of the peritoneal covering ; and it may be some such sensation which
first brings the patient under observation. Unless the portal vein or one
of its large branches be interfered with by the development of gummatous
tissue around it, the general health, as a rule, is but little disturbed. A
very important though rare ])henomenon is the occurrence of fever. In
one recorded case of a boy, who presented traces of old interstitial
keratitis, the appearance of a large apparently solitary gumma in the
liver was accompanied by a daily rise of temperature to 102° or 103°,
in hectic fashion, for a period of many weeks. The fever subsided and
disappeared within a day or two of the commencement of treatment by
potassium iodide (Bristowe). A trace of such fever has been known to
occur in connection with hepatic gumma in the adult.
As the ilbi'oid chaiige sets in and the gumma gives place to cicatricial
tissue, any further development of symptoms will dej^end entirely on the
position and extent of the change. The portal vein, or some of its large
branches within the liver, may chance to lie in the grasp of the contract-
ing filirous tissue. There ensues, then, all the train of phenomena M'hicli
haA'e already l)een descriljcd as marking ])ortal olistruction : ascites,
ha^matemesis, the external appearance of dilated veins, and grave inter-
ference with the digestive functions of stomach and intestine. By similar
interference with the main hepatic bile-ducts jaundice may be pi-oduccd,
but it is a far less common occurrence than ascites. It follows that the
alcoholic and the syphilitic forms of the disease may be indistinguishalile
by their symptoms alone. Gummata, however, may be definitely felt in
the epigastrium ; or there may be a history of syphilis and no histoiy of
alcfiholic excess. And in young subjects all evidence of hereditary
syphilis nuist be sought for, in skin, teeth, eyes and bones.
CIRRHOSIS OF THE LIVER 191
Treatment. — A rational plan of treatment will be founded, in the first
place, on a knowledge of the cause of the cirrhosis ; and in the second
place, on an appreciation of the exact manner in which the disease
produces impairment of health and a tendency to death.
In all cases, whatever the cause, alcohol must be strictly avoided,
though occasions may arise in a late stage of the disease when its
temporary use may be called for. If there is reason to believe that
malaria has played a part in the causation, the choice of residence in a
suitable locality, either at the seaside or at a bracing moderate altitude,
is of the first importance. If there be direct evidence that the disease is
of syphilitic origin, or if indeed there be any suspicion that the disease is
not of the ordinary alcoholic form, a trial of potassium iodide, with or
without mercury, is the correct course to pursue. The prognosis is
certainly less unfavoura])le on the whole in the syphilitic than in the
alcoholic disease ; but this difference is present only in the early or
gummatous stage. By the timely use of antisyphilitic remedies the growth
of gummatous tissue may be checked and its comjDlete absorption materi-
ally hastened ; so that symptoms derived from interference with portal
vein or bile-duct may subside in an early stage and may not recur.
Instances of such a happy result have often been recorded. But if the
fibroid condition be already advanced, and if symptoms due to the
contraction of broad fibrous bands traversing the liver have set in,
there is no evidence to show that any drug can be credited with the
power of arresting the disease ; and as regards the probability of
recovery, the syphilitic and alcoholic forms are from this stage forward
on a par.
As concerns the management of the patient, the regulation of his daily
life, and the handling of the various symptoms that may arise, all forms
of cirrhosis may be roughly grouped together. The diet must be plain
and simple ; it should be ample for the maintenance of strength, while
excess must be carefully avoided. At the beginning of treatment
milk should form the main (if not the only) article in it. From three
and a half to four pints a day may be given to an adult, in various ways
according to taste ; slightly diluted with some alkaline water, or as a
jelly, or in the form of a milk soujd containing some vegetables. It is
well to avoid meat entirely for a time, or at any rate to allow only
Avhite meat or fish in small quantities. All meat, broths and soups
may well be discarded, unless their temporary stimulant effect be
required. Vegetables and fruit may be allowed, those kinds being pre-
ferred which contain least starch. And, as a general rule, it is well to
reduce all forms of starchy and saccharine food to a minimum in \\g,w of
the state of the stomach and the proneness of these substances to undergo
fermentation.
If possible, complete rest and plenty of fresh air should be secured for
these patients.
In the matter of drugs, the limits of the use of potassium iodide have
been laid down already. And it is reasonable to believe that in the
192 SYSTEM OF MEDICINE
general medicinal treatment the use of acids, bitter tonics, and, sometimes,
the milder preparations of iron carries us as far as we can go. Bismuth
and magnesia are often of use in allaying the tendency to vomiting
produced by the catarrhal condition of the stomach ; and thymol serves
sometimes to check the flatulence which is commonly troublesome.
There is no douljt that diuretics, such as digitalis, scjuill, copaiba, and
diuretin, Avhich have received ample trial and recommendation from time
to time, do in some instances ensure the passage of an increased amount
of urine, even so far as to promote a pcrcej)tible dimiiuition of the ascites.
Though such a treatment is probably harmless it is too often useless,
especially in cases of extreme ascites where the diminished secretion
of urine is atti'ibutable to pressure on the renal veins. Perhaps the most
satisfactory diuretic to be used in such a case is the well-known combina-
tion of mercury, digitalis, and squill.
The propriety of attempting to remove ascitic fluid by powerful
purgatives is still more questionable ; but this method of treatment Avas
at one time generally practised. It is of course well to ensure free daily
evacuation of the bowels by the matutinal use of saline aperients, such
as Carlsbad salts, but anything more drastic than this is certainly not to
be recommended.
Our views as to the expediency of paracentesis have undergone
modification in the last few years. The operation was formerly regarded
as a last resom'ce, and was consequently looked upon as the herald of
death. Increased experience has led to its extended adoption at a much
earlier period of the disease ; it should undoubtedly be employed whenever
much discomfort is produced l>y the ascites, and more especially whenever
there is any marked degree of upward pressure upon the heart or lungs.
The occurrence of hsematemesis, however slight, must be taken as
the signal for absolute rest of the body as a whole, and especially
of the stomach and adjacent part of the a>sophagus. All food by the
mouth must be forl)id<len, and, at any rate during the few days of danger,
the patient must be kept entirely on rectal feeding. It is extremely
doubtful whether eigol; or ergotin is of any avail : the use of nitrite of
amyl lias l)cen suggested on definite grounds. But opium, preferably as
the hypodermic injection of morphia, is certainly of indirect value in
calming the patient and allaying his anxiety.
Diarrhcx3a is apt to be intractal)le. Although the attendant loss of
fluid from the portal area is at any rate not harmful, yet the ])assage of
the contents of the bowel is at the same time so hurried that absorption
of nutritive food-products is imperfect. Gastric digestion and absor])tion
])Oing already at a low ebb, this diarrhoea has a disastrous eft'ect, and
in many instances it is the bcguining of the end. The subnitrate or
salicylate of ])isnuith in large doses is perhaps the most cHicient means
of coping with it ; the mineral acids, catechu, and the strong preparations
of iron, such as the pernitrate, may also be tried ; but opium is seldom
safe at this stage of the disease. In many cases all treatment fails to
check it.
CIRRHOSIS OF THE IIVER 193
In conclusion, when the use of alcohol has been effectually stopped, a
satisfactory diet enjoined, and a regular action of the bowels estal>lishcd,
it remains to deal with such complications as ascites, haemorrhage, diarrhcea,
and pleuritic effusion. But whether the individual patient will succumb,
or whether he is to be one of that small number in Avhom the symptoms
disappear, is beyond our knowledge ; yet the residt will depend largely
on the stage of the disease at which treatment was begun.
In conclusion I may mention a rare combination of cirrhosis with (so-
called) adenoma, described by Dr. Kelynack and others ; but as the disease
has no clinical imjiortance I need do no more than refer the pathological
reader to Dr, Kelynack's paper which is indexed below in the list of
references.
• Herbert P. Hawkins.
REFERENCES
General Literature
1. Briegek. Virch. Arch. Bd. Ixxv. Heft 1. — 2. Bristowe. Brit. Med. Journal,
April 23, 1892 (Prognosis).— 3. Brit. Med. Journal, November 19, 1892 (Discus-
sion on Prognosis and Treatment). — 4. Charcot. Lerons siir les Alaladies du Foie.
— 5. CoRNiL and Ranvier. Manual cVhistologie pathologiquc. — 6. Frerichs. Clin.
Treatise on Diseases of the Liver. New Syd. Soc. — 7. Goodhart. JVeio Syd. iSoc.
Atlas, fascie. 4, 1882. — 8. Green. Trans. Path. Soc. 1876. — 9. Laennec. Traif.e de
V auscultation mediate, t. ii. p. 501. — 10. Lancereaux. Atlas d'anatomie pathologique.
— 11. Price. Guy's Hosp. Iteports, 1884. — 12. Sappey. Mem. deVAcad. dc Med. xxiii.
269.— 13. Taylor. Trans. Path. Soc. 1879-80.-14. Trans. Path. Soc. 1889 (Discussion
on Morbid Anatomy and Pathology of Chronic Alcoholism). — 15. White, Hale.
Gui/'s Hosp. Reports, 1882. — 16. Wilson and Ratcliffe. Brit. Med. Journal, Dec.
27, 1890.
Special Literature
Malarial Cirrhosis : 17. Davidson. Hygiene and Diseases of Warm Climates. —
18. Kiener and Kei.sch. Arch, ele Phys. norm, etpath. 1878, 1879. — 19. Lancereaux.
Loc. cit. Biliary Cirrhosis: 20. Clarke, Michell. Brit. Med. Journal, May 3, 1890.
21. Charcot and Gombault. Archives de Phys. 1876 (two papers). — 22. Hanot.
£tude siir une forme de cirrhose hypertrophique du, foie. These de Peiris, 1875. — 23.
Legg, W. St. Bart. Hosp. Reports, 1873. — 24. Saundby. Trans. Path. Soc. 1879. —
25. Sharkey. St. Thomas's Hosp. Reports, 1888. Cirrhosis associated with Tuber-
culosis: 26. Hanot and Gilbert. Compt. rend. Soc. de Biol. 1890 and 1892. Con-
nection of Cirrhosis with specific Fevers : 27. Botkin. Berl. klin. Wochenschr. 1872,
No. 22.-28. JoLLYE. Brit. Med. Journal, April 23, 1892.-29. Klein. Trans.
Path. Soc. 1877. — 30. Pepper. Journal Amer. Med. Assoc. July 2, 1887. Cirrhosis
and Adenoma : 31. Kelynack. Edinh. Med. Journal, 1897, p. 187.
H. P. H.
VOL. IV
194 SYSTEM OF MEDICINE
TUMOURS OF THE LIYERi
Secondary cancer of the liver is by far the most common
form of tumour. Thus, I find that in the Clinical Reports of the
jMedical "Wards of Guy's Hospital during the years 188S-1893, both
inclusive, there were admitted 58 cases diagnosed at the bedside to be
cancer of the liver, of which certainly not more than tM'o or three were
primary ; 15 cases of syphilis of the liver; 12 of abscess ; 12 of hydatid,
and 7 of sarcoma. The frequency Avith which secondary cancerous de-
})osits take place in the liver is shown by the fact that at Guy's Hospital,
during the years 1885-1893, both inclusive, out of about 4200 post-
mortem examinations 136 examples of secondary deposits in the liver were
met with in the dead-house, and of these at least 126 were carcinomatous ;
that is to say, secondary carcinomatous deposits are found in the bodies of
3 per cent of all persons who die in Guy's Hospital, a percentage Avhich
exactly coincides with that given by Leichtenstern. Further, I find that
of all pei'sons in whom at death malignant disease of any organ is found,
about 50 per cent have secondary deposits in their liver.
So many of the symptoms of cancer of the liver are due to physical
alteration in shape of the organ that it will perhaps be best to describe
first the morbid anatomy.
Morbid aiatomy.— If the patient die soon from the effects of the
primary growth, the secondary deposits found in the li\er may be few
and small ; but, inasmuch as the primary growth is usually in some
oi'gan, the blood of which is returned by the portal vein, the hepatic
tissue often becomes atiected early ; and in many instances, therefore,
there is an enormous deposit of cancer in the liver by the time of the
jDatient's death. Cancer causes the liver to be heavier than any other
disease of it ; in the last case under my care the liver weighed nineteen
pounds, and even heavier livers have been recorded. The secondary
deposits take the form of whitish nodules scattered about irregularly in
the liver substance, suggesting, by their distribution, that we are correct
in believing that cancer elements are conveyed in the portal blood to the
liver, and multiply wherever they may hajipen to be deposited. At the
patient's death all the nodules are not of the same age, and they are of
various sizes, from those Avhich require a microscope for their detection to
those which are as large as a fcetal head. In a marked case the organ
has bosses all over it, especially perhaps on its ui)pcr surface. The
older of these are umbilicated, and often there is a little local thickening
of the peritoneum over them. The nodules, which at first are more or
less globular, grow most easily in the direction of least resistance, and
this, to some extent, may explain the fact that cancerous nodules are
usually absent from the interior of the liver uidess some are also
' These will be considered in the order of their clinical importance.
TUMOURS OF THE LIVER 195
visible under its peritoneal coat. The nodules destroy the hepatic tissue,
but they increase more rapidly than they destroy ; hence the enormous
weight of the liver in an advanced case. Gradually those which are
contiguous coalesce ; so that, on section of the liver, large irregular
white masses of various shapes, and rounded nodules, occupying, it may
be, several cubic inches, are seen let into the hepatic substance, as it
were, which is dark by contrast. This striking contrast is often much
enhanced by the bright yellow tint of the growth, due to staining by the
bile, the dark red due to haemorrhage, and the pale yellow due to fatty
degeneration.
There is no special alteration to describe in the hepatic tissue itself. The
cancer as it grows causes atrophy of the hepatic cells ; hence, even Avhen
the liver is very heavy, there is much less hepatic tissue than normal ;
what is left appears, however, healthy except that the cells in immediate
contact with a cancerous nodule are compressed. Although the growth
cannot be shelled out from the hejjatic tissue, the demarcation between
cancer substance and liver substance is very sharp. Injection experiments
have shown that blood-vessels from the hepatic artery grow into the
cancerous growth along its septa. The growth resembles that of the
primary seat of the disease ; hence its consistency, its tint, and the
amount of juice obtained by scraping it all vary. After they have
attained a certain size the nodules begin to degenerate in the centre, the
part farthest removed fi'om the blood-supply. The cancer cells may
become fatty and break up, and, consequently, the centre of the nodule
becomes yellow, soft, and of the consistency of batter ; and if, as sometimes
happens, much of the stroma has softened, most of the growth may be
washed away wath a stream of water, so that a ragged, shreddy mass of
stroma is left behind. The fibrous tissue of the cancer, however, usually
contracts as time goes on ; and as this contraction is most marked in the
centre, where softening has been greatest, the growth when on the
surface of the liver becomes uml)ilicated. The process of softening some-
times lays open the blood-vessels of the stroma, especially in those
rapidly-growing tumours which are from the first red and vascular. Thus
considerable haemorrhage may take place into the cancer, which becomes
a soft, dark red mass ; and it may even extend into the substance of the
liver itself. Sometimes, under these circumstances, the liver may clinically
be found to enlarge very rapidly ; and in rare cases haemorrhage has
taken place from a nodule on the surface, and blood has poured into the
peritoneal cavity. Often the new growth undergoes yellowish, cheesy
degeneration ; and sometimes also a quantity of clear fluid collects in its
interior and replaces the atrophied cells, which have become absorbed.
Usually some bile-ducts are compressed by the new growth in their course
through the liver, which, consequently, becomes stained here and there
of a deep yellow colour ; this colour often extends into the cancer masses
themselves, and the growth of these into the veins, which is a very
common event, leads to considerable ante-mortem clotting in them.
A cancerous mass may envelop and infiltrate the gall-bladder, but often
196 SYSTEM OF MEDICINE
Avhen this appears to have happened the growth has been primarily in
the gall-bladder, and has affected the liver secondarily. In the same way,
when, as is not uncommon, a malignant mass is seen to implicate both the
])ylorus and the liver, the stomach should be regarded as the ])rimary
seat. Sometimes cancer of the liver grows directly into the diaphragm,
which thus becomes adherent ; and I have seen prominent nodules on the
surface of the liver leading to the growth of cancerous nodules on the
peritoneal lining of the abdominal Avail at the spot in contact with the
hepatic growth : this has occurred even when no adhesions betAveen the
liver and the abdominal Avail have taken place, but, on the other hand, I
have known the adhesions so firm that the liver did not move up and
doAvn Avith respiration, and at the autopsy some of the anterior
abdominal Avail had to be taken aAvay Avith the liver in order to remoA'e
the organ.
The groAvth in the liver often leads to the formation of a malignant
nodule at the umbilicus ; and in such a case I have seen the Avhole of
the round ligament converted into a cancerous cord. If the groAvth
has been long present in the liver, or if the organ Avhich is the seat of the
primary cancer retiu'ns its blood into them, the glands in the transverse
fissure will be secondarily enlarged, even to the size of a hen's egg.
Their pressure on the common bile-duct leads to distension of the gall-
bladder, converts the mottled bile -staining of the liver into a deep
yelloAV staining of the Avhole organ, and the jaundice of the entire
body becomes extreme and persistent. If the cystic duct be compressed,
so that no bile can reach the gall-bladder, the latter is found contracted
and contains a little mucus only. It is rare for the groAvth to spread to
the suprarenal capsules, kidnej", duodenum, or colon. As the secondary
cancers of the liver repeat in every particular the histological characteristics
of the primary groAvth, it is unnecessary to give a description of their
microscopical appearances, Avhich Avill l)e found in treatises on ])athology.
It is not unusual to find gall-stones in the ducts or gall-bladder, and
consequent dilatation and ulceration of the bile passages may occur.
Sometimes the gall-stone by its irritation has set up a primary groAvth of
the gall-bladder or the ducts. It is outside our subject to describe the
post-mortem appearances of the primary growth in other organs, the
secondary deposits elscAvhere than in the liver, the bile-stained condition
of the body generally, and the post-mortem signs of death from cancer.
It is Avorth Avhile, howcA^er, to point out that secondary cancerous deposits
usually take place by the agency of the lym})hatics and not by the venous
system, and are conveyed by the portal vein ; and that probably the reason
Avhy secondary deposits in the liver are so common, is that the primary
growth, being out of reach of siu'gical interference, goes on to ulcei'ation ;
peripheral twigs of the portal vein are thus laid open, and infection of the
liver takes place by this vein.
Although a colloid cancer of the liver, secondary to colloid cancer else-
Avhere, repeats the a]ipearance of the ])riniaiy growth, colloid cancer in-
vading the liver by ilirect extension from the peritoneum has, according
TUMOURS OF THE LIVER 197
to Schueppel (^Ziemssen's Encyclopcedia), quite a difterent appearance ; for
the invasion takes place by the lymphatics, and thus we see at first
numerous subserous rows of colloid material, and later, these appear to
run through the liver like colloid strings. Ultimately the organ may
thus become one mass of colloid material.
Symptoms. — In more than half the cases the deposit of cancerous
nodules in the liver produces no symptoms by Avhich they can be
recognised during life, and then, as far as we know, they do no harm. If
the secondary growths in the liver. do produce symptoms, those of the
primary growth will exist side by side with those of the hepatic affection.
The stomach, which is the seat of the primary growth in more than a
quarter of all the cases, the gall-bladder, rectum, and pancreas are each a
common source of cancer of the liver. The great frequency of cancer of
the pelvic organs and breasts of women explains the fact that the
proportion of males to females that die with cancer of the liver is as
3 to 4.
In about half the cases in which the liver is obviously affected, the
seat of the primary growth cannot be discovered during life ; then it is
often found after death in the pancreas, and usually in the head of this
organ.
In the following account I shall omit all reference to symptoms due
to the primary growth, or common to cancer in any part of the body.
The ages of 75 per cent of all patients with cancer of the liver are between
forty and seventy years ; rather under 20 per cent are under forty, and
rather over 5 per cent are over seventy. Hepatic cancer is all but
unknown under twenty.
The symptoms by which we can recognise secondary cancer in the
liver are as follow^s : — Both by percussion and tactile examination en-
largement of the liver can usually be made out. It may reach far below
the umbilicus, the hepatic dulness may be increased upwards in the mid-
axillary line as far as the fifth rib, and on the left side it may blend with
that due to the spleen. The edge of the enlarged organ can nearly always
be felt to move up and down with respiration ; and, as Sir William Jenner
remarks, it often appears lower during life than in the post-mortem room,
for as the last respiratory movement is expiratory, it is drawn up at
death as high as possible. It is quite common, when the patient becomes
much wasted, for movement of the enlarged liver and outward bulging of
the right lower ribs to be easily visible. The edge feels hard, and, owing
to the presence of several carcinomatous nodules, is often irregular : the
nodules can be felt also on so much of the upper surface as comes below
the ribs, so that the whole organ feels irregular, knobby, and hard.
In rare cases the nodules can be made out to be umbilicated, and if
this be ascertained it is absolutely diagnostic of cancer : occasionally, if
they are either growing or degenerating very rapidly, they are soft, and
give an obscure sense of fluctuation. Sometimes, too, a rub can be both
felt and heard over the liver. This indicates either some local peritonitis,
or the presence of a cancerous nodule in the parietal i)eritoneum against
198 SYSTEM OF MEDICINE
which a cancerous nodule in the liver is rubbing. Before deciding that
a liver is not carcinomatous, the patient should always be made to take a
deep insi)iration, for this may reveal a nodule that Avould otherwise remain
hidden under the ribs. Sometimes the cancer grows so fast that the
enlargement of the liver may be watched from week to week ; and
occasionally the whole organ enlarges even more rapidly, and individual
nodules may become more prominent within a day. This is A'ery strong
evidence in favour of cancer, and indicates considerable htemorrhage into
the liver. In a fcAv instances the nodules slowly get smaller as they
undergo degeneration.
There are certain rare cases in which the new growth infiltrates the
whole liver, which is then enlarged and hard ; but no nodules can be felt.
Another important sign is tangible distension of the gall-bladder,
Avhich appears as a rounded tiimour at the lower edge of the liver, and
indicates that secondarily enlarged glands are pressing on the common
duct. It has already been mentioned that the umbilicus is often affected,
and during life it may be hard and enlai-ged.
Tlie patient usually, but by no means always, complains of pain in
the region of the liver, both back and front, due probably to stretching
of the capsule or to some local peritonitis ; and, especially when this has
occurred, the organ is tender, and he sutlers from a cutting pain when he
coughs. Pain is often referred to the right shoulder-joint, a point of
considerable diagnostic importance. I have had but little experience to
show whether the localised cutaneous tenderness Avhich Dr. Head has
shown to be associated ^Wth visceral disease is of much importance in
cancer of the liver. Probably not, for the patients are very ill and weak,
and the tender areas due to the primary disease may well overlap those
due to implication of the liver. When the liver is A'ery large the
patient experiences a sense of fulness and dragging in the right hypo-
chondrium.
About half the patients who during life present symptoms of carcinoma
of the liver are jaundiced ; and this nearly always means that enlarged
carcinomatous glands in the transverse fissure are pressing on the connnon
bile-duct : but in some cases the pressure is due to the primaiy growth,
especially if it be in the head of the pancreas ; and occasionally enough
of the hepatic ducts in the liver may be compressed by nodules of new
growth for jainidice to appear. Or there may be primary cancer of the
bile-ducts (p. 208). It is extremely important to bear in mind that by
far the most frequent cause of long-standing jaundice is cancer of the
liver, Avhich also produces deeper jaundice than any other common
disease ; thus patients suffering from cancer present, in the most extreme
form, those symj^toms due to circulation of bile in the blood and to its
/ibsenco from the intestines. The jaundice, too, is permanent ; the only
exceptions to this rule are those excessively rare cases in which, altho\igh
the patient has cancer of the liver, the jaundice is due to a gall-stone in
the common duct, which is oitlior passed on or slips back. The skin,
deeply and slowly stained by bile, gradually becomes more and more green,
TUMOURS OF THE LIVER 199
and ultimately assumes a peculiar earthy dark green tint, "which, especially if
the patient be aged and wasted, is almost diagnostic of cancer of the liver.
The other effects of bile in the blood are also evident. The urine is
very dark and has a yellowish froth, the numerous scratch marks show
the intense pruritus, the bitter taste in the mouth is very unpleasant, the
sweat may be bile-stained, and if, as often happens from secondary
deposits in the lungs, the patient gets bronchitis or pneumonia, the ex-
pectoration may be yellow. Sometimes the pulse is slow ; in rare cases
the patient may complain of xanthopsy, and occasionally patches of
xanthelasma appear. The usual cause of death is. bile poisoning, or
cholttmia as it is named. In such cases, although the end may be rapid,
usually the patient gradually becomes more and more drowsy, with in rare
cases an occasional convulsion ; day by day his coma slowly deepens \ his
breathing becomes shallower and shallower ; at last he cannot be roused,
and sometimes for days l^efore he passes away a superficial observer might
think that death had already taken place. There are few things more
characteristic in medicine than to see an aged gray-haired patient extremely
wasted, with dry, dark green skin hanging in loose folds, lying perfectly
still, so drowsy that he is more dead than alive. If we turn down the
bed-clothes the liver may be seen deforming the shape of the abdomen ;
and it will be noticed that the sheets are stained yellow, either from urine
or sweat. The absence of bile from the intestine causes indigestion and
constipation, the motions are pale, they smell horribly, and contain much
undigested fat.
Authors differ as to the frequency of ascites. For my own pari., I
think that it is not so common as jaundice, and that it usually comes on
late in the case. It may occur with or without jaundice, the two being
associated in only about 20 per cent of all cases of cancer of the liver
diagnosed as such during life. The fluid is clear, it is often stained
yelloAvish green by bile, and, if any of the superficial hepatic growths have
bled, it may contain blood. Inasmuch as ascites may be absent when
there has been considerable pressure on the common bile-duct to which
the portal A^ein lies so near, it seems reasonable to doubt whether it is due
to pressure on this vein; especially as I have elsewhere (p. 120) brought
forward evidence to show that in perihepatitis, in which disease ascites is
often such a prominent feature, it is probably due to chronic peritonitis. I
think carefully-made autopsies will show that in many cases at least of
cancer of the liver in which ascites is present there is also chronic peri-
tonitis due to malignant nodules in the peritoneum ; moreover, as I have
myself observed in dogs, ligature of the portal vein does not produce
ascites. The amount of ascitic fluid is very variable, and occasionally
paracentesis is required. As the quantity increases the pain often
lessens, and the observer may find it necessary to make a sudden
deep depression in the abdominal parietes in order to feel the liver —
to dip for it, as the phrase is.
Occasionally the growth extends through the diaphragm and sets up
right-sided pleuritic effusion. The effused fluid is then usually blood-
200 SYSTEM OF MEDICINE
stained, and in qnite cxceptioiiul cases an empyema may form. Even with-
out pleural effusion, if the liver be very large, we find physical signs of
compression of the lower part of the right lung. The wciglit of the liver
may also hamper the circulation through the vena cava; if so, the
superficial abdominal veins will show up as prominent dark blue cords
on the dark green wasted skin. Thrombosis may take place in either
internal saphena vein, and towards the end of the case a little albuminuria
may appear. The spleen is very rarely enlarged. As in many other
diseases of the liver, the urine may be loaded with lithates ; and as in
cancer of other organs, we occasionally meet Avith indicaniu'ia, and in a
few cases with slight pyrexia of a hectic type. Some patients suffer from
an annoying reflex dry cough. AVhcn cancer is discovered in the liver a
thorough search must 1)0 made for the primary seat.
Prognosis. — If the diagnosis is correct, death is inevitable. Usually
all is over in less than six months. Some patients die very rapidly, even in
a few weeks. I have recently had under my care a patient who only
began to complain of Avoakness six weeks, and gave up work three weeks
before death ; yet he became rapidly jaundiced, and his Mxgv Aveighed
nineteen pounds. On the other hand, life may l)e prolonged for a year
(and some authoi's say even longer) after the symptoms have declared
themselves ; it is a point of consideraljle importance that at any period
the condition of the patient may remain stationary for weeks together,
and under careful dieting and rest in bed even improve for a time. I
once saw a clei-gyman in consultation in whom this respite occurred, and
the friends, much to the annoyance of the medical attendant, persistently
spread the report that the diagnosis must be incorrect. My experience
of malignant disease certainly is that if after a thorough examination we
have satisfied ourselves that the patient is suffering from it, we ought to
hesitate very much before we siirrender this diagnosis. I have known
patients live over a year after a malignant growth in the stomach Avas
palpal )le.
Diagnosis. — If this rest principally on the physical examination of
the liver, many fallacies beset us. One is that the liver may appear
irregularly enlarged ■when it is normal, and the apparent enlai-gement
mjry be due to hardened fa>ces in the transverse colon, which is
tender from the enteritis set up by them. Bright gives some excellent
instances in point in his memoir on al)dominal tumours. An enema Avill
generally clear up this mistake. I have seen tumours of the stoniacli and
also tlie thickened puckered omentum that is found in chronic pei'itonitis,
Avhether sinii)le, tubercular, or cancerous, considered to be the tiiickened
indurated edge of a ]i\er afl'ected Avith cancer. A careful consideration
of the shaf)e of the tumour, the detection of the edge of the liver above
it, and, in the case of an omental tumour, the discoveiy of lesonancc
between it and the liver, together with a jjrojwr estimation of all the
symptoms of the case, should prevent this eiror. I have also known a renal
enlargement ascrilted to the liver ; and in all such cases the error has been
largely duo to forgotfulness of the fact that as the stomach, the kidney,
TUMOURS OF THE LIVER 20I
and the colon to which the omentum is attached, touch the liver they
may well, like the edge of it, make a consideral)le excursion diu'ing deep
breathing. Then, again, tumours in the wall of the abdomen occasionally
lead to mistakes, or the liver may appear enlarged when, in reality, its
size is unaltered. For example, it may be pressed down by lacing, by
pleural effusion, by pericardial effusion, or by an abscess between it and
the diaphragm ; or the line of hepatic dulness may be higher in the chest
than normal, because the liver is pressed up by ascites or some large
intra-abdominal tumour. Lastly, an enlargement of the liver may be
concealed by tympanites or emphysema.
But even Avhen we have evaded all these fallacies, our difficulties are
by no means at an end. Often there is no easier diagnosis in medicine
than that of cancer of the liver, but in those cases in which the primary
growth cannot be found it may be very difficult ; and if at the same time
the liver is not enlarged, it may be almost impossible. Fortunately such
a combination is rare, unless the cancerous deposit in the liver is limited
to a few small nodules. In the only specimen of contracting carcinoma
we have in the Museum at Guy's Hospital there was a primary growth in
the breast. At the liedside the question nearly always takes this form : —
Is this patient, who has no decided evidence of any primary malignant
disease and whose liver is enlarged, suffering from malignant disease of
it ? The liver may not only be enlarged by malignant disease, but also
from passive venous congestion, as in heart disease, passive portal con-
gestion, the active congestion of hot countries, malaria, yellow fever,
leuchaemia, Hodgkin's disease, pernicious anaemia, diabetes, fatty liver,
hydatid, tropical abscess, the single large abscess of those who have never
been abroad, suppurating hydatid, actinomycosis, tubercular abscess,
obstruction of the common liile-duct, lardaceous disease, hypertrophic
cirrhosis, congenital syphilis, and acquired syphilis ; moreover, in peri-
hepatitis, if the capsule be very thick, it may appear a little enlarged.
The majority of these diseases never present any difficulty ; but the
big cirrhotic liver, the syphilitic liver, and, much more rarely, obstruc-
tion of the common bile-duct, or hydatid, often give rise to much hesita-
tion.
The large cirrhotic liver is uniformly large, and the palpable nodules
on the surface of it are small. Sir William Jenner says that if any
of them appear bigger than a cherry the case cannot be cirrhosis ;
they arc never umbilicated, and neither they nor the whole liver ever
tangibly increase in size in a few days ; and although jDain and tender-
ness may be present, neither of these is as severe as it usually is in
cancer. Although jaundice is seen only in about half the cases of growth,
and in about the same proportion of the cases of hypertrophic cirrhosis,
yet this symptom is often the very means of establishing a diagnosis ;
for in hypertrophic cirrhosis the jaundice is not commonly very deep,
and it always remains yellow ; but in cancer it soon becomes intense,
and slowly changes to the characteristic deep dirty green colour
already described. A patient with malignant disease often dies soon
202 SYSTEM OF MEDICINE
after the occurrence of cither jaundice or ascites, but he frequently lives
many months ; on the other hand, the supervention of these symptoms
in the large cirrhotic liver usually points to death in less than ten weeks.
The ol)Struction to the flow of bile is never great enough in cirrhosis
to cause distension of the gall-bladder or definitely clay-coloured stools,
so that either of these symptoms would turn the scale in favour of
malignant disease. The spleen is enlarged in i-ather more than half the
cases of hypertrophic cirrhosis, and Inxt rarely in malignant disease.
Regard must, of course, be paid to the history and the age of the patient
and to the lack of any other evidence of alcoholic poisoning. The aspect
of the patient and the dryness of the skin may suggest cancer, but we
must rememl)er that wasting may lie very marked in cirrhosis. Lastly,
piles are more common in cirrhosis than in cancer.
The diagnosis between malignant disease and syphilis may be
difficult. Congenital syphilis, although, if there be much fibrous tissue
and gummas \q.vy numerous, it may cause the liver to be irregularly
enlarged and hard, is probably never detected in this organ after
puberty, because, I suppose, before then the gummas are all absorbed.
Acquired syphilis also leads to the formation in the liver of deposits of
fibroid tissue and gummas. As the former contract and the latter are
absorbed, scar-like deiDressions mark the siu-face, and between them the
unaltered liver substance, Avhich has undergone compensatory hyper-
trophy, projects, and these nodules of healthy liver and those of un-
absorljed gummas cause the liver to be covered with lumps of all sizes,
giving the whole organ on physical examination a close resemljlance to a
cancerous liver ; this is the more embarrassing as, owing to syphilitic
lardaceous disease of it, the total enlai'gement may be quite as gi-eat
as is usually the case in hepatic cancer. It is conceivable that the glands
in the transverse fissure might be much enlarged from gummatous deposit
— and we have a specimen in Guy's Hospital Museum showing this ; if so,
they might press on the common bile-duct and cause jaundice and dis-
tension of the gall-bladder, but this and the deposition of lardaceous
material in them are pathological curiosities : if, then, the patient be
jaundiced, or his gall-bladder distended, it is all but certain that the
enlargement of his liver is not syphilitic. It is, too, Avithin the range of
possibility that in the same patient S3'i)hilis might not only distort the
liver, Init also cause perihepatitis and chronic ])eritonitis, and so induce
ascites ; however, not only is it extremely inilikely that two rare residts
of syphilis should be present in the same case, but the jierihepatitis would
smooth over the syphilitic irregularities on the liver. In a case of doubt,
therefoi'e, ascites is very strong evidence in favour of cancer. Other
points of distinction are that we never find in syjjhilis the rajnd enlarge-
ment of the whole liver or its nodules that may occur in cancer ; on the
other hand, in cancer we never get the marked dimiiuition of both that
we find in syphilis, especially in cases under treatment by iodide of
potassium, l^iin and tenderness are not so extreme in syphilis as in
cancer. Itajjidity and great severity of the general symptoms are, of
TUMOURS OF THE LIVER 203
course, much in favour of cancer ; and I need hardly add that a careful
search must be made for other signs of syphilis.
Cases in -which, owing to non-malignant obstruction of the duct, bile
is retained in the liver, causing it to be enlarged and the patient to be
jaundiced, sometimes present very great difficulty. Nearly always gall-
stones have set up chronic inflammatory thickening outside the com-
mon and cystic ducts. A remarkable instance is recorded by Bright,
in which the parts about the entrance of the common duct into the
duodenum were thus hardened and matted together. The common,
hepatic, and cystic ducts were dilated to the size of a healthy gall-bladder ;
and the gall-bladder was so dilated that, Ijoth during life and after death,
it almost reached the crest of the ilium. The ducts in the liver were
dilated into a number of vesicles. , The pancreatic duct was also much
dilated. The patient, a Avoman aged fifty-six, gave a history of sjmsmodic
pains five years before admission. She was jaundiced and had great hepatic
pain and pale stools for four and a half months before she died drowsy
from cholaemia. She was very sick and wasted much, but the jaundice
Avas never of an oliA'e green colour ; in fact, it was stated to be brilliant
a fcAV days before her death. I have recently seen, Avith Mr. A. G. Wells,
a lady aged about sixty Avho had suffered from gall-stones years before.
Her present illness consisted, on our visit, of some loss of flesh, much hepatic
pain and tenderness, enlargement of the liver, jaundice, A'omiting, con-
stipation, and Avhite stools. Here the diagnosis lay between growth and
inflammatory thickening. A fortnight before death the jaundice dis-
appeared, but a day or tAvo afterwards symptoms of i)3^0emia set in. At
the post-mortem examination Ave found so much inflammatory thickening
on the under surface of the liver that it took some time to discover the
gall-bladder ; this AA^as empty, sloughing, and contained a gall-stone.
The common and hepatic ducts Avere enormously dilated, and in the
former lay a gall-stone easily movable; and no doubt the accidental
shifting of it led to the disappearance of the jaundice. The liA'er Avas
studded Avith minute abscesses. To shoAV hoAv extensive this inflam-
matory thickening due to gall-stones can become, I may mention that
I once made a post-mortem examination on a Avoman Avho during life
had had almost complete pyloric obstruction. This was found to be
due to inflammatory thickening and matting Avhich started from the
gall-bladder and iuA'aded the pylorus. It was set up by numerous gall-
stones.
The main points of distinction between cancer of the liver and inflam-
matory thickening about the biliary passages are that in the latter case the
patient does not look as though she Avere sufFei'ing from cancer ; the hepatic
enlargement is uniform, never so great as it often is in cancer, and the
jaundice does not become dark green. If it disappear for a time, this
probably means that a gall-stone has shifted its position ; that the jaundice
of cancer should disappear is almost unknoAvn.
Hydatid of the liver seldom gives rise to difficulty, for usually the
tumours are only one or tAvo, and they are smooth, regular, not tender,
204 SYSTEM OF MEDICINE
cause neither pain, jaundice, ascites, nor general emaciation, and may
give a thrill. It is extremely rare for a hydatid tumour to 2:)ress on a
bile-duct and so lead to jaundice, which is, however, occasionally caused
by the rupture of a hydatid cyst into the bile-duct. Such a case may be
extremely dithcult to diagnose, but our chief guides will be the sudden
onset of jaundice, the physical examination of the liver, and the absence
of wasting and pain. The exogenous form of hydatid may form multiple
tumours, and tliese and the multiple tumours formed by the alveolar or,
as it is often called, multilocular variety, may, if they happen to cause
jaundice, give rise to great uncertainty. But they are so rare that it
will be necessary to think of them only in those instances in Avhich the
age, the wasting, and the long duration of the illness lead to the con-
clusion that the case cannot be one of cancer.
Treatment. — This can only be palliative. Morphia may be given to
relieve the pain, and sometimes the pruritus is so intractable that it yields
to nothing else. This symptom is often most distressing. Perhaps pilo-
carpine subcutaneously or warm alkaline baths are the best remedies.
Constipation and vomiting will be treated on ordinary principles ; for the
latter it is often of great service to wash out the stomach. The ascites
may require paracentesis. Quite recently Mr. INIayo Robson has de-
scribed a case in which he excised a cancer of the liver, but suitable
cases must be excessively rare.
Primary cancer of the liver. — There is little doubt that many
cases formerly regai^led as instances of primary carcinoma of tlie liver
were examples of secondary deposit in that organ ; and I have therefore
examined ovu' recent records at Guy's Hospital, and shall only use for
the basis of this description cases in which a careful autopsy showed
that the growth was undoubtedly primary in the liver : I have excluded
all in which there was a deposit in any other organ, except that in one
or two a minute nodule was detected in the lung.
During the twen'.y-four years, 1870-1893, both inclusive, eleven such
cases have been seen in the post-mortem room, and about 1 1,500 post-mortem
examinations have been made. Therefore, less than 0"1 per cent of all
the persons who die in a large hospital succumb to primary carcinoma of
the liver. The proportion of imdoubted primary to secondary carcinoma of
the liver is about 1 to 25. During these twenty-foui- years there have lieen
seven cases in which the growth was by some regai"ded as primary in the
liver, although many other organs were affected ; l)Ut, inasmuch as the
primary seat of these cases must to some extent be a matter of con-
jecture, they have not been used as a basis for this account. Frerichs
gives the proportion of primary malignant disease of tlu; liver (without
growth elsewhere) to othei- cases of malignant disease of the liver as 1 to
5 ; but the post-mortem examinations of all his cases were made prior to
1861, and I tliink it probable that improved systematic methods of care-
ful search for the j)ri?nary seat, and the fact that Frerii-lis does not allude
to the possibility of the primary seat being in the gall-bladder or bile-
TUMOURS OF THE LIVER 205
ducts, will explain the difference between a proportion of 1 to 5 and 1
to 25.
There are three forms of primary cancer of the liver. In the most
common foim the new groAvth is deposited in nodules, and the whole
liver exactly resembles the organ when it is the seat of secondary deposits.
Out of the eleven cases from Guy's Hospital six fall into this group.
In another form the growth consists of one large tumour in the liver.
A very good instance in point is recorded by Bright in his memoirs on
abdominal tiimours. Here " the tumour within the liver was the size of
an adult's head and of rounded form." It Avas in the left lobe of tlie liver,
and many of the recorded cases have begun there. Schueppel states that
such a growth may destroy half the liver, that caseous degeneration and
haemorrhages in it are common, but that the portal glands are not often
enlarged. Among the eleven cases from Guy's there is none in which
there was a single large tumour ; but there were two in which one cancer-
ous mass was huge, and the rest were quite small ; so that these cases
perhaps belong more to this group than to the first.
In the third group the cancer cells are uniformly diffused through the
liver, and there is a great increase of fibrous tissue in all directions. This
often contracts, so that, although at first the liver is larger than normal,
later it may be smaller. Three out of the eleven Guy's cases were
considered by Dr. Fagge (4) to belong to this group, and the livers
weighed respectively 180, 62, and 36^ oz. In these cases the organ is
very hard, retains its shape, and looks like a coarse cirrhosis, the nodules
varying in size from a pea to a cherry. When cut it also resembles
cirrhosis, for there are wide, white, vascular bands of connective tissue
running through the organ, the gland tissue between them has vanished,
and, according to Schueppel, in an extreme case, every hepatic acinus
has been replaced by one of cancer. On scraping, some white fluid
may be obtained ; but Schueppel states that the retrogressive changes
hardly ever go farther than fatty degeneration of the cells, and hsemor-
rhage is never seen ; but in two of the three cases recorded by Dr. Fagge
some of the cancerous masses were cheesy and would shell out, and in
one case there Avas haemorrhage into them. The glands in the portal
fissure are rarely affected, the cancer hardly ever grows into the bile-
ducts, and only rarely into the portal vein ; but it has been described as
implicating the gall-bladder. Secondary groAvths in other parts of the
body are almost unknoAvn. We see, therefore, that this form of cancer
differs much from the common variety ; and this, together Avith the
naked eye and microscopical resemblance to cirrhosis, accounts for the
fact that some observers often regard a case as cirrhosis Avhich others
regard as primary infiltrated carcinoma.
The folloAAnng analysis of the chief points of the eleven cases we have
had at Guy's Hospital brings out the leading features of primary cancer
of the liver : —
Age. — The case of a boy aged twelve, recorded by Dr. Pye Smith (7),
had better be omitted from consideration here, because, judging by his ex-
2o6 SYSTEM OF MEDIC LYE
treme youth and the exceptionally long duration of the disease, it is prob-
able that his case was one of some extremely rare affection of the liver of
which we know little. In the remaining ten cases the oldest patient was
seventy-one years old, and the youngest twentj'^-three. Five were more than
fifty years old. Of seven cases (which, as sarcoma is so rare, we may assume
to have been mostly cancers) recorded in the Pathological Society's Transac-
tions from 1871 to 1891 in sufficient detail to be available, and not included
in the eleven ca:^es from Guy's Hospital, the oldest jiatient was sixty-
nine years, and the youngest thirty-three ; five were over fifty. We thus
see that it is a disease of adult life, and generally of old age — a fact which
is equally true of secondary cancer of the liver.
Scj: — Among the eleven Guy's Hospital cases, six were men and five
were women ; and among the seven cases of the Pathological Society two
were women and five were men ; so that among eighteen cases eleven
were men. This is interesting, as conlirming the assumption that these
were genuine cases of primary malignant disease of the liver ; for
we have seen that secondary hepatic cancer is commoner in women
than men.
Family history. — In none of the clinical reports of these eleven cases
is it said that any of the patients' relatives had cancer. It is very difficult
to obtain an accurate family history from hospital patients ; but as there
was no family history of cancer in any of the cases of primary malignant
disease of the liver recorded by IMurchison, the point is worthy of further
investigation.
Symptoms. — As might be expected, the patients are often wasted,
sometimes they vomit ; often there is constipation, but the stools are
never mentioned as being pale. If the jaundice be sufficient, a little bile
may be detected in the urine, which in two instances contained albumin.
Temperature. — In four cases the temperature ranged about 101° or
102°; in one, in spite of extreme collapse, it was 99°, and IMurchison
gives two cases of primary malignant disease with pyrexia ; it appears,
therefore, to be commoner when the disease is primary in the liver than
when it is secondary. If this should turn out to be the case, it may be
of some value as a means of diagnosis.
Jnnndice. — Out of the eleven Guy's cases, in five there was no
jaundice, in two it did not appear till just before death, in three it was
slight, and in one it was considerable. Among the seven cases of the Patho-
logical Society it is only mentioned as being present in four, and in one
of these it was slight. We may thus conclude that in primary malignant
disease of the liver jaundice may be absent all through the illness; if
present it is usually slight, and comes on late. We never meet with the
long-lastini' dark stainiuLC so common when the liver is aftected secondarily.
The explanation of this may be that, as the disease is rapidly fatal, there
is not time for jaundice to supervene. It cannot be entirely due to the
circumstance that the portal glands are rarely enlarged in primary carci-
noma of the liver, for in the only case in Avhich the jaundice was deep it
is expressly stated that the portal glands were normal. Probably the
TUMOURS OF THE LIVER 207
rarity of their enlargement is clue to the death of the patient before there
is time for infection of them to take place.
Ascites. — In seven of the eleven Guy's Hospital cases there was
ascites, and in most of these it was sufficient to be detected during life.
Among the seven cases of the Pathological Society ascites is only definitely
mentioned as being present during life in two ; and in one other a little
fluid was found at death. Probably we shall be near the mark if we say
that in about a third of the cases there is definite ascites capable of
detection during life. The growth often grew into and caused thrombosis
of the branches of the portal vein, and in some cases this may explain the
ascites.
Enlargement of Liver. — The liver, Avhich was usually painful and
tender, was always enlarged except in the instance in which it only
weighed 36i^ oz. I found that among fifteen cases of primary malignant
disease of the liver which are available, in the Guy's Hospital and the
Pathological Society's cases, for calculating the weight, the heaviest was
267 oz., the next 200 oz., and the least 36^ oz. The one of 200 oz. was
the exceptional case in the boy aged twelve, and the one weighing 267 oz.
is recorded as a case of sarcoma. If we exclude these two the average is
116 oz., or if we only exclude the boy it is 127 oz. The usual weight is
from 120 to 130 oz.
Prognosis. — Omitting, for the reasons already given, the case of the
child, I find that, after the first symptoni appeared, two patients lived
four months, three lived three months, one lived two and a half months,
two lived two months, and in one the duration could not be determined.
That gives, roughly speaking, an average duration of twelve weeks. It
is especially noteworthy that there are no wide limits of duration, so that
it may be safely said that primary malignant disease of the liver is usually
rapidly fatal ; thus forming a striking contrast to those cases in which the
organ is affected secondarily, and in Avhich the patient often lingers for a
long while. This conclusion is fully borne out by the cases recorded in
the Pathological Society's Transactions, for in the four in which it is
mentioned the duration was two, a half, three, and two months respectively.
It appears, therefore, that primary cancer of the liver resembles the
secondary form in many symptoms, but that the duration from the first
symptom probably never exceeds four months. Less important facts are
that it is probably commoner in men than in women, pyrexia is not
infrequent, jaundice is never deep olive green, is often abseiit, and if
present is usually slight, and the motions are rarely pale. The glands in
the portal fissure are not often enlarged.
In one case treated at Guy's Hospital disease of the liver was never
suspected. A woman aged thirty - nine was admitted for what Avas
regarded as the vomiting of pregnancy ; there was no jaundice, and
no one even thought of disease of the liver. Premature labour was
induced, but the woman sank. The post-mortem revealed the fact that
the liver was the seat of extensive malignant growth, but that all the
other organs of the body were absolutely normal. A case almost
2oS SYSTEM OF MEDICINE
parallel to this is recorded by Tivj', in -which, if the abdomen had not
been examined and the liver found to be enlarged, it would have been
impossible during life to sus})ect disease of this organ ; yet the man
quickly sank and died. To be quite accurate, I ought not to have used
the cases recorded, in the Pathological Society's Transactions, as sarcoma ;
but I have done so because primary sarcoma is very rare, and is clinicallj'^
indistinguishable from cancer. Frequently, moreover, there is nnich
vai-iance of opinion among histologists whether a primary growth be a
carcinoma or a sarcoma ; but all the eleven cases in Guy's Hospital were
regarded as carcinoma.
Perhaps this is the most suitable opportunity to call attention to the
fact that malignant disease occurs occasionally in a liver which is cirrhotic.
This happened in the last of the cases of primary malignant disease of the
liver which occurred at Guy's Hospital. The ])atient, a man aged forty-
nine, had drunk hard, and he was admitted under Dr. Goodhart in 1892
for ascites and right ])leural effusion. AVhen the ascitic fluid was drawn
off, a lump was felt in the hepatic region ; he was never jaundiced, and
he died three days after the paracentesis. The liver weighed 118 oz.,
and there was extreme cirrhosis in the parts unafl'ected by the growth,
Avhich formed a large mass in the right lobe together Avith smaller masses
scattered about in the rest of the liver. It was a spheroidal carcinoma.
Our museum contains the liver of this case, and also that of a man aged
sixty-eight, who was under Dr. Pye-Smith in 1891, and in whom at
death a spheroidal carcinoma was found in a cirrhosed liver. In 1885 I
made a post-mortem examination on a man aged sixty-three, also under
Dr. Goodhart. He had sarcoma of many bones. There was a secondary
growth in the liver which weighed 60 oz, and was very hard and cirrhosed.
Primary Carcinoma of the Gall-Bladder. — This is not nearly
so rare as was formerly supposed. Most authors agree that often it
owes its origin to gall-stones, which are present in 95 per cent of the
cases ; and this explains the fact that it is four times as common in
women as in men. Secondary deposits in the liver and in the glands in
the poi'tal fissure are very common, and therefore the symptoms are
much the same as those of secondary carcinoma of the liver, except that
in 68 per cent of the cases a definite tumour can be felt in the region of
the gall-bladder, and frequently there is a history of gall-stone colic.
Carcinoma of the gall-bladder often spreads by extension to the liver,
stomach, and colon. An excellent account of the record of the subject
is given by Ames (1).
Primary Carcinoma of the Pile-Ducts. — Our knowledge on this
subject has been recently put together by Dr. Rolleston (9). The growth
is nearly idways a cylindrical-celled carcinoma; and when it takes place
in the liile-ducts within the liver it is, until examined histologically, very
liable to be confounded M'ith pi-iniaiT carcinoma of the liver. When the
"lowth occurs in ducts outside the liver it thickens tlieir walls and fills
TUMOURS OF THE LIVER 209
their lumen Avitli shaggj^ growth. The gall-bhxdder and the ducts behind
the growth become very much distended. It is about equally common in
men and Avomen. The chief symptoms are deep jaundice, pain, and uniform
enlargement of the liver. Usually the organ contains but few secondary
nodules, and therefore they are not felt during life. It is obvious that
it is in these cases that cholecystenterostomy is most likely to aftbrd
temporary relief.
Sarcoma of the Liver. — This occurs in two forms, primary and
secondary. As has just been mentioned, the primary cannot be distin-
guished, clinically, from carcinoma, and after death it often happens that
it is a very dithcult matter to decide between them. I have known
different opinions given upon the same section. Its extreme rarity is
evident from the fact that none of the eleven cases of primary malignant
disease which I have quoted as found in the post-mortem room at Guy's
Hospital were sarcomatous. A primaiy sarcoma of the liver, which weighed
nearly 17 lbs., is recorded in the Pathological Society's Transactions.
Secondary sarcomas in tlie liver exactly reproduce the form of the
original growth. They are rarely diagnosed, for the patient usually dies
before they give rise to symptoms. In the years 1885-93 Ave haA'e had
six cases at Guy's Hospital. The primary seat Avas in the bones in five
cases ; the secondary groAvths Avere usually A'ery numerous in A^arious
parts of the body. In most of the cases there Avas a solitary growth in
the liver, and in one this Avas 2| inches in diameter. In one only Avere
the secondary growths \'ery numerous, and then they Avere small.
Pigment Tumours of the Liver. — These tumours, Avhich are either
sarcoma or carcinoma, form such striking objects that museums con-
tain many specimens. They only diff'er from the sarcomas and carci-
nomas, already described, in that the groAvth is coloured black or dark
broAvn; and under the microscope the cells of the tumours are seen to be of
a brown colour, and many contain abundant black j^igment granules.
Melanotic sarcoma is much more common than melanotic carcinoma, and
these sarcomas are almost ahvays secondary to a melanotic sarcoma either
in the eye or the skin. Many cases are on record : for instance, Bright
gives tAvo, in both of Avhich, from the presence of melanotic deposits in
the skin, a correct diagnosis was made. In both the liver Avas enormous.
The second case illustrated the usual form, for there Avere innumerable
melanotic nodular tumours in the liver. In the first case the melanotic
n&w groAvth Avas diffused uniformly throughout the liver. This diffuse
melanosis is A^ery rare, but is mentioned by Schueppel. In Eright's case
some non-melanotic secondaiy tumours were associated Avith this diffuse
melanosis ; and sometimes in the same case Ave find some of the secondary
nodules pigmented Avhile others are free. Often only one or tAvo melanotic
sarcomatous masses are found in the liver ; doubtless because the patient
died before others could form. We have a specimen in Guy's Museum
in which there Avas only one tumour. Sometimes, as in Dr. Murchison's
vol. IV p
2IO SYSTEM OF MEDICINE
case, altliough numerous, they are so sniall that they jDroduce no
symjitoms.
There are at least five cases of primarj'- melanotic sarcoma of the liver
on record : one by Frerichs, one by Block, one by l)cle})ine, one by A\'ick-
ham Legg, and one by Holsti (5). Block records his as an example
of endothelioma, but Schueppel thinks there is no douljt that it was
sarcomatous.
Melanotic carcinoma is excessively rare. I have, however, seen one
case. The only symptoms observed during life were progressive wasting
and uniform hepatic enlargement. The li\'cr weighed \22^ oz. I made
the post-mortem examination, and there is no doubt the growth was
primary in the liver. The case is described in fvdl (14). In Dek'pine's
case the tumour grew so rapidly that the patient positively gained
weight (3).
Pigmentary malignant disease has no separate clinical symptoms from
ordinary malignant disease ; so unless a primary melanotic tumour is
discovered during life it cannot be foretold that pigment will be found
in the hepatic growths, unless, on exposing the urine of such a
patient to the air, a brownish or blackish discoloration of it were to
appear (melanui'ia), Avhen a tolei'ably sure indication of the kind of
growth would be obtained.
Adenoma. — There is often considerable variety of opinion among his-
tologists as to the exact boundary-line between adenoma and carcinoma
of the liver ; in fact, some regard adenoma as merely a stepping-stone to
carcinoma. It would be well, as Coats suggests, to limit the word to the
form known as nodular hyperplasia ; for the other so-called adenomas
— as, for example, Greenfield's case (11) — have more the habit of
cancer. Restricting the name in this way, we may descrilie adenomas
as perfectly well-defined tumours having the same structure as proper
hepatic tissue, except that the cells are a little larger than is usual, and
often have double nuclei, and there may be an increase of fibrous tissue
between them. If large, the tumours are solitary, and we have a
specimen in our museum in which a globular mass Ijinch in diameter pro-
truded from the surface of the liver. It consists, histologically, of
normal liver tissue, except that there is an excess of fibrous tissue. The
patient was twenty-six years old ; he dicn^l of strangulated hernia. If the
tumours are small, they are multiple and sharply defined. They are
rare in man, but common in dogs. Sometimes an excess of fibrous
tissue surrounds them. These innocent adenomas never give rise to
symptoms during life.
Li/mphadenoma. — New formations consisting of lymphoid tissue, either
generally dilTused through the liver or occurring as nodules, arc not
uncommon ; but they are only met with in Hodgkin's disease or in
leuchccmia, and then form but a part of a widespread foi'mation of lymphoid
tissue.
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 211
Cavernous angioma of the liver is common, but produces no symptoms
during life. Murchison refers to a case of myxoma and to one of
cystosarcoma, but these are too rare to be of any clinical interest.
Cysts of the liver, not hydatid, are so exceptional, so infrequently give
rise to any symptoms during life, and are so obscure in their mode of
origin, that the discussion of them would be out of place here. They
are very fully considered in the following papers, in which also references
on the subject will be found (8, 10, 11, 1.3). MiixUte fibromas are occasion-
ally found in the liver in the post-mortem room, but they do not cause
any symptoms.
W. Hale White.
REFERENCES
1. Ames. Johns Hopkins Hospital Bulletin, \.'^o.A\. — 2. Block. Arch. d. Heilk,
xiv. 1875, S. 412. — 3. Del^pink. Trans. Path. Soc. Land. xlii. p. 161. — 4. Facge.
Path. Trans, vol. xxxi. p. 125. — 5. Holsti. Brit. Med. Joxir. Epit. May 25, 1895. —
6. Legg, WiCKHAM. St. Barth. Hasp. Pep. xiii. ]). 160. — 7. Pye-Smith. Path. Trans.
xxxi. p. 125.— S. Ibid, xxxii. p. 112.— 9. Rolleston. Med. Chron. Jan. 1896.— IQ.
Savage and Hale White. Path. Trans, xxxiv. p. 1. — 11. Sharkey. Path. Trans.
xxxiii. p. 168. — 12. Tivy. Pat.lb. Trans, vol. xxv. — 13. Hale White. Path. Trans.
XXXV. p. 217. — 14. Ibid. vol. xxxvii. p. 272.
W. H. W.
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS
Introductory and general remarks. — Until quite recently diseases
of the gall-bladder and bile-ducts could be adecpately considered with
diseases of the liver ; but the general advance of medicine, and its closer
alliance with surgery, have given to these affections a place of their own
in medical literature.
Before the last decade the ailments in question were studied from
a purely medical standpoint — the standpoint still in the earlier stages
of all cases, and throughout the entire course of many ; but in no cases
have the recent advances in surgery brought about such an enlargement
of our resources, nor in any have the physician and surgeon been able to
combine their forces to better effect. Yet even now we must not feel
altogether satisfied ; much still remains to be done in this field of work,
not only from the pathological point of view and in the perfecting of
diagnosis, but also in effecting a more scientific and direct therapeusis, in
perfecting the older methods, and possibly in inventing more complete and
thorough surgical procedures.
I propose to consider the subject under three heads: — (i.) Inflam-
matory affections of the gall-bladder and bile-ducts; (ii.) Tumours;
(iii.) Gall-stones.
212 system of medicine
Inflammatoiiy affections of the gall-bladder and bile-ducts.
— These may conveniently be considered under the following divisions :
— A. Catarrhal inrtammations : {a) Acute catarrh (Catarrhal jaundice) ;
{b) Chronic catarrh. 13. Suppurati\e intlannnations : («) Suppurative
catarrh : (a) Simple empyema, (/?) Suppurative cholangitis ; {h) Ulcera-
tion, perforation and stricture of the gall-bladder and bile-ducts; (r)
Acute parenchymatous iiiHanuuatiou and gaiigixMic of the gall-bladder.
Catarrh of the gall-bladder and bile -duets. — The larger bile-
ducts and the gall-])ladder, being lined with mucous membrane having a
cylindrical epithelium and ordinary racemose glands, like other mucous
passages, are subject to catarrh which may be acute or chronic.
Acufe catiirrh is supposed to give rise to that evanescent form of
icterus, known as catarrhal jaundice, which more frequently occurs in
young persons, usually comes on as a sequence of dyspepsia or as a result
of exposure to cold, and is ordinarily unaccompanied hy pain or serious
illness ; medical help is sought on account of the marked objective
symptom of jaundice.
When it is borne in mind that the bile-ducts have a small calibre,
that the mucous lining is ca23able of swelling, and that the secretion of
bile takes place under very low pressure, it is easy to suppose that
catarrh in this situation may lead to jaundice, though absolute proof
of this causation is wanting ; simple catarrhal jaundice furnishes no
necropsies. Fagge, indeed, doubted that catarrh of the bile-ducts gives
rise to swelling of the mucous membi'ane. He says : " A more probable
suggestion is that catarrh of the duodenum obstructs the oblique and
narrow passage of the duct through the walls of the gut." If so, we may
ask why jaundice does not more commonly follow what is probably a
frequent disorder. Moreover, we should exj^ect a chronic catarrh to
produce permanent jaundice.
The usual cause of acute catarrhal jaundice is probably an extension
of inflammation from the duodenum; and as the common bile-duct
traverses the walls of the duodenum very obliquely, this narrow terminal
portion of the duct is i;sually the seat of the primary obstruction.
Beside gastro- intestinal catarrh, cxposiu-e to cold, extension to the
bile-ducts of inflammation from the parenchyma of the liver, carcinoma
of the liver, gall-stones, hydatids, pneumonia, and other acute inflannna-
tions and infectious fevers must be mentioned as causes of catarrh, direct
or indirect. Murchison gives gout and syphilis as causes, and under
this head Fagge includes jaixndice due to fright and that occurring
in epidemics. Although it is well known that in cancer of the liver
jaundice is a very variable sign, it is not always recognised that the
icterus is at times dependent on an associated catarrh which may be
relieved by treatment, though the original disease persists and pro-
gresses. The same remarks apjjly with almost equal force to nuiltilocular
hydatids.
The .symptoms of acute catarrh of the bile -ducts (catarrhal
jaundice) may be so slight that the patient may know nothing of his
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 213
condition until he is told that he is yellow ; but ordinarily symptoms
of gastro-intestinal disturbances — such as coated tongue, bad taste, eructa-
tions, want of appetite, nausea and sickness — precede the jaundice.
According to the duration of the jaundice so will be the interference
with health and with the general nutrition of the patient.
Enlargement of the liver or of the gall-bladder is not seen in
ordinary slight cases ; but, if the affection be prolonged, the liver may
be swollen and the gall-l)ladder somewhat enlarged. Under ordinary
circumstances the symptoms pass off in two to six weeks, and the patient
may feel quite well some time before the jaundice has quite disappeared.
In other cases, especially if carelessly treated, the disease may drag
on for weeks or months, the liver enlarging and considerable emaciation
taking place, so that the question of serious organic disease has to be
considered.
Where, however, the symptoms depend on simple catarrh, recovery
usually takes place under proper management; but if the acute catarrh
complicates some other disease, the symptoms will depend on the cause,
and may be both serious and persistent.
Though other symptoms may be almost absent, catarrhal jaundice
always demands the most careful consideration, lest the case turn out
to be one of acute atrophy of the liver ; which, however, is fortunately
an extremely rare disease. The absence of serious symptoms (especially
of delirium and rapid pulse) and the usually speedy recovery under treat-
ment are, as a rule, sufficient to enable a diagnosis to be made ; but, as Dr.
Donkin pointed out in reporting a case of malignant jaundice in a child two
years of age, " a practical lesson to be learned from such cases is to be very
guarded in the prognosis of all so-called and apparent cases of ' simple ' or
' congestive ' or ' catarrhal ' jaundice in children, when the jaundice does not
abate within a week, and still more when it increases " (11). The absence
of pain and of the preceding characteristic gall stone attacks will ordinarily
distinguish simple catarrh from that accompanying cholelithiasis. More-
over, the jaundice in gall-stones usually passes off rapidly, or, if persistent,
is generally intensified after pain, and is often associated with ague-like
seizures. In cancer, catarrh of the bile-ducts is probably the chief cause
of the jaundice ; l)ut loss of flesh, ascites, and nodules or tumour of the
liver usually afford sufiicient data for diagnosis.
In cirrhosis, the slighter degree of jaundice, the usually more advanced
age, the previous history of drunken habits, and the ascites, together with
the generally more serious symptoms and the physical examination of the
liver, afford in nearly all cases sufficient help to prevent mistakes. As a
rule it may be said that jaundice in a young person coming on without
pain, or any apparent cause except disordered digestion, is most probably
catarrhal.
As catarrh of the bile -ducts is generally an extension of duodenal
catarrh, abstinence from alcohol, a light simple diet, and mild saline
aperients are indicated. If other medicine be thought necessary, a simple
rhubarb and soda mixture will answer well. Half a pint, or a pint, of
314 S YSTEM OF ME DICINE
the natural Carlsbad water, taken warm the first thing in the morning, is
often of service as an aperient ; if this be insufficient, a teaspoonful of
Carlsbad salts can be added, or these salts may be taken in ])lain hot
water. As a rule the patient need not be put to bed, but he should be
warmly clothed and avoid chills.
If the cause be chill, a warm bath with hot applications over the liver
and a diaphoretic medicine will be advisable. Salicylate of soda is said
to be of service. As in jaundice the bile is principally excreted by the
kidneys, it is important to maintain their action by diluent di'inks and by
other diuretics if required.
When the jaundice is long continued, the administration of oxgall
may assist the assimilation of fats ; and creasote may prove of service as
an intestinal antiseptic.
Rectal injections of hot water, from one to two joints daily, at a
temperature of from 60° to 90°, to be retained as long as possible, are
said to prove beneficial by causing a contraction of the gall-bladder which
may overcome obstruction due to accumulation of mucus in the common
duct.
Chronk catarrh of the gall-bladder without jaundice forms a distinct
and definite disease ; and I have seen several cases in which careful
observers had diagnosed cholelithiasis and had recommended operation,
but in which neither the gall-bladder nor ducts contained anj^thing firmer
than thick ropy mucus, Avhich seemed to be the cause of the painful
contractions of the gall-bladder simulating gall-stone colic. In one case
of this kind, in a lady of fifty-six on whom I operated, the gall-bladder
contained 1)ile mixed with thick mucus which formed i^lugs something like,
small grains of boiled sago. There were no other signs of disease, but
the gall-bladder was very large and pouched and its mucous membrane
thickened. The gall-bladder Avas drained, and it was kept open for a
fortnight ; the Avound was then allowed to close. The joatient continues
well, and is freed from her formerly frequent attacks.
Although in these cases the gall-bladder is usually distended it rarely
forms a distinct tumour, and there is an absence of pain on pressure over
it. Unless gall-stones have been present at some time there are usually
no adhesions of the gall-bladder or ducts to the neighbouring viscera.
This proves that the inflammation has not penetrated to the peritoneal
coat, as usually it does when dependent on gall-stones.
This catarrh ma}' be the sequence of gall-stone irritation ; but in other
cases it is pr^iljably due to the dependent position of the fundus of the
gall-bladder, or to chronic constipation and accumulation of f feces in the
hepatic flexure of the colon interfering Avith the regular emptying of the
gall-bladder.
The diaijnosis of this affection from cholelithiasis mav usuallv be
made by observing that the attacks are less severe and less prolonged
than in gall-stone colic; that no gall-stones are found in the evacua-
tions after an attack ; that jaundice seldom su])ervenes, or if it do
is only veiy slight ; that there is no tenderness on pressure between
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 215
the ninLli costal cartilage and the iimoilicus, and that the affection, as a
rule, will yield completely to treatment. Should medical treatment fail
to give relief, it may be difficult to distinguish chronic catarrh of the gall-
bladder from cholelithiasis ; but if, under the belief that the case is one
of gall-stones, the gall-bladder be exposed and no concretions found,
drainage of the gall-bladder will probaljly effect a cure.
Chronic catarrh of the bile-duets may be simply a sequel of the acute
form ; it may then give rise to a more or less persistent jaundice leading
to a suspicion of more serious organic disease. Although dyspeptic
symptoms are present, due to the associated gastro-intestinal catarrh and
jaundice, and some loss of weight, yet the retention of bodily strength,
and the absence of such serious sequels as ascites, hsemorrhages, and so
forth, generally suggest a good prognosis ; moreover, the symptoms
usually yield to proper treatment.
Catarrh of the bile-ducts probably always accompanies jaundice from
whatever cause ; and, as Dr. Moxon has pointed out, when an obstruction
in the common duct is complete, a colourless mucus is always found
in the bile-duct. A search through the pathological records of Guy's
Hospital for twenty years failed to discover any exception to this rule.
When the oljstruction is partial the mucus may be charged with bile, as
the backward pressure is not sufficient to stop the secretion and the
pouring out of bile into the ducts.
As a concomitant of cancer of the liver and of the l^ile-ducts chronic
catarrh is common, and is frequently the cause of the accompanying
icterus. Thus the relief to the jaundice afforded by treatment in a
necessarily fatal disease is accounted for ; whereas when the jaundice is
dependent on pressure of the growths on the ducts, it will be slightly or
not at all influenced by remedies.
The same remarks apply to the effects of hydatids, of abscess, and of
other organic diseases of the liver.
Gall-stones are probably always accompanied by catarrh and by the
formation of thick, ropy mucus which, as it passes, sets up attacks of
pain ; and it seems not unlikely that some minor seizures of pain,
followed by little or no jaundice, are of this nature — in which case, of
course, no gall-stones Avill be found in the evacuations.
Chronic catarrhal jaundice needs practically the same treatment as the
acute form : careful dieting, regular exercise, a saline aperient in the
morning, and an alkaline medicine, being the chief means required. In
case the disease prove obstinate, treatment at Carlsbad or Harrogate will
probably be of service.
Should the catarrh depend on organic disease, the treatment may
require some modification to meet the special features of the case.
In chronic catarrh of the gall-bladder, regular exercise, massage over
the hepatic region, the avoidance of anything tight round the waist
(which will increase the dependence of the fundus of the gall bladder),
careful regulation of the diet, and the judicious employment of saline
aperients, should in all cases be recommended.
21 6 SYSTEM OF MEDICINE
A tumblerful of the natural Carlsbad water, with a little hot water,
taken before breakfast each morning ; and every other morning, in
addition, a dose of Carlsbad salts, or of sulphate of magnesia, are un-
doubtedly useful ; as is also an alkaline tonic dose containing soda and
nux vomica taken before lunch and dinner.
The spasmodic attacks may require the administration of a sedative :
if slight, a grain of exalgine in hot water, repeated in half an hour, will
often relieve the pain ; or twenty drops of spirit of ether in half an
ounce of chloroform Avater, the dose to be repeated every fifteen mimites
until relief is obtained. The application of hot fomentations, and the
administration internally of a })int of hot Avater, will at times affbid
efficient relief ; but in some cases nothing short of a subcutaneous in-
jection of morphia will suffice. If, after a few weeks of general treat-
ment, the symptoms are not relieved, the disoixlcr will prol)ab]y be
attributed to gall-stones, and operative treatment will be considered.
If the gall-bladder and ducts be found free from gall-stones, chole-
cystotomy and di-ainage should nevertheless be performed ; and it will
be found useful after the third day to syringe a little warm water
gently through the drainage-tube daily so as to wash out the ducts;
after a week or ten days the tube may be left out, and the wound
allowed to close.
General treatment directed to the causes should be contini;ed for
some time afterwards.
Suppurative inflammation of the bile passages. — At first sight
suppurative inflammation of the gall-bladder and bile- ducts woidd seem
to be capable of description in small compass and under one heading ;
but the sul)ject is by no means as simple as it would appear.
For instance, simple empyema or su])purative catarrh of the gall-
bladder, which is closely allied to su])purative cholangitis, differs alto-
gether from phlegmonous cholecystitis ; this latter, however, is also
associated with pus in the gall-bladder, and may thus quite properly be
called an empyema. Phlegmonous cholecystitis, however, if not operated
on expeditiously, is one of the most fatal of diseases, as not only is
there a tendency to gangrene, but also to a rapidly-spreading and lethal
form of peritonitis. The different clinical characters of suppurative
inflammation can probal)ly be accounted for by the presence or absence
of certain organisms ; and although the bacteriology of this region is
still in its infancy, sufficient good work has been done to make a review
of it well worth our consideration. It has l)een su])posed that the bile
is an antiseptic fluid which tends to prevent decomposition in the ali-
mentary canal ; but in a series of observations which I published some
years ago on a case of biliary fistida (31), I found that the absence of bile
from the intestine of a woman duiing a ])eiiod of fifteen months did
not lead to any irregular fermentative process ; the alleged antisejttic
effect of bile on the fieces is, therefore, probably imaginary. Normal
bile is, however, generally steiile : this was proved by Netter in 1884,
who experimented on dogs; and the fact has been confirmed by Gilbert
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 217
and Girode, and, later, by Naunyn, who found it sterile in two cases
within a few hours of death.
In a case of mucous fistula, due to stricture of the cystic duct, the
constantly clean ajipearance of the edges of the fistula suggested to me
that the fluid secreted by the gall-bladder might possess antiseptic
properties ; moreover, when collecting the fluid for experimental pur-
poses, I found I could leave the flasks exposed to the air for several
days without any apparent change, an observ^ation which strengthened
the presumption. Professor Birch, to whom I supplied some of this
fluid, performed numerous cultivation experiments, and came to the
conclusion that its antiseptic properties were but slight, the Avant of
change being probably due to poverty of the fluid in nutrient
materials (3).
When, however, the flow of bile from the cystic duct is arrested,
micro-organisms often enter the gall-bladder; and Charcot and Gom-
bault, after ligaturing the common duct in dogs, demonstrated the
presence of organisms Avithin the gall-bladder.
This observation Avas confirmed by Netter, Avho found that tAventy-four
hours after aseptic ligature of the common duct in dogs, organisms — a
staphylococcus and B. culi communis — could be cultivated from the bile.
. The B. coli communis is said to be the most abundant and most
frequent of the bacteria found in the healthy man. It has been demon-
strated in every part of the alimentary canal, from the mouth to the
anus. It varies greatly in its virulence, and in experiments on animals
it appears to be harmless Avhen taken from the normal intestines. If,
however, the intestine, or its diverticula, become the seat of a morbid
process, then the bacillus becomes Adrulent. At one time, as shown
by Escherich, it may act as an ordinary pyogenetic oi'ganism pro-
ducing local abscesses ; at another as an active pathogenetic organism
producing fatal septicaemia.
In simple catarrhal empyema of the gall-bladder, organisms are not
necessarily present ; for instance, in a case in Avhich 1 recently oper-
ated, Avhere a tumour of the gall-bladder had been present for a year,
and from Avhich I removed sixteen gall-stones and two ounces of thick
muco-pus. Dr. Buchanan and I failed to discover any organisms. In this
case the walls of the gall-bladder Avere not thickened, and the serous
coat Avas free from inflammation. Moreover, there Avere no adhesions
except over the cystic duct, where the largest gall-stone had been
impacted. On the other hand, Mr. C. B. Lockwood found streptococci
and other organisms (but no amoebse coli) in an empyema of the gall-
bladder.
In acute or phlegmonous cholecystitis the Avails of the gall-bladder
are SAvollen and oedematous, and they may be infiltrated with pus.
In three out of five of such cases Naunyn found the B. coli communis in
the pus. Bonnecken in 1890 demonstrated these organisms in the sac
of a strangulated hernia, although there Avas no perforation. Barbacci
has also shown that peritoneal sepsis may occur without perforation of
I
2i8 SYSTEM OF MEDICINE
the gilt. Though there be no perforation, the spread of infection
through the walls of the gall-bladder may occur in these cases, as may
virulent peritonitis. Gilbert and Girode found t3-plioid bacilli in the
pus from a case of emjn'ema of the gall-bladilcr -which came on as a
sequence of enteric fever. Gilbert and Dominici also assert that they
produced suppuration in the gall-bladder and liver of rabbits by injeci-
ing a culture of typhoid bacilli into the common duct. These bio-
logical facts are borne out by the clinical observations of Dr. Murchison
and Dr. Hale "White, who found eviilence of inflammation and ulceration
of the biliary passages in ■\vell-markcd and fatal cases of typhoid fever.
From the foregoing observations it Avould seem that though the
bile-channels and their contents, under ordinary conditions, are free
from organisms, their proximity to the intestinal canal, where bacteria
abound, renders them liable to invasion ; infection does not occiu",
however, when the organs are healthy, but only under some abnormal
condition such as gall-stone obstruction or typhoid ulceration.
Suppurative catarrh of the gall-bladder and bile-duets. — In the
greater number of cases, both of simple empyema of the gall-bladder
and of suppurative cholangitis, gall-stones are the primary cause ; but
hydatid disease and cancer of the ducts may also dispose to suj)purative
inflammation.
Suppuratice catarrh of the bile-tracts must always be a serious affair ;
though simple catarrhal empyema of the gall-ljladder alone, due to
obstruction in the cystic duct, is of much less serious import than when
it is associated with suppuration of the ducts within the liver.
In catarrhal empijema of the gall-bladder, without invasion of the
hepatic ducts, the symptoms will depend on the cause ; but, as this is
in nearly all cases cholelithiasis, there will be the usual history of gall-
stone attacks, followed by a swelling under the liver and by a continued
instead of an intermittent pain.
Tenderness is nearly always present in consequence of the local
adhesive peritonitis, which is rarely absent.
The tumour, if seen at an early stage, will descend with the liver
on respiration, and will be palpable as a rounded swelling. After a
time the swelling may become more diffused and general, and the
movements during respiration will be less marked, or may cease if the
inflammation extend to the abdominal walls. If the suppuration extend
beyond the gall-bladder the pus may make its Avay through the
parietes, and an abscess may form either under the ribs or at the
umbilicus. For the description of the physical signs see the sections
on Tumours of the Gall-bladder (p. 226).
At first the constitutional symptoms may be but slightly marked,
and there may be no increase of temperature ; though in some cases
from the begiiming, and in others in the later stages, rigors or chills
with fever may point to the formation of pus.
The patient may be driven to bed at an early stage on account of
the pain on movement. The loss of appetite and the fever lead to loss
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 2ig
of flesh and weight, and yet the case may go on for several Aveeks, or
even months, before relief by 02:)eration is sought.
In suppurative cholangitis there is progressive enlargement of the
whole liver, which may descend as low as the umbilicus ; the swelling
being uniform, smooth and tender on pressure! If the cause be in the
common duct, and the gall-bladder has not iireviously become con-
tracted, there will be the additional enlargement caused by its dis-
tension ; but when contraction has taken place, as also "when the
obstruction is in the hepatic duct, there will be an absence of the
signs of empyema of the gall - bladder. Pain may be absent, as in
one case, on which I operated, Avhere the disease Avas dependent on
cancer of the common duct ; but where it is dependent on gall-stones
the pain may be scA^ere and paroxysmal, each attack being accom-
panied by ague-like seizures and an intensification of the jaundice.
Jaundice is ahvays present, and is both persistent and intense.
Continued fever, with occasional rigors and profuse perspiration, is a
feature of the disease, and Avith it rapid loss of flesh and strength.
Pneumonia or pleural empyema not infrequently supervenes. Although
the disease often proves fatal, recoA'ery may occiu" if the cause can be
removed at a suSiciently early stage.
In a case of suppurative cholangitis, dependent on cancer of the
common bile-duct, AA^hich proved fatal in the Leeds Infirmary, the bile-
ducts throughout the Avhole of the liver Avere found full of pus, the riain
channels being considerably dilated. If the disease be less acute, the
inflammation concentrating itself in some parts of the liver may lead
to abscess, Avhich may form a distinct tender swelling and give rise to
the usual symptoms and signs of hepatic abscess. For a full account of
cholangitis the reader is referred to p. 2 1^9.
The treatment of simple empyema of the gall-bladder is almost
purely surgical : it consists in evacuating the pus, draining the gall-
bladder, and removing the cause if this be possible. If the patient
be very ill the operator may have to rest content Avith cholecystotomy
and drainage, leaAn'ng the obstruction to be dealt Avith afterAvards. If
the case be seen at an early stage, the cause, if removable, should be
dealt AA'ith at once. The operation yields excellent results, and I can
point to a number of patients thus treated Avho are noAv quite Avell.
Even in suppurative cholangitis, Avith distended gall-bladder, chole-
cystotomy should be performed and free drainage established. Although
good results cannot be expected in all cases, an amelioration of the
symptoms may be looked for in a fair proportion, and in others complete
relief.
If a localised abscess be discovered in the liver it should be opened
and drained ; and though it is scarcely to be expected that the results of
operation can be brilliant in these otherAvise almost hopeless cases, yet
the chance of permanent benefit is Avorth snatching at.
Of general means, AA^arm applications to the hepatic region, an initial
mercurial purge folloAved by milder laxatives if required, intestinal anti-
220 SYSTEM OF MEDICINE
sepsis hv hismuth and siilol, the relief of pain, if called for, In' sedatives,
and the treatment of other symptoms as they arise, ■VA'ill afford some
amelioration, though the relief will probably be only temporary.
Ulceration, perforation, fistula, and stricture. — These pathological
conditions may conveniently be considered together, as they usually,
though not constantly, own one origin, namely, gall-stones ; moreover,
perforation, fistula, and stricture are all accompanied or preceded by
ulceration.
Ulceration of the gall-bladder and bile-ducts is found to be present in
many though not in all cases where a gall-stone is impacted ; and it may
help to explain the ague-like attacks which are present in some cases of
cholelithiasis and absent from others. Ulceration is generally found also
whore gall-stones have led to empyema of the gall-bladder or to supi)urative
cholangitis. The ulcers may be quite superficial, mere abrasions of the
epithelial lining, or they may be deeper, extending into or through the
other coats. Ulceration is, however, chiefly important from its effects
— perforation, fistula, or stricture. Ulceration, or even perforation of the
gall-bladder or bile-ducts, may occur independently of gall-stones.
Dr. Hale White (38) described a fatal case of enteric fever in a boy of
seventeen, in Avhich there Avere, besides the usual signs of the fever in the
intestine, suppuration and ulceration in the gall-bladder ; there was no
obstruction to the passage of bile. In some places the walls of the gall-
bladder were very thin and almost perforated. Murchison, in his Avork
on the Continued Fevers, says : " The lining membrane of the gall-
bladder is very liable to become inflamed in enteric fever without pro-
ducing very marked symptoms during life" ; later, he refers to a case of
death from perforating ulcer of the gall-bladder in a youth aged nineteen
on the fifteenth day of typhoid fever.
Perforation of the bile passages is not uncommon, but general
peritonitis from this cause is rare ; as the ulcer advances, extravasation
is prevented by adhesive peritonitis.
General suppurative peritonitis from this cause does, however,
occasionally occur, leading to a sudden peritoneal catastroj^he and, as a
rule, to a speedily fatal termination.
In cases of rupture of the gall-bladder from straining, as in cases
reported by Dr. \\'illards (39) and by Mr. Lake (20), there was in all
probability some previous disease, such as ulceration, leading to thinning
and weakening of the walls of the gall-bladdex', and disposing to rupture
from slight causes.
Dr. George P. Biggs reports a fatal case of perforating ulcer in
a woman who had suttered a month previously from gall-stone colic.
The onset was sudden, and was accompanied by cramp-like ])aiMS in the
upper al)domen, which were rapidly followed by .signs of acute general
peritonitis. She died on the fourth day of illness. At the autopsy
the abdomen Avas found greatly distended and full of a dark brown,
bile-stained fluid having a slightly faecal odour ; the peritoneum was
covered with fibrinous exudation. Just inside the orifice of the common
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 221
bile-duct a large gall-stone was imjDacted, and at the junction of the gall-
bladder and cystic duct a minute oblique perforation was found in the
floor of an old ulcer. The cystic, hepatic, and common ducts were all
much dilated, the latter admitting a cylinder one centimetre in diameter.
The muscular w;dl of the gall-bladder was hypertrophied, and the mucous
membrane thickened from chronic inflammation ; near the outlet there
was superficial ulceration.
If perforation be recognised and operated on at once, recovery is
possible — as in the case of a man aged forty-five, Avhom I saw with Dr.
Braithwaite of Leeds, and who, after symptoms of inflammation in the
hepatic region extending over several weeks, suddenly became worse and
showed signs of general peritonitis. I opened the abdomen in the right
linea-semilunaris and evacuated several pints of bile and pus. The
abdomen was washed out, and drainage-tubes were passed, between the
liver and diaphragm, into the right kidney pouch and downwards towards
the pelvis ; the patient recovered and is now in perfect health.
One of the most remarkable cases of perforation of the gall-bladder
following typhoid ulceration, successfully treated by abdominal section,
is reported by Dr. Monnier AVilliams and Mr. JMarmaduke Sheild (40). The
case occurred in a married women, aged thirty-one, who was treated by
operation on the fifty-first day of the disease ; the gall-bladder was then
found to be rigid, thickened, and of a dark plum colour, with a sharply
circular sloughy ulcer, the size of a threepenny jDiece, near its neck ; the
gall-ljladder contained about one and a half ounce of thick offensive pus ;
the abdomen was washed out, the distended intestines were emptied by
puncture, and gauze -packing with drainage was adopted: a complete
cui'e was the result. There seems to be a question Avhether the case were
not one of phlegmonous cholecystitis from the first, but there can be no
question as to the brilliant success of the treatment.
In the greater number of cases perforation occurs slowly, as in a case
of a feeble, aged woman whom I saw with Dr. Chad wick of Leeds a
few days before her death. Jaundice had been present for five years,
and at the necropsy a large gall-stone was found lying in a cavity out-
side of the common duct, but pressing on it. The cavity was shut off
from the general peritoneal cavity by adhesion of the neighbouring
viscera.
In some cases, as in one reported by Mr. Norton, the primary per-
foration may lead to the formation of a second cavity bounded by
plastic lymph, which in its turn may rupture and lead to fatal peri-
tonitis. The following is a brief account of the post-mortem appearance
in the case referred to ; the patient was a woman of sixty : — " The
body was Avell nourished, the abdomen was distended, and on open-
ing it much orange-coloured fluid escaped, and general recent adhesive
peritonitis was discovered. Just Ijelow the liver was a cavity the size of
an orange, bounded above by the under surface of the liver, and in front
by the thin margin of the liver and the omentum which had been
adherent to it. Below, it was separated from the colon by much
222 SYSTEM OF MEDICINE
thickened tissue. On its inner side lay the omentum, and on its outer
side, covered by adhesions between the liver and adjacent parts, lay the
gall-bladder, which ojjcned^into the cavity by an aperture Avhich would
admit one or two fingers. The Avail of the gall-bladder was much
thickened, and several stones half an inch in diameter were found lying
in it. Whore the omentum had before been adherent to the antei'ior
edge of the liver, forming the anterior wall of the cavity, it had become
detached, and thus the bile had escaped into the peritoneum and set up
fatal peritonitis. Xo doubt at one time the gall-bladder, containing gall-
stones, had perforated under these surrounding adhesions, and thus the
secondary gall-liladder had been formed Avhich in its turn had finally
ruptured into the peritoneum. The old gall-bladder AA'as not dilated to
any extent.'
In several cases I have seen a large gall-stone ulcerate its way quietly,
almost without symptoms, into the duodenum or colon, and produce no
distress until in the intestinal canal, Avhen all the symjitoms of acute
intestinal obstruction were produced. Itarely gall-stones have ulcerated
their way into the pelvis of the right kidney and set up symptoms
of renal stone. Where adhesions form between the gall-bladder and
the parietes an abscess may form in the abdominal Avail, either over the
region of the gall-bladder, at the umbilicus or elscAvhere, Avhich, on being
opened, discharges pus and gall-stones, and leaves a fistula Avhieh, Avithout
further treatment, may become permanent, and discharge mucus or muco-
pus or bile ; sometimes such a fistula may close spontaneously if the
obstruction have passed aAA^ay. Contrary to Avhat one might suppose,
fistulas betAveen the bile passages and other holloAv viscera in the majority
of cases close spontaneously, leaving A'isceral adhesions : thus the fistulas
are but rarely found post-mortem.
A fistula may at times open the AA'ay to septic absorption and to death
from septic complications. Mucous fistulas are occasionally seen after the
operation of cholecystotomy Avhere the obstruction in the cystic duct has
not been overcome, or Avhere that duct is the seat of stricture. In one
case of this kind Avith Avhich I am acquainted, the patient has so little
inconvenience that she does not think it Avorth Avhile to undergo any
further treatment. In two other cases of mucous fistula dependent on
stricture of the cystic duct I removed the gall-bladder, cfi'ecting thereby
a complete and permanent cure.
Biliary fistula may also continue after cholecystotomy Avhere the
common duct is strictured, or Avhere the obstruction is permanent, or has
not been removed. In tAvo cases of this kind, dependent on stricture, I
connected the gall-bladder to the intestine by means of decalcified bobbins,
and then closed the external Avound ; thus the fistula Avas cured and the
flow of bile restored to the bowel : both jjatients are noAV in very good
health.
Stricture is probably ahvays the result of ulceration due to gall-stones,
and may not manifest itself mitil the original cause has passed away.
If in the cy.stic duct, it leads to a gradual and almost painless disten-
DISEASES OF THE GALL-BLADDER AND BILE- DUCTS 223
sion of the gall-bladder ; if in tlie hepatic duct, to a gradual increasing
jaundice with enlargement of the liver, but without distension of the
gall-bladder ; if in the common duct, to jaundice, enlargement of the
liver and distended gall-bladder ; though if the stricture have been
caused by gall-stones in the common duct the gall-bladder may be con-
tracted. In one such case (not yet reported), in which I recently
operated, the history of gall-stones had extended over a period of eighteen
years, and for three years there had been persistent jaundice dependent
on stricture of the common bile-duct.
The first and last events are not very uncommon, as .will lie gathered
from the foregoing remarks ; but stricture of the hepatic duct is probably
very rare, though a fatal case was lately reported.
A form of stricture not commonh' described, but which may be found
occasionally, is one in the middle of the gall-bladder producing an hour-
glass contraction of that ordinarily pear-shaped cavity : in one case I
found the upper cavity separated from the lower by a stricture apparently
impermeable ; both cavities contained gall-stones Avhich were successfully
removed.
Needless to say, stricture of the bile passages will scarcely call for
diagnosis apart from its cause ; though different treatment Avill be
demanded when the disease is recognised at the time of operation.
In stricture of the cystic duct the gall-bladder should be removed,
otherAvise the symptoms will recur Avhen the wound closes, or there will
be a permanent mucous fistula.
As an alternative, the gall-bladder may be " short-circuited " into the
intestine, as in the remarkable case reported by Mr. Swain (34). In
stricture of the common duct cholecystenterostomy must be performed,
not a simple cholecystotomy ; otherwise a permanent biliary fistula will
certainly be formed.
Acute phlegmonous cholecystitis and Gangrene. — Acute or phleg-
monous inflammation of the gall-bladder was described by Courvoisier in
1890 under the name of acute progressive empyema of the gall-bladder;
and he stated that it usually leads to a fatal termination in a few days
from diffuse peritonitis. Only seven cases are recorded in Courvoisier's
voluminous statistics. Potain also says that, besides the ordinary variety
of empyema of the gall-bladder, there is an acute empyema of a very
grave kind, which is followed by rapid peritonitis and death. In one
case, which he describes, death occurred on the second day after the
onset of the attack ; and although there Avas no perforation of the Avails
of the Aascus, infection had spread through the coats to the general
peritoneal caA'ity. Osier (28) also refers to it as an extremely rare
disease.
A case described by Mr. "W. Arbuthnot Lane affords a good example
of phlegmonous inflammation Avhich, OAving to the secondary peritonitis,
simulated acute intestinal obstruction. A man, aged fifty-four years,
AA'as suddenly seized Avith severe abdominal pain immediately after
224 SYSTEM OF MEDICINE
a rather hearty meal. This continued and was accompanied by fre-
quent vomiting : next day the vomiting became less frequent and
then ceased ; ingestion of food, however, caused much distress and
a renewal of the vomiting. The abdomen became much distended,
the pain and distension being more marked on the right side. These
symptoms increased in severity till the fourth day of illness, when
Mr. Lane first saw him. The bowels had not moved since the onset.
He Avas now in a very prostrate condition with a small, rapid pulse and a
very distended, painful, and tender abdomen, the hardness and fulness
being most distinct about the right hypochondriac region and its vicinity.
There was no i)revious history of gall-bladder trouble nor of intestinal
obstruction. From the distended condition of the small intestines and
caecum, and the collapse of the colon on the left side, the case was supposed
to be one of obstruction about the hepatic flexure. On opening the peri-
toneal cavity a very thick layer of firm lymph Avas found, covering
the edge of the liver and extending over the adjacent transverse colon ;
beyond this i)art the colon was empty, in marked contrast Avith the
distended cojidition of the proximal part of the bowel. In immediate
relation Avith the transverse colon and the duodenum, Avhich AA^as also
covered Avith lymph, A\'as found a tightly-distended livid gall-l)ladder
Avhich, though not larger than normal, Avas evidently very acutely in-
flamed. The Avhole of the lymph Avas carefully remoA'cd, and the gall-
bladder tapped of its contents, Avhich consisted of a thick muco-
pus. The opening AA'as then enlarged, a drainage-tube inserted, and the
margins of the Avound stitched to the peritoneum. No gall-stone AA'as
discovered. The jxitient made a complete recovery.
The comparative frequency of gangrene in the A^ermiform appendix
might lead one to suppose that gangrenous inflammation of the gall-
bladder would not be uncommon ; yet it is extremely rare, and so far as
I know, the case reported by Dr. L. W. Hotchkiss is the only one
recorded. In this case, a boy, aged nineteen, was admitted to the Belle
Vue Hospital, Xcav York, Avith acute peritonitis ; it had come on suddenly
and Avas thought to be due to appendicitis, as the pain Avas most se\ere
over the c;ecal region. No previous history of gall-stones Avas obtainable.
Exploration of the abdomen revealed a tumour of purplish hue, very
tense and markedly congested ; some pus Avas found on its outer side,
and, Avithin it. thin, sticky fluid of a yellowish broAvn colour, together Avith
a number of gall-stones. The lower end of the gall-bladder Avas almost
black ; its Avails Avere extremely thin and apparently gangrenous. Death
occurred seven hours after the operation — thirty-four hours after the
onset of the attack ; the vomiting, rapid pulse, and high temperature con-
tiiuiing to the end.
In order to explain the occurrence of gangrene three factors have to
be borne in mind: ((f) thrombosis of the nutrient vessels ; (i) bacterial
infection \ (c) absence of drainage and consequent tension. The tAvo
latter are present in both gall-bladder and a])pcndix inflammation ; but
the first factor is more frequent in the verniifoiin appendix, which is
DISEASES OF THE GALL-BLADDER AND BILE- DUCTS 225
supplied by one nutrient artery only ; Avhereas the gall-bladder has a
very free blood- supply, not only through the branches of the cystic
artery, but also through their anastomoses with the hepatic, where the
organ is fixed to the liver.
In Dr. Hotchkiss' case there was an abnormal circular constriction of
the gall-l:»ladder with lymph infiltration, which was apparently sufficient to
cut off" the blood-sup[)ly from the extremity of the part.
Although the disease is usually associated with gall-stones, Mr. Lane's
case would seem to 2")rove that acute cholecystitis may arise indepen-
dently of them ; in this it resembles appendicitis, which may occur
without the presence of foreign bodies.
Typhoid fever may give rise to it, as in the case recorded by Dr.
Monnicr AVilliams and Mr. Marmaduke Sheild, which is referred to in the
section on Ulceration.
Whatever be the cause, the disease usually manifests itself somewhat
suddenly with pain on the right side of the abdomen, which rapidly
becomes general. A rapid and feeble pulse, quick thoracic breathing, fever,
intense general depression, marked tenderness, especially over the right
side of the abdomen, rapidly increasing tympanites, persistent vomiting,
and an extremely anxious expression of countenance, are its chief symp-
toms. The acute peritonitis, significant of the disease, may be localised
at first ; but later it becomes general. Jaundice may or may not be
present ; and although an elevation of temperature is usual, it is by no
means constant, and affords but slight assistance in diagnosis or prognosis.
If the disease be of the very acute or gangrenous variety, death speedily
occurs ; but if of the subacute form, an abscess may form round the gall-
bladder, and the peritonitis may become localised ; the disease then
resembles a perityphlitic abscess in its course.
The diagnosis of phlegmonous cholecystitis practically resolves itself
into a diagnosis of the cause of an acute peritonitis starting on the right
side of the abdomen. Although this may be due to perforation of
the stomach at or near the pylorus, to perforation of the duodenum
or ascending colon, to perforation of the gall-bladder or bile-ducts, or
to some other such ]ieritoneal catastrophe, the chief affection with which
it is likely to be confounded is acute appendicitis.
In appendicitis the pain begins at a lower point in the abdomen and
passes towards the umbilicus, whereas in gall-bladder mischief it begins
below the right costal margins, and passes towards the epigastrium
and back to the right scapular region. In the one case the most acutely
tender spot will probably be over the caecum ; in the other it is over
the region of the gall-bladder. The symptoms of acute peritonitis and
paralytic obstruction of the bowels are common to both. The appendix
may be abnormally situated under the right costal arch. Fortunately,
the treatment by exploratory incision is that appropriate to any one of
the various conditions mentioned.
Eelief of pain by subcutaneous injections of morphine will prob-
ably always be demanded as a primary measure ; and as it is clearly
VOL. IV Q
226 SYSTEM OF ^f ED WINE
impossible to make a diagnosis of this serious malady within the first
few hours, warm applications, absolute rest, the stoppage of feeding
by the mouth (unless it be in very small quantities), and the relief of
symptoms as they arise, must be our temporai-y measures ; but as soon
as the diagnosis of phlegmonous cholecystitis can be established, and it is
found that the patient is getting Avorse rather than better, an exploratory
incision should be made, and the gall-bladder incised and drained, the
cause, if any obvious cause be found, being then removed. If, however,
gangrene be discovered, the gall-bladder should be removed, the indica-
tions for that measure being as distinct as in the case of a gangrenous
vermiform appendix. If, in subacute cases, the inflammation becomes
localised, and a swelling with tenderness be found beneath the right
costal margin, incision and drainage is called for; at the same time
cholecj'stotomy may be performed, and if gall stones be present in the
gall-bladder or ducts they may be removed. If the patient be too ill to
bear a prolonged operation the latter procedure may be left to a
subsequent occasion.
Tumours of the CxAll-bladder and bile-ducts. — If by tumour be
understood new growth, then tumours of the gall-bladder and bile-ducts
are not common ; but if we accept the usual interpretation of the word,
and call all enlargements tumours, we shall find them liy no means rare ;
the greater number depend directly or indirectly on gall-stones.
The following classification includes the chief tumours of the gall-
bladder and bile-ducts : —
I. Tumoiu's of the Gall-bladder.
A. Distension : {a) with l)ile ; {h) with gall-stones ; (c) with mucus,
" hydrops " ; {d) with pus, " empyema."
B. New growths, (a) Malignant ; (A) Simple.
II. Tumours of the Bile-ducts.
A. Distension.
B. New growths, {a) Malignant ; {h) Simple.
I. Tumours of the grall-bladder. — Etiology. — The gall-bladder may
become hard and almost calcified by the deposit of lime salts in its
walls in consequence of disease of its mucous membrane. Usually
it can then be felt under the liver maTgin as a hard nodule, though
it seldom forms a tiimour of any size. Though a considerable collection
of gall-stones, or one lai-ge concretion contained in the gall-bladder,
may cause a palpable tumour, this is rare ; the svvelling, as a rule, is
due to distension of the gall-bladder in consequence of an obstruction
of the lumen of the ducts by gall-stones, so that the escajie of the secre-
tions is ])revented. If a gall-stone, in passing down the cystic duct,
become impacted, so as to block the passage, the gall-bladder gradually
becomes distended with mucus, and a tumour is formed. If a concretion
be impacted in the common duct the gall-bladder may be distended with
bile for a short time, though if the obstruction continue mucus will
replace the bile.
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 227
Stricture or tumour of the cystic or of the common duct may produce
distension of the gall-bladder ; so also may hydatid disease, movable
kidney and malignant growth lying outside the bile-ducts but pressing
on them.
If the symptoms be acute and associated with inflammation, the con-
tents of the gall-bladder may become purulent and a so-called empyema
be formed. In certain cases of empyema the size of the tumour may be
increased by the formation of jdus outside the gall-bladder. The pus may
then lie in an irregular cavity either in the liver or below it, but shut
out by adhesions from the general peritoneal cavity.
Of the tumours dependent on new growth, so-called, " cancer of the
gall-bladder " is the most important ; innocent growths, except of inflam-
matory origin, are excessively rare.
Cancer of the head of the pancreas is usually associated with a per-
ceptible tumour of the gall-bladder, as the new growth embraces and
obstructs the termination of the common duct and thus causes retention
of secretions.
Signs. — Enlargements of the gall-bladder may vary from a tumour
just perceptilile to the touch to one of such a size that it may resemble
an ovarian cyst, as in cases reported by Kocher and Lawson Tait ; though
an enlargement of greater size than a lai'ge pear is exceptional. The same
tumour may also vary in size at difterent times — a variation frequently
found in gall-stone obstructions. The symptoms of tumour of the gall-
bladder depend for the most part on the cause, and consequently vaiy
considerably — being at times slight and unimportant, at times both
urgent and serious.
The gall-bladder, as a rule, enlarges doAvnward and forward in a line
which, drawn from the ninth or tenth costal cartilage, crosses the linea
alba a little below the umbilicus ; but the position of the tumour varies
with the size of the liver. When this organ is of normal size the neck of
the gall-bladder is opposite the ninth costal cartilage ; Avhereas when the
liver is enlarged the gall-bladder will be pushed down so that the neck of
the tumour may be opposite to the umbilicus, or even below it. If un-
complicated it will have a smooth, rounded and pear-shaped outline, the
larger end below being quite free and movable from side to side, the
upper end being fixed and passing under the lower margin of the liver at
the fissure of the gall-bladder.
A distinct sulcus between the liver and gallbladder is nearly always
perceptible to the touch : if the warm, flat hand be laid over the right
side of the abdomen, and the patient be told to take a deep breath, the
tumour and the liver will descend together and pass under the fingers.
Bimanual palpation will frec[uently throw additional light on the
case ; the right hand is to be placed in front of the abdomen, and the
left over the right loin, and gentle pressure made forwards. In other
cases additional information may be obtained by placing the patient in the
genu-pectoral position, and passing the flat hands round the abdomen from
behind, when a tumour of the gall-bladder will rest directly on the hands ;
22S SYSTEM OF MEDICINE
on deep inspiration it will be felt to move just beneath the abdominal
Willis : the upper surface of the liver is also capable of palpation in this
way. The sac, as a rule, is far too tense for fluctuation to be felt,
though at times, when it is less tense, this sign may be obtained. In
some of the larger swellings a thrill, almost like the hydatid fremitus,
may be felt on gently flicking the tumour with the finger-nail. Percus-
sion l)y no means always discovers dulness coextensive Avith the tumour,
and is especially deceptive if the surrounding intestines be distended :
dulness on percussion is therefore a very variable sign ; pali)ation will
be found more trustworthy. Inspection of the abdomen, with the patient
recumbent, will at times show the tumour descending on respiration ; but
this sign is usually to be observed only in thin patients and in cases
uncomplicated with itiflammation. When there is inflammation and
matting of the adjoining viscera, a fixed swelling, dull on percussion,
and decidedly tender, may be seen over the right hypochondrium.
Tenderness on palpation is a variable symptom, depending on the
presence or absence of local peritonitis ; as a rule it is absent in uncom-
plicated enlargements of the gall-ljladder.
Jaundice may accompany tumours of the gall-bladder, both being
dependent on the same cause — the blocking of the common bile-duct.
Although not absolutely pathognomonic of malignant disease, the com-
bination should always raise a suspicion of cancer of the head of the
liancreas, or of the liver or bile-ducts, especially if it be associated m ith
great loss of flesh and strength, and with absence of characteristic gall-
stone pain.
In a considerable number of cases I have observed distension of the
gall-bladder with jaundice to be associated with malignant disease ; but
much less often the combination of tumour, jaundice, and gall-stones. The
explanation of this apparent anomaly is that the gall-liladder frequently
becomes diminished in size as the result of gall-stone irritation, so
that when the common duct becomes blocked by a stone jaundice occurs,
but the previously shrunken gall-bladder is unable to expand. If, how-
ever, the common duct become blocked by gall-stones before the gall-
bladder has contracted and formed adhesions, the comlnnation of jaundice
and tumour may occur. If, when the common duct is blocked by a new
growth, the gall-bladder has not been subjected to previous irritation,
and has not therefore become contracted, it will distend at once. Thus,
in malignant disease of the head of the pancreas we usually find the
combination of jaundice with tumour of the gall-bladder.
Gall-l)ladder tumours usually contain mucus, occasionally pus, rarely
bile. In all cases where the cystic duct is obstructed and inflammation
has not followed, mucus alone is present ; though, when inflammation
coexists, pus oi* muco-jius may be found. In ol)struction of the common
duct l>y gall-stones, the gall-bladder, though usually contracted, may be
found distended Ijy bile at first and by mucus later. As a rule, however,
the swelling su1)sides more or less rapidly, the gall-bladder shrinks, and
no tumour persists. "Where the obstruction becomes absolute, as in
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 229
malignant disease of the head of the pancreas, the tumour formed is per-
sistent ; and although the block is in the common duct, bile soon ceases
to reach the gall-bladder, and the tumour is always found to contain
mucus only.
lJiag7iosis. — Tumours of the gall-bladder may have to be distinguished
from — {a) movable right kidney, (h) tumour of the right kidney or
of the suprarenal capsule, (c) tumour of intestine or fa3cal impaction, (d)
tumour of liver, (e) pyloric tumour, (/) al^normal projection of liver.
The diagnosis of enlargement of the . gall-bladder from movable right
kidney in thin persons is as a rule easy, but in those who are stout, or
have tense or strong muscular abdominal walls, difficulties may and do
arise which, however, can usually be overcome by examination under an
anaesthetic (vide art. "Nephroptosis," p. 338).
These enlargements resemble one another in that they form mode-
rate-sized, distinctly-defined, smooth, rounded, and moA'able tumours on
the right side of the abdomen, which descend on inspiration. The
previous history may throw light on the individual case, especially if
there have been definite cholelithic attacks or jaundice. By inspection
of the abdomen a gall-bladder tumour is often apparent, moving rhyth-
mically with the respiratory movements when the patient is recumbent ;
a floating kidney can rarely be so detected.
The general outline of the tumour, as detected by palpation, may
affoid valuable assistance ; thus, in distension of the gall-bladder, the
tumour formed is pear-shaped, with the apex toAvards the fissure of the
gall-bladder, and its long axis in a line from about the tip of the ninth
costal cartilage downwards, forwards, and inwards towards a point a little
below the umbilicus. In floating kidney, especially in patients with lax
abdominal walls, the tumour may be grasped and its characteristic shape
made evident. Should adhesive peritonitis accompany the gall-ljladder
condition there will be tenderness and pain on pressure over the tumour,
especially near its apex. These signs are rarely if ever present in
floating kidney.
The gall-bladder tumour on manipulation can usually be moved to a
limited extent inwards and outwards ; but under no circumstances can
it be depressed into the pelvis. On relieving the pressure it tends to
resume its old position under the liver. Floating kidney generally has a
Avider movement; it can be depressed into the pelvis, and, when relieved
of pressure, it tends to pass towards the right loin, especially when the
patient is recumbent.
A valuable diagnostic sign is the sulcus often felt between the lower
margin of the liver and the gall-bladder tumour. This can usually be
felt when the warm flat hand is placed over the upper part of the swell-
ing, and the patient breathes deeply.
In the case of renal tumour, as well as in movable kidney, by dis-
tending the intestine with gas the kidney will be pressed back into the
loin ; but the gall-bladder will be pushed up towards the liver and made
more prominent. The last test is usually also sufficient to enable a
230 SYSTEM OF MEDICINE
diagnosis to be made between a distended gall-bladder and a tumour of
the right suprarenal body; but this point is not always to be relied upon.
In a case I saw with Dr. Kebbell of Flaxton, Ziemssen's test pushed the
swelling upwards ; and on performing al)dominal section, a sarcoma of
the suprarenal capsule Avas found and removed. The explanation was
that the colon was fixed below the growth and pushed it up wlien the
bowel was distended.
In tumour of the intestine or of the pjdorus the associated sj^mptoms
are usually sufficient to enable us to make a diagnosis ; but, when in doubt,
distension of the stomach or bowel with gas, or examination under an
ana3sthetic, will help to clear it up. Tumour of the liver itself — whether
cancer or hydatid disease — may be almost indistinguishal)lc from one of
the gall-bladder; though the presence of nodules in the liver, with the his-
tory and other symptoms of malignant disease, will usually be sufficiently
distinctive in cancer, while the less localised and more generally fluctuat-
ing swelling, together Avith the longer history and absence of pain, will
distinguish hydatid tumour. It should not be foigotten that the right
lobe of the liver may have an abnormal projection either in the site of
the gall-bladder or to the right of that position, and may thus at first be
mistaken for an enlarged gall-bladder ; but the absence of symptoms,
together with careful bimanual palpation, will usually enable a correct
diagnosis to be made, and, as Professor IJiedel has pointed out, the gall-
bladder may frequently be felt apart from the swelling. Puncture with
an exploring syringe would, of course, give valuable information ; but, as
this measure is not devoid of risk, it should not be lightly undertaken ;
death has occurred on more than one occasion as a direct result of this
apparently slight operative procedure. If it be decided to emplo}' an
exploring needle, the aspirator should always be used in order that the
tense cyst may be emptied ; otherwise leakage from the punctm'e is
almost certain to occur.
In cases of doubt, especially where the symptoms demand interference,
exploration of the tumour through a small abdominal incision can be
undertaken "with very little risk ; and further treatment, if called for,
can be readily carried out at the same time.
Cancer of the gall-bladder is by no means frequent, and as a primary
affection is somewhat rare. INIusser has collected the chief cases. It
is usually secondary to gall-stones or to cancer of adjoining organs, and
in the latter case it is hardly amenable to surgical treatment. It is an
unfortunate circumstance that very few of the specimens of so-called
cancer of the gall-bladder have been submitted to careful microscopic
examination ; but of those that have been so examined, the growth has
been found in the form of cylindrical epithelioma. The disease occurs as
a uniform thickening of the walls of the gall-liLidder, and in the centre of
the mass a cavity containing gall-stones is often found. It may attain
the size of a large pear.
Symptoms and Sir/mt. — If the growth be primary, there will be the
history of a more or less rapidly-growing tumour developing under the
DISEASES OF THE GALL-BLADDER AND BILE- DUCTS 231
right costal margin ; it is accompanied by a sense of discomfort shortly
changing to pain which is often worse at night, and which, though at
first localised to the right hypochondrium and epigastrium, usually
extends round the side to the right infrascapular region. AVhen the
enlai'gement is first noticed, it is felt as an egg-shaped swelling beneath
the liver, descending Avith that viscus on inspiration. The tumour is
hard to the touch, and very slightly or not at all tender to piessure.
At a later stage it becomes more fixed and more diff"used, and nodules
may form and be felt on its surface. As the growth extends, it invades
the liver and sometimes the duodenum and stomach.
Dissemination is rare. When it occurs, nodules may be found in the
liver, and generalh^ over the peritoneimi ; in such cases ascites appears.
The lymph-glands in the hilum of the liver usually become affected.
As the hepatic or the common bile-ducts are or are not invaded, so
will be the presence or absence of jaundice ; but in nearly half of the
cases some degree of icterus will be found as the disease advances.
Interference with the action of the bowels, even to partial or complete
obstruction, occurs at times. General failure of health, continued wast-
ing with loss of strength, ascites, and marked cachexia characterise the
later stages. If gall-stones be present there will be the usual antecedent
history cf cholelithiasis. I have known the combination of gall-
stones and cancer of the gall-bladder to be unaccompanied by jaundice.
"Where gall-stones Avith jaundice complicate cancer of the gall-bladder,
exacerbations of pain will usualh^ be accompanied by rigors and fever
(" ague-like attacks "), with an intensification of the icterus ; moreover, in
such cases petechioe in the skin and haemorrhage from t£e nose and
rectum usually appear.
Diagnosis. — Cancer of the gall-bladder may usually be diagnosed by
the progressive character of the disease, and by the presence of the
characteristic hard tumour ; but it is by no means always easy to diagnose
cancer from a tumoiir formed by matted intestines, due to local peri-
tonitis in the neighbourhood of the gall-bladder.
In a doubtful case of this kind, in a woman of fifty, I opened the
abdomen, and found what appeared to be a malignant tumour of the gall-
bladder, which was punctured in several spots with an exploring syringe.
Finding it firm and hard I concluded it was malignant, and as it w^as too
extensive for removal I closed the abdomen, thinking nothing more could
be done. The patient, however, recovered forthwith, is now well, and
has no remnant of her tumour. In all probability it was an inflamma-
tory swelling associated with gall-stones. In another case of tumour,
where there was a suspicion of malignancy, an al:)scess of the liver, con-
taining thirty gall-stones, was opened, with marked relief, though only
for a time ; death superA^ened four months later, when cancer Avas foimd.
AVhen in doubt exploration is advisable, as treatment may be carried out
at the same time.
That cancer of the right suprarenal body mav afford a difficulty in
diagno-sis is shoAvn by the case referred to in the chapter on tumours of
232 SYSTEM OF MEDICINE
the gull-bladder. The same difficulty applies to cancer of the p3'lorus,
which, however, is accompanied for the most part by characteristic stomach
symptoms.
Treatment. — The alleviation of symptoms, especially of pain by
sedatives, is practically all that can be done, except in those rare cases
where the disease is limited to the gall-bladder, when cholecystectomy
may be performed. That cholecystectomy is occasionally practicable in
cancer of the gall-bladder, is proved by a case I reported at the June
1896 meeting of the lioval Medical and Chirurgical Socictv, in which I
had reiuo\'ed from a middle-aged woman not only the Avhole of the gall-
bladder but a considerable portion of the adjoining right lobe of the
liver also ; the patient made a good recovery. The disease had started
at the neck of the gall-l)ladder behind an impacted gall-stone. Mici'O-
scopic examination showed the growth to be epithelioma.
II. Tumours of the bile-duets rarely form projections so large as to
be distinguished through the abdominal walls. Tumour, however, in
such cases, as a rule, is present sooner or later on account of the obstruc-
tion in the ducts and secondary distension of the gall-l)ladder ; or if
the gall-bladder be contracted, the common duct may be dilated to such
a size as to form a cystic tumour presenting all the characteristics of a
distended gall-bladder.
Terrier describes four cases in which an external fistulous opening
was established from the common bile-duct. In three of these the duct
was much distended, and formed a distinct abdominal tumour. The first
case was one in which median laparotomy was ])erformed for the removal
of a swelling regarded as a cyst of the pancreas. The nature of tliis
swelling having been revealed by the discharge of bile after puncture, a
small portion of the wall of the cyst was excised, and the edges of this
opening were attached to the external wound. The biliary fistula thus
formed bled freely for some days after the operation, and afterwards
suppurated. The ])aticnt died on the twenty-ninth day from ana'mia
and exhaustion. In the second case the much -distended duct, which
had been regarded as a hydatid cyst of the liver, was exposed by
laparotomy, incised, and attached to the wound in the alxlominal wall.
The i)atient died on the eighth day from collapse. In the third case
the dilated duct was opened and stitched to the external wound under
the supposition that the tumour was a distended gall-l)!adder. In the
original report of the fonrth case it is not clearly stated whether the di\ct
was distended or not. In this instance the hepatic portion of the divided
duct was fixed to the surface of the abdominal wall, after I'cmoval of the
gall-l)ladder, the c^'stic duct, and a small portion of the liver for cancer.
The patient did well for some time after the operation, but died six
weeks later from cachexia. In his comments on these records. Terrier
points out that in two of the cases the distension of the bile-duct, though
clearly due to ob.struction, was not associated with lithiasis. In the third
case the duct was found completely obstructed at its intestinal orifice by
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 233
a small calculus. In each instance of distended bile-duct the gall-bladder
was much shrunken, and its walls were sclerosed and surrounded by
cicatricial tissue. Although hitherto the results of choledochostomy have
always been fatal, probably in consequence of the fact that extreme dis-
tension of the bile-duct is often accompanied by infection of the biliary
passages, it would be Avell, Terrier thinks, to reserve our opinion on the
prospects of the operation. As yet very little information can be
obtained on this subject ; cases of distension of the common bile-duct are
very rare, and those in which surgery has intervened are still rarer. An
extremely interesting case is reported by Mr. W. P. Swain (34), in Avhich
he connected a dilated bile-duct to the jejunum by one of Murphy's buttons.
The size of the tumour, which occurred in a girl of seventeen and was
associated with gall-stones, may be gathered from the fact that over seven
pints of fluid were withdrawn from it at the time of operation. Three
months later the patient was progressing satisfactorily, save that the
temperature rose occasionally, and that the button had not been passed.
Tivo forms of new growth have been found primarily in the bile-ducts :
(fl) Cylindrical epithelioma ; (h) Papilloma. The latter is probably an
earlier stage of the former, and is rare.
Mr. Bennett removed one from the common duct of a woman aged fifty-
eight, in St. George's Hospital; the specimen was shown at the Pathological
Society of London in May 1894. The growth was white and somewhat
granular to the naked eye, and it was in immediate relation with an
impacted gall-stone. Microscopically it resembled a glandular poh^pus of
the intestine. The papilloma was a2:)parently clue to the irritation of the
stone, which from the history appeared to have been impacted for two
months.
Cancer, in most if not in all cases, is secondary to gall-stones ; though,
as in a case on which I operated and which I reported at the Clinical
Society in October 18S9, they may not always be found, as the stones
may have passed into the bowel before the operation.
Although these tumours are usually seen in the common duct, they
may occur in the cystic or in the hepatic duct. If forming in the cystic
duct, jaundice will be absent at first, coming on later when the growth
advances so far as to press on the common duct and obstruct the passage
of the bile. The gall-bladder enlarges at an early stage, and this will
probably be the earliest sign ; pain may be absent unless gall-stones exist,
when the usual spasmodic pain Avill occur so long as the muscular coat of
the gall-bladder retains its contractile power.
When the growth is in the common duct jaundice comes on at an
early stage, and persists throughout, the liver gradually increasing in
size, and the gall-bladder also enlarging ultimately.
Suppurative cholangitis is apt to supervene, in which case the
course is more acute, and is accompanied by fever, ague-like attacks, and
rapid loss of flesh and strength.
If the tumour form in the hepatic duct, jaundice Avill be the earliest
symptom, and the case will resemble one of obstruction in the common
234 SYSTEM OF MEDICINE
duct, except in the absence of enlargement of the gall-bladder. Needless
to say, the disease is uniformly fatal though operation may delay the
final catastrophe. The growth is usually a cylindrical epithelioma.
Ijcsides primarj' carcinoma of the bile-ducts, malignant disease may
invade them, by direct continuity, from the gall-bladder, from the pan-
creas, or from the liver ; when the symptoms are those of growth of the
bile-ducts engrafted on the original disease.
The diagnosis of new growth from gall-stones in the bile -ducts is
practically impossible ; the symptoms are the same, and in fact the
two frequently coexist. The absence of pain and the rapid deteriora-
tion of health may afford a little help, but in some cases the pain is as
acute as in cholelithiasis.
Cystic dilatations of the bile-ducts are indistinguishable from enlarge-
ments of the gall-bladder, for which indeed they are usually mistaken
until the abdomen is opened.
The operative treatment of these tumours is in its infancy, and thus
far has not proved very satisfactory. Any growth should be removed
if possible ; but, where this is impracticable, the dilated gall-bladder
may be opened, stitched to the surface, and drained ; or better still,- it
may be drained into the duodenum or jejunum by making an anasto-
mosis by means of a Mur[)hy's button. Choledochostomy in cystic
dilatation of the bile-ducts has not yielded good i^esults ; Avhercas the
establishment of an anastomosis between the cyst and the intestine, so
far as our experience has gone, has been so satisfactory as to establish
some claims to our attention as the best method of treatment.
In operating, it is important to bear in mind that the cause of dilata-
tion of the ducts may be a removable one, such as gall-stones ; and if so,
and if removal be practicable, that should be done.
Gall-stones.— The importance of this subject may be gathered fiom
the fact that post-mortem records on Europeans of all ages and of both
sexes prove that gall-stones are present in from 5 to 10 per cent. In
Strasburg the record is 12 per cent (Schroedcr), in Kiel 5 per cent,
and in Manchester 4 '4 per cent (Brockbank) ; but as these statistics are
taken from hospital patients representing the working classes, who are
the least subject to gall-stones, the estimate is probably below the mark.
On the other hand, in India, and in the East generally, gall-stones are
said to be extrcmoly rare ; one or two cases only have been recorded.
Patholog'y and Etiology. — Gall-stones, which, when small, are often
spoken of as biliary sand, may vary from a concretion just perceptible to
the naked eye up to a mass the size of a tenm's ball, or even larger.
They may be round, egg-shaped, bairel-shaped, elongated with pointed
ends, or angular ; the surface l)eing smooth, mammillated, or irregularly
faceted. Gall-stones, when large, are usually single, but when small or
moderate in .size, several hundreds may be ])resent ; for instance, in March
189.5 I successfully removed l)y cholecystotomy no less than 720 stones
from the gall-bladder and dilated cystic duct of a woman aged fifty-six.
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 235
Their colour is variable; in some cases it is white or gray, in others very
dark, or even quite black ; the usual colour is a dark yellow or brown. In
consistency they are ordinarily firm, but may without much difficulty be
fractured by pressure between the thumb and forefinger, the fracture being
crystalline ; but they may be as hard as a lithic acid calculus, or as soft
as half -set putty. The chief constituent of gall-stones is cholesterin,
which always occurs in the crystalline form ; but bile pigments, bile salts,
lime, mucus, degenerated epithelium, and, rarely, foreign bodies may enter
into their composition.
Margarate, stearate, and palmitate of lime, combined with mucus,
usually form the cement which binds the cholesterin crystals together to
form a concretion.
Gall-stones formed almost entirely of bile pigment may be seen ; and
on two occasions I have found soft concretions of this nature in large
numbers in the hepatic ducts within the liver. Since cholesterin is
the chief constituent of gall-stones, our attention in considering their
formation must be directed chiefly to the physiology of this monatomic
alcohol, which occurs, normally, not only in the blood, but also in the
various organs of the body.
Although cholesterin is always present in the bile in a proportion,
according to different authors, varying from "045 to 1"18 per cent, very
little is known of the processes which determine its existence. As there
is no proof that the liver excretes cholesterin from the blood, or that it
is a result of hepatic metabolism, Ave are driA^en to the conclusion that it
is formed in the bile-ducts or gall-bladder ; and, as it is found in other
passages lined by mucous membrane Avhere there is no bile near, there is
no reason to believe that it is formed from any constituent of the bile,
but rather that it is a product of the epithelium of the bile passages —
that, in fact, it is a secretion of mucous membranes genei'ally \yide
y\ hy, Avhen ordinarily present in all persons, cholesterin should form
concretions in some and not in others, may be dependent on several
causes; possibly in some cases cholesterin occurs in positive excess, Avhile
in others there may be a diminution of the bile salts Avhich should hold
the cholesterin in solution, or it may even be precipitated from solution.
There is no doubt that catarrh of the mucous membrane of the bile
passages increases the amount of cholesterin present, and that the longer
bile remains in the c:all- bladder the more cholesterin it Avill contain.
Anything, therefore, Avhich causes stagnation of Ijile may dispose to gall-
stones ; on the other hand, Avhatever leads to a regular emptying of the
bile passages \f\\\ tend to clear out such detritus as cast-off cells and
incipient collections of cholesteiin crystals and mucus, and thus to
prevent the formation of gall-stones. Among the remoter causes Ave must
consider age, sex, habits, dress, diet, diathetic conditions and disease.
Age. — Although gall-stones may occur at any age, and even in the
ncAvly-born (Portal and Lieutaud), they are rarely found under the ages
of 25 or 30 ; Schroeder says that under the age of 20 the percentage is
236 SYSTEAf OF MEDICINE
2-4; from 20 to 30, 3-2; from 30 to 40, Wb ; from 40 to 50, 111 ;
from 50 to 60, 9*9 ; and over 60, 25"2 per cent.
Sex. — Gall-stones occur more frequently in women than in men;
Schroeder finds that in Germany they are found in 20 per cent of female,
and in 4*4 per cent of male necropsies. Out of 228 autopsies on
women in the Manchester Hoyal Infirmary, Dr. Brockbauk found 18,
and out of 542 post-mortem examinations in men, 16 cases of gall-stones;
which gives 7*9 per cent in female, and 2'0 per cent in male subjects.
Pregnancy would seem to be a factor in the causation of gall-stones,
as, in a large series of cases, 90 per cent of women affected had been
pregnant. The wearing of corsets, which tend to force down the front of
the liver, and to depress the fundus of the gall-1)ladder, is probably a
distinct etiological factor, especially when coml)incd wilh want of exercise.
Habits. — ^Vuut of exercise, whether from lethargy or from necessity,
as in some forms of chronic heart disease, leads to stagnation of bile in
the gall-bladder, and to the deposition of cholesterin ; since the gall-
bladder is unaided in its expulsive efibrts by the aljdominal muscles.
Catarrh of the gall-bladder and bile-ducts probably acts as a cause in
two ways ; in the first place, it leads to stagnation of bile by paresis of
the muscular coats of the passages, and in the second place by increasing
the amount of cholesterin present.
Dkt. — The following facts go far to prove that diet exercises a strong
influence in the formation of gall-stones. It seems probable that free
cholesterin in the bile passages is due, in many cases, to the deficiency
of the solvents of it in the bile ; these solvents being the glycocholate
and taurocholate of soda Avhich arise from the metabolism of nitrogenous
foods. If the supply of nitrogen in the food be limited, the bile salts
■will be diminished and cholesterin may be precipitated. This may serve
to explain the presence of gall-stones in gouty persons who on account
of the lithic diathesis limit their intake of nitrogen. The larger consump-
tion of farinaceous food in Germany may also serve to explain the greater
prevalence of gall-stones there than in P^ngland, where meat enters more
extensively into the dietary. In diabetes, Avhen nitrogenous food is
prescribed, gall-stones are rarely found.
Thudiclaun in his work on gall-stones states that he cannot find any
recorded instance of the discovery of gall-stones in the wild carnivora ;
though on two occasions they have been found in the gall-bladders of
domesticated carnivora. On the other hand, Brockbauk could find no
evidence of their occurrence in wild herbivora, though at times they are
found in domesticated horses, cattle and sheep, as well as in pigs. More-
over, in pampered dogs fed on farinaceous foods they are found occa-
sionally. In man who is omnivorous they occur in from 5 to 12 per
cent.
It will thus be seen tliat in those who take an abundance of allniminous
materials in their food, and where, therefore, the bile salts are in sufficient
quantity, there is little tendency to the deposition of cholesterin ; whereas
when little albuminous food is taken, and the bile salts are presumably
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 237
insufficient to hold the cholesterin in suspension, gall-stones form ; this
tendency is aided by insufficient exercise, as in stall-fed cattle, pampered
dogs, and indolent men. The formation of some gall-stones containing
lime may possibly be caused by drinking hard water, Ijut this is by no
means proved. An insufficiency of diluent drinks may possibly act as a
cause, and I think I have found this to be a factor in some cases.
Symptoms. — In discussing the symptoms of cholelithiasis we must
note, in the first place, that gall-stones may be found after death with-
out having produced any symi3toms during life. In such cases they are
as a rule in the gall-bladder, and not in the duets ; and there are no
signs of irritation in the shape of adhesions. But more than this ; there
can be no doul^t that even a large gall-stone may ulcerate its way into the
bowel, and produce symptoms of intestinal obstruction, Avith few or no
signs to indicate that such serious organic mischief has been going on. It
follows, therefore, that in considering cases of intestinal obstruction, gall-
stones cannot be excluded, though there has been no symptom of chole-
lithiasis. It is just possil)le that as some persons may pass urinarj^ stones
with few or no symptoms, so others may pass small biliary stones ; this,
however, has yet to be proved, and in the meantime it is difficult to
explain why in some persons gall-stones should produce such serious
trouble and in others none at all.
In certain cases there may be a history of dyspepsia, with depression
of spirits and a feeling of discomfort or weight, or even ill-defined pains
over the right side of the abdomen ; but an entire absence of those
characteristic symptoms which give definiteness to diagnosis.
The ordinary symptoms of cholelithiasis are paroxysmal attacks of
pain which, occurring at irregular intervals, often without apparent cause,
start in the right hypochondrium or in the epigastrium, and radiate thence
over the abdomen and through to the right scapula. The attacks aie
often accompanied by sickness or vomiting and, if severe, by collapse.
They may be folloAved by jaundice with its well-known symptoms, but
this is frequently absent. At times a feeling of fulness in the right
hypochondrium accompanies the attack ; but the formation of a tumour
does not occur as a rule unless the ducts are blocked. Accompanying
these special symptoms will usually be found much depression of spirits,
Avant of appetite, dyspepsia, and loss of weight.
According to Naunyn, there is a regular and an irregular form of the
disease. The former occurs where the calculi are simply lodged in the
gall-bladder, or the stones pass along the ducts ; the latter is seen when
there is infectious angiocholitis, with abscess in the liver, fistula, and other
complications (see sections on Inflammatory Affections of the Gall-bladder
and Bile-ducts).
The following symptoms will be considered in detail : —
(a) Paroxysmal pain. — For the most part the patient complains of
pain under the right costal margin or in the epigastrium, whence the pain
radiates over the abdomen and to the right scapula ; but in some cases
the pain radiates to the left shoulder. These attacks come on suddenly,
23S SYSTEM OF MEDICINE
when the patient is ajjparently quite "well ; and usnally end l>y causing
nausea or an attack of vomiting. The vomiting leads to relaxation of
the duct, and if the gall-stone be small it may pass on and thus end the
attack. The seizures come on without apparent cause, although at times
they may appear to be caused by exertion or by taking food. Not
infrecpiently, after an attack has passed otf, a dull aching is felt for some
time, perhaps until another seizure.
{b) Vomitiiuj. — Though as a rule the vomiting is paroxysmal, it may
be almost continuous, and so of itself prove dangerous. In one case of
this kind, on which I operated at Sunderland, the patient was so weak
from persistent vomiting that I feared she could scarcely bear the opera-
tion I had gone to perform ; and even after the cause of irritation had
been removed, the vomiting persisted for days : ultimately, however, she
made a satisfactory recovery. In another case Avhich I saw in the south
of Ireland the vomiting had been so incessant that the patient had been
fed almost solely by nutrient enemas for six Aveeks before I operated ; and
even afterwards, though the operation was satisfactory and the after-
progress all that could be desired in other respects, the emesis persisted
for a fortnight, and ultimately proved fatal from sheer exhaustion. The
vomiting as a rule occurs towards the end of a seizure, and in fact
frequently determines its cessation. In such cases the stomach contents
are first rejected, after which, if the common duct be free, bile is vomited ;
at times I have even seen the severe vomiting become stercoraceous.
(c) Collapse. — On several occasions I have seen patients so profoundly
collapsed by attacks of cholelithiasis as to lead to a difficulty in diagnosis;
the case l)eiiig moi-e like one of perforation of some abdominal viscus or
some intra-abdominal haemorrhage : but the history of previous seizures,
and of the onset of the present attack, will usually help us to arrive at a
correct diagnosis. The acute agonising pain may of itself cause death,
as in the case of a lady whom I saw in consultation, when gall-stones
were diagnosed. The next attack of pain unfortunately proved fatal, and
at the autopsy a gall-stone was found half extruded into the duodenum.^
Not only may the agonising pain of a single attack prove . fatal, but
repeated attacks of pain occurring owe after the other, without sufficient
interval for recovery, may produce very serious illness, or even death by
exhaustion.
{d) The formation of a tumo\ir in the region of the gall-bladder i:)
seldom seen in acute cases ; yet it may be noticed with each attack, and
it is then due to the violent contraction of the muscular Avails of the gall-
l)Li(lder on its contents. It is, hoAvever, a frequent sign in the more
chi'onic cases, as is fully discussed in the section on Tumours of the Gall-
bladder.
(«) The presence of (lall - stones in the motions after an attack is
valuable evidence, but their absence does not negative cholelithiasis. I
^ Such a case, in a young and liealtliy marrii-d woman, occurri'd some years ago in my
own practice : the stone liad passed about four-iilths of the way down tlie comiuou duct.
There was no other morbid condition. — Ed.
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 239
have operated on many cases and found gall-stones Avhere none had at any
time been detected in the motions, although diligently sought for.
The way to search foi- gall-stones is to let the patient pass the motion
into a sohition of carbolic acid, to have it well stirred, and then to pass it
through a fine sieve with about -^^ inch mesh.
(/) Jaimdim. — So long as the gall-stones are in the gall-bladder or
cystic duct there is nothing to prevent the bile from passing down the
common duct into the intestine ; but should the gall-stones be impacted
in the common duct, the passage of the bile is obstructed, and jaundice
ensues. Intermittent jaundice may also occur if a small gall-stone in the
common duct act as a ball-valve (Fenger).
In these cases a decision concerning operation is difficult ; chronic
jaundice too often indicates malignant disease, and not only do patients
with cancer bear operations badly, but when jaundice is associated with
it there is the same tendency to persistent oozing of blood from the wound
after operation as there is to spontaneous haemorrhage where no ojjerative
measures have been undertaken.
{(j) Ague4ihe attacks. — Dr. Orel drew attention to the production of
intermittent pyrexia by gall-stones, and stated that his attention had been
first called to this symptom by some remarks of the late Dr. Murchison
on a case of a distinguished medical officer who, after his return to
England, was attacked at regular weekly intervals with paroxysms of
shivering, followed by fever and sweating. He was supposed at first to
have a recurrence of an old intermittent fever, and later to have hepatic
abscess ; but at last his symptoms indicated and the necropsy proved that
his actual and only disease was a gall-stone so impacted as to produce
great irritation, but not complete obstruction of the common duct.
Similar cases have been noticed by Charcot (8), who argued that the fever
is due to the absorption of some poison into the blood. Dr. Murchison was
of opinion that such attacks are not of a poisonous or septic origin, but
are due to nervous irritation.
From the cases I have seen I should think that both explanations are
admissible ; the fever not being unlike that known as " urethral," in which
the same contention as to causation arises. In a very interesting and
important paper, Dr. Osier of Baltimore (28) says that the combination of
the following symptoms is characteristic of the existence of gall-stones
in the common duct, and is, therefore, valuable in distinguishing between
that form of obstruction and malignant tumour : —
1. Jaundice of varying intensity, deepening after each paroxysm,
which may persist for months or even years.
2. Ague-like paroxysms characterised by chill, sweating, and fever,
after which the jaundice usually becomes more intense.
3. At the time of the paroxysm, pains in the region of the liver, with
epigastric disturliance.
This is fully borne out by my experience, and in a number of cases of
jaundice of several months' duration, where there was this combination of
symptoms, I have operated and found gall-stones impacted in the common
240 SYSTEM OF MEDICINE
duct, and have succeeded in crashing them and passing on the fragments
into the bowel.
In addition to the symptoms already mentioned, the following compli-
cations may be met with, and ma}' constitute the prominent changes
threatening life and requiring treatment; the original cause having perhaps
disappeared, or being masked by more serious sequels : — (i.) Ileus, due
to atony of the bowel, leading to enormous distension and to the symptoms
and appearance of acute intestinal obstruction, apparently the conse-
cpicnce of the violent pain, (ii.) Acute intestinal obstruction dependent
on : ((f) paralysis of gut due to local peritonitis in the neighbourhood of
the gall-bladder ; (A) volvulus of small intestine ; (c) impaction of a large
gall-stone in some part of the intestine after ulcerating its way from the
bile-channels into the bowel ; ((/) stricture of intestine or adventitious band
originally produced by gall-stones, (iii.) General haemorrhages, the result
of long-continued jaundice, either dependent on gall-stones alone or on
cholelithiasis associated with malignant disease. (iv.) Localised peri-
tonitis producing adhesions, which may then become a source of trouble
and pain, even after the gall-stones have been got rid of. I believe that
neai'ly every serious attack of biliary colic is accompanied by adhesive
peritonitis, as my experience is that adhesions are found in all cases where
there have been characteristic seizures, (v.) Dilatation of stomach depend-
ent on adhesions around the pylorus, (vi.) Ulceration of the l)ile passages
establishing a fistula between them and the intestine, (vii.) Stricture of
the cystic or common bile-duct. (Anii.) Abscess of the liver, (ix.) Localised
peritoneal abscess, (x.) Abscess in the abdominal walls, (xi.) Fistula
at the umbilicus or elsewhere on the surface of the abdomen, discharging
mucus, muco-pus, or bile, (xii.) Empyema of the gall-bladder, (xiii.)
Suppurative cholangitis. (xiv.) Septicaemia or pyaemia. (xv.) Phleg-
monous cholecystitis, (xvi.) Gangrene of the gall-bladder, (xvii.) Per-
forative peritonitis due to ulceration or to rupture of the gall-bladder or
ducts, (xviii.) Extravasation of bile into the general peritoneal cavity,
(xix.) Pyelitis of the right side, (xx.) Cancer of the gall-bladder or of the
ducts, (xxi.) Subphrenic abscess, (xxii.) Empyema of the right pleura,
(xxiii.) Pneumonia of the lower lobe on the right side, (xxiv.) Chronic
invalidism and inability to perform any of the ordinary business or social
duties of life.
Diagnosis. — In the sections on Tumours of the Gall-bladder and
on Intlanuuatory Affections of the Bile Passages the diagnosis of the
complications of gall-stones is more fully dwelt upon; so that in this section
it is only necessary to remark on the diagnosis of uncomplicated cholclithic
attacks : under this heading we have to consider tlie several ailments
which ma}' produce painful seizures in the right side of the abdomen.
These are : — (a) Hysteria or nervous spasms ; (^) Acute dyspepsia with
flatulency ; (y) Ajipendicular colic ; (6) Kight renal colic ; (e) Spinal
neuralgia ; (^) Malignant growth in or near the liver ; (r;) Pyloric
stenosis ; (B) Lead colic.
The diagnosis chiefly rests on paroxysmal attacks of pain, suirting in
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 241
the right hypochondrium, and radiating thence over the abdomen and
through to the right scapula — the attacks being often accompanied by
vomiting or colhipse, and sometimes followed by jaundice, although jaundice
is frequently absent. If jaundice be persistent, the presence of malignant
disease may be suspected. If, however, the jaundice be dependent on
gall-stones, ague-like attacks will probably be present.
Just as in appendicitis there is tenderness over M'Burney's point,
so in gall-stones, with very few exceptions, marked tenderness will be
found on pressing the finger deeply over the region of the gall-bladder, or
over some point between the ninth costal cartilage and the umbilicus.
In several cases that I have seen, the pain in the so-called " spasms "
has been referred to the left side, thence radiating to the left infra-
scapular region ; and in operating on such cases I have found the pylorus
adherent to the gall-bladder or cystic duct. In hysteria, the irregularity
of the attacks, their association with other neurotic phenomena such as
polyuria, globus hystericus, and so forth, together with the absence of
collapse and of the physical signs of gall-stones, will enable us to arrive
at a correct conclusion. In acute dyspepsia with flatulency, the relief
following on simple treatment, the pain over the stomach rather than over
the gall-bladder, the discovery of a manifest cause and the absence of
serious symptoms distinguish so-called stomach " spasms " from gall-stone
attacks. In appendicular colic, the almost universal signs of tenderness at
a point midway between the anterior superior spine of the ilium and the
umbilicus ("M'Burney's point"), the presence of a swelling in the right
iliac fossa or near it, and the absence of right scapular pain, render the
diagnosis of this condition free from serious difficulty, though in cases of
phlegmonous cholecystitis with peritonitis the latter has sometimes been
attributed to appendicitis instead of its actual cause. In right renal colic,
the associated urinary symptoms, together with the character of the urine
and the pain passing down the right genito-crural nerve into the testicle,
are distinctive.
In lead colic, the more or less persistent "stomach ache," the absence
of the usual gall-bladder paroxysms, and the presence of a blue line on
the gums, will usually assist in the diagnosis ; but if in doubt, the result
of treatment by iodide of potassium and saline aperients will shortly
clear it up.
In pyloric stenosis, if accompanied by adhesions around the pylorus,
the symptoms are not unlike those of gall-stones, with which, in fact, the
affection may be associated, as in several cases I related before the Clinical
Society in 1893. The presence of dilated stomach, the characteristic
vomit, the contraction of the stomach wall, the pain in the left- of the
abdomen, and the absence of the characteristic gall-bladder pain, will
usually establish the diagnosis.
In spinal neuralgia, the presence of tenderness over the spine, the
course of the pain along the branches of the corresponding spinal nerves,
the presence of tenderness of the skin, and the absence of collapse and of
vomiting put aside all difficulty.
VOL. IV R
o
242 SYSTEM OF MEDICINE
In malignant disease, the absence of pain and tenderness, or, if pain
be present, its continned character, the gradual and j)ersistent loss of
flesh, and the more marked failure of strength, usually indicate the sciious
nature of the aflection. The persistence of jaundice when once it super-
venes, the absence of ague-like attacks, and, if the disease involve the head
of the pancreas, the almost constant presence of a tumour due to cnlai'ge-
mcnt of the gall-bladder, atlbrd landmarlvS which as a rule prove true
guides ; but in many cases gall-stones exist along with malignant disease,
and then these symptoms become indeterminate, though the rapid wastiii
and loss of strength will often lead to a successful diagnosis of the co
existence of the two conditions. If nodules form in the liver, and if
ascites with oedema of the feet supervene, the condition becomes manifest
at once.
The so-called diagnostic operations of sounding for gall-stones, and
aspii'ation of a distended gall-bladder, I believe to l)c futile and dangerous ;
a small exj^loratory incision is far better, whether for information or
treatment.
The treatment of gall-stones may be considered under the headings
■ — rj'cventive. Palliative, and Radical. The two former resolve them-
selves into medical, the latter into surgical treatment.
Medical treatment. — The preventive treatment of cholelithiasis is
chiefly a matter of diet, exercise, and general hygienic surroundings.
As women suffer from gall-stones much more frequently than men, it has
been thought that their mode of dress, and es})ecially the wearing of stays,
may be one of the causes ; but probably the want of sutlicient exercise,
with constipation' and rich living, its frequent concomitants, are more to
l)lame. In prescriliing prophylactic measures one would recommend
ratijnal clothing (which of course includes the avoidance of tight lacing;,
temperance in diet, wai^m baths, fresh air and regular exercise. In
regard to diet, more depends on temperance than on the choice or refusal
of certain foods. In giving directions on diet patients may ■with advan-
tage be told to avoid over-indulgence in sweet and starch)' foods and
in rich dishes, which tend to induce dyspepsia. Alcohol should only be
taken in moderation, well diluted, and with food.
According to the views expiessed in considering the cause of the
formation of gall-stones, either a sufhciency of albuminous food in the
shape of meats or game should be taken, or farinaceous foods which con-
tain a fair proportion of nitrogen. If there be any Ijeneiit in the adminis-
tration of olive oil, the use of butter or of animal fats, if taken in
quantities short of producing dyspepsia, should have a similar eflect.
Dr. Lauder Brunton gives some valual)le hints on treatment, and
shows how the system of dieting adopted at cei-tain watering-places,
when cond>ined with exercise and the administration of diluent beverages
(water being the essential element), has very beneficial results. I have
been accustomed for some years to recommend })atients suifering from
cholelithiasis to drink a tumblerful of the natural Carlsbad water with a
little hot water before breakfast, and a tumblerful of simple hot Avater
DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 243
before the later meals ; for I think there can be no doubt that, as a rule,
too little water is taken, and the inspissated or stagnant l)ile and mucous
deposit, if not removed, will tend in the long run to form concretions ;
just as drains, if not flushed from time to time, will become blocked by
the deposit of solid matter.
Alkaline saline waters (particularly the hot Carlsbad) act beneficially
by stimulating the peristalsis of the digestive tract, and increasing the
flow of blood to the abdominal organs. In the peristalsis the bile
passages participate, and the movements of the bowels act as a form of
massage, Avhile the diseased mucous membrane benefits by the increased
flow of blood. The injection into the rectum of large quantities of hot
water serves the same purpose. When gall-stones have once formed, no
medicine, so far as we know, can dissolve them or produce any material
benefit except by way of palliation ; and although numerous remedies
have been vaunted as beneficial in the dissolution of gall-stones, their
advocates have argued as if the gall-stones were in a test-tube ; forgetting,
apparently, that no drug can reach the concretions save by a circuitous
route, and in an extremely diluted form : thus benzoic acid, benzoate of
soda, salicylic acid, turpentine, ether, chloroform, and numerous other
agents reputed to be beneficial, can really have no material effect. I
would not for a moment say, however, that rational medical treatment
may not restrict the increase of gall-stones already formed, or prevent the
formation of new ones, and thus prove really curative, if the patient have
the good fortune to part with those already formed.
The experiments of Dr. Brockbank (5) effectually dispose of the
supposition that the so-called saline cholagogues have any solvent action
on gall-stones ; for after allowing concretions to stand in a 1 per cent
solution of the various salts for fourteen days and then weighing them,
he found that there had been no loss of weight. Among the drugs ex-
perimented on were the salicylate, the sulphate, the benzoate, the
phosphate, the liicarbonate, and the chloride of soda ; the sulphate of
potash and the chloride of ammonium.
Similar experiments Avith olive oil, oleic acid, and a solution of sapo-
animalis, yielded far different results. A gall-stone, placed in pure olive
oil, in two days lost 68 per cent of its original weight, and then broke
up into small pieces. With pure oleic acid a similar result followed in a
much shorter space of time : a small gall-stone disappeared in twenty-
four hours, and a larger one, after losing 63 per cent of its weight in tAvo
days, l)roke up into small fragments in four days. The effect of a solution
of animal soap on the concretions is remarkable : after standing for a few
hours in a 5 per cent solution, a gall-stone becomes coated Avith a l)luish-
white filmy material, and in time the solid matter becomes viscid. In
view of the fact that the administration of olive oil is said to exert a
curative eflect in cholelithiasis, these experiments are interesting ; but
as there is not the slightest evidence that the oil can reach the gall-stone
in the gall-bladder or cystic duct, there must be some other than direct
solvent action to explain the beneficial efiect ; indeed, the effect itself is
244 SYSTEM OF MEDICINE
doubted by sonic observers, and requires more direct proof before it can be
accepted. An explanation is ofl'ered in Dr. Brockl)ank"s paper : — "Another
explanation of the reported disappearance of the gall-stones after large
doses of oil may be derived from the action of soap and fats on cholesterin.
A digested fat passes into the circulation from the alimentary canal in
three forms — as unchanged fat, and as the corresponding fatty acid and
soap. All occur normally in the bile, and the amount present in the bile
increases Avith the amount of fat taken in the diet. Oil, fatty acids, and
soaps all dissolve cholesterin readily and break up a gall-stone. If, then,
the oil, fatty acid and soap appear in the bile in increased amount after
large doses of oil, it is very probable that the gall-stone is attacked by
them, especially by the soap, and in time is dissolved, or so reduced in
bulk as to be enaljled to pass out into the duodenum."
I have tried olive oil in large doses in several cases, and cannot say
that I have seen any good to result from its employment, unless it were
in one case of impacted calculi in the common duct, on which I operated
after the olive oil treatment had been tried for some "weeks ; I then found
that the gall--tones yielded more readily than usual to the pressure of
the finger and thumb, as if the treatment had lessened their consistency.
The oil may be administered either by the mouth or by the rectum ;
in either case from two to ten ounces should be given daily. It is not
readily taken except with food, and then it is apt to excite dyspepsia.
Dr. Good hart gives an account of five cases of probable chole-
lithiasis in which olive oil had been administered with apparent benefit.
He remai'ks : " With reference to the results, I wish to say that it is
cbvious that I cannot claim for these cases anything more than a suspicion
in favour of the value of the administration of oil. In no one of the
cases have gall-stones l;)een proved to have passed, and in none of the
cases has the improvement been so immediate that effect and cause
certainly go together." Dr. Kishkin's experiments apparently show how
a mistaken idea of its benefit has arisen. The supposed calculi which
"were jDarted with were found to consist of oleic, palmitic, and margaric
acids combined %Wth lime ; and similar concretions could be produced
at any time by giving olive oil to any person suffering from scanty biliary
secretion ; no true gall-stones were ever found in the motions after the
olive oil treatment.
Belladonna has been said to have a specific action in cholelithiasis ;
and I can conceive that if a small concretion were passing along the ducts,
by its special action on involuntary muscular fibre, it might aid in its
expulsion. But my own experience Avould lead me to disagree entirely
with a medical writer who says that a pill containing a (piarter of a grain
of belladoiuia and a quarter of a grain of ])odophyllin resin is a remedy
as nearly approaching a specific as it is pos^i])le to obtain.
Massage finds a strong advocate in Dr. George llarley, "who says:
"For Avitliout doubt, perseverance and o])i)ortunity will in the end
enalile them (the operators) to discover gall-])ladders equally as readily
as the trained fingers of the ex])ert do, and that, too, even through
DISEASES OF THE GALL-BLADDER AND BLLE- DUCTS 245
abdominal parietes so thick tliat untrained hands cannot so miich as
make out the boundary of the solid liver through them. While,
again, they Avill ultimately find that they will be able to extrude
small impacted biliary concretions, be they in the shape of sand, gravel,
or stones, from the bile-duct into the duodenum with as much safety and
certainty as they can pass a catheter through a stricture into a human
urinary bladder. At the same time, for the sake of the patient's welfare
as well as their own reputation, they must never forget to be as careful
in the mode of operative procedure in the one case as in the other,
as neither operation is invariably unattended Avith danger. This is
especially the case when the manipulative operation has been, unfortu-
nately, delayed until the gall-stones have grown large and hard, and, on
account of the prolonged pressure, begun to ulcerate through the tissues
they have long pressed against."
It is scarcely necessary to do more than draw attention to the
description of the gall-stones at the beginning of this chapter in order to
point out how futile, nay more, how injurious massage must be in many
cases, however skilfully performed ; for not only is it unlikely, but in by
far the greater number of cases it is utterly impossible that the concre-
tions can be forced through passages as narrow as Ave know the cystic and
common ducts to be.
Some little time ago I Avas called to a distance to operate on a patient
Avho had been under this treatment judiciously and systematically carried
out, and had nearly died under the process ; so that I had to operate in a
much more unfavourable condition than AVould otherAvise have been the
case. Fortunately, hoAvever, I Avas able to remove the gall-stones, and the
patient is now well. I can only say that were I the subject of chole-
lithiasis I Avould not submit to massage, nor could I conscientiously recom-
mend it ; although it may possibly aid in the expulsion of small calculi,
it is impossible to diagnose the absence of large ones, or to knoAv the
exact condition of the ducts Avhich may possibly be ruptured by manipu-
lation.
During a gall-stone attack, relief is urgently demanded ; at times the
drinking of a pint of Avater as hot as it can be taken, especially if
combined Avith the application of hot fomentations over the region of the
liver, Avill assuage the pain ; at other times the administration of thirty
drops of spiritus etheris in tAvo teaspoonfuls of chloroform Avater eveiy
quarter of an hour Avill ansAver the same purpose. In some cases I haA'e
found exalgine, in one-grain doses, dissolved in a teaspoonful of hot Avater
and repeated every half-hour for three or four doses, to prove of service.
In many cases, hoAvever, the only satisfactory remedy is a morphia
injection.
Surgical treatment. — After medical treatment has been fairly and
fully tried and failed, I think both physicians and surgeons are noAv
agreed that surgical measures should be resorted to. While chole-
cystotomy is generally recognised as the operation to be aimed at in the
treatment of affections of the gall-bladder or bile -ducts, especially in
246 SYSTEM OF MEDICINE
cholelitbi;isis, it is often impossible to say what operation Avill have to be
done iintil the abdomen is opened.
The indications for operating would seem to me to be as follows : —
1. In frequently recurring biliary colic Avithout jaundice, with or
without enlarirement of the erall-bliuldor.
2. In enlargement of the gall-bladder without jaundice, even if un-
accompanied by great pain.
3. In persistent jaundice ushered in by pain, and where recurring
pains, with or without ague-like paroxj'sms, render it probable that the
cause is gall-stones in the common duct.
4. In empyema of the gall-bladder.
5. In peritonitis starting in the i-ight hypochondrium.
6. In abscesses around the gall-bladder or bile-ducts, whether in the
liver, under or over it.
7. In some cases where, although the gall-stones may have passed,
adhesions remain and prove a source of pain and illness.
8. In fistula, mucous, muco-pundent or biliary.
9. In certain cases of jaundice, Avith distended gall-bladder dependent
on some obstruction in the common duct. In such cases the increased
risk must be borne in mind, as malignant disease maj'^ be the cause of the
obstruction, and operation in such cases is attended with greater danger
than ordinary.
10. In phlegmonous cholecystitis and in gangrene if the case be seen
and recognised at a sufficiently early stage of the disease.
Supposing the case to be a suitable one for cholecystotomy, and the
gall-bladder and ducts can be cleared Avithout great difficulty by means
of forceps within and the fingers outside the ducts, the opening in the
gall-ljladder can be sutured to the aponeurosis — which I think preferable
to skin fixation — and so drained; this I infinitely prefer to immediate
suture of the opening.
But if the ducts cannot be cleared, what may be done 1
{a) Cholelithotrit}', or crushing of the gall-stones in place by means of
the finger and thumb, or by padded forcei)s ; I have successfully per-
formed this operation on many occasions, and I jn-efer it to the more
formidaljle procedure of incising the ducts or of fixing the gall-bladder
to the intestine.
(h) Choledochotomy, or incising the duct, whether cystic or common,
the incision being afterwards sutured ; this is no easy matter on account
of the de])th of the parts to be coa])ted ; I have found the stitching to be
best effected by means of a rectangular cleft-palate needle. A drainage-
tube should always be inserted into the right kidney pouch in these
cases ; and if a transverse incision be made and the tube brought out
through the lower end of this, the drainage is so efficient that even if the
sutuies fail to close the wound in the duct there will be little fear of
extravasation.
(f) Cholecystenterostomy, or the making of an anastomosis between
the gall-bladder and intestine, is easily effected if the gall-bladder be
DISEASES OF THE GALL-BLADDER AND BILE VUCTS 247
dilated, but with difficulty if the gall-bladder be contracted, as often is
the case. I have performed this operation six times, with immediate
success and recovery in all, and with complete and permanent cure in
five. ]My decalcified-bone bobbin enal)led me to accomplish the anas-
tomosis rapidly. Howe"\"er, I used " Murphy's button " in my last three
cases, and in future I shall always employ it in such cases, as being a
more speedy method.
((/) The daily injection of fluids, after an interval of some days,
through the cholecystotomy opening, Avliich will either soften or dissolve
the concretions. For this I have used hot Avater, ether, and ether and
turpentine Avith more or less success ; but I think Dr. Brockbank's
suggestion to use an injection of olive oil, or of oleic acid, or a 0"5 per
cent solution of sapo-animalis, is worth a fuller trial.
(<?) Cholecystectomy, or excision of the gall-ljladder, can seldom be
advisable or necessary as a primary operation in gall-stones, and extremely
rarely possible in malignant disease. It may be required as a secondary
operation in cases of stricture of the cystic duct, the common duct being
free. On three occasions in which I have excised the gall-bladder it was
for mucous fistula depending on stricture of the cystic duct following on
gall-stones, and all the patients were completely and permanently cured.
In cholecystotomy, where it is impossil)le to bring the margins of the
incised gall-bladder into the wound, and where the parietal peritoneum
cannot be tucked down to meet the edges of the opening, I have made a
tube of the omentum ; but in such cases no hesitation need be felt in
trusting to a drainage-tube, as the peritoneal cavity soon becomes
occluded around the drain, and there is little or no tendency for the
bile to pass among the viscei'a ; a suprapubic drainage opening, therefore,
is quite unnecessary.
The combined button and drainage-tube suggested by Dr. Murphy
may prove useful in some cases of this kind ; but as the gall-bladder is
usually shrunken, I susjiect it will be of service in exceptional cases only.
With very few exceptions, I have found a vertical incision along the upper
part of the right linea semilunaris to give ample room, but if I'equired I
have not hesitated to get further room by a transverse cut in addition.
Suture of peritoneum, aponeurosis, and skin by separate stitches
effectually guards against ventral hernia, if the patient be kept recumbent
for from twenty-one to twenty-eight days ; and if a firm oval pad be worn
under a belt for a few months subsequently. In all cases strict antiseptic
precautions should be observed, and the abdomen must be left as clean
and dry as possible.
In conclusion, I would emphasise that with due skill and adequate
care, operations on the gall-bladder and bile -ducts are among the most
successful of the major operations ; but as many of them are extremely
difficult, and as it is impossible to say beforehand whether any case may
not prove so, I think such surgical work should be undertaken only by
those who have had experience in abdominal surgery, and who have
witnessed or helped in several operations of this kind. As soon as this
248 SYSTEM OF MEDICINE
rule is miderstood we shall cease to witness the var3nng rates of mortality
in the hands of ditierent operators — from 50 to almost 0 per cent — and
we shall probably find that, excluding cases of malignant disease associated
with jaundice, the all-round mortality will not exceed 5 per cent. I hope
the time is not far distant Avhen it will he fully recognised that though
chololithiasis, so far as its causes and its early treatment are concerned,
is distinctly a condition for medical treatment, it is both unjust to the
patient and unfair to the profession to continue medical treatment and
to postpone surgical aid until serious complications supervene, or the
patient is almost, if not quite past relief.
A. W. JVIayo Robson.
REFERENCES
1. Barbacci. Medical and Surgical Be.ports, June 1, 1889. — 2. Biggs, G. P.
New York Hospital Gazette, 1895. — 3. I5iucH, Dk Buiigh. Journal of Physiology,
No. vii. — 4. Bkockisaxk, E. M. On Gall-stones. London, 1896. — 5. Idem.
Medical Chronicle, November and December 1893. — 6. BurxTux, Lauder. Goul-
stonian Lectures, Brit. Med. Journ. 20111 June 1891. — 7. Chadwick. Brit. Med.
Jonrn. Jan. 1895, p. 1143. — 8. Charcot. Maladies du Foie, 1877. — 9. Charcot and
GoMiiAULT. Arch, de physiol. et path. 1876.— 10. Courvoisier. Casuistisch-Stat.
Beitrdcje z. Path. u. Chir. d. Gallentvegc. Basel, 1890. — 11. Donkix, H. B. Lancet,
Jan. 5, 1895, p. 28.— 12. Escherich. FortschrUt drr Medccin, 1885.— 13. Fexger.
Amer. Jour, of Med. Sciences, Feb. 1896. — 14. Gilbert and Dojiixin. Compt. rend.
See. Biol. Dec. 23, 1893.— 15. Gilbert and Girode. Ibid. 1890, No. 39.-16. Ibid.
Dec. 2, 1893.— 17. Goodhart. Brit. Med. Journ. 30th Jan. 1892.— 18. Harley, G.
Medical Annual for 1890. — 19. HuTCHKiss, L. W. Annals of Surgery, Feb. 1894. —
20. Lake. Lancet, March 1894.-21. Lane, W. A. Lancet, Feb. 25, 1893.— 22.
LocKWOOD, C. B. Lancet, March 2, 1895. — 23. Mitsser. Boston Med. and Surg.
Joum. Oct. 15, 1889. — 24. Nauxyn. Kliii. dcr Cholelithiasis, 1892. — 25. Netter.
Progrhs medical, 1886. — 26. Norton, C. A. Lancet, 1893.-27. OiiD. Address to
Brit. Med. Assoc. 1887. — 28. O.sler. Principles and Practice of Medicine. — 29. Idem.
"Symptoms of Chronic Obstruction of the Common Bile-duct by Gall-stones," Annals
of Surg'^ry, March 1890. — 30. Potain. Journ. denied, etchir. Nov. 1882. — 31. Robson,
A. W. ]\L Proc. Royal Sac. vol. xlvii. — 32. Rolleston. Med. Chronicle, Jan. 1896. — 33.
ScHROEDER. Statistics quoted ill Dr. Brockbank's paper. — 34. Swaix. Lancet, Mar. 2i,
1895. — 35. Idetn. Lancet, March 23, 1895.-36. Terrier. Brit. Med. Jonrn. 1894.-37.
Thudichum. Treatise on Gall-stones, 1863. — 38. White, Dr. Hale. Path. Soc. Trans.
vol. xiii, — 39. Willards. Trans. Amer. Med. Assoc. 1893. — 40. "Williams and
Sheild. Lancet, March 2, 1895.
A. W. M. R.
CHOLANGITIS 249
CHOLANGITIS
Infective Cholangitis, or infective catarrh of the bile-ducts, is usually
due to gall-stones in the common duct, which favour the entrance of
organisms from the intestine through the duodenal oi'ifice.
Courvoisier, Osier, and Feiiger have each described the ball-valve
action of gall-stones in a dilated common bile-duct or in the ampulla of
Vater ; thus accounting for the intermittent character of the jaundice and
the irregular course of the disease. ,
Charcot was one of the first to describe the disease under the name
of intermittent hepatic fever.
I have operated on a considerable number of cases of infective chol-
angitis dependent on gall-stones in the common duct, but although on
several occasions the gall-stones were freely movable or even floating,
in by far the greater number they were multiple and more or less
impacted.
The usual history is one of spasms for several years without jaundice ;
then comes a more severe seizure followed by temporary icterus. If the
gall-stone pass, there is an end of the trouble ; if not, the next attack of
pain is probably followed at once by a shiver and by all the symptoms
of an "ague fit," the temperature frequently reaching 104° or 105°.
After it has passed off, the skin is more deeply tinged and the jaundice
may persist, though inconstant in degree ; it rarely, however, disappears
completely between the attacks ; there is usually a slight icteric tinge of
the conjunctivae, even though the interval between the attacks may be
one of weeks or months. The rigors may be repeated daily or at
irregular intervals.
The gall bladder may be felt as an enlargement below the right
costal margin, but this is not usual, as if gall-stones be present it is
more common to find the gall-bladder contracted. The liver at first is
not enlarged, but later it may descend considerably. Tenderness over
the gall-bladder or in the epigastric region can generally be elicited. There
is usually well-marked loss of flesh and strength ; and, if unrelieved by
nature or art, the disease may run on into suppurative cholangitis and its
complications.
Infective cholangitis may persist off" and on for years, and may lead
to recovery ; on the other hand, it may assume an acute form and lead
to death from pain, biliary toxaemia and exhaustion. The complications
which may follow are diffuse hepatitis, abscess of the liver, cholecystitis
and empyema of the gall-bladder, perforation of the ducts, endocarditis,
pleurisy, pneumonia, and other septic diseases.
Diagnosis. — Ague, being now a rare disease in England, is not so
readily assumed as it is in countries where malaria is endemic, though
the regularity of the chills and the slight jaundice and enlargement of the
250 SYSTEM OF MEDICINE
spleen in some cases may suggest it ; yet the pain and tenderness, the
history of cholelithiasis, and the failure of relief by large doses of quinine,
soon settle any doubts.
As infective diseases in the bile passages are prone to end in suppura-
tion, abscess of the liver and suppurative cholangitis maj^ supervene ; Ijut
the more i^rolonged course of infective cholangitis, the comparative good
health between the attacks, the irregularity in the course of the disease,
and the absence of rajjid and progressive deterioration of health Avill
usuallv enable a diagnosis to be made.
"When suppuration exists Ave usually find increased tenderness over
the liver area, continued or irregular intermittent fevei', and intense and
persistent jaundice.
Treatment. — If possible the cause should be removed, but, should this
prove impossil)le, the ducts can be drained ; fortunately this may be
accomplished Avith every prospect of success, if, as is commonly the case,
the primary disease be gall-stones. For instance, I have operated on
two hundred cases of disease of the gall-bladder and bile-ducts, and in
no case Avhcre gall-stones were unaccompanied by malignant disease or
by suppurative cholangitis have I lost a patient; even if I include
all the complicated cases, the rate of recovery is still 96 per cent.
Indeed, there can be no doubt in the piinds of those Avho have observed
many of these cases that it is better to anticipate the complications ; and
that as soon as medical treatment has been fairly tried and failed, the
removal of gall-stones by surgical means should bo resorted to.
Suppurative cttolangitis of the bile-ducts is a subject of consider-
able interest both to the physician and surgeon. Its gi-avity lies not
only in its causation, but in the combined effects of biliary obstruction
Avith septic infection, and their local and constitutional effects also.
Etiolog'y. — The most frequent cause is gall-stones, and of this series
the museums furnish many examples. One in Gu3''s Museum shoAvs the
ducts throughout the liver inflamed, dilated, and associated Avith several
small abscess cavities ; the cause being a gall-stone floating in the common
duct. The parts Avere taken from a Avoman, aged thirty, Avho had had
enteric fever five months before death ; the death Avas due to pyrexia
accompanied by rigors.
But, besides gall-stones, hj^datid disease, cancer of the bile-ducts,
typhoid fever, and influenza may cause suppurative cholangitis ; and I
suspect that the disease not infrequently accompanies other acute infectious
ailments.
There are good examples of cholangitis due to hydatid disease in
St. Bartholomew's, Guy's, St. George's, and the Middlesex JNIuseums ; so
that it is evidently no infrequent cause. In some of these instances a
hydatid C3'st has burst into a bile-duct, and in scAx-ral of these a piece of
rolled-up hydatid membrane projects through the papilla into the duo-
denum. In all these cases the ducts throuifhout the liver are dilated
and filled Avith pus.
CHOLANGITIS 251
Some years ago I operated on a case of suppurative cholangitis
dependent on malignant disease in the common duct. The patient was
decidedly relieved for a tirne by the drainage established by chole-
cystotomy ; he ultimately died, however, from the original disease, and at
the autopsy the whole of the ducts throughout the liver were filled with
muco-pus.
A very good example of suppurative cholangitis arising as the result
of cancer of the ampulla of Vater may be seen in St. Thomas's Museum.
In typhoid fever the disease arises irrespective of any organic
obstruction in the ducts, as is shown by a specimen of Dr. Hale White's
in Guy's Museum, where death occurred in the seventh week of typhoid ;
there was inflammation of the bile passages within and outside the liver,
together with cholecystitis.
I do not think that influenza has been noted as a cause of suppurative
cholangitis. I observed the connection some time ago ; and the symptoms
were so characteristic, and came on, in a lady of sixty-two, within so short
a time of influenza, that I think there is every reason to believe this infec-
tion to have been the origin of the suppuration.
The aforementioned diseases are somewhat remote terms in the series
of causation ; the immediate cause is the presence of pyogenetic organisms
within the biliary passages.
Symptoms. — In suppurative cholangitis there is usually progressive
enlargement of the whole liver, which may descend as low as the
umbilicus ; the swelling being uniform, smooth, and tender to pressure.
If the cause be in the common duct, and the gall-bladder has not pre-
viously become contracted, there will be the additional enlargement
caused by its distension ; but when contraction of the gall-bladder has
taken place, and also when the obstruction is in the hepatic duct, there
will be no signs of cholecystitis.
Pain may be entirely absent, as in one case on which I operated,
where the disease was dependent on cancer of the common duct ; but
when the cause is gall-stones, as in many cases that I have seen and in
some on which I have operated, the pain is severe and paroxysmal,
each attack being accompanied by ague-like seizures and an intensification
of the jaundice. Jaundice is ahvays present, and is usually both per-
sistent and intense ; though where the obstruction is a floating gall-stone,
acting like a ball-valve in the common duct, the jaundice may vary from
time to time, or may almost disappear. Fever, with occasional rigors
and profuse perspiration, is a prominent feature of the disease, and rapid
loss of flesh and strength likewise. The disease is always serious, and
often proves fatal ; though, if the cause can be removed at an early stage,
recovery may occur.
If the course be subacute the inflammation may concentrate itself in
some part of the liver and lead to abscess ; in this case a distinct tender
swelling may form and give rise to the usual symptoms and signs of
hepatic abscess. If ordinary infective cholangitis pass on to general
suppurative cholangitis recovery is improbable.
252 SYSTEM OF MEDICINE
Hepatitis and multiple liver abscesses frequently follow cholangitis,
and are usually followed l)y general and fatal infection of the system.
Pneumonia and pleurisy ending in emp\ema are serious and not
infrequent complications.
Endocarditis at times occurs, and as it has heen known to follow
cholangitis without hepatitis, and cholangitis without abscess, this cause
should never be lost sight of in any case of infective endocarditis.
In these cases the bacillus in the vegetations on the inflamed endo-
cardium has been found to be identical with that discovered in the
infected bile.
Jaccoud and Aiibert have also found endocarditis in cases of
cholangitis.
Treatment. — Unless free evacuation of the infected contents of the
bile passages can be accomplished, either naturally or artificially, treatment
is virtually useless. If practicable, cholecystotomy should therefore be
performed, and free drainage established and continued until the bile is
sterile, or nearly so. Although good results cannot be expected in all
cases, an amelioration of the symptoms may be looked for in a fair pro-
portion, and complete relief in others.
If a localised abscess be discovered in the liver, it should be opened
and drained, and though in these serious cases it is scarcely to be expected
that operation can be always successful, the chance of permanent benefit
is worth snatching at, even under the most desperate conditions. Of
general means, warm applications to the hepatic regions, an initial
mercurial purge followed by milder saline laxations, intestinal antisepsis
by bismuth and salol, the relief of pain by sedatives if called for, and the
treatment of symptoms as they arise, will afford some amelioration, though
the relief Avill probably be but temporary.
Surgeons have been performing cholecystotomy for infective cholan-
gitis for some years (for instance, my first operations for cholecystitis and
cholangitis occurred so far back as 1888); yet I think it is just to give
the chief credit of specially pointing out the great importance of surgical
treatment in cholangitis to M. Terrier.
On the opening of the gall-bladder a certain number of important
therapeutic results follow.
1st, The septic contents of the gall-bladder are evacuated. 2nd, Calculi,
which are most frequently present there, are removed. 3rd, The other
biliary passages, more or less obstructed either by calculi or by swelling
of their walls, are rendered as free as possible. 4th, The septic bile is
allowed to escape and mechanically washes out the lower passages, carry-
ing away through the drainage-tube many of the infectious elements.
5th, The relief of pressure prevents absorption of the septic elements.
6th, The relief to the kidneys, by allowing the bile to escape freely, is
also of importance ; as they are thus enabled to perform their function
more freely in relieving the system of septic and other materials.
In the paper referred to, M. Tenier narrates several cases in the
utmost detail, an account especially interesting, as he describes the
CONGENITAL OBLITERATION OF THE BILE-DUCTS 253
bacteriological examination of tlie discharge from the fistula at different
dates, and conclusively shows the gradual diminution in the virulence of
the discharge after some days' drainage, and points to the need of
rather more prolonged drainage than some of us have been wont to
employ ; until, indeed, the bacteriological examination of the discharge
shows it to be sterile, or nearly so.
A. W. Mayo Robson.
REFERENCES
1. Charcot. Maladies du Foic, 1877. — 2. Jaccoud and Aubert. Clin. m&l. de
Lariboisiere. — 3. Netter and Martha. Arch, de phijsiol. vol. ix. 1886. — 4. Ord.
Brit. 31ed. Journ. Aug. 1887. — 5. Osler. Annals of Surgery, 1890. — 6. Robson,
Mayo. On Gall- Stones, 1892.— 7. Terrier. Rev. de chir. 1895, p. 966.
A. W. M. R
CONGENITAL OBLITERATION OF THE BILE-DUCTS
Deseription. — Under the heading of " Congenital Obliteration of the
Bile-ducts " may be described a series of cases of infantile jaundice in
Avhich there is a progressive inflammatory condition of the bile-ducts and
gall-bladder. The morbid process originates in intra-uterine life from an
unknown cause, leads generally to complete obliteration of the lumen
of the aff'ected parts accompanied by biliary cirrhosis of the liver, and
always ends in early death.
The disease is a comparatively rare one, but some sixty or seventy
cases authenticated by post-mortem examinations have been put on
record. It presents features of considerable interest, not only on
account of the obscurity of its causation, but also because it represents, as
it were, one of Nature's attempts at " experimental pathology."
Clinical features. ^ — The parents of the patients seem generally to
have been healthy people, and yet, in a considerable proportion of the
cases, it is found that they have previously had one or more infants
similarly aff'ected. Instances are on record where as many as seven or
even ten cases of infantile jaundice, apparently of this nature, have
occurred in one family. Boys are affected about twice as often as
girls.
At birth the child appears normal and well nourished, and nothing
attracts special attention to it until either the whiteness of the stools or
the yellow discoloration of the skin is noticed.
The jaundice is always a very marked feature, but the date of its
onset varies considerably. Sometimes it is present at birth, often it is
not noticed until the second or third day of life, occasionally it does not
set in until the ninth, tenth, or even fourteenth day. When first observed
254 SYSTEM OF MEDIGINE
the yellow colour is slight in degree, but Avithin a day or two it noticeably
deepens, and soon becomes of a dark greenish-yellow hue. It remains
until death ; it may, however, vary a little in intensity from day to day,
and, if the child live for some time, the tint is often paler during the
last few weeks.
It is to be observed that in those cases where only one of the hepatic
ducts is obliterated, and also in those where all the ducts seem pervious,
the jaiuidice may be just as severe as where the common duct is completely
obstructed.
In some cases a quantity of dark, apparently normal meconium is
passed in the usual way, and is followed at once by colourless motions ;
in others the faeces are devoid of colour from the very first. Rarely are
any yellow fiieces passed, but after a dose of mercury the stools may be
partially greenish for a time. The bowels are generally costive. The
urine is deeply bile-stained.
The occurrence of spontaneous haemorrhages in various situations is a
very characteristic symptom. A considerable number of the children suffer
from bleeding at the na\'el, a sym})tom which usually sets in shortly after
the separation of the cord (hfth to ninth day). It is of the nature of a
general oozing from the raw surface, and is exceedingly difficult to stop ;
indeed it almost invariably results in death within two or three days at
the farthest. Of those patients who survive the first fortnight a large
number suffer from spontaneous bleeding from other parts, such as sub-
cutaneous ecchymoses or epistaxis ; or the blood may be vomited, or passed
with the motions.
If the children are not carried off by haemorrhage or some othei- such
cause duiing the fii'st week or two, they generally live from three to
eight months. It is interesting, however, to observe that in those
instances in which more than one child in a family was aftected the
tendency to haemorrhage is particularly sti'ong, and the patient scarcely
ever survives the first fortnight.
Towards the end of the case there is more or less emaciation ; but the
interference with the general nutrition is usually much less than might
be expected from the gravity of the lesion. Fits not infi'equently come
on, and, in the exhaustion of appi'oaching death, some intercuri'ent
disease, perhaps of a trifling kind, brings life to a yet earlier close.
Morbid anatomy. — The degree of the lesion affecting the bile-ducts
and the gall-bladder varies to a very large extent in difierent cases. In a
few, where the patient has not lived more than a week or two, no disease
may 1>c visil)le to the naked eye, and no evident obsti'uctiou to the out-
flow of bile may be discovered ; in others the walls of the ducts are
markedly thickened here and there. In most cases, however, some
poition of one or other of the ducts or of the gall-bladder has its lumen
completely obliterated, and the fi])rous tissue round it is greatly increased
in amount. Not infrerpxently parts of the affected structures have
disappeared entirely, so that after death there is not even a strand of
fibrous tissue to be found in theii- })lace. Extreme defects of this kind
CONGEmTAL OBLITERATION OF THE BILE-DUCTS 255
are most frequently found in cases where the patient has lived for
months ; but sometimes this is the state even at birth.
The exact site of the obliteration, when present, also varies in-
definitely, there seems to be no place more apt to be affected than
another.
The contents of the gall-bladder and ducts are by no means constant.
If the child have lived more than a month it is usual to find colourless
mucus only in the gall-bladder. Where coloured bile is present it is
often described as unusually thick ; and in one case (Campbell) the common
duct was found blocked by an indurated cord-like plug of inspissated
bile. In at least one instance (Bouisson) a gall-stone was found; and it
seems quite possible that most, if not all, of the very rare cases in which
gall-stones have been reported (IS) in young infants may be examples of
this disease.
Reports of microscopic examinations of the affected parts and the
tissues in their neighbourhood are much wanted. In one case (2.3), where
the lumen of the gall-bladder was almost totally destroyed, its walls were
found enormously thickened and infiltrated with round cells, so as to look
like granulation tissue. AVhat remained of the cavity, however, was lined
with cylindrical epithelium of normal appearance.
The blood-vessels of the liver are normal in uncomplicated cases.
The li\er itself, when the child has lived for any length of time, is
generally Ijut not always enlarged. It is very tough in consistence,
slightly uneven on the surface, and of a dark olive-green colour ; on
section it shows fine bands of fil:)rous tissue forming a network through
it. Under the microscope the size and consistence of the organ are found
to be due to the presence of tyjDical biliary cirrhosis, and the green
colour to innumerable small plugs of inspissated bile which distend the
lesser ducts in many places up to their farthest ramifications ; they may
even seem to occupy miiuite cavities within the liver-cells.
The spleen is usually much enlarged.
The peritoneum, in most cases, is quite free from traces of disease,
either past or present ; but occasionally ascites or purulent peritonitis
has been found. In a few of the reported cases there were adhesions
in the neighbourhood of the ducts imjjlicating the blood-vessels ; in almost
all of these there was good reason to suspect the presence of syphilis.
Nature and progress of the disease. — The nature of the lesions of
the gall-]jladder and ducts is such as to indicate that they must be the
result of chronic progressive inflammation affecting the walls of these
structures in a considerable extent of their course.
When this morbid process begins we cannot say ; but certainly the
period at which complete obstruction to the passage of bile occurs varies
very greatly. In those cases in which no coloured meconium is passed it
seems as if the ducts must have been blocked not later than the third
month of intra-uterine life ; while in others, where the amount of ordinary
meconium is normal, the obstruction cannot have taken place until a very
much later period.
2;6 SYSTEM OF MEDICINE
The inflammatory lesions follow the course of the bile so closely that
we can scarcely avoid the conclusion that they are secondary to some
irritating change in the character of this fluid. That inspissated bile and
gall-stones should have been found is, therefore, of importance. The
frequent occurrence of complete stoppage of the passage of bile before
there is any absolute anatomical blocking of the lumen of the ducts is
also worthy of note, and suggests the possibility of a descending catarrh
from irritating bile, such as is said to occur in poisoning by toluyl-
endiamin and other substances (Stadelmann, Hunter).
Probably by the time that the infant is born the disease is always
pretty far advanced. After birth the inflammator}'^ process continues to
spread, and leads to extensive obliteration and deformity ; just as it
sometimes does in adults when there is an impacted gall-stone (Courvoisier).
The longer the child lives the more advanced, as a rule, is the de-
formity which is met with after death.
When the disease has gone on far enough to cause interference with
the free passage of bile from the liver, biliary cirrhosis begins, as it does
in the livers of animals Avhose common duct has been tied (Charcot and
Gombault) ; and the amount of glycogen is diminished (Legg). This
results in an increasing interference with those important functions of the
liver by virtue of which it protects the organism from the dangers of
auto-infection (Roger). To a sort of chronic blood-poisoning are due such
symptoms as the vomiting, spontaneous haemorrhages, and convulsions ;
and it gradually leads to emaciation, diminished vitality and death.
Etiolog"y. — The causation of the disease is still most oliscure. It
seems certain, however, that congenital syphilis is not an essential
element, although this has often been alleged. We learn from a study
of the published cases that — (i.) Evidence of syphilis in the parents has
very rarely been obtained — not in a tenth of the cases ; (ii.) The brothers
and sisters of the patients seem never to have shown signs of it; (iii.) In
twenty-three cases, where the infants lived to be three months old and
upwards, only tA\ace wei'e there noticed any of the symptoms which are
u.sually attributed to congenital syphilis ; (iv.) Ordinary sj^philitic lesions
have scarcely ever been found post-mortem in patients who' have died of
this disease. As already mentioned, however, it is just possible that
the presence of this taint may promote the farther extension of the
disease.
Severe digestive disturbances have been noted in the parents in several
cases ; and have been regarded as perhaps of etiological importance (Binz,
Glaister).
The very remarkable fact that the disease so frequently occurs in
several mem])ers of one family is one which nuist be taken into account in
any theory of its etiology. This, and the very early period at which the
morbid process begins, have led to its being attributed to an arrest of
development. Nothing definite, however, can be said in support of this
opinion.
The diagnosis may present some difficulty at first ; but within a few
CONGENITAL OBLITERATION OF THE BILE-DUCTS
'■:)i
days tliG deepening jaundice, colourless motions, and bile-stained nrine
render it evident that there is something more serious the matter than
ordinary icterus neonatorum. Moreover, the comparatively slight effect
produced at first upon the child's general health readily distinguishes
these cases of jaundice from those associated with umbilical phlebitis and
like septic conditions.
As the child grows older the occurrence of spontaneous hsemorrhages
and the gradual enlargement of the liver and spleen strongly confirm the
diagnosis.
The ppogncsis is, of course, of the utmost gravity ; no child proved
to have this com])laiut has ever lived eight months. It. should be men-
tioned, however, that a few cases of infantile jaundice have been reported
as ending in recovery which, from their symptoms, and from their occur-
ring in the same families as other children with obliterated bile-ducts, seem
possilJy to have been cases of this disease (Anderson, Freund, Grandidier).
Treatment. — Our ignorance of the causation of the disease, and the fact
that it begins during intra-uterine life, put curative treatment out of the
question in the only stage at which it could possibly be of any avail.
In a recent case (Giese) the abdomen was opened during life in the hope
that, if the obstruction were situated low down, it might be possible to
re-establish communication between the bile-channels and the intestine.
This was not found practicable ; and the pathology of the disease certainly
gives us little encouragement to expect even temporary relief from any
surgical procedure.
John Thomson.
REFERENCES
1. Andekson. i?os<o?iil/co?. a?ic?;S'i<r(7. JbMr?i. 1850, Jan. 2, p. 440. — 2. Binz. Virdiovfs
Archiv, xxxv. S. 360. — 3. BouissoN. Dc labile, de ses varieUs, etc. JMoutpellier, 1843.
— 4. Campbell, A. D. Northern Journ. of Med. Aug. 1844, p. 237. — 5. Charcot and
GoMBAULT. Arch, de jihysiol. iii. 1876, p. 273. — 6. Cheyxe. Diseases of Children,
vol. ii. p. 8. — 7. CouKVoisiER. Casuistisch-Statistischc BcitrdcjC z. Path, xmd Chimrcj.
d. Gallenicege. Basel, 1890. — 8. Fkei'XD. Jakrh. f. Kindcrhcilk. ix. 1876, S. 178. —
9. Gessner. Ueber congenital en Verschluss der grosien Gallengdnge, Diss. Halle, 1886.
— 10. Giese. Jahrh. f. Kinderhcilk. sMi. \^^Q, S>. 2b'2. — 11. Glaister. i«?i(;c<, 1879,
i. p. 293. — 12. Gr.^xdidier. Journal f. Kinelerkreinkheiten, May 1859, S. 380. — 13.
Henoch. Lectures on Children's Diseases, New Sydenham Soc. Tran>l. vol. i. p. 28.
— 14. Hunter, W. Journ. of Path. a?id Bacterial. July 1895, p. 264. — 15. Legg,
WicKHAM. Bile, Jaundice, and Bilious Diseases, 1880, p. 641. — 16. Idem. St. Bart.
Hasp. Rep. 1873, ix. p. 178.— 17. Lotze. Berlin, klin. IVocherschr. 1876, No. 30, S.
438. — 18. Mercat. " De la coliqne hepatiqiie chez I'enfant," These de Paris, 1884. —
19. Roger. Gaz. des h6p. 1887, No. 66, p. 525. — 20. Smith, Eu.stace. Disease in
Children, 3rd edit. p. 718. — 21. Stadelmann. Der Icterus, Stuttgart, 1891, S. 260.
— 22. Thomson, John. Edi^i. Med. Journal, Dec. 1891, and Jan. and Feb. 1892 ; tliis
paper gives an almost complete list of previous cases. — 23. Idem. Edin. Med. Jo-urn.
June 1892. — 24. Underwood. Diseases of Children, 5th edit. vol. i. p. 29. — 25.
"West. Diseases of Infancy and Childhood, Sth edit. p. 718.
J. T.
VOL. IV
2^S SYSTEM OF MEDICINE
ICTERUS NEONATOKUM
Synonyms. — Xormal, physiological, or idiopathic jaundice of new-born
children.
Description. — Icterus neonatorum is a mild transitory form of
jaundice of unknown etiology, which appears soon after hirth in a large
proportion of children otherwise normal, and passes off without subsequent
ill effects.
Clinical features. — The disorder is an extremely common one, being
met with, in a more or less marked degree, in a very large numl)er of
new-born children. Thus, Runge states the proportion of infants affected
in this way as 80 per cent, Porak as 79-90 per cent, and Bouchut at
80-90 per cent. Probably the lowest pi'oportion given is that of Holt,
who reports that of 900 children born in the Sloane Maternity Hospital
in New York, 300 were icteric.
It seems to be a matter of general experience that this discoloration
is more freqiiently observed in hospital than in private practice. This
has been attriljuted to the weakliness of hospital infants ; but this may
be but an apparent prevalence due to the good light more uniformly
obtainable in institutions than in the bed-i'ooms of I3ri\'ate houses.
Certainly, however, it is more common in weakly infaiits with atelectasis,
and in those that are born prematurely. Tlie presentation at birth, the
duration of the labour and its character — whether natural or artificial —
are said to have no infiuence upon its production (Holt) ; and it is
doubtful Avhether one sex is more aff'ectcd than the other.
The yellowness of the surface of tlic body is generally the only dis-
coverable symptom ; the children in all other respects being perfectly well.
The icteric tint is usually seen for the first time on the second or third
day of life, or a day or two later. It increases in depth for one or two
days and then slowly disappears. In slight cases it maybe quite gone in
three or four days ; often it lasts a week or more ; but rarely, and in very
severe cases only, does it persist for more than a fortnight. The degree
of the discoloration varies from the slightest perceptible tinge to a deep
yellow. When extremel}' slight it is best detected by pressing the ])oint
of the finger on the infant's red skin, and looking for a yellow tinge on
the pale spot which the pressure produces.
The distribution of the jaundice and the order of its appearance are
somewhat peculiar. First, and most distinctly, it is seen on the skin of
the face — especially on the forehead and round about the mouth — and on
the chest ; later it appears on the sclerotics, and last of all on the hands
and feet. Compared with the skin, the sclerotics are usuall}'^ but slightly
aff'ected, and sometimes they remain quite normal in appearance. The
slight and late in)])lication of the eyes in these cnses is an interesting
point, as in ordinary obstructive jaundice the sclerotics are usually
among the parts first and most deeply aff'ected. The peculiarity is
ICTERUS NEONATORUM 259
perhaps better expressed by saying that the skin in this form of jaundice
is particularly early and particularly deeply tinged. This makes the
degree of the jaimdice appear much greater than it really is ; this is to be
attributed to the fact that the new-born infant's skin is especially
hypertemic (Cruse).
The urine, in most cases, appears quite normal, and does not leave a
yellow stain on the child's napkins. In severe cases, however, bile
pigment is present in it to such an extent as to discolour it. Parrot and
Eobin found little amor})hous irregular masses of yelloAV pigment, some-
times floating free in the urine, sometimes embedded in epithelial cells
and tube-casts. It seems that bile acids, although present in other fluids
of the body, have never been demonstrated in the urine. According to
Hofmeier, uric acid and urea are excreted in larger amount than by non-
icteric children.
The faeces are normal in colour and in other respects. They are
never decolorised as in ordinary obstructive jaundice.
Morbid anatomy. — Nearly all the internal organs show a yellow
tinge, and this is true even of such tissues as the cartilages, brain, and
spinal cord, which in adult jaundice are not generally discoloured. The
tinge, however, is but slightly marked in the spleen and kidneys, and in
the liver it is rarely discernilile to the naked eye even in the most severe
cases. The intima of the arteries, the endocardium, and other serous
membranes, and also the serous fluids are deeply stained. The pericar-
dial fluid contains not only bile pigment but bile acids also, as Birch-
Hirschfeld, Hofmeister, and Halberstam have demonstrated.
The bile-ducts are normally formed and pervious ; and apart from
the general bile-staining of the tissues, no abnormality of any of the
organs is discovered. In the necropsies which have been recorded,
however, the condition of the ductus venosus, as to patency, does not
seem to have received the attention it deserves.
Etiology. — A very large number of hypotheses have from time to
time been propounded by eminent pathologists to account for this
malady. Many of these have turned out to be baseless assumptions ;
others are still put forward as satisfactory explanations of the phenomena.
None of them, however, has yet found adequate verification.
That bile acids as well as bile pigment are found in the pericardial
fluid of icteric new-born children, and not in that of others, proves con-
clusively that the yellow colouring matter is really bile and comes from
the liver. This effectually disposes of some of the older views, according
to which this condition was a purely hsematogenous form of jaundice, or
even no jaundice at all, but merely a kind of local discoloration due to
the red of the hyper^emic skin turning yelloAv as a bruise does in the
process of fading. Soon after birth very radical changes take place in
the child's digestive organs and in its blood ; these changes make it
probable that at this time of life an especially large secretion of highly
pigmented bile may occur as a physiological phenomenon. Yet how does
this bile finds its way into the general circulation ?
26o SYSTEM OF MEDICINE
The most important of the hypotheses which have been proposed to
exphiin this problem may be summarised (Runge) as follows: —
i. A large numl)cr of observers have supposed that the hindrance to
the outtiow of bile lies in the bile-ducts themselves. Thus Yirchow
thought that plugs of mucus, which he found in the common duct, were
the main cause of the jaundice ; and Cruse and Epstein assimied that the
circulatory changes occurring at birth induced hyperpemia and catarrh of
the bile-ducts, with blocking fnmi the desquamation of their epithelium.
Kehrer, again, suggested that the bile-ducts must be the seat of positive
congenital narrowing ; and Cohnheim, that the bile Avas so much increased
that the normal ducts became inadequate for its free escape for the time
being.
ii. Others have attrilmted the supposed arrest of the flow through
the bile-ducts to pressure on them from Avithout by neighbouring blood-
vessels. Weber thought that in the course of the ordinary circulatory
changes following birth, the portal and heimtic veins might become so
distended as to exert pressure on the ducts. Birch-Hirschfeld supposed
that during or after birth the area supplied by the umbilical and portal
veins becomes engorged, and that this leads to oedema of the connective
tissue of Glisson's capsule, and thus to compression of the ducts. Silber-
mann drew attention to the destruction of coloured blood -corpuscles
observed by him and Hofmeier in new-born children. He pointed out
that where blood-dissolving processes go on there must be an increase in
the fibrin ferment in the blood ; so that the infant gets into a state of
slight " fermentsemia," as he barbarously calls it. This would give rise
to stasis and thrombosis in the portal system, resulting in compression of
the bile -ducts and consequent reabsorption of the stagnant richly-
coloured bile.
iii. Another group of authors, of whom Frerichs is the most prominent,
say that the reabsorption of bile is due to a lowering of the blood-pressure
in the capillaries of the liver tissue following on the closure of the
umbilical vein.
iv. In 1885, Quincke proposed a very ingenious explanation which
differs materially from those formerly suggested, and has not yet been
disproved. He supposes that, in children with icterus neonatorum, the
ductus venosus, which closes normally between the second and fifth days
of life, remains open unusually late, and that this constitutes the
essential cause of the jaundice. The blood of the portal A'ein usually
contains a certain amount of the bile which has been reabsorbed into it
from the bowel, and which it is carrying back to the liver. If, however,
the ductus venosus remains open, it follows that part of this bile-contain-
ing blood will pass aside through it into the vena cava, and hence into
the general circulation of the body. Although this suggestion stands in
need of further anatomical confirmation, it may be mentioned that in one
jaundiced infant of eleven days Ashby found the ductus venosus large
enough to admit a director.
The diagnosis in uncomplicated cases presents no difficidty. The
ICTERUS NEONATORUM 261
absence of serious symptoms, the slight degree of the jaundice, the pale
urine, and the coloured stools suffice to distinguish even extreme instances
of icterus neonatorum from cases of septic or catarrhal jaundice, and from
those which depend on Buhl's disease, syphilitic disease of the liver or
congenital obliteration of the bile-ducts.
The prognosis is invariably good ; no treatment is necessary.
John Thomson.
REFERENCES
1. AsHBY. Medical Chronicle, 1885, vol. i. No. 1. — 2. Birch - Hirschfeli).
GcrharcWs Handh. der Kindcrtmnkhciten, Bd. iv. 2, 1879, S. -676, and Virchow's
Archiv, 1882, Bd. Ixxxvii. S. 1. — 3. Bouchut. Maladies dcs nouveau-nes, 1885, p.
631. — 4. CoHNHEiM. Lectures on General Pathology, New Syd. Soc. Transl. vol. iii.
p. 901. — 5. Cruse. Arch, fur Kinderhcilkunde, 1880, Bd. i. S. 353. — 6. Epstein.
Volkmann's Sammlung klin. Vortrage, 1880, No. 180. — 7. Fkerichs. Klinik der
Leberkrankheiten, 1858,- Bd. i. S. 199. — 8. Halberstam. Bcit.rag zior Lehre von
Icterus Neonatorum, Diss. Dorpat, 1885. — 9. HoFMEiER. Zeitschr. filr Gebiirtsh. und
Gynaek. 1882, Bd. viii. S. 287. — 10. HoFMEiSTERaiid Birch-Hirschfeld. Virchoxvs
Archiv, 1882, Bd. Ixxxvii. S. 1. — 11. L. Emmett Holt. Diseases of Infancy and
Childhood, 1897, p. 76. — 12. Kehrer. Oesterr. Jahrhuch filr Pddiatrik, 1871, Bd.
ii. S. 71. — 13. Parrot and Robix. Revue mensuelle de medecine et chirurgie, 1879,
No. 5. — 14. PoRAK. Ihid. 1878, Nos. 5, 6, and 8. — 15. Quincke. Arch, fur expcr.
Pathologic u. Pharmakologie, 1885, Bd. xix. S. 34. — 16. Runge. Die Krankheiten
der ersten Lehcnstage, 2 Aiifl. 1893, S. 216. — 17. Silbermann. Archiv fiir Kinder-
heilkunde, 1887, Bd. viii. S. 401. — 18. Virchow. Gcsammelte Abhandlungen, 1856,
S. 858. — 19. Weber. Beitrdge zur patholog. Anat. d. Neugehorenen, 1854, 3 Lief.
S. 42.
J. T.
DISEASES OF THE PAXCREAS
That the pancreas not infrequently proves a source of serious and
often fatal disease has become especially apparent Avithin the past
few years. The significance of haemorrhage Avithin this gland, or in its
vicinity, Avas made prominent by Zenker in 1874, and his observations
have been confirmed by those of Prince, Draper, and others. The
concurrence of pancreatic disease and diabetes, at first recognised by
Cowle\', was made especially conspicuous by Lancereaux, and was demon-
strated by the exj^eriments of von Mering and Minkowsky. The attention
given of late years to the physiology and pathology of this organ has shoAvn
that the so-called characteristic symptoms of disturbances of function of
the gland, namely, fatty stools and lipuria, excessive salivation and watery
dejections, bronzed skin, and coeliac neuralgia, and excessive emaciation,
are in no way limited to diseases of the pancreas. Eecent investigations
lead to the conclusion that there are no pathognomonic symptoms of
disease of this gland, although the presence of glycosuria should arouse
the suspicion that the pancreas may be diseased. Attention shoidd be
called, however, to the statement by Walker, that disease of the pancreas,
even when the liver is normal, may cause colourless stools. The affections
which have been most thoroughly studied are pancreatic haemorrhage and
infiannnation, calculi, cysts, and cancer. These I shall consider in the
order in which I have enumerated them.
Pancreatic hsemorrhage.^ — The names pancreatic hfemorrhage and
pancreatic apoplexy are applied to the occurrence of bleeding, usually
within the pancreas, from mipture of its vessels : this bleeding not infre-
quently extends to the subperitoneal fat in the vicinity of the jjancrcas,
and to the cavity of the lesser omentum.
Etiology. — Slight degrees of pancreatic haemorrhage are occasionally
found in cases of olistruction to the venous outflow, and in those diseases,
infectious or not, in which minute hemorrhages are wont to appear in
various parts of the body. There is no satisfactory explanation, other
than trauma, of the cause of serious pancreatic haemorrhage. It occurs
most frequently in persons beyond iniddlc life, although it may be seen
in young adults. It has been found rather more often in fat than in
lean persons. Although more commonly present in persons addicted to
the excessive use of alcoholic liquor, it has been observed also among
DISEASES OF THE PANCREAS 263
the temperate or abstemious. There is nothing in age, sex, habits, con-
dition, or previous disease of the individual which makes it ossible to
apprehend the probable occurrence of this lesion.
Morbid anafojiii/. — In the grave form of p.mcreatic haemorrhage the
source of the bleeding has not been discovered : no rupture of a large
vessel has been found. The blood is infiltrated into larsrer or smaller
portions of the gland, one or several centres being affected. The head
alone may be the seat of the haemorrhage, or the bleeding may be limited
to the body or to the tail ; the portion of the gland infiltrated with
blood may be enlarged, dense, of a purple colour ; or of normal size, soft,
and friable. The presence of reddish yellow spots, and the recognition
in them of crystals and granules of haematoidin, give suggestive evidence
of a previous occurrence of the haemorrhage. The gland-cells may show
no abnormal appearances, or may be found granular or fatty. "When the
haemorrhage occurs in fat persons the interstitial fibrous tissue of the
pancreas is usually in a state of fatty infiltration. If the bleeding extend
l)eyond the region of the pancreas it is frequently continued into the
root of the mesentery, into the fat of the omentum, and into that behind
the colon or around the kidney.
Sympto)iis. — In the non-traumatic cases unexpected abdominal pain is
the most frequent incipient symptom. It is usu;dly severe or intense,
but may be slight or insignificant. Although sometimes referred to the
epigastrium, it is often regarded as a colic, and is not sharply localised. In
some cases a sense of constriction in the loAver part of the chest is com-
plained of. Neither nausea, vomiting, constipation, nor diarrhoea is of
sufficient frequency to suggest a conspicuous lesion of the digestive
apparatus. The symptoms which are suggestible of the nature of the
lesion are those of collapse, characterised rather by feeble pulse and
dyspnoea than by disturbance of intelligence ; and they may lead immedi-
ately to death or persist for a period of some hours.
Prognosis. — That recovery from pancreatic haemorrhage sometimes
occurs is indicated by the evidence of antecedent haemorrhage in the
form of htematoidin granules and crystals and by the history of earlier
mild attacks of symptoms like those above mentioned. The severer
attacks are usually fatal, either within a few minutes or in the course of
twenty-four hours. If the patient's life be prolonged beyond the latter
period the case is no longer one of simple haemorrhage, but becomes one
of combined haemorrhage and inflammation, which will be considered
under the subject of acute pancreatitis. Even the severer varieties may
not be absolutely hopeless, and patients attacked by pancreatic haemor-
rhage, demonstrated by laparotomy, have recovered both from this opera-
tion and from the lesion.
Treatment.- — The relief of pain and the stimulation of the patient are
the especial indications for treatment. For the former the administration
of morphia is required, usually subcutaneously, in quantity sufficient to
control the pain. Alcoholic stimulants, the subcutaneous injection of -^
of a grain of sulphate of strychnia, and the use of one-drop doses of a one
264 -^ y-^ TEM OF ME DICINE
jper cent solution of nitro-glycerine are indicated in the treatment of the
symptoms of collapse. No intentional attempt to treat the early stages
of p.iiicreatic liiomori'hage radically by surgical procedure has been made.
Pancreatitis. — It is noteworthy that the pancreas may be the
seat of such parenchymatous changes as granular degeneration of
the cells, multiplication of the nuclei, and redness and swelling of
the gland. These conditions have been observed in the infectious dis-
eases, but they are incapable of recognition by means of clinical mani-
festations. The occurrence of more extreme alterations — such as ex-
tensive implication of the interstitial tissue, frequent characteristic
changes in the parts remote from the pancreas, and the association
of symptoms which have led repeatedly to a recognition of the inflam-
mation of the pancreas — demand a conspicuous place for i)ancreatitis in
moilern text-books on medicine. Acute and chronic varieties of this
affection arc to be considered. The former include the hemorrhagic,
gangrenous, and suppurative forms ; the latter fil)rous pancreatitis
with its several complications, a state which is of especial significance in
connection with its probable intimacy of relation to certain varieties of
saccharine diabetes.
Acute pancreatitis. — There are two kinds of acute inflammation of
the gland. The one rejjresents a coml)ination of inflammation and
hiemorrhage, the more frequent termination of Avhich is gangrene ; the
other is independent of hpemorrhage, and is characterised rather by
suppuration than by gangrene.
Etiology. — Acute pancreatitis usually occurs in adult males, especi-
ally in those beyond middle life, and particularly in very fat persons.
Although in many of the reported cases the free use of alcohol is
noted, it is not probable that this agent acts otherwise than as a
disposing cause. More important are antecedent and frcquentl}* recurrent
attacks of gastro-duodenal catarrh, and injury from external violence. It
seems probable that the catarrhal inflammation extends continuously
from the duodenum along the course of the pancreatic duct.
Morbid anatomy. — The panci-eas is enlarged either throughout its
length or at one extremity, especiall}'' at the head. Its colour varies from
a slight but uniform redness to a dark red, sometimes reddish black ;
the darker shades of red being found in the hsemorrhagic and gangrenous
varieties of pancreatitis. The haemorrhages are usually present in 2)atches
of vai'ious size, and are sometimes so considerable as to pi'oduce a swell-
ing half the size of the fist. In such cases a section of the pancreas
shows a A'ariegated surface : patches of red, gray, and yellow can be seen.
A further variety of colour often results from the presence of opaque white
spots and lines due to a ncci-osis of the pancreatic fat-tissue. The pan-
creatic duct is usually patent throughout, but may contain a thick lluid
more or less intimately mixed with blood. In the ha^morrhagic A'aricty
evidences of more or less extensive bleeding are to be found in the fat
around the pancreas, especially near its head, and in the subperitoneal
fat of the omentum, root of the mesnntery, mesocolon, and in the region
DISEASES OF THE PANCREAS 265
of the left kidney. Small patches of necrosis of the subperitoneal
fat are common. If gangrene follow, more or less of the gland is
transformed into a dark gray mass, which tends to become spongy and
to form a slough, in some cases attached to the abdominal wall by a
few shreds of tissue only. The peritoneal surface of the diaphragm,
of the lesser omental cavity, and of neighbouring coils of intestine is
covered with a fibrinous false membrane forming adhesions. The
omental bursa (lesser sac of the peritoneum) frequently contains offensive
blood-stained fluid, in which detached masses of necrotic fat may be
found. Evacuation of the contents of this circumscribed peritoneal abscess
may take place through a perforation into the stomach or duodenum.
In suppurative pancreatitis the enlarged pancreas contains single or
innumerable abscesses. The peritoneal covering of the pancreas is likely
to become involved in the inflammation, which becomes extended to the
peripancreatic tissiie and to the walls of the lesser peritoneal pouch.
Extensive suppuration may thus be produced, and evacuation of the pus
by the stomach or duodenum occur. Fat-necrosis is rare in suppurative
inflammation of the pancreas.
Thrombosis of the splenic vein is of frequent occurrence, the throm-
bus perhaps extending from the spleen to the portal vein, and sometimes
being in a state of puriform softening. Variations in the size and con-
sistency of the spleen are frequent, but enlargement, even Avhen the
splenic vein is obliterated, is inconstant. Abscesses of the liver are
more common in suppurative than in ha3morrhagic or gangrenous pan-
creatitis. Despite the frequent, almost constant, occurrence of a circum-
scribed peritonitis, extensive inflammation of the general peritoneum is
rare. When the peritoneal surface of the diaphragm is affected, the in-
flammation may extend to the pleura and pericardium. On microscopical
examination many of the lobules present the appearances characteristic of
a coagulation-necrosis, and the interstitial tissue is extensively infiltrated
with red blood corpuscles, leucocytes, fibrillated and granular material.
Red blood corpuscles and leucocytes are also to be found in the ducts.
Bacteria, especially the colon bacillus, first recognised in this affection by
Welch, are found in the inflamed gland and in the focuses of fat-necrosis.
Owing to the important relation which multiple disseminated fat-
necrosis bears to disease of the pancreas, it is desirable to call particular
attention to this condition. Subperitoneal fat-necrosis, combined Avith
evidences of haemorrhage or inflammation, is almost invarialjly found in
connection with pancreatitis, and with it alone. This relation is so
constant as to indicate the importance of disease of the pancreas in its
etiology, and to raise a doubt of the thoroughness of the examination of
the pancreas in those cases where subperitoneal fat-necrosis is stated to
have occurred in the absence of pancreatic disease. Langerhans has
injected the minced pancreas of a rabbit into the subcutaneous fat of
another rabljit with the production of fat -necrosis. Whitney, of the
Harvard Medical School, succeeded in producing hiTemorrhagic pancreatitis
and fat- necrosis in a dog. Hildebx'and produced typical fat-necrosis in
266 SYSTEM OF MEDICINE
the pancreas, the omentum, and tlie mesentery, l)y experiments on the
pancreas of cats. Such evidence corroborates the previously maintained
etioh^gical importance of acute disease of the pancreas in the production
of multiple, disseminated fat-necrosis.
Synipfoiitafolo;/!/. — Acute pancreatitis visually begins unexpectedly with
severe symptoms. The patient, ])reviously well, or at the most having
suffered from some irregularity of digestion, is seized Avith abdominal pain,
often severe, even intense, and either persistent or paroxysmal. The pain
is usually in the epigastric region, and is sometimes referred to the region
of the pancreas, altliough generally it is not sharply defined. In j'are
instances of suppurative pancreatitis the onset of the disease is gradual
with little or no pain.
Vomiting closely follows the pain, and is occasional, constant, or re-
peated. It may be copious, and the vomit consists of paitly digested
food or of slimy matter. It may become green or black, and at times
contains liquid or clotted blood. Slight or severe degrees of collapse
usually follow the iin'tial pain and A'omiting. Chills occasionally occur
at the outset, l)ut more frecpiently take place later in the disease, especially
in supi)urative pancreatitis, in which variety they may be frequent and
irregular.
The temperature is likely to become elevated in the course of twenty-
four hours, and, as a rule, it ranges from 100° to 104° F. throughout the
disease ; but in rare cases there may be no definite rise. In suppurative
pancreatitis exacerbations and remissions may take place, the course of
the fever being irregular. Hiccough sometimes occurs, and mild degrees
of delirium may appear. Slight jaundice also takes place occasionally,
and the urine may contain albumin and casts. The upper part of the
abdomen usually becomes swollen and tympanitic, and at times, as noted
by Elliot, gives evidence of a deep-seated circumscribed resistance in the
region of the head of the pancreas, where tenderness may be found on
palpation. Deep pressure on the intercostal spaces in the region of the
spleen may be painful. If the patient survive the initial sym})toms, the
subsequent coui-se of this disease is that of a localised peritonitis. The
abdominal swelling increases in size, even to an enormous degree, and is
either general or limited to the ei)igastrium or to the left half of the
al>domen. The distended abdomen is usually tympanitic, but it may be
dull in the flanks. Moderate abdominal pain, at first apparent in painful
and tender spots, and due to disseminated fat-necrosis, becomes more
general. Vomiting and diarrhrea are frecpient, and the patient loses
flesh and strength. A severe jiaroxysm of lancinating pain may super-
vene during the third oi' fourth week, followed by frequent and copious
discharges from the intestine, and disappearance of the alxlominal swell-
ing as the exudation from the bowels is evacuated. In the most pro-
longed cases of suppiuative pancreatitis extending over a period of
months, ascites or anasarca may occur ; and a bronzing of the skin and
glycosuria have been noted.
Diagnosis. — Acute i^ancreatilis is to be suspected a\1u'ii a previously
DISEASES OF THE PANCREAS 267
healthy person or a sufferer from occasional attacks of indigestion is
suddenly seized with violent pain in the epigastrium followed by vomiting
and collapse, and in the course of twenty-four hours by a circumscribed
epigastric swelling, tympanitic or resistant, with slight elevation of
temperature. Circumscribed tenderness in the course of the pancreas and
tender spots throughout the abdomen are valuable diagnostic signs. The
action of an irritant poison is excluded by the history of the case and by
an examination of the vomit. A perforating ulcer of the stomach or
duodenum is eliminated by the absence of pain after eating and of
haemorrhages from the stomach or intestine. The - seat of the pain and
tenderness, and the absence of previous attacks of biliary colic and
jaundice, are useful in excluding a diagnosis of gall-stohes.
Acute pancreatitis in its early stages most frequently suggests acute
intestinal obstruction ; it is distinguished, however, by the severity
of the onset, by the absence, in the early stages, of distension of the
intestine, by the localised tenderness, if present, in the region of the
pancreas, and by the infrequency of obstruction of the small intestine in
the epigastrium. The patency of the large intestine may be determined
by inflation or injection. In the later stages of acute pancreatitis, the
physical characteristics due to the associated inflammation of the lesser
sac of the peritoneum are suggestive of a cyst of the pancreas ; but the
severity of the eai'lier symptoms, the septicremic characteristics of the
later stages, the more acute course, and, when necessary, an exploratory
puncture, suffice to set aside pancreatic cyst.
Prognosis. — Although acute pancreatitis has been shown to be a
disease of extreme gravity, yet it must be admitted that mild cases
occur. Similar but less severe symptoms have been recorded at an earlier
date, in cases eventually proving fatal ; when on autopsy hsematoidin
crystals and granules and fibrous thickening give evidence of previous
haemorrhage and inflammation. Osier and Korte have reported cases in
which laparotomy established the diagnosis of acute pancreatitis in
patients who recovered from both operation and disease. Trafoyer's
patient was alive seventeen years after the sloughing pancreas had been
discharged from the bowel. The circumscribed nature of the resultant
peritonitis, and its successful treatment in rare instances by drainage of
the abscess, make it probable that with greater accuracy of diagnosis a
more favourable prognosis may become possible. In rapidly fatal cases
death from collapse results in a few days. If the patient survive this
period, death from septicaemia usually occurs in the course of one or two
months. If the patient's life be prolonged for six months or a year,
death may result from progressive emaciation and debility, or from
diabetes.
Ireatment. — The early stages of acute pancreatitis demand the sub-
cutaneous injection of morphine to assuage the pain, and the use of
stimulants by the mouth or rectum to relieve the symptoms of collapse.
The preservation of the patient's strength by easily digested, nutritious
food, by milk and broths, with the addition of farinaceous diet if possible,
268 SYSTEM OF MEDICINE
is essential for the eventual surgical treatment of this affection. The
latter course is indicated as early as the second or third week of the
disease, if there is reason to believe that a peritonitic exudation, limited
to the boundaries of the lesser peritoneal cavity, exists. Thaj-er has
reported a successful operation by Finney on the twelftli day.
Chronic pancreatitis. — Although suppui-ative inflammation of the
pancreas not infrequently assumes a chronic course, extending over a
period of many months, and may result in a considerable increase of
fibrous tissue in the gland, its symptoms are distinctly those of a suppura-
tive process. Induration of the pancreas may result from chronic
obstruction to the portal circulation or from obstructive disease in the
heart or lungs, but with symptoms cpiite subordinate to those occurring
elsewhere. There is a genuine chronic fibrous pancreatitis, on the other
hand, which pursues a latent course, is associated usually with disturb-
ances of digestion, and of late years has received much attention on
account of its frequent connection with saccharine diabetes.
Etiolof/)/. — The occasional presence of a fibrous thickening of the
pancreas in infants is attributable to congenital syphilis, but it is
not known that acquired syphilis may give rise to it. Although alco-
holic excesses have been assumed to be among the causes of fibrous pan-
creatitis, the characteristic appearances of the latter affection are not
often found in drunkards. The most probable cause is a chronic catarrh
of the pancreatic duct, continued from the duodenum into the pancreas,
which in certain cases may be due to the abuse of alcohol : this assump-
tion is based rather upon the frequency of antecedent and persistent
symptoms of chronic gastro-duodenal catarrh than upon the presence of
morbid changes in the wall of the duct. Obstruction and dilatation
of the duct result in fibrous atrophy of the gland. A fibrous thicken-
ing of parts of the pancreas is often associated with ulcer of the stomach
or duodeiumi, tumours of the stomach or suprarenal capsule, aneurysm
of the aorta or cteliac axis, or Avith di.sease of the spine.
Morbid anatomy. — The increase of fil^rous tissue takes place through-
out the gland or is limited to certain portions of it, especially to the head.
The size of the pancreas may become so increased as to suggest a
tumour, particularly a cancer of this organ. More frequently, in con-
sequence of the contraction of the iiitei-stitial tissue, the pancreas is
found diminished in size. The surface is smooth, nodular, or granular,
and is of a reddish gray or grayish Avhite colour. The consistency
becomes increased ; at times it is of the density of cartilage. The
subperitoneal fibrous tissue in the neighbourhood of the pancreas,
especially around the coeliac axis, at the root of the mesentery and near
the suprarenal capsule, may be thickened and indurated. On section of
the pancreas the surface is either more homogeneous or more finely
granular than normal, according as the lobules are diffusely infiltrated
with filjrous tissue or project in consequence of the contraction of the
latter. A speckled yellow a])pearance is indicative of associated fatty
degeneration of the gland -cells. Klebs has found within the fibrous
DISEASES OF THE PANCREAS 269
tissue small white streaks or spots containing calcareous granules and
crystals of fat-acids resemljling those occurring in fat-neci'osis.
The pancreatic duct may appear normal even when the pancreas is
considerably enlarged ; or it may be dilated, tortuous, and more or less
sacculated; especially when inflammation or obstruction of the duct seems
to be the cause of the pancreatitis. The presence of concretions and the
formation of cysts deserve separate consideration.
Symptoms. — Digestive disturbances, epigastric pain and tenderness, and
progressive loss of flesh and strength are the symptoms which occur in
fibrous pancreatitis, and may precede death for months or years. The
digestive disturbances consist of loss of appetite, nausea, vomiting (rarely),
belching, pyrosis, and a sense of epigastric fulness and weight. These
symptoms, usually attril^uted to gastric catarrh, in rare instances
may be absent. Diarrhoea frequently exists ; the dejections are some-
times fatty and may be colourless even Avhen there is no jaundice.
Jaundice occasionally occurs, and is persistent if the common bile-duct be
compressed by the contracted head of the pancreas.
The epigastric pain is deep-seated, dull, burning or boring in character,
perhaps paroxysmal ; and if severe, is associated with extreme anxiety,
restlessness, and a sensation of faintness. Epigastric tenderness has been
observed, especially on the left side, and resistance either defined to the
right of the median line or extending outward to the left. Enlarge-
ment of the spleen sometimes occurs, and a moderate degree of ascites.
A most important symptom, if present, is glycosuria, for the disease then
is likely to put on the character of a severe diabetes.
Cowley, in 1788, first reported a case of diabetes associated with
pancreatic disease (calculous), and Lancereaux in 1877 maintained that
there is a pancreatic diabetes characterised by polyuria, polyphagia,
polydypsia, rapid loss of flesh and strength, and dependent upon grave
alterations of the pancreas; von Mering and Minkowsky in 1890 demon-
strated that complete extirpation of the pancreas in dogs immediately
produced a severe form of rapidly fatal diabetes. Their observations
were almost simultaneously confirmed by de Dominicis, and since then
by numerous experimenters, and upon various animals. According to
Minkowsky, when a relatively small amount of pancreas remained in
the body, the diabetes Avas only moderately severe ; if one-eighteenth to
one-twelfth of the gland were left, a sort of alimentary glycosuria alone
resulted ; if more than one-tenth of the gland was left, there Avas ordinarily
no glycosuria. Minkowsky maintains that the diabetes results from the
loss of a " glycolytic ferment," a sugar-destroying agent produced in the
pancreas and absorbed by the lymphatics of this gland. It is claimed by de
Dominicis, on the contrary, that this variety of experimental diabetes is
the result of disturbed tissue-metamorphosis caused by the absence from
the intestine of pancreatic juice, a view based in part upon the production
of glycosuria by simple ligature of the duct of Wirsung. Williamson has
collected one hundred cases of diabetes in which pancreatic lesions were
noted : in thirty -nine there was more or less atrophy ; in eight the
270 SYSTEM CF MEDICINE
atrophy was very marked ; in thirteen there Avas extensive fibrous
thickoiiinpj, Avhile fatty dcgeiieivition with or without fibrous thickouing
and calculi, cysts with or without calcification and fibrous thickening,
haemorrhagic and suppurative pancreatitis, made up the balance. Hanse-
mann, although recognising that the pancreas may be diseased either from
acute infiannnation, sclerosis, lipomatosis, calculi, or cancer, exi)lains the
absence of dial:)ctes in these cases by the probable presence of a sutHcient
number of functionally active cells to permit the physiological action of
this gland upon the glycolytic process. Hence, although various altera-
tions of the pancreas, especially fibrous atrophy, have been found
associated with diabetes, it is to be remembered that extensive lesions
of the pancreas may exist Avithout diabetes, and that the latter disease
often occurs without disease of the jjancreas.
Frogmsis. — The prognosis of chronic fibrous pancreatitis is necessarily
grave since we have no evidence that reproduction of this gland is possible.
It is to be recognised, however, that patients may live for years apparently
in good health after the removal of a considerable part of the pancreas by
operation, sequestration and evacuation ; or after its atrophy from cystic
degeneration or fatty infiltration. Of great value, as suggesting a faA'our-
able prognosis, are the experiments above mentioned, which show that a
small portion of the pancreas suffices for the preservation of the health of
many animals.
Treatment. — The treatment of chronic pancreatitis necessarily consists
in the attempt to relieve the digestive disturbances by means of a diet
Avliich shall be least irritating to the duodenum, and Avliich demands the
least possible quantity of pancreatic juice for its digestion. As the
pancreatic juice promotes the digestion of fat, a diet relatively free from
fat is indicated. The use of raw minced pancreas and of pancreatin is to
be recommended, since Abelmann has shown that after extirpation of the
pancreas the digestion of fat is promoted by their use. AVhen a chronic
pancreatitis is suspected to be the cause of diabetes the diet should be
largely nitrogenous and relatively free from farinaceous and saccharine
articles of food. The frequent use of minced pancreas is indicated in such
cases also, especially since experiments show that the retention of small
portions of the gland, or the transplantation of a portion of the pancreas
when the gland has been removed, may prevent glycosuria. According
to Bccher, carljonated waters increase both the flow and the proteolytic
action of the pancreatic juice of dogs. The pancreatic secretion of rabbits
was found by Gottlieb to be increased by the administration of dilute
acid.s, oil of mustard, and spices.
Pancreatic calculi. — L'/iologi/. — The mode of origin of stones in the
pancreatic duct is presumably the same as in the case of gall-stones. A
catarrhal condition of the pancreatic duct and retention of secretion are
probably the chief factors in the precipitation of their constituents. The
retention of secretion may be the result of a pathological jjrocess outside
the duct producing obstruction to the escape of its contents ; or, on the
other hand, the duct may become obstructed and dilated by the stone.
DISEASES OF THE PANCREAS 271
Morhid anatomy. — The calculi chiefly contain cnrhonate of lime
with some phosphate of lime, and, at times, cholesterin ; they vary
in size from grains of sand to that of a walnut. Not infrequently a
mortar-like material is present. Single stones may be found impacted
in the duct, or more than a hundred may be present. Their shape is
usually rounded or oblong, sometimes elongated and branching. They
are of a light gray or white colour, and iheir surface smooth, rough, or
spinous. The concretions, though tough, are usually easily crushed into
irregular fragments.
Not only are the duct of AVirsung and its branches commonly dilated,
but atrophy and induration of the pancreas, and sometimes fistulous
communications Avith the stomach, duodenum, or peritoneal cavity, are,
at times, associated with stone. Cancer of the pancreas is present also
in rare cases.
Si/inpt(ims. — Calculi may exist in the pancreas Avithout any definite
evidence of their presence. As a nde, symptoms of gastric or gastro-
duodenal indigestion precede those due to the presence of the stone.
These latter are attacks of pain associated with the incarceration or escape of
the stones, or a complex group of symptoms dependent upon the secondary
changes occurring in the pancreas. The pain is either dull, giving a sense
of pressure sharply defined to a limited spot of the epigastrium, or it may
be intense and paroxysmal, radiating along the left costal border toward
the spine and the left shoulder-blade. The seat of the pain is not
especially sensitive. The paroxysms resemble those produced by gall-
stones, and are sometimes accompanied by jaundice. Indeed, gall-stones
and joancreatic stones may coexist in the same person. Minnich notes
that his patient, Avho previously had suftered from very severe attacks of
biliary colic due to typical pigmented gall-stones found in the stools, could
not discriminate these attacks of colic from those in Avhich concretions
apparently pancreatic" Avere discharged. Although it may not he possible
to distinguish bctAveen some attacks of pancreatic and of biliaiy colic, the
symptoms Avhich result from the prolonged presence of pancreatic calculi
are AvhoUy different. They resemble those mentioned as a result of
fibrous pancreatitis, Avhich condition often accompanies pancreatic calculi.
The patient loses flesh and strength : the dejections are often liquid,
contain abundant fat-acids, an excess of undigested muscular fibre, and
sometimes concretions Avhich present the characteristics of pancreatic
stones. More significant is glycosuria, either intermittent or persistent.
Rarely a cystic tumour may develop in the epigastrium after the local
pain has disappeared.
Diagnosis. — The presence of pancreatic calculi is to be inferred from
severe attacks of deep-seated epigastric pain radiating to the left, simu-
lating biliary colic, Ijut Avithout jaundice ; followed by the evacuation of
concretions resembling those alwve described, and, in the course of years,
by progressive loss of flesh and strength and by glycosuria. Minnich
confirmed his diagnosis by the discovery of the concretions in the
stools; and an autopsy established the diagnosis of Lichtheim AA-hich
272 SYSTEM OF MEDICINE
was based provisionally on the occurrence of diabetes after the attacks
of colic.
Prognosis. — Recovery may follow the evacuation of pancreatic calculi
through fistulous communications with the stomach or duodenum, or, as
seems i)robable in the case reported by Capparelli, with the abdominal
wall. More commonly the }>rognosis is that of chronic pancreatitis ^ith
frequent resultant diabetes, or of pancreatic cyst. An immediately fatal
result following peritonitis from perforation is a rare incident.
Treatment. — The attack of pancreatic colic is to be relieved by morphine,
ether, or chloroform, and the external application of heat as in the case
of biliary colic. Holzmann states that the attacks of colic disappear after
the injection, three times a week, of 1 c.c. of a 1 per cent solution of
l^ilocarpine. Ihe medical treatment of the remoter effects of the stones
is that mentioned for chronic pancreatitis. "With the possibility of
forming an early diagnosis will come the opportunity for the surgeon to
remove the concretions before the incurable results of their presence take
place.
Cysts of the pancreas. — Under this term have been included a
variety of lesions which in the main have been regarded as due to
dilatation of the duct of Wirsung. It is probable, however, that many
reported cysts of the pancreas were circumscribed collections of fluid
wholly outside the pancreas, and that other varieties of cysts of the
pancreas occur besides those due to dilatation of its duct.
Etiologii. — As a rule, pancreatic cysts in the adult occur with equal
frequency in the two sexes. Richardson's case of the extirpation of a cyst
presumably pancreatic from a child of foiu-teen months is unicjue, and
suggests that, at times, these tumours may be of congenital origin. Pye-
Smith also reports a case suggestive of a similar etiology. The con-
spicuous place given to traumatism in the etiology of pancreatic cysts is,
as advocated by Lloyd, probably due to a confusion of peritonitis limited
to the lesser peritoneal cavity with cysts of the pancreas. It is possible
that injury may produce an acute pancreatitis, resulting in an obstruction
to the duct with subsequent dilatation ; it seems more probable that the
resultant acute pancreatitis becomes extended to the peritoneal covering
of the pancreas, which forms the posterior wall of the smaller sac of the
peritoneum. !Morc important in the etiology of the genuine pancreatic
cyst is the extension of inflammation from the duodenum into the pan-
creatic duct, resulting in its obstruction. The most common variety is
that due to obstruction and dilatation of the duct with retention of its
contents. The obstruction may result from inflammation within or
Avithout the wall of the duct, from the pressure of tumours or the pre-
sence of calculi. Durante's case of assumed pancreatic cyst from obstruc-
tion of the duct of Wirsung \)y a lumbricus is unique. It is possible
that the lesion in this patient may have been an inflammation of the
lesser peritoneal pouch secondary to a pancreatitis. Rarest of all is the
neoplastic cystoma of the pancreas.
Moi'bid anatomy. — A cyst may arise in any part of the pancreas ;
DISEASES OF THE PANCREAS 273
there may be one or many cysts, varying in size from those almost
microscopic to others as large as a pregnant uterus at full term. When
large, a spherical tumour is formed which does not suggest the pancreas ;
or numerous small cysts may be grouped along the course of this gland.
They lie behind the lesser peritoneal cavity, the Avails of which at times
are fused Avith them. The inner surface of the cyst-wall is smooth or
trabeculated, often contains openings communicating with smaller cysts,
sometimes bears papillary outgrowths, and is lined with cylindrical
epithelium. At times the duct of Wirsung is to be followed from the
duodenum, and from the tail of the pancreas to the interior of the cyst ;
or again the duct may be obliterated. The largest cysts may contain
fourteen quarts of fluid : this is of a grayish colour, slightly opaque,
viscid or watery, alkaline, of a specific gravity from 1010 to 1024.
On microscopical examination, leucocytes, epithelial cells in a state of
fatty degeneration, fat-drops, cholesterin and acicular crystals may be
found. The fluid may emulsify fat, saccharify starch, and digest
albumin and fibrin like pancreatic juice ; the older the cysts, the less
likely are all these reactions to be present. Much diagnostic importance
often is attached to these characteristics ; but Boas asserts that other
fluids possess diastasic and emulsifying qualities, while even in the
fluid contents of a pancreatic cyst the peptonising power may be absent
or slight. The presence of blood in the cysts has likewise been regarded
as of marked diagnostic importance. This view is based particularly
upon the appearance of the fluid from assumed cysts of the pancreas of
traumatic origin. As has already been stated, such accumulations of
fluid, even if they present the properties of the pancreatic juice, may be
due to an encysted peritonitis of the peritoneal covering of the pancreas
the ducts of which may be opened. Typical pancreatic cysts may
contain no blood, and circumscribed collections of bloody fluid in the
vicinity of the pancreas may lie Avholly outside this gland. Although
multiple cysts of the pancreas are usually retention-cysts, the cases re-
ported by Salzer and Hartmann suggest that the pancreas, like the ovary,
may give rise to cystoma. That cystoma of the pancreas may be malig-
nant as well as benignant is indicated by the case reported by Hartmann
and Gilbert.
As the pancreatic cyst increases in size it causes atrophy of the gland,
the lobules of which are to be found in its wall ; or it may project from
the pancreas as a pedunculated tumour. The stomach is usually pushed
upwards, more rarely downwards, and the transverse colon lies in front or
below. A small cyst may lie to the left or right of the median line
according to the part of the pancreas from which it arises. The larger
cysts usually occupy first the epigastric and the left hypochondriac
regions ; but they may extend into the right hypochondrium, and the
lower border may be found at the brim of the pelvis. The anterior
wall of the cyst may be fused with the posterior wall of the stomach,
rendering extirpation diihcult, if not impossible. Eupture of the cyst
may take place into the lesser peritoneal sac, into the general peritoneal
VOL. IV T
274 SYSTEM OF MEDICINE
cavity, or into the stomach. Rupture into the lesser cavity may exphiin
the presence of a large cystic tumour, communicating with the interior
of the pancreas in those cases in which a considerable portion of the
organ remains unaltered.
Congenital cystic disease of the pancreas may be associated with
cystic disease of the liver and kidneys.
Si/mj)toms. — There may be no symptoms suggestive of a cyst of the
pancreas before the recognition of an abdominal tumour. With its appear-
ance, however, symptoms of a more or less serious character usually
occur. These may be unimportant imtil the cj'st has attained a large
size, for the tvunour has been accidentally discovered, in persons appa-
rently healthy, after child-birth or during conA'alescence from typhoid fever.
As a rule, however, the patient sutlers from attacks of epigastric
pain, perhaps constant and severe, Avith symptoms of colhipse. The pain
may last for hours, days, or weeks, and may extend perhaps over a
period of years. It may radiate from near the ensiform cartilage either
downwards or latei-ally, especially toward the left side ; or may extend into
the left shoulder or into the left half of the face. The painful paroxysms
may have no apparent cause, or may follow an error in diet, when
belching, vomiting, diarrhoea, or constipation occurs, and the patient com-
plains of a sensation of fulness in the epigastrium which may be tender
to the touch. The attacks of pain may be followed by jaundice, and
recurrent intestinal haemorrhage has been observed. Strength and
nutrition are unaffected, or weakness and emaciation may appear.
Although the cyst usually is of slow growth and may remain quiescent
for years, even becoming smaller for a while, it may appear soon after an
attack of pain and vomiting, and rapidly enlarge within a few months.
"When haemorrhage takes place from its wall the cyst may attain the
size of a child's head within a fortnight. Commonly it is observed first
in the left hypochondrium between the costal cartilages and the median
line ; and, as it enlarges, it causes a swelling of the upper half of the abdo-
men which may extend from the ensiform cartilage to the pubic symphysis
and into each flank, and is of globular shape, resistant, inelastic, and
smooth on the surface. As a rule the cyst is slightly movable both
vertically and laterally, and often transmits the beat of the aorta, but
has no expansile pulsation. It is dull on percus.sion wliere not overlain
by stomach or intestine, and on auscultation a systolic souffle transmitted
from the adjacent aorta is sometimes heard. The smaller and more
deeply-seated the cyst, the more likely is it to suggest a solid tumour ;
although, when large and superficial, fluctuation may be present. The
pressure of the contained fluid may be sucli that the liquid will spurt
several feet from a trocar plunged through the Avail.
As the tumour becomes apparent the epigastric pain and digestive
disturbances ai'c likely to bo more persistent, and the lai-ger its si^e the
greater the loss of flesh and strength. The cyst may be so large or so
situated as to interfere Avith the descent of the diaiihragm and to
produce dyspnoea ; or it may press upon the portal vein or inferior vena
DISEASES OF THE PANCREAS 275
cava and cause ascites or anasarca. By compression of the intestine it
has produced symptoms of obstruction of the bowels. In rare instances
fat and an excess of undigested muscular fibre have been found in the
fseces, and albumin or sugar in the urine.
Diagnosis. — Physical are more important than rational signs in
establishing the diagnosis of cyst of the pancreas. A smooth, rounded
tumour is to be recognised, first appearing in the epigastrium or left
hypochondrium, slightly movable especially vertically, and usually
separated from the liver and spleen by a resonant area. Inflation of the
stomach shows that the tumour lies behind and usually below this organ.
Inflation of the colon gives evidence that the latter either crosses or lies
below the tumour. Exploratory puncture permits the escape, under high
pressure, of an alkaline fluid which may be more or less bloody, and
which usually emulsifies fat, transforms starch into glucose, and may
digest albumin and fibrin. The continued escape of such a fluid after
the establishment of drainage is in favour of the pancreatic origin of the
cyst. In the differential diagnosis solid tumours are easily excluded hy
exploratory puncture. The transmitted, non-expansile pulsation, dis-
appearing when the patient is on the hands and knees, sets aside
aneurysm of the aorta. A drojDsical gall-bladder is continuous with the
liver and lies in the right half of the abdomen. Hydronephrosis of the
left kidney is manifested by an oblong tumour more limited to the left
half of the abdomen than is a cyst of the pancreas, the lower border of
which lies near the brim of the pelvis ; and the inflated descending colon
rather follows its length than crosses it transversely. Enormous cysts
of the pancreas may be confounded with cystic ovarian tumours. The
latter produce an increase in the size of the abdomen from below upwards,
and the lowermost portion of the tumour is not overlain by the intestine.
The aspirated contents are usually free from blood, are likely to be more
gelatinous, and do not produce the above-mentioned reactions with fat,
starch, and allmmin.
It may be impossible to discriminate between collections of fluid in
the lesser peritoneal sac (omental bursa) or in the mesentery and cysts
of the pancreas. The former may arise from the pancreas, as the echino-
coccus cyst ; or may be due to dilated lymphatics, as the chylous cyst ; or,
more frequently, may result from an inflammation caused by traumatism,
perforating ulcer of the stomach or duodenum, or acute pancreatitis. It
may not be possible to exclude serous or sero-hsemorrhagic inflammation of
the lesser peritoneal cavity ; but the character of the fluid may permit us
to exclude suppurative peritonitis, an echinococcus cyst and a chylangioma.
Prognosis. — Cysts of the pancreas have persisted for twenty years,
giving rise to but little disturbance. Even the larger cysts may interfere
but slightly with the digestive process, although it is possible that diabetes
may be the result. The larger cysts are especially dangerous from their
liability to rupture, and to interfere mechanically with respiration, Avith
circulation, and with the passage of food through the stomach and
intestines.
276 SYSTEM OF MEDICINE
Tn'atincitf. — The suiiillor pancreatic cysts accidentally discovered and
producing no disturbance require no treatment. The larger cysts demand
surgical treatment, either drainage or removal ; the latter operation is
preferable, but not always possible. Either operation usually i-esults
favourably, although the fistula consequent on the establishment of
drainage often remains open for months.
Cancer of the pancreas. — Although tubercle, gumma, lymphoma
and sarcoma may be found as tumours of the pancreas, they are of such
rai'ity as not to require particular consideration ; especially as the symp-
toms of lymphoma and sarcoma arc virtually those of cancer.
"Willigk and Lebert state that cancer of the i)ancreas occurs in about
6 per cent of all cancers. Dr. Herringham has made a study of 57 cases,
and Mirallie has l.)een able to collect 1 1 3 cases of primary cancer of the
pancreas. According to the last observer and Segre, rather more than
two-thirds of the patients are males. The aflection occurs must frequently
between the ages of thirty and fifty years, although it may be present
in childi'en and infants, and has been found at birth. Unlike cancer of
the gall-bladder, it is rarely associated with calculi.
Murhid anatomy. — Any part of the pancreas may be the seat of cancer,
although the head is usually affected ; while other portions of the pancieas
may show no abnormal appearances. It may form a circumscribed tumour
the size of a child's head, or the entire gland may be infiltrated with the
ncAV growth. The colour varies in accordance Avith the greater or less
abundance of fibrous tissue and epithelioid cells, the kind and degree of
degeneration affecting the latter, the quantity of blood, the occurrence
of recent and old haemorrhages, and the presence of bile pigment. The
consistency varies from that of soft encephaloid to the cartilage-like
density of scirrhus. Dilatation of the duct of Wirsung may result from
its peripheral obstruction or obliteration by cancer of the head of the
pancreas, and obstruction of the common bile-duct also is frequently thus
produced.
The disease is likely to extend to the adjacent lymphatic glands, and
secondary nodules may be found in the liver or spleen. Invasion of the
peritoneum also maj'' occur, and adhesions are often found between the pan-
creas and the stomach, colon, small intestine, spleen, liver, and gall-bladder.
Sijinptums. — Thei'C may be no suggestive symptoms, and cancer of the
pancreas is sometimes found unexjjectedly after death from other causes.
The more characteristic symptoms may be preceded for years by disturb-
ances of digestion, such as loss of appetite, belching, nausea, vomiting,
and a sensation of epigastric fulness. In rare instances symptoms of
pancreatic diabetes — polyphagia, polydypsia, glycosuria and emaciation
— may be present. Paroxysms of pain also may occur, extending from
the epigastrium into the back, and are often regarded as attacks of lund)ago.
According to Mirallir's analysis, jaundice and pain are the disturbances
Avhich most often immediately precede the graver symptoms of cancer
of the pancreas. The jaundice, the result of pressure uj)on the common
bile-duct, may appear suddenly or gradually ; it usually persists and
DISEASES OF THE PANCREAS 277
progressively increases in severity. It may be preceded by rigors
and be accompanied by pain resembling biliary colic. The liver is fre-
quently enlarged, and, when jaundice is present, the gall-bladder is
usually dilated. Epigastric pain may precede or accompany jaundice,
and is often transitory, but is intense in at least one-half of the cases.
It may become continuous, or perhaps be interrupted by paroxysms ; it
comes without apparent cause, and is more frequent at night. It radiates
as a coeliac neuralgia, and may be accompanied with a sensation of faint-
ness and anxiety. The most characteristic sign is the tumour which,
in from one-fourth to one-half of the cases, is to be observed in the
epigastric or umbilical region, as a deep-seated, rounded or elongated,
sometimes nodulated swelling, varying in density and defined with diffi-
culty. It may be sensitive to the touch, and its mobility is slight. It
is likely to transmit the aortic pulsation, and perhaps to cause a murmur,
but it is not expansile. The cancer may produce obstruction to the flow
of blood through the portal vein and cause ascites, or may press upon the
inferior vena cava and cause dropsy of the lower extremities. In the former
case the tumour may first become apparent after removal of the ascitic fluid.
When obstruction of the duodenum is produced, dilatation of the stomach
or intestinal obstruction may result. Hydronephrosis, from compression
of the left ureter by cancer of the tail of the pancreas, is very rare.
With the appearance of jaundice, coeliac neuralgia, and tumour, the disease
rapidly advances. The appetite may remain unaffected, or may become
even excessive. When vomiting is present the evacuated contents of the
stomach may contain blood, free fat, or fat-acids. Constipation may be
present, or the action of the bowels may be increased or irregular. The
stools may contain, though rarely, liquid or solid fat or fat-acids ; and
blood may be present. More important, perhaps, is the presence of
abundant imdi2;ested muscular fibre in the absence of diarrhoea. There
may be polyuria, and the urine frequently contains albumin, more rarely
sugar ; although both glucose and maltose have been found, and glycos-
uria, after persisting for some time, may disappear shortly before death.
When pancreatic juice does not enter the bowel, indican is diminished
and ingested salol is not decomposed ; but the evidence based upon these
reactions is as yet somewhat contradictory and insufficient to make
them of diagnostic importance. Although the general nutrition may
remain but little affected till death occurs, emaciation and debility may
be present and rapidly increase toward the fatal termination. The
duration of the disease after its recognition is usually a matter of Aveeks
or months, but it may continue a year or more. Death sometimes occurs
suddenly from gastro-intestinal or intra-peritoneal haemorrhage, or from
pulmonary emboli?m.
Diagnosis. — The most important evidence is furnished by the tumour,
and by the symptoms resulting from obstruction of the pancreatic duct and
common bile-duct. The seat of the tumour is determined by inflation of the
stomach and colon. It may be mistaken for cancer of the pylorus, duo-
denum, transverse colon, or liver. Cancer of the pylorus is more freely
278 SYSTEM OF MEDICINE
moral )le, and is more romilai-ly associated with a dilated stomach:
moreover, jaundice is less likely to occur. Cancer of the duodenum may
produce the same symptoms as cancer of the ])ancreas, and, indeed, is in
most instances due to an extension from the latter. Cancer of the trans-
verse colon is more freely movable, and its seat is determined hy inflation,
while its symptoms are those of chronic intestinal obstruction. The pre-
sence of abundant indican in the urine is suggestive rather of intestinal
cancer tliaia of cancer of the pancreas. Cancer of the liver is more freely
movable, more fre(iuently associated with ascites, and moi-c likely to be
accompanied with enlargement of the organ ; yet, as cancer of the i)ancreas
lies nearly always in the head of it, jaundice is a frequent symptom of
cancer in either viscus. The most satisfactory evidence, at ])resent, of
deficient jiancreatic juice in the bowel is afforded by the abundance of
undigested muscular tilire in constipated stools after a meat diet, and by
the absence of carbolic acid in the urine when a drachm of salol is taken
in divided doses during the day. Neither fatty fseces, lipuria, nor glycos-
uria is of especial value in the diagnosis of cancer of the pancreas.
Fror/nosif;. — Always fatal. Death, as a nde, rapidly follows the occur-
rence of jaundice and ascites. It may occur within four weeks after the
former, and within six weeks after the latter.
Treatment. — Symptoms are to be treated as they arise ; the use of
pig's pancreas has produced a diminution of the pain and of the jaundice.
Reginald PI. Fitz.
REFERENCES
1. Boas. Berl.klin. Wochenschr. 1891, xxviii. p. 40. — 2. Cappakei-li. Jahresher.
Viicliow-Hirscli, 1883, p. 267.-3. Cowley. London Med. Jour. 1788, ix. p. 286. —
4. DoMiNirTS, DE. Gior. internaz. d. sc. vied. Napoli, 1889, N.S. xi. p. 801. — 5. Dhaper.
Tr. Ass. Am. Plnjsicians, 1886, i. p. 243. — 6. Durante. Allg. Died. Ccntr.-Zdj. fieri.
(Abs.) 1894, Ixiii. p. 427. — 7. Elliot. Boston Med. and Surg. Jour. 1895, cxxxii. p,
351. — 8. Fitz. Boston Med. and Surg. Jour. 1889, cxx. p. 181. — 9. Goitlieb.
Verhandl. d. naturh. med. Ver. zu Heidelb. 1894, N.^^.V. 203. — 10. Hansemaxn.
Ztschr. f. klin. Med. Berl. 1894, xxvi. p. 314. — 11. HartM'ANN and Gilbert. Congr.
franc, de ehir. Proc.-verb. 1891, 618. — 12. Heuringham. St. Barth. Hasp. Jicp. Lond.
1894, XXX. p. 5. — 13. HiLDEBRANn. Ccntralbl. f. Chir. Leipz. 1895, xxii. p. 1.— 14.
HoLZ.MANN. Miinclicn. med. Jl'ochenseltr. 1894, xli. p. 390.^15. Klebs. Handh. d.
path. Anat. 1S7G, i. 2, p. 553.— 16. I'^ihiTE. Arch. f. Idin. Chir. Berl. 189-1, xlviii.
p. 721. — 17. Lancereaux. BuU. Acad, de med. Paris, 1891, 3 s. xxvi. p. 367. — J8.
Langerhaxs. Fcstchr. Rudolf Vircliow, Berl. 1891. — 19. Lichtheim. Berl. llin.
Wochenschr. 1894, xxxi. p. 185. — 20. Lloyd. Brit. Med. Jour. Lond. 1892, ii. p.
1051. — 21. ^Iering and Minkowski. Arch. f. exper. Path. u. Pharmakol. Leipz.
1889-90, xxvi. j.. 371.— 22. Minkowski. Arch. f. exper. Path. u. Pharmakol. 1892-93,
xxxi. p. 85.— 2i. MiNNicH. Berlin, klin. IVocken. 1894, xxxi. p. 187.— 24. Miralli^.
Gaz. dcs hfrp. Pari.s, 1893, Ixvi. p. 889. — 25. Osler. Pi-inciphs and Practice of JHedicine,
1892, p. 459.-26. Prince. Boston Med. and Surg. Jour. 1882, cvii. p. 28.-27.
Pve-Smitii. Tr. Path. Soc. Lond. 1885, xxxvi. p. 17.-28. Richardson. Tr. Am.
Surg. Ass. Phila. 1892, x. p. 211.-29. Salzer. Ztschr. f. Hiilk. 1886, vii. p. 19.—
30. Seou£. Centralbl. f. klin. Med. 1888, xlviii. p. 884.— 31. Thayer. Am. Jour.
Med. Sci. 1895, ex. p. 396.-32. Trafoyer. Jf'ien. med. Woclienschr. 1880, xxx. p.
139.— 33. "Walker. Med. and Chir. Soc. Trans. 1889, Ixii. j). 25.-34. Welch. Med.
Nexcs, Phila. 1891, lix. p. 669.-35. Williamson. Med. Chron. Manchester, 1891-
92, XV. p. 367. — 36. Zenker. Deutsche Ztschr. f. prakt. Med, Leipz. 1874, i. p. 351.
E. II. F.
DISEASES OF THE KIDNEYS
GENERAL PATHOLOGY OF THE EENAL FUNCTIONS
A. The Urine
In health the composition of the urine remains fairly constant, with
some fluctuation in the amounts of the individual constituents. In disease
the changes in its composition are due either to morbid processes in the
kidney itself interfering with its excretory functions, or to changes in the
general tissue metabolism producing substances not normally found in the
economy ; and these, after circulating in the blood, are excreted in the urine.
Not infrequently the excretion of these bodies in the urine may injure
the kidneys. Disease may alter the quantities of normal constituents of
the urine, or it may lead to the presence in it of abnormal substance.
Urinary water. — The quantity of water voided by a healthy adult in
24 hours is from 40 to 50 ounces. These limits may be exceeded or
not reached; the quantity may rise to 80 or fall to 20 ounces.
In health, inasmuch as the water in the tissues remains fairly constant,
the quantity of the urine is affected by (i.) the amount of fluid consumed ;
(ii.) the amount of fluid eliminated by other channels, as by the lungs,
skin, and alimentary canal.
In disease the amount of water in the tissues may undergo great varia-
tions, and these variations will produce effects on the urinary flow ; thus
dropsy, from whatever cause, will necessarily lead to a diminution in the
quantity of urine. Ultimately the amount of urine is determined in
health by the functional activity of the glomerular tuft, and this in turn
depends upon (a) the activity of the glomerular epithelium ; (b) the rate
of the flow of the blood through the tuft. Besides these two factors it
is probable that the nervous system controls the kidney, so as to in-
fluence the amount of urine, and even to cause suppression.
The varying blood -flow through the kidney is, however, the factor
about which most is known. Dilatation of the renal vessels, produced
either through the nervous system, or on the direct stimulation of the
blood-vessels by some chemical constituent of the blood circulating
through the organ, causes a greatly increased flow of urine. The diuresis
produced by local dilatation of the renal vessels is still further increased
if the local renal dilatation is accompanied by a general constriction in
other vascular areas. Conversely, local constriction of the renal vessels and
282 SYSTEM OF MEDICINE
general dilatation of all the other vessels of the bod}', by lessening the
blood-tlow throuirh the kidney, cause a diminished flow of urine. Sul>
stances that produce an increased flow of urine — for instance, urea, sugar,
cafTein, and so forth — cause experimentally a dilatation of the renal
vessels ; but not always a simple dilatation : thus caff'ein produces an
initial constriction followed by dilatation. Drugs like digitalis cause an
increased flow of urine, although they produce constriction of the renal
vessels ; but here the result is due to the considerable rise in general blood-
pressure and the increased velocity of the blood whereby, notwithstanding
the constriction of the renal vessels, more blood proljalily flows through the
kidnej' in a given time. The action of substances like urea, which cause
diuresis with vascular dilatation, is a local one on the kidney, since all the
effects can be produced after complete division of the renal nerves.
Althoi;gh the state of the renal vessels is the factor in the secretion
of urine with which we are best acquainted, my experiments show that the
quantity of kidnej'^ substance has a profound eflfect on the amount of lu-ine
excreted. The removal of small portions either from one or both kidneys
is followed by an increase in the quantity of urine secreted ; and if so
much as two-thirds of the total kidney weight l)e removed, the urinary
flow may be permanently doubled "\\'ithout undergoing any other altera-
tion in its composition. If a considerable Avedge be removed from each
kidney a still greater increase of the urinary water is obtained. The
removal of three-fourths of the total kidney weight is followed, not only
by a still greater increase in the urinary flow — so that it may be
quadrupled in amount — but also by an augmentation of the excretion of
urea. These observations show that the removal of portions of the kidney
influence the amount of urinary water excreted very materially ; and this
notwithstanding the fact that the remnants of kidney do not undergo
any marked pathological change.
Although no nerves have been found that exercise any influence on
the secretion apart from the vaso-motor mechanism, yet no doubt the secre-
tion of urine may sometimes be totally arrested without any great effect
being produced on the renal circulation at the same time. To expose the
ureter and put a canula into it will sometimes completely arrest the
secretion of urine. On the other hand, puncture of the medulla causes a
great increase in the amount of urine ; and although the effects of the
latter experiment may be explained as a result of vaso-motorial influence,
this cannot be the case in the former, since there is no experimental evi-
dence that interference with the lu-eter leads to any circulatory changes
in the kidney.
In disease the quantity of the urine may be increased or diminished —
the latter more usually than the former. If increased, the increase may
be either permanent or temporary. In diabetes mellitus and in diabetes
insipidus the increase is permanent. In lardaceous disease of the kidney
and in renal cirrhosis the increase, although not present throughout the
disease, yet persists for considerable periods. In chronic parenchymatous
nephritis, or diffuse nephritis, considerable temporary increase is seen
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 283
during the period of the subsidence of the dropsy, and also subsequently
when all trace of dropsy has disappeared. In diabetes mellitus the in-
creased excretion is usually held to be due to the presence in the urine of
lai'ge quantities of sugar and urea. In diabetes insii)idus the cause of the
diuresis is obscure, but it is attributed to some functional l>ul1)ar change,
causing dilatation of the renal vessels {vide vol. iii. p. 24:1). In both diseases
there is great thirst, but this is probably the result rather than the cause
of the flow of urine.
In diffuse nephritis the quantity of urine varies inversely as the
amount of dropsy. In the other chronic destructive diseases above men-
tioned the increased flow is due either to the diminution in the amount
of kidney substance or to the altered state of the blood-vessels or to the
abnormal blood-pressure.
Most diseases lead to a diminution in the quantity of urine ; thus
febrile disorders, with the increased loss of water by sweating and by
hurried respiration, are marked by the excretion of a scanty concentrated
urine. Dropsy, whether of cardiac, renal, or hepatic origin, leads to a
deficient and scanty excretion of urine. Diseases causing profuse diarrhoea
may even cause complete suppression, as in cholera. All diseases pro-
ducing a diminished flow of blood through the kidney o"\ving to venous con-
gestion— for example, thrombosis of the renal vein or vena cava, cardiac
valvular disease, pulmonary lesions, and so forth — lessen the quantity of
urine. Lastly, acute and certain chronic inflammatory and other destruc-
tive diseases of the kidney diminish the flow. This failure in excretion,
however, is more frequently seen in acute and subacute nephritis than in
well-established chronic nephritis.
The diminution in the quantity of urine may go on to absolute sup-
pression, of which two varieties are described, the so-called obstructive and
non-obstructive supj^ressions. In the former there is some direct impedi-
ment to the exit of the urine along the ureter ; in the latter no such
obstruction exists, the renal pelvis and the ureter are quite patent ; never-
theless no urine, or only very small quantities of it, are excreted. The
latter condition is much the more serious, and usually ends fatally in from
two to four days, or even in twenty-four hours. It is seen in very acute
nephritis, sometimes also in chronic nephritis, and in certain forms of
granular kidney and other diseases of the kidney. It may also be seen dur-
ing the course of acute specific fevers, as, for instance, in diphtheria, Avithout
any marked alteration in the kidney ; also in perforating peritonitis, and
after severe injuries. In these latter cases it ma}'- occur A\ath the kidneys
apparently perfectly healthy and not presenting any coarse lesions
post-mortem. This form of suppression has been known to occur after
operations on the kidney, when one organ has been exposed and incised
with the view to the detection of a stone, and yet where no stone or other
disease has been found. In many of these cases the kidneys are not
healthy ; but cases have occurred where total suppression has followed
exploratory incision into the kidney, and yet post-mortem examination
has revealed no obvious disease of the kidnevs.
284 SYSTEM OF MEDICINE
Suppression is not an uncommon sequel of catheterisation, when the
kidneys are diseased secondarily to mischief in the lower urinary tract.
Obstructive suppression is seen mi bilateral calculous disease, and
■where after one kidney has been practically destroyed by calculous
pyelitis the ureter of the only active kidney becomes blocked by stone.
It is also seen where, owing to disease in the pelvis, as in carcinoma of
the uterus, both ureters are simultaneously closed. In these conditions
the first effect is not suppression, but rather the production of hydro-
nephrosis ; no urine is emitted, but it is still secreted by the kidney.
Sooner or later, however, if this condition be not relieved actual suppres-
sion ensues.
Speeifle gravity. — The specific gravity of the urine is usually from
1015 to 1025, but it may fall as low as 1002 persistently, as in diabetes
insipidus, or it may rise as high as 1060. Persistently low specific
gravity, especially in the urine voided in the early morning, or in the
urine of the total twenty- four hours, is produced by such diseases as
diabetes insipidus, cirrhosis of the kidney, lardaceous disease of the
kidney, chronic ditl'use nephritis, hydronephrosis, cystic kidneys. Severe
Briglit's disease, however, sometimes even fatal Bright's disease, can
exist with a urine having a specific gravity as high as 1025.
The specific gravity is raised by the presence of large quantities of
urea and salts in the urine, and by sugar. A character of the presence
of the last substance, however, is a high specific gravity of a pale, dilute-
looking urine; thus, a specific gravity of 1035 in pale urine suggests
sugar, but a specific gravity of 1035 in a high-coloured febrile lu'ine
would have no such significance. Sugar ma}'', however, be present, even
in a considerable cpiantity, with a specific gravity as low as 1010; and
when the specific gravity is raised by the presence of sugar the two do
not necessarily vary together. A higher percentage of sugar may bo
present with a rather lower specific gravity. This is due to the effect on
the specific gravity of other constituents, and more especially of urea and
salts. In diabetes, provided the flow of urine be large and hence dilute,
the specific gravity gives a fairly accurate notion of the. quantity of
sugar ; but this is not the case if the quantity of urine be comparatively
small.
Reaction. — The reaction of the normal urine is acid, but the acidity
varies largely under the influence of meals. Although the urine voided
in healtli is usually acid, the tu'ine secreted by the kidney undergoes
greater fluctuations in reaction. Thus, the morning urine is highly acid ;
the urine secreted two to three hours after a meal may be even alkaline,
but probably, owing to admixture with acid uiiiic in the bladder, the
fluid voided will still be acid. The reaction of the normal urine is most
influenced by diet ; and, speaking broadly, an animal diet increases the
acidity and a vegetal>le diet diminishes or even annuls this reaction.
The acidity of the total urine in twenty -four hours in health is equivalent
to two grammes of oxalic acid, and is dependent upon the ]>resence of
acid phosphate of soda. Probably as meat contains a considerable amount
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 285
of this acid phosphate it is this constituent of meat which increases the
acidity of the urine.
If in disease the quantity of urine be diminished, as in fever, the
relative acidity is increased.
Patients living "high" and suffering from so-called litheemia also
excrete highly acid urine. The urine in diabetes, more especially in
diabetic coma, the so-called acetonsemia, is highly acid, and is said to
contain a number of abnormal acids, more especially /?-oxybutyric acid.
In disease the acidity of the urine is more frequently diminished,
and not uncommonly it is alkaline. The acidity is greatly diminished in
cases of dilated stomach, and especially, it is said, as the result of washing
out the stomach.
Two varieties of alkaline urine are recognised — one where the
alkalinity is dependent upon the presence of a fixed alkali, and the other
where it is dependent on the presence of a volatile alkali. The former is
often associated with a diet rich in vegetable matter, and it is sometimes
seen for long periods in nervous, dyspeptic, neurasthenic, hypochondriacal
patients. Such urine is frequently milky from the precipitation of
phosphates, more especially calcic phosphates. It is not a condition of
any very great consequence, except that it may possibly lead to the
precipitation of amorphous tricalcic and also of monocalcic phosphates,
and may cause the formation of some of the rarer phosphatic stones.
Alkalinity from volatile alkali, on the other hand, is a very serious
condition, and is usually dependent on decomposition of the urea into
carbonate of ammonia, owing to microbic infection of the urine, usually
from the introduction of dirty catheters. Sometimes the infection reaches
the urine from within, owing to the rupture of an abscess into some part
of the urinary tract ; and it is perhaps possible that occasionally organisms
may reach the urinary bladder, either by ascending the ureter or even
by passing through the kidney from the blood. Alkaline urine loaded
with bacteria is occasionally seen in Bright's disease.
Normal pigments. — Attempts have been made to explain the colour
of the normal urine as dependent upon a single pigment, but at the
present time there can be no doubt that several pigments are present,
and, further, that the yellow colour is not dependent upon any substance
yielding a banded spectrum. Normal fresh urines, when examined
spectro-photometrically, show relative as well as absolute variations in
the extension coefficient for any part of the spectrum. In this respect
opinion has reverted somewhat to the earlier views of Schunk and
Thudichum. The following pigments have been obtained from normal
urine : —
Urohllin, a pigment obtained from the urine by precipitation with lead
salts and suljsequent extraction with alcohol acidified with sulphuric acid ;
or by saturation of the urine with ammonium sulphate. Urobilin is
readily soluble in chloroform, and yields a definite absorption band at F.
Some observers think that the yellow colour of the urine is dependent
upon this body ; others that, although it is undoubtedly present in
286 SYSTEM OF MEDICINE
normal iiriue, yet, as only traces ai'c present, it plays an unimportant
part in tlie production of the normal colour. The main facts in support
of this latter view are that, whereas urobilin itself is freely soluble in
chloroform, chloroform does not take up the yellow colour of normal
urine ; and that, whereas urobilin yields a very definite and dark absorp-
tion band at V, normal iu"ine, even when viewed in deep layers, only shows
a shading here. To account for the small amount present normally, and
also for the fact that this amount is increased by exposure, oxidisation,
and the like, it has been assumed that a mother sulistance, or chromogen
of urobilin, is present in normal urine, Avhich yields urol)ilin on oxidisa-
tion. Uroliilin is present in the bile, and is probably identical Avith
hydrobilirubin, fox'med from bilirubin by the action of potash and sodium
amalgam. It is also identical with, the body formed from acid haematin
by the action of zinc and hydrochloric acid.
Uroeri/thrin. — This is the pigment that causes the pink colour of the
uratic deposits, seen occasionally even in health. This pigment can be
extracted from normal urine by means of amylic alcohol. It is an
amorphous reddish substance, acid in reaction, soluble in alcohol, ether,
and water. The alcoholic extract of pink urates yields two absorption
bands between D and F. Uroerythrin, treated with caustic alkalies,
yields a green colour.
Hiemafoporphi/rin. — This pigment has been found by several ob-
servers in the urine as a result of the administration of sulphonal ; and
afterwards by Dr. A. Garrod as a trace in normal urine. Uroha?mato-
porphyrin Avas described by Mac^Iunn as a pigment present in the urine
in certain diseases ; but it has been asserted that it is really a mixture of
hrematopor[)hyrin and urobilin — this body or bodies being present in
traces only.
Urochrome. — None of the above-mentioned pigments, although
present in normal urine, will account for the yellow colour of the fluid,
and to a substance yielding a yellow solution, but not yielding any bands
spectroscopically. Dr. Thudichum gave the name of urochrome. Kecently
this observation has been revived and extended by Garrod. Thudichum
obtained a substance forming yellow crusts, freely soluble in water, fairly
so in ether, less in alcohol. Schunk found two yellow pigments, one
soluble in ether, the other not. Garrod has obtained an amorphous
brown substance, insolul)le in ether and chloroform, freely soluble in
water. Although there are differences in solul)ility between the results
of these various observers, there can be no doubt that they all operated
on the same substance, and that this yellow pigment does not yield a
banded spectrum ; moreover, by Garrod's method at any rate, the urine
was not acted upon by powerful reagents, capable of causing decomposi-
tion of the pigments present. Hence urochrome is probably the substance
to which lu'ine owes its colour.
Jfunwus pigments. — Normal urines are found to darken materially
when treated with mineral acids, and amongst the various pigments that
are formed under these circumstances the so-called humous pigments
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 287
described by Udranzky must perhaps be included. These are dark
brown pigments, formed when carbohydrates are treated with acids or
alkalies. They yield no bands, and they are soluble in amylic alcohol
and in caustic alkalies ; inasmuch as the normal urine contains carbo-
hydrate derivatives it is quite possible for these substances to be
formed.
The urine, in addition to the pigments described above, contains
several other substances which, although not coloured themselves, yield
well-marked and characteristic pigments on treatment with acids. The
most important of these are the indoxyl and skatoxyl sulphates of potash.
Indiam. — ^^Indigo, as such, does not appear in normal urine, but in
exceptional cases in decomposed urine it is seen in quantity sufficient to
give the liquid a blue colour. It exists in the urine as indican, a com-
pound of indoxyl, sulphuric acid and potash. Indoxyl is also said to be
present in the urine in combination with glycuronic acid ; as much as
20 mgrms. of indigo may be passed daily in the urine under normal con-
ditions. The indigo owes its origin to indol formed in the intestines
from proteid decomposition. Indigo is readily obtained from the urine
by treating it with an equal volume of hydrochloric acid, and adding a
solution of calcium hypochlorite, drop by drop, avoiding any excess. If
the urine is then shaken with chloroform, the latter dissolves the indigo.
Indigo is occasionally seen in urinary sediments and calculi. In disease
the indican of the urine is greatly increased in cases where there is con-
siderable intestinal putrefaction. Thus it is increased in constipation
and in cases of long-continued intestinal obstruction. It is, however,
seen also in cases of putrid inflammation ; for example, in puti'id empyema
and gangrenous pneumonia, also in tuberculous peritonitis, gastric ulcer,
cancer, and other diseases. •
Skatol jdgmcnts. — These have a similar origin to the indol pigments ;
part of the skatol formed in the intestine yields jDotassic skatoxyl
sulphate, and is excreted in the urine. On treating urine containing
this body in abundance with an acid, the fluid becomes of a deep red
colour. This pigment, like indigo, is present in increased amounts in the
urine in constipation ; and this perhaps accounts for its presence in
diabetes and in chlorosis.
Abnormal pigments. — In disease normal pigments may be excreted
in greatly increased quantify ; or again pigments, not normally present,
may be excreted. Amongst the latter haemoglobin and its derivatives,
and bile pigments may be mentioned.
Urohi/in. — As stated above, the normal urine contains only traces
of urobilin ; but in a great number of diseases urine is voided of a reddish
brown colour and containing a large quantity of this pigment. To
the eye the urine looks as if it contained l,)ile or altered blood pigment;
in fact this mistake is often made, more especially because such patients
are often distinctly yellow, and the conjunctivae are yellow. The stools,
however, are of normal colour, and in testing the urine no bile reaction
is obtained ; on spectroscopic examination the deep black absorptive
288 SVSTEM OF MEDICINE
baud at F, characteristic of urobilin, is seen. Some observers consider
that this urobilin is different froiu the urobilin in normal urine, and that
it only exists in the urine normally as a chromogen ; to it the name of
pathological or febrile urol>iliu has been given. There is considerable
doubt, however, -whether there is any distinction between the so-called
normal and so-called pathological urol)ilin, and I have therefore used the
name urobilinuria, as I believe that the substance is the same as the so-
called normal lu'obilin, but that it is present in greatly increased
amount. The important point is that in disease this pigment may be
found in the urine in such quantity as to cause a superhcial resemblance
to bile-stained urine.
Urobiliiuiria is seen after copiotis internal haemorrhage, such as follows
the slipj^ing of ligatures after abdominal qjierations, ruptured tubal
gestation, or pelvic ha^matocele. In pernicious anaemia it is this jjig-
ment that causes the well-known brown colour of the urine, and also the
lemon -tin ted skin, conjunctivae, and fat ; and here probably it has the
same origin, that is, the destruction of hfPn;ogloV)in. Urobilin is also found
in the urine in increased amount in cirrhosis of the liver, with or without
the presence of jaundice and of bile pigments in the urine. In febrile
diseases the dark colour of the urine is due in part to excess of urobilin ;
and in paroxysmal ha?moglobinuna urobilin, in addition to haemoglobin
derivatives, has been found in the urine.
The haemoglobin of the blood may be passed in the urine in the form
of blood corpuscles, or it may be separately present. The former is
usually spoken of as haematuria, the latter as hajmoglobinuria ; although
the latter is frequently a mixture of ha?moglobin with A'arious derivatives,
such as methaimoglolnnuria, acid-htematin.
Hcematuria. — Here blood corpuscles are present in the urine in
varying amount. Blood may be added to the urine for purposes of
deception ; otherwise haematuria is due to hannorrhage into some part of
the urinary tract. Haemorrhage from the kidney may come either from
the kidney substance or from the renal pelvis. The former is seen in
acute nephritis and in infarction of the kidney, passive congestion, or
tumours ; the latter in pyelitis, in calculous and tuberculous disease.
Profuse haemorrhage is sometimes seen in cases of jjur^jura luemorrhagica ;
probably it comes from the A^essels in the loose cellular tissue of
the renal pelvis, as in fatal cases copious submucous haemorrhages are
seen in this situation. In granular contracted kidney very profuse
haemorrhage is sometimes seen, so that the urine is bright red in colour ;
and here also it is probable that the haemorrhage is really from the renal
pelvis and not from the kidney itself. In cases Avherc the haemorrhage is
actually from the kidney substance the urine will contain renal casts and
very probably blood-casts. A\'hen the l)lood comes from the kidney or
pelvis of the kidney, the blood is intimately mixed with the urine ; and
if it is present in small quantities only, the urine Mill be smoky from the
action of the acid salts of the urine on the blood pigment, some of the
hiemoglobin being converted into acid-ha^matin and methaemoglobin. If
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 289
the blood is present in large quantities it Avill impart a bright red colour
to the urine, notwithstanding its renal origin.
In A'ery profuse haemorrhage from the kidney and from the renal pelvis
clots may form and temporarily block the ureter, and the patient may
suffer from attacks of renal colic. Casts of the ureter may sometimes be
passed.
The bladder is a common source of blood in the urine, and vesical
haemorrhage may be so profuse that the organ may become dis-
tended with l)lood-clots. In vesical haemorrhage the blood may be
uniformly mixed with the urine, but very frequently the blood is only
seen, or is seen more abundantly in the last portions of urine passed, the
first portions being quite clear. In prostatic haemorrhage the bleeding is
also apt to be seen at the end of mictiu-ition. H?ematin is often found in
the urine in cases of vesical bleeding, the blood having been decomposed
by the acid urine.
A small amount of blood in the urine associated with a large amount
of albumin points to the existence of renal disease. The blood in the
urine may, by the ej'^e, be confounded with bile and with urobilin.
From the former it may be distinguished at once by the greenish
tinge always seen on the surface of urine containing bile. From
urobilinuria the mistake may be avoided at once by spectroscopic
examination. Blood is most readily detected by microscopic examination
of the lower strata of the urine after settling or centrifugalising. The
blood corpuscles may be seen either but little altered or crenated ;
occasionally in dilute urine they may be distended and difficult to
recognise as blood corpuscles. As confirmatory tests the guaiacum test.
Heller's test, and the spectroscope may be used ; but the last is not of
much avail when traces of blood only are present. Hsemin crystals may also
be formed, and afford a A'ery certain indication of the presence of blood.
Hmnoglohinmia. — Here the colouring matter only of the l:)lood,
more or less altered, is found in the urine. It is exceptional for
haemoglobin to be present alone ; it is usually mixed with methsemoglobin.
The redder the urine, the greater the amount of haemoglobin ; the browner,
the more methaemoglol)in. It is possible that in many cases haematin is
also present. Haemoglobinuria is seen under the following conditions : —
(a) Paroxysmal haemoglobinuria or hcemogloUnuria afrigore. In sufferers
from this disease exposure to cold is folloAved l)y the disappearance from
the circulation of very large numbers of blood coi^puscles ; thus, in an
attack the patient may lose half the total number of blood corpuscles ;
the urine is as dark-coloured as porter, and contains no blood corpuscles,
but a granular debris and oxalates. It is loaded with albumin, and the
brown colour is due to a mixture of methaemoglobin, haemoglobin, and
urobilin. As the attack passes off the urine becomes of a lighter and
redder tint, and finally returns to its normal colour.
(b) So-called symptomatic haemoglobinuria. This is a condition
where the haemoglobin\;ria is simply an accompaniment of another
malady. Thus it is occasionally seen in malaria and in Raynaud's disease,
VOL. IV U
290 SYSTEM OF MEDICINE
and the phenomena are nnich the same as in the idiopathic hauiioglobiniiiia.
It also occurs after severe hurns and in .acute infective diseases.
(c) Toxic h:emoglobinuria. This may be produced in poisoning by
arseniuretted hydrogen, chlorate of potash, pyrogallic acid, naphthol, or
carbolic acid.
H;>?moglobinuria is most easily recognised l)y spectroscopic examina-
tion ; the bands of the methsemoglobin resemble those of oxyhasmoglobin,
and, moreover, the l)and in the red is very characteristic of meth<>?mo-
glolnn. If the amount of haemoglobin be large, and the urine be
examined "without dilution, only the band in the red will be seen, all the
rest of the spectrum l)eing cut off; but on dilution the two bands in the
yellow Avill be seen, and care must be taken not to dilute too rapidly,
otherwise the band in the red will be missed. Heller's test is also
applicable. On microscopic examination of the urine, either no blood cor-
puscles or extremely few are seen. A number of droplets of a yellowish
colour are frequently found. In fatal cases these are also seen in the
cortical tubules of the kidney.
Hipmntoporphiirin. — This, as stated above, occurs in traces in normal
urine, but occasionally in disease it is present in sufficient quantity to
colour the urine a deep red or port wine colour. It has been observed
in rheumatic fcA^er, Addison's disease, peritonitis, and cirrhosis of the liver.
It is also present in the urine after the administration of various drugs,
more especially suli)honal. ]\Iac]Munn coi.siders that the pigment in the
urine is not always hiematoporphyrin or iron free htematin, but a modifica-
tion of it, to which he has given the name of urohfematoporphyrin. This
pigment can be precipitated from the tirine by barium chloride and
barium hydrate, and extracted with acidified alcohol ; the bands char-
acteristic of it can then be seen on spectroscopic examination.
Melanin, a pigment containing sulphur, is rarely found in the
urine. Occasionally urine of a caf6 an. htit colour is passed by ]iatients
suffering from melanotic sarcoma. On the addition of nitric acid to such
urine it becomes 1)lack in colour, the chromogen of melanin being con-
verted into melanin. Ferric chloride, when added to such urines, causes
a grayish brown or black precipitate, solul)le in excess of ferric chloride.
Bromine water, when added to the urine, gives a yellow precipitate, which
gradually Ijlackens. ]\Ielanuria is occasionally seen in wasting diseases,
apart from the presence of melanotic sarcoma.
Chnluria. — In jaundice the bile pigments are found in varying
quantity in the urine, and impart to it a colour varying from reddish
l^rown to almost black. The upper surface of the urine, on an oblique
illumination, has a greenish tinge, and on shnking such urine a greenish
yellow froth is seen. Bile pigments can often be recognised in the urine
in cases of jaundice before the yellow coloration of the skin is marked.
The yellow colour of the skin may persist at a time when the pigmenta-
tion of the urine is slight or absent. It is held by some that bile
pigments appear in the urine under the following conditions : (a)
Obstruction of the bile-ducts, so-called hepatogenous jaundice ; (//) De-
GENERAL PATHOLOGY OF TILE RENAL FUNCTIONS 291
composition of h?emoglobin in the blood-vessels with the formation of
biliary pigments, so-called haematogenous jaundice ; {c) Decomposition
of haemoglobin after extravasation into the tissues and the formation there
of biliary pigments. There is, however, some doubt as to the production of
cholnria under conditions (ji) and (c). In many cases of decomposition
of haemoglobin either within or outside blood-vessels, large quantities of
urobilin are excreted in the urine, and the urobilinuria so produced has
a certain superficial resemblance to choluria. Some observers still assert
that in hiiemoglobinuria, and after lai'ge internal hemorrhages, bile
pigments appear in the urine along with the urobilin and metha^mo-
globin. However this may be, the great bulk of cases of choluria
undoubtedly depend upon obstruction of the bile-ducts, large or small.
Although l)ile pigments are present in the urine in obstructive jaundice,
and are readily recognised, this does not apply to bile salts ; and even in
cases of complete and permanent obstruction of the bile - ducts it is
difficult to detect them in the urine unless special methods are employed.
For the recognition of bile pigments Gmelin's nitric acid test is the best ;
but the acid should not contain too much yellow fuming acid, as Avith
this the oxidation occurs too rapidly, and the play of coloiu's is not
readily seen The test can be performed on a plate or blotting-paper or
on a slab of plaster of Paris. These methods are all better than pour-
ing the urine on the nitric acid in the bottom of a test - tube. Bile
cannot be said to be present unless a gi"een colour is seen as the first
colour in the play. Bile pigments may be precipitated Avith milk of
lime, the precipitate collected and treated with Avater, and then shaken
Avith chloroform acidified Avith acetic acid. The chloroform solution of
the bile pigments may then be used for Gmelin's reaction. The recogni-
tion of the bile salts in the urine is more a matter of scientific than of
clinical interest \yiih " Functions and Functional Disease of the Liver "].
Occasionally their presence may be recognised by Pettenkofer's reaction
in the urine itself, that is, by treating the urine Avith a solution of sugar
and some sulphuric acid, and shaking ; the purple colour characteristic
of the reaction may be seen in the froth. ]\Iore usually this procedure
fails, and then some ounces of urine must be evapoiated to dryness, the
residue extracted Avith alcohol, the salts precipitated by ether, dissolved
in AA'ater, and Pettenkofer's reaction sought Avith this solution. To the
eye, urine containing bile may be confounded Avith urine containing large
quantities of urobilin, and Avith urine containing decomposition products
of haemoglobin, such as methaemoglobin and haematin.
It is of interest to note that in cases of external biliary fistula, Avith
complete obstruction of the bile-ducts, the urine maintains its normal
yelloAV colour, notAvithstanding that all the bile secreted is passed out-
Avards, and none enters the intestine. This fact throAvs considerable
doubt on the vicAV that the urinary pigments (urochrome, urobilin, etc.)
are derived ultimately from the bile pigments.
PijrocatecJiin and hydrochinon. — The former substance occurs norm-
ally in small amounts in the urine, and is greatly increased in cases
292 SYSTEM OF MEDICINE
of carboluria. The latter occurs only in cases of poisoning Avith carbolic
acid. Both these substances exist in the urine as ethereal compounds of
sulphuric acid. Urine containing pyrocatechin is colourless when passed,
but darkens on exposure to the air ; if this substance be abundant, the
urine will become black. It is to this body and to hydrochinon that the
greenish black colour of the urine in carboluria is due.
Nitrogenous extractives. — About 15 grammes of nitrogen are ex-
creted daily on an average during health, and the most important nitro-
genous constituents of the urine are urea, tiric acid and kreatinin ; others,
such as xanthin, guanin, hippuric acid, althotigh present, are not of great
clinical importance.
Urea. — Normal human urine contains, rouglily speaking, 2 per cent
of urea, occasionally rising in health to as much as 3 per cent. The daily
quantity excreted has been stated to vary between 22 and 40 grammes,
the average being usually stated at some 30 grammes. Approximately
0*5 grni. of urea is excreted per kilogramme of body weight. Children
excrete rather more relatively to their body weight. Normally the amount
of urea excreted is largely dependent on the diet, and hence is greatly in-
creased after meals. Copious water-drinking increases the urea exci'etion,
at any rate temporarily. Exercise does not lead to any notable increase.
In disease the excretion may be diminished or increased, and if increased,
the increase may be absolute or relative, temporary or permanent.
Observations on the urea excretion in disease are of little value unless
the amount and nature of the foods consumed be taken into consideration.
In diabetes mellitus the quantity of urea excreted is greatly and per-
manently increased, and here the increase is dependent largely upon the
increased appetite and nitrogenous diet, partly also upon the wasting.
In diabetes insipidus the quantity of urea is also slightly increased.
In febrile diseases the percentage of urea is greatly increased, owing to
the density of the urine ; and the amount is always relatively increased,
since even if quantities of urea, equal to the normal, are excreted, owing
to the failure of appetite the amount is really greater than that excicted
by a patient with a normal temperature on the same diet.
In wasting diseases, such as cancer of the oesophagus and stomach,
associated with vonu'ting and with practical starvation, the amount of urea
is diminished ; and this is the case also in diseases destroying the liver
substances, as in atrophic cirrhosis ; it reaches its minimum in acute yellow
atrophy, where the urea may entirely disappear from the urine. In renal
diseases the m-ea is diminished in cases of consecutive nephritis, Avhere
urine of a very low specific gravity is passed, which contains a very small
percentage of urea. In acute nephritis also very little urea is jjassed,
owing largely to the great diminution in the quantity of tu'ine.
In chronic nephritis the amount of the urea excretion varies. In
cases associated with dropsy, and where, therefore, but little urine is
secreted, the quantitv of urea excreted is small in amount ; but in cases
of chronic nephritis not accompanied with dropsy, and where there is no
urajmia, the quantities excreted are often equal to those seen in health ;
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 293
and in my experience I have found it is not uncommon for daily quan-
tities of 30 grammes to be passed. It is usually held that in chronic
nephritis a sudden and great, diminution in the urine and urea excretion
points to the imminence of urremia.
In renal cirrhosis considerable quantities of urea may be passed, and
it is not uncommon, in cases of this disease, for uraemia to occur at a
time when the patient is passing large cpiantities of urea, quantities quite
commensurate with the amount of nitrogenous food taken, although per-
haps the amount is less than that passed by a healthy adult on full diet,
such patients being usually on a low diet.
The c[uantity of urea is usually estimated for clinical purposes by the
hypobromite method. This method, even when most carefully performed,
gives erroneous results to the extent of 8 per cent. In performing a
determination it is important that the hypobromite of sodium should be
freshly prepared, that it should not be used in large excess, and that the
mixing of the urine and the hypobromite should be carried out very
slowly.
Other methods of estimation are those known as Liebig's and the
precipitation with phosphotungstic acid. These methods, however, are
not commonly employed in clinical work.
Uric add. — This substance is excreted to the amount of 1 gramme a
day. It is present in the urine in the form of a quadriurate. Uric acid
is probably formed in the liver and spleen. It is known definitely that
it is formed in the liver of birds ; but in the mammal the seat of its
formation is largely a matter of inference, and it has been asserted that
it is formed in the kidney. The amount excreted is largely increased by
meals, and the increased excretion after meals is said to occur sooner than
the increased excretion of urea. The increase after meals is not entirely de-
pendent upon the nature of the meal, although a proteid meal is the one most
likely to produce it. This increased excretion is most marked during the
alkaline tide. All kinds of nitroijenous food lead to an increased excre-
tion of uric acid ; but it is not clear that large quantities of meat produce
a greater excretion than vegetable food, although, owing to the acidity of
the urine with a meat diet, and the relative alkalinity of the urine with
a vegetable diet, the uric acid is perhaps more liable to precipitation.
All urines, if kept from putrefaction, deposit uric acid sooner or later ;
but if it occurs some twelve hours after the passage of the urine, its deposi-
tion has no clinical significance ; if it takes place within this time, and more
especially if it occurs within four or six hours or sooner, then it becomes
important, inasmuch as it might occur whilst the urine is in the urinary
passages, and so lead to the formation of a renal or of a vesical stone.
Uric acid is very insoluble in cold water (1 in 15,000), but more sol-
uble in boiling water. Uric acid, in fact, derives most of its clinical
importance from its insoluljility. In a weak alkaline solution, such as 0'2
per cent of bicarbonate of soda, it is more soluble, owing to the formation
of a quadriurate ; but if this solution be allowed to stand, crystals of biurate
of soda are deposited owing to the decomposition of the quadriurate.
294 SYSTEAf OF MEDICINE
Uric atitl itself crystallises in the form of rhomhic prisms, but the size
and shape of the crystals vary Avith the relative purity of the liquid from
which the crystals are formed ; and the process is greatly modified by
the presence of albuminous substances in the solution.
If precipitated by an acid from a solution in bicarbonate of soda, uric
acid crystallises in plates ; from the urine, ho\ve\'er, the usual form is
lozenge-shaped crystals. The crystals are usually brownish red in colour,
from the taking up by the uric acid of some of the urinary colouring
matter, more especially uroerythrin ; and owing to this peculiarity, uric
acid deposits are usually recognised at once by the naked eye.
The ultimate source of the uric acid of the urine is rather doubtful.
Formerly it was held to be derived in part from the food, and in part
from the proteid metabolism of the body. Now it is considered to be the
end product of the metabolism of nuclein ; hence it is possible that the de-
structive metabolism of the blood corpuscles, both red and white, may, in
part at any rate, provide the uric acid daily excreted. On this vicAv,
the increased excretion after meals would be dependent ujion the rapid
destruction of the leucocytes associated with the mechanism of absorption.
It must be remembered, however, that nuclein exists in the food as well
as in the body.
In disease the uric acid excretion is diminished during the paroxysm
of gout, but after the attack the amount excreted is increased. It is also
said to be diminished in chlorosis and in most chronic diseases. On the
other hand, it is increased in pernicious anaemia, in splenic leukaemia, in
febrile diseases, in ague, and in certain forms of diabetes mellitus, some-
times called gouty diabetes. In jDcrnicious anosmia and in leukiemia the
increase may be very great ; thus, in the former, from two to three times
the normal amount may be excreted when the patient is taking very little
food ; and in leukaemia the increase may be still greater. The quantity
excreted, however, is not so important as the rate of its deposition, since
urines containing less than the normal amount of uric acid (for example,
the urine of renal cirrhosis) may still deposit uric acid ; so that the nature
of the urine, its acidity, and the amounts of its salts and pigments are
frequently matters of more practical moment than the amount of uric
acid present.
The deposition of uric acid, as such, from the urine is influenced
mainly by the acidity of the urine, the quantity of salts present, and the
amount of pigment. The salts of the urine keep the uric acid in the form
of a soluble quadriurate ; hence dilute urines deficient in salts and colouring
matter frequently deposit uric acid, Avhereas a concentrated highly acid
febrile urine, containing a considerably higher jsercentage of uric acid, will
lead to the formation of a deposit of urates.
The most delicate test for uric acid is the Avell-known nuu'cxidc test.
Uric acid or urates are treated with fuming nitric acid and, when cold,
ammonia added ; a beautiful purple-red colour is thus produced. Potash
produced a purplish blue instead of a j)urplc-red coloiu-.
Quantitative estiiruUion of uric acid. — In certain diseases, gout, pernicious
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 295
ansemia, leukaemia, etc., it may be advisable to determine the quantity of
uric acid present ; for this purpose one of the following methods is usually
employed : —
Heintzs method. — To 200 c.c. of filtered urine 10 c.c. of hydrochloric
acid are added, and the mixture set aside in a cool place for forty-eight
hours. The crystals are collected on a weighed filter, washed repeatedly,
and dried at 100° C. This method is only approximately accurate, since
some of the uric acid is retained in the acid and in the washings. Further,
uric acid may be present in urine and yet not be j)i'ecipitated by the
addition of hydrochloric acid (Salkowski and Leube).
.Fokker's mdliod. — This method is more accurate than the former, but
also more tedious. 200 c.c. of urine are rendered alkaline by the addition
of an excess of sodium carbonate. To this alkaline urine 20 c.c. of a
strong solution of ammonium chloride are added. The mixture is allowed
to stand for forty-eight hours and then filtered through a weighed filter.
The urates are thus collected on the filter, and to them is added 10 per cent
hydrochloric acid, the filtrate being returned again and again to the filter.
Finally, the filtrate is allowed to stand and deposit crystals of pure uric
acid in colourless plates, which are collected on the same filter, washed
with water, then with alcohol, dried and weighed, and '03 grm. added to
the weight obtained.
Hopkins^ method. — This method will probably replace all others ; it
is based on the fact that ammonium urate is insoluble in ammonium
chloride. To 100 c.c. of the urine about 50 grms. of powdered ammonium
chloride are added, care being taken that some of the salt remains un-
dissolved. After standing for two hours the precipitate is collected on a
filter and washed with a saturated solution of ammonium chloride. The
precipitate is washed into a small beaker with hot distilled water, and
heated to boiling with an excess of hydrochloric acid. After standing for
two hours the uric acid separates and is collected and washed on a filter
and dissolved in a weak solution of sodium carbonate. The bulk of the
liquid is now made up to 100 c.c, mixed with 20 c.c. of sulphuric acid,
and titrated with one-twentieth normal potassium permanganate; 1 c.c. of
this solution is equal to '00375 grm. of uric acid.
Urates. — As mentioned above, uric acid is normally excreted in the
form of a quadriurate, the bases being sodium, potassium, calciimi, .'ind
magnesium. In health the quadriurates remain soluble, even Avhen the
urine cools ; but if the quantity of urine be diminished, as the result of
sweating, for example, then the urates are only soluble in the warm fluid,
and in the cool become deposited in the well-known brownish i-ed amor-
phous form. This in time is decomposed, and, provided the urine is not
allowed to decompose, deposits crystalline uric acid. The decomposition
of the quadriurate into biurate and uric acid is readily effected by distilled
water ; so that in order to collect the quadriurate deposit it must be
washed and filtered with alcohol and not with water. Urates are
abundant in feljrile urines, and more especially towards the end of a
febrile illness. They are also increased in dyspepsia and other diseases of
296 SYSTEM OF MEDICINE
the stomach, an<l in atrophic hepatic cirrhosis. Urates are also abundant
in the dense higli-colourcd urines secreted in cases of venous con<;estion ;
as, for instance, in diseases of the heart and hmgs. Occasionally the
urates are present in the urine in a crystalline form, more especially the
acid sodium and ammonium ur,.te ; the latter especiallv is apt to form
crystals with spiny processes which, in the case of children, may cause
considerable irritation in the urinary tract, and even in the urethra ; and
this may lead to the temporary sup])ression of urine.
In all dense high-coloured urine the risk of mistaking the reduction
of copper produced by urates for the cft'ects of sugar must be ke[)t in mind.
As a rule, urates require longer boiling to reduce the copper, and they
tend to produce a yellowish green deposit rather than the brick-red
deposit seen with sugar. Reliance should be placed in doubtful cases on
the presence of some other sugar test, such as the fermentation test and
the phenyl-hydrazin test. Other nitrogenous constituents of the urine,
such as xanthin, hypoxanthin, are not of sufficient clinical importance to
be considered here.
Kreatinin, after urea, is the most abundant nitrogenous constituent
of the urine ; but, as its solu])ility is so great, it is a body of little interest
to the clinician ; thus, although there is twice as much kreatinin excreted
as there is uric acid, yet the latter is of far greater importance.
The kreatinin of the urine is probably largely derived from the
kreatin of the food, but it has also a tissue origin ; for in Avasting
diseases it is considerably increased in amount. The main importance of
kreatinin lies in the fact that it reduces copper like sugar, and hence,
occasionally, its presence in the urine in unusual quantity may be mistaken
for traces of sugar. Kreatinin and urates between them account for a
large part of the reducing action of normal urine. The mistake of con-
founding kreatinin and sugar may be avoided, either by precipitating the
kreatinin by mercuric chloride, or by testing for sugar by the fermenta-
tion test.
Leucin and Tyrosin. — These bodies, formed normally in the alimentary
canal, are occasional constituents of the urine ; more especially is this the
case in acute yellow atrophy of the liver (p. Ill), and in cases of phosphorus
poisoning (vol. ii. p. 923). It Avas formerly thought that these substances
were not present in the urine in jihosjihorus poisoning, so that by their
means a differential diagnosis between phosphorus poisoning and acute
yellow atrophy could be arrived at. Leucin and tyrosin have, however,
been found in small amount in several cases of undoubted phosphorus
poisoning (p. 90). Leucin and tyrosin have also been found in the urine,
in small quantities, in cases of hepatic cirrhosis. It is to be remembered
that in this disease widespread degenerative changes occtu- in the liver-
cells, giving rise to a condition sometimes sjioken of as secondary yellow
atrophy ; hence the presence of leucin and tyrosin in the urine is of
interest in the pathology both of this malad}?^ and of acute yellow ati'0])hy.
When these l)odies are present the amount of urea is generally much
below the normal, and in acute yellow atrophy it may even be absent.
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 297
Tyrosin occurs both as crystals and also dissolved in the nrine ; the
crystals are usually of a greenish colour, and are deposited in the form
of sheaves and rosettes. Leucin, on the other hand, is usually found in
crystalline globular masses. Crystals of calcic phosphate, of sodic
phosphate, and of the lime and magnesium salts of fatty acids, are
sometimes found in the urine iu the form of sheaves and rosettes, and
may be mistaken for tyrosin ; but, in the case of the phosphates, the
individual needle-like crystals are broader, and they are usually colourless.
Eeliance, however, should not be placed on the crystalline appearance
alone, but some tests characteristic of tyrosin should also be employed.
Tests for tyrosin. — The best known of these are Piria's and Hoffman's
reactions. Tyrosin when heated with Millon's reagent yields a brilliant
crimson colour (Hoffman's reaction).
Tyrosin, if treated with concentrated sulphuric acid and warmed,
gently turns pink. The mixture is allowed to stand, diluted with water,
saturated with barium or calcium carbonate, and filtered while hot. On
the addition of dilute perchloride of iron free from acid, the filtrate yields
a violet colour (Piria's reaction).
Leucin is not readily recognised by chemical tests unless a considerable
quantity of the pure substance is available, hence in the urine its presence
is to be detected by its microscopic characters.
In cases in which leucin and tyrosin are found in the urine, lactic acid
may also be present. This is true of the urine of j^hosphorus poisoning,
and also in cases of acu*"e yellow atrophy of the liver. The excretion of
lactic acid in the urine, associated with the diminished excretion of the
normal nitrogenous extractives in these conditions, resembles the condition
brought about experimentally by the removal of the liver in birds ; since
after this operation the nitrogenous extractives in the urine fall to a very
small amount, and lactic acid and ammonia are excreted.
Salts. — Snljluites. — Two grammes of sulphuric acid a day are ex-
creted in normal urine, and the bulk of it is excreted in combination with
inorganic bases, such as sodium, potassium, magnesium. Some of it,
however, is excreted in the form of a double salt, one of these bases being
usually potash in combination with certain aromatic bodies, such as
phenol, cresol, indol, or skatol ; these form the well-known aromatic
sulphates or potash salts of phenyl-sulphuric acid.
A small quantity of sulphur is also excreted in combination with
amides, forming bodies of the taurin (amido-ethyl-sulphonic acid) class.
Cystin (amido-sulpholactic acid) is another example of these bodies. The
amount of sulphur so eliminated is very small. The sulphates excreted
as inorganic and as aromatic sulphates are derived in part from the
food and in part from the metabolism of the tissue proteids ; and their
main clinical interest lies in the relation between the amounts of the
aromatic and the total sulphates. Normally, the proportion existing
between the aromatic and simple sulphates is approximately one part of
the former to twelve to twenty parts of the ordinary sulphates. The
aromatic sulphates are derived mainly from the decomposition of protsicl
298 SYSTEM OF MEDICINE
matter, and largely from decomposition and putrefaction in the intestine.
Hence the amount of aromatic sulphates excreted is considerably increased
in intestinal and abdominal diseases associated with retention and putre-
faction of the intestinal contents ; as, for example, in intestinal obstruction,
and in tuberculous and other forms of peritonitis. In typhoid fever they
are said not to be increased. They are increased in cases where putrid
decomposition of proteid matter arises, as in puti-id empyema, pulmonary
gangrene, and the like. In fact they arc necessarily increased in cases of
the kind which lead to indicanuria, inasmuch as indigo is present in the
urine as an indoxyl sulphate. Aromatic sulphates are also greatly
increased in amount in cases of poisoning by carbolic acid.
Ci/afin and ci/stinuria. — This sulphur-containing body is occasionally
present in the urine, and it may even give rise to the formation of
calculi. It crystallises in flat hexagonal plate-like tables, insoluble in
acetic acid, but freely soluble in ammonia, and so difl'ering from uric
acid. Cystin burns with a bluish-green flame on platinum foil. If the
crystals are boiled with caustic potash and oxide of lead, sulphite of lead
is formed. Similarly, if heated with caustic potash on a silver dish or
silver coil, a black mark is left on the silver from the formation of sulphite
of silver.
The main interest of cystinuria lies in the fact that this condition is
simply an excessive secretion of a substance closely allied to bodies which
exist in traces in normal urine.
Fhotiphates. — Two to six grammes of phosphoric acid are excreted
daily in the form of mixed phosphates of potash, soda, lime, and
magnesium ; and the acidity of the urine is dependent mainly upon the
presence of acid sodium phosphate. A large quantity (two-thirds to
three-quarters) of the phosphoric acid excreted is united with potash
and soda, and, whether the salts formed be acid, neutral, or basic, they
are soluble in the urine, and hence are not seen as urinary deposits.
Earthy phosi)hates of lime and magnesium are only soluble in acid
urine, hence the neutral and basic phosphates of lime and magnesium
tend to he deposited in faintly acid, neutral, and alkaline urines. In
urines alkaline with ammonia animonio-magnesic phosphate is formed, which
is also insoluble. xVnnnonio-magnesic phosphate has l)een found deposited
from urines still faintly acid. The phosphates are derived largely from tlic
food, partly from the tissues. The amount of phosphates in the tu'ine is
largely inci-eased after meals, and then, owing to the diminished acidity
or even positive alkalinity of the urine, it is not uncommon for some
precipitation to occur ; the amount of deposit, however, is no index to
the amount of phosphatic material present in the urine, inasmuch as its
deposition depends simply on the reaction. In all cases, if the amount
excreted is to be determined, reliance must bo placed on quantitative
methods of estimation, and not on the amount of depo.sit. To the
clinician the main interest lies rather in the deposit of earthy and of
triple phosphates than in the total amount of phosphates exci-eted ; for
the latter depend very largely on the quantity and nature of the food.
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 299
In febrile disease the quantity of phosphates excreted is at first
diminished ; later it is increased. It is held that in certain states of
neurasthenia the quantity is increased ; and the name of phosphatic
diabetes has been given to a condition in which, along with general
malaise and various neurasthenic symptoms, large quantities of urine,
containing an excess of phosphates, are excreted [vide vol. iii. p. 253].
On heating urine faintly acid, neutral, or alkaline, a cloudy deposit of
earthy phosphates is produced ; or, if the liquid previously contained a
deposit of phosphates, this is increased. If the liquid is not actually
raised to the boiling-point, the deposit will redissolve on cooling ; but if
it be boiled, the deposit is permanent. If the boiling be done in a sealed
tube, the precipitate can be produced and dissoh'^ed several times in
succession. There are several possible exj)lanations of this fact, (rt) That
the boiling drives off the carbonic acid by which the phosphates were
kept in solution; {h) That the boiling causes a decomposition to ensue of
such a character that two molecules of dicalcic phosphate and one of
monocalcic phosphate undergo an interaction, which leads to the formation
of one molecule of triple and one molecule of dicalcic phosphate, the
former of which, being far less soluble, is precipitated ; (c) It has also
been suggested that on boiling, sufficient urea is decom|)Osed into ammo-
nium carbonate to render the urine sufficiently alkaline to cause the
precipitation of phosphates. It is improbable that the precipitation is
simply dependent on the lower solubility of certain phosphatic salts in
hot urine than in cold ; and it is more likely that a decomposition of the
nature described above ensues. The deposition of phosphates in the
urine depends partly upon the amount present, but largely upon the
degree of acidity of the urine. The deposition of earthy phosphates
— for example, the tricalcic — is associated with an alkaline action due to
fixed alkali. This deposit is amorphous, and is often seen after meals.
Occasionally stellar phosphate — that is, dicalcic phosphate — is thrown
down when the acidity of the urine is diminished; but it usually occurs
in urine still faintly acid, it is rarely seen in neutral or alkaline urines.
The crystals are frequently arranged in stars and rosettes, or in sheaf-
like bundles, thus oftering a distant resemblance to tyrosin crystals.
This deposit is rarely seen in healthy urine ; it occurs, however, in the
urine of diabetes and of other maladies, such as cancer, which produce
grave distiu'bance of nutiition. In urines alkaline from volatile alkali, a
deposit of triple phosphate (ammonio-magnesic phosphate) is common ;
and this crj^stalline deposit frequently leads to the formauion of a calculus
enclosing most usually a nucleus of uric acid or of oxalate of lime that
has been formed in the kidney and passed on to the bladder. This
triple phosphate is also prone to encrust the surface of vesical
growths ; and it tends to be deposited whenever there is cystitis : the
amorphous deposit of tricalcic phosphate, on the other hand, owing to its
amorphous character, rarely forms calculi.
Chlorides. — Although these salts play an important part in the
economy, and are excreted in the urine in abundance — 10 to 15 grammes
300 SYS TEA/ OF MEDICINE
being the amount of the daily excretion of sodium chloride — the varia-
tions in the amount of chlorides excreted are not of any great clinical
importance. They depend largely upon the amount of chl()ri<les in the
food. The principal fact is that the chlorides are diminished dining the
height of the pyrexia of febrile diseases ; and more especially in pneu-
monia, where, during the duration of the fever, they may almost dis-
appear from the urine to reappear again at defervescence and during
recovery. The amount present does not afford any valuable indication
as regards diagnosis or prognosis of febrile states, although it is in pneu-
monia especially that the chlorides undergo this great diminution. The
same phenomenon is seen to a less extent in other febrile diseases, and more
especially when the fever is high, as in tonsillitis, for instance, so that the
diminished excretion is dependent rather on the general febrile process than
on the i^articular incidence of it on the king. To determine roughly the
amount of chlorides present in the urine it is sufficient to acidulate the urine
with nitric acid, to add a few drops of niti-ate of silver, and to compare the
precipitate obtained with the amount obtained by a similar procedure
with normal urine. If necessary, the precipitate of chloride of silver may
be collected and weighed in the usual manner employed in quantitative
determinations.
Oxalates. — About 20 milligrammes of oxalic acid are excreted daily
from the normal urine in the form of a salt kept in solution by the acid
phosphate of soda normally present. Oxalates are deposited in the ui'ine
in the form of oxalate of lime, which tends to crystallise either in octo-
hedra, or as dumb-bells or ovoids. The crystals are visible to the naked
eye as brilliant points, and usually crystallise like uric acid on any
irregularities, such as scratches on the glass vessels in which the urine is
contained. Urine depositing oxalate of lime is usually acid, rarely
neutral. The dumb-bell form of crystals deposited is perhaps due to the
disturbance of the form of crystallisation by mucin and other colloids
present. A scanty deposit is not unusual in health, and more especially
after certain articles of diet, such as rhubarb and other vegetables. A
persistent deposit, however, is pathological, although it is not clear upon
what this oxaluria depends. The name oxaluria ought, of course, to be
restricted to an increase of the excretion of oxalic acid, and not simply
to its deposition. In niany cases the increased excretion or deposition of
oxalic acid may lead to the formation of an oxalate of lime calculus,
without the production of any other symptoms except those due to the
stone. In other cases the persistent excretion of these insoluble oxalates
is accompanied by a series of symptoms of a dyspeptic character, together
with some mental depi-ession, neurasthenia, or even actual hypochondriasis,
and it is not clear whether there is any definite cause of association
between the two sets of phenomena, although many observers regai-d
the d3'speptic, nervous, neurasthenic symjjtoms as ^jrimarily due to the
oxaluria.
Albuminuria. — The name albuminuria is generally taken to signify
the presence of proteid matter in the urine. The proteids met with
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 301
in the urine are serum albumin, serum globulin, albumose, peptone,
fibrin, nucleo-albumin, and perhaps occasionally a casein-like body, and,
if blood or blood pigment be present, haemoglobin. In health the
urine is free from any large quantity of proteid matter, although in
some 30 per cent of persons apparently healthy the urine is found to
contain proteid matter in small quantities. To this condition the name
of j)hysiological albuminuria has been applied. This albuminuria is, in
some of the cases, always present ; in others, it ajDpears only under
certain conditions, as, for instance, on first rising in the morning, after
a cold bath, or after meals. Some of these varieties have received special
names ; such as intermittent albuminuria, dietetic albuminuria, postural
and cyclic albuminuria.
Albuminuria is either " physiological " or pathological ; by the former
it is understood that in appai'ently healthy persons albumin — usually
in small quantity — is found in the urine ; sometimes so little that it
requires special tests, such as picric acid, to reveal it ; at other times
it is in sufficient quantity to yield a distinct precipitate with the heat
test or with cold nitric acid. In these cases it is important to exclude
what may be called accidental albuminuria, cases, that is, in which the
urine itself, originally free from albumin, has been contaminated by some
albuminous impurity ; as in gonorrhoea, vaginitis, and seminal discharge.
Probably in no case of so-called physiological albuminuria is the
quantity so large as to amount to one-third or even one-fourth of the
urine. This albuminuria in the apparently healthy is not necessarily
continuous. It may be seen only after meals, and moie esiDecially
after breakfast, or on first rising in the morning, or after severe
exercise. It is supposed in inany cases to depend upon a vascular dis-
turbance in the kidney, leading to temporary venous congestion ; and in
the dietetic cases it has been thought that digestive products, such as
albumoses, might be formed, either in greater abundance than usual, or
else of abnormal quality, and, absorbed as such, be subsequently excreted
by the kidney. It is extremely doubtful, however, whether such cases of
albuminuria should be called "physiological." It is quite possible that,
in many such cases, no serious kidney lesion is present, nor yet, perhaps,
any condition likely to eventuate in a serious kidney lesion ; yet, on the
other hand, such kidneys cannot be considered quite sound. In a con-
siderable proportion of cases of "physiological albuminuria" the use of
the centrifuge shows that the urine contains definite formed elements,
such as white blood corpuscles, casts, spermatozoa and so forth. In
other words, the presence of casts in small amount is not restricted to
"pathological albuminuria." It must be remembered that in renal
cirrhosis the urine may contain only traces of albumin ; and the possi-
bility of the presence of this insidious disease in some cases of so-called
functional albuminuria must be kept in view.
Pathological albuminuria. — Albuminuria may be due to disease of
any part of the urinary tract, such as pyelitis or vesical disease ; but in
these cases, to speak strictly, the albuminuria is factitious and is due to
302 SYSTEM OF MEDICINE
admixture -with albumin after the urine lias left the kidney. When
the albumiiuu'ia is of renal origin, the albumin transudes into the urine,
owing to some definite lesion, temporary or permanent, of the kidney
epithelium. Sometimes the kidney lesion is primary, at other times it is
secondarily induced hy the ingestion or i)roduction of toxic and irritat-
ing sul:)stances in other parts of the bod}'. At other times, again, the
changes in the kidney are dependent upon other secondary disturbances ;
thus the following causes of albuminuria may be recognised : —
{a) Congestion of the renal vessels, active or passive.
{h) Toxic or febrile albuminuria.
(t) The all)uminuria of organic renal disease, such as acute nephritis,
chronic Bridit's disease.
(«) Active congestion. — The loss of albumin in this condition is
usually not large, as the quantity of urine secreted is small and often
blood-stained. It is difficult to distinguish the albuminuria of active
congestion from that due to toxic agents, as in many cases poisons, such
as turpentine and cantharides, produce extreme congestion. The albumin
uria of acute Bright's disease is usually quoted as an instance of this form
of albuminuria.
Passive congestion is a frequent cause of albuminuria, more especially
in heart and lung diseases, and as the result of various abdominal diseases
leading to pressure on the renal veins or vena cava. Passive congestion
causes a considerable diminution in the quantity of urine secreted, and
this may contain blood and blood-casts. In cases of pressure on the renal
veins from abdominal diseases the percentage amount of albumin present
may be large, but in cardiac and pulmonary cases the quantity is usually
small. From the mere amount of albumin, however, no conclusion can
be drawn as to whether the albuminuria l>e due to passive congestion or
to nephritis. It may be large in the former and small in the latter, or
conversely. Blood may be present in either case. The question is best
answered by the character of the casts present. In passive congestion
blood-casts and hyaline-casts are occasional!}' found; in nephritis, on
the other hand, casts containing definite renal elements are fouiid.
(p) Febrile or toxic albuminuria. — This is dependent, in all probability,
on the excretion by the kidney of toxins produced by the organi.sms causing
the disease. These toxins apparently lead to changes in the renal epithelium,
glomerular and tubal, and thus allow the proteids of the blood -plasm to
pass out. In this wa}' the febrile albuminuria resembles the albuminuria
produced experimentally by the injection of egg-albimiin, albumoscs, or
peptones. The proteid matter found in the urine subsequent to this pro-
cedure is not only the albumose or other proteid injected, but also
the proteid matter of the blood-plasm ; and the amount of proteid
recoverable from the urine is frequently far greater in amount than the
quantity injected. Thus the albuminuria brought about by the intra-
venous injection of these proteid substances resembles the albuminui'ia
due to such poisons as cantharides. On the other hand, many toxins
l^roduced in disease apparently do not cause the extreme congestion that
GE.VERAL PATHOLOGY OF THE RENAL FUNCTIONS 303
is seen with such poisons as canitharides. In scarlet fever, the early
albuminuria of the disease, which is of this nature, must be carefully
distinguished from the later albuminuria dependent upon nephritis often
persistent and progressive. The kidney lesion that produces the albumin-
uria of febrile diseases, often spoken of by French writers as transitory
nephritis, is remarkable, inasmuch as this lesion generally disappears com-
pletely, leaving the kidneys practically healthy. In this respect the initial
all)uminuria, or so-called febrile albuminuria, of scarlet fever is strikingly
different from the later albuminuria, which is dependent on a progressive
and destructive lesion in the kidney. In the great majority of cases the
changes produced in the kidney by these toxins do not lead to permanent
Bright's disease ; and the albuminuria of typhoid, scarlet fever, diphtheria,
and pneumonia usually clears up entirely. Occasionally in typhoid fever,
diphtheria, and pneumonia, and x^ry frequently in scarlet fever, there is a
further and more severe lesion produced in the kidney, and the case be-
comes one of acute or subacute nephritis, with dropsy and suppression of
urine. Hence it is difficult to draw a hard and fast line between the
febrile albuminuria produced by toxins, or the nephrife passagere of the
French, and a ^^crmanent and often progressive lesion like Bright's
disease.
In some febrile diseases the urine, besides serving as a channel
of excretion for toxins, contains also the organisms causing the disease.
This is not uncommon, for instance, in typhoid fever ; and it is probable
that in all diseases where the organisms circulate freely in the blood-
stream they may be detected in the urine.
In some febrile diseases, more especially in pneumonia and in cases of
suppuration, such as empyema and cerebro-spinal meningitis, albumoses
are present in the urine in comparative abundance, but rarely alone,
seium albumin and globulin being also present. The albumoses are
formed in the exudation produced at the seat of the disease ; forinstance,
in the solidified lung of pneumonia, or in the purulent exudation of em-
pyema, they are absorbed by the blood and are carried to the kidney,
where they are excreted.
(c) Albuminuria of renal disease. — In Bright's disease the albuminuria
is due to the damage and the shedding of the renal epithelium in the
glomeruli and tubules. Some authors regard the change in the kidney
structures as primary and brought about either by vascular changes, as
in Bright's disease due to cold, or by toxic agencies, as in the Bright's
disease due to alcohol, and in the sequel of acute specific maladies such as
scarlet fever and pneumonia. Others look upon many forms of Blight's
disease as being due to a disease of the blood, and hold that the kidneys
are affected secondarily to this blood change. However this may be, the
immediate cause of the albuminuria is the anatomical change in the renal
epithelium.
Even in renal cirrhosis, where the albuminuria has been attributed to
the high blood-pressure, it is more probably due, perhaps, to the accompany-
ing epithelial lesions ; for although the main lesion is in the interstitial
304 SVSTEAf OF MEDICINE
tissue, yet in this disease there ai-e always considerable tubular and
glomerulai- changes.
In renal disease the actual amount of proteid matter found in the
urine varies within very wide limits, being least in renal cirrhosis
where there is sometimes but a trace, and i-arely more than a few
grammes in the twenty - four hours. On the other hand, in some
forms of chronic Bright's disease, and in certain forms of lardaceous disease
of the kidney, the amount may reach forty gi-ammcs a day. In acute
Bright's disease, although the percentage of proteid matter in the urine
is high, the amount lost is not very great, owing to the small amount of
urine secreted. In the small white contracted kidney the amount of
albumin lost is often considerable, amounting not infrequently to as much
as twenty grammes daily. In diseases of the pelvis of the kidney, as in
calculous, septic, or tuberculous pyelitis, the alljumin in the urine, from
the mere presence of pus or blood in the urine, is often considerable ;
and it is often of great moment to determine Avliether the albuminuria be
due merely to the i)roducts of the pyelitis, or whethor there is coexisting
renal disease. In the latter case the amount of albumin in the urine may
still be considerable after the pus or blood has been removed, either by
subsidence or by the centrifuge. Again, if the albumin be of renal
origin the urine Avill probal)ly contain renal casts. In all such cases,
however, the pus, blood, and other impurities sliould be removed from
the urine before the latter is tested for alljumin.
In renal diseases the proteids are usually present as a mixture of serum
albumin and serum globulin. Sometimes albumoses are present, and
occasionally, in renal cirrhosis, in large quantities, and serum albumin
and serum globulin are present in traces only ; so that if the urine is
tested in the ordinary way by boiling, the presence of a large amount of
proteid matter may be overlooked.
These, cases of albumosuria in renal disease are rare, and their nature
and cause are obscure, since the presence of considerable quantities of
albumose in the urine is usually the result of absorption of the all>umose
from some inflammatory exudation into the blood ; but in renal cirrhosis
the albumosuria occurs without the presence of any inflammatory complica-
tion. It is possible that the albumose may be derived from the intestine.
Albumosuria occurs most frequently in cases of pneumonia and
empyema ; or, indeed, whenever there is a large collection of pus in any
part of the body. The mechanism of the albumosiiria in these cases
is simple, inasmuch as albumoses are abundant in the inflammatory
exudation, whether it be pus or the fibrinous exudation of the pneumonic
lung. Some of the albumose present in the exudation is absorbed into
the general blood-stream, and is thence excreted by the kidney just as it
is after the experimental injection of albumoses intravenously.
Proteid tests. — The ordinary tests in use for the recognition of proteids
in the urine are (a) the heat test; (/3) the cold nitric acid test (Heller's
test) ; (y) the picric acid test ; (8) the copper sulphate and caustic
potash test ; (e) the salicyl-sulphonic acid test.
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 305
(a) The heat test is perhaps the one most commonly used, inasmuch as it
is simple, ojjen to few fallacies, and fairly delicate. In performing this test
the reaction of the urine must be previously ascertained ; and, if neces-
sary, it should be rendered faintly acid with acetic acid before boiling.
Some authors prefer to add the acid after boiling ; but it is probable that
in this way small quantities of proteid matter may be overlooked. If the
urine is not acid at the time of boiling, the proteid matter is liable to be con-
verted on heating into alkali albumin, which is not coagulated by heat,
and thus the presence of small quantities of proteid matter may be over-
looked. It is no less necessary to avoid over-aciditv of the urine, for in
such urine, particularly if rendered acid with a strong mineral acid, the
proteid coagulated may subsequently be redissolved. The principal
fallacy in the heat test, however, is the precipitation of phosphates on
warming faintly acid or neutral urines. This cloudiness is usually dis-
tinguished from the precipitated albumin by the particulate form of the
latter : further, the phosphatic cloud disappears instantly on acidification ;
the proteid precipitate, on the other hand, does not.
(/3) The cold nitric acid test. — This is an excellent test, if properly
performed ; but it is not quite so delicate as the heat test. The nitric
acid must be pure, and, after being placed at the bottom of the test-tube,
the urine to be tested should be floated on its surface with a pipette.
If jDroteid matter is present in abundance, a ling is formed at once. If
the amount is small, the ring only appears after standing. The fallacies
of this test are as follows : — Proteid matter, if present, may be missed if
the urine and the nitric acid are mixed up ; hence nitric acid causing any
effervescence of the urine, owing to the presence of nitrous acid, is not
suitaVde for this reaction. Proteid matter, even if not present, may be
suspected if a crystalline deposit of nitrate of urea be formed at the junc-
tion of the urine and the acid ; this deposit is more apt to occur in concen-
trated urines, and the mistake is easily avoided by noting that the ring is
crystalline in appearance. Occasionally mistakes arise from the formation
of a dense highly-coloured ring at the junction of the urine and the acid.
This ring (see Pigments of urine) is due to the formation of pigment
from a chromogen present in the urine : it is coloured and not particulate ;
the proteid ring, on the other hand, is white and particulate.
By the nitric acid the presence of all^umoses can be detected, bodies
which are not brought into evidence by heat. Albumoses, and especially
hetero-alljumoses, which are the kind commonly present in the urine, form
a precipitate on the addition of nitric acid. In testing for albumoses it is
often better to add the nitric acid drop by drop to the suspected urine
rather than to float the urine on the nitric acid. The characteristic
reaction of albumose, however, is that the precipitate, formed by nitric
acid, dissolves on heating, to reappear on cooling. The reaction is so
characteristic that it may even be possible, although not advisable, to
carry o;it the test in the presence of other proteid matter ; as under these
circumstances, if the quantity of albumose present be considerable, the
coagulum produced by the nitric acid ^\^ll diminish in amount on heating,
VOL. IV X
3o6 SYSTEM OF MEDICINE
to increase again on cooling. It is better, however, to remove the scrum
albumin and serum gh)l)ulin, either roughly by heating, or by precipita-
tion with some neutral salt, before testing the filtrate for alljumoses with
nitric acid.
Many resinous bodies after their administration arc excreted in the
urine, and these substances, on the addition of an acid, yield a precipitate
that may be mistaken for albumin. This is especially true of copail)a
and of oil of turpentine. The precipitate can be distinguished from
proteid by its solul)ility in alcohol ; but the addition of alcohol to nitric
acid may cause an explosion.
(y) Picric acid. — A cold saturated solution of picric acid is a useful test
for proteids, and it has the advantage that it can also be used in testing
for sugar. The addition of picric acid to a urine containing proteids is
followed by the formation of a cloudiness or a co])ious jirecipitate, accord-
ing to the amount of proteid matter present. From a clinical point of
view the only serious objection to the picric test is that, in the first place,
mucin is precipitable as well as ordinary proteids ; and, secondly, that,
as a proteid test, it errs on the side of delicacy : quantities of proteid are
discovered by it M'hich, at any rate, are of no serious clinical importance.
Picric acid is the agent that is more especially used in the investiga-
tion of cases of so-called physiological or functional albuminuria.
(8) Copper sulphate and potash. — Copper sidphate and potash are reagents
sometimes used in testing the urine, and the value of these lies in the
fact that, whereas this test yields a rose colour with albumoses, it gives a
violet colour with ordinary proteids ; in fact, for the detection of small
quantities of albumoses this test is, on the whole, preferable to the nitric
acid test.
(e) Saliryl-s a! phonic acid. — This reagent is intermediate in delicacy be-
tween Heller's test and the heat and acetic acid test. A cold saturated
solution of salicyl-sul phonic acid in water is used, and is added to the
suspected urine in the quantity of one to three dro])s ; however, an excess
of the reagent does not interfere with the test. The fluid is then well
shaken.
An immediate precipitate betokens the presence of an appreciable
amount of prcteid. If the precipitate does not fall in from one to two
minutes the quantity of all)imiin is minimal ; and if an interval be allowed
to elapse, the test is really more delicate than the heat and acetic acid
test. Normal urines give no precipitate with this reagent. This test is
also of use for recognising alljumoses and peptones, inasmuch as with
these substances precipitates arc obtained which dissolve on heating and
reappear again on cooling.
Salicyl-sulphonic acid does not give any precipitate with bile salts, with
urates, with alkaloids, nor with urine containing copaiba resin. \\\{\\ a
large amount of nnicin, however, a small amofint of preoijiitate is obtained.
This test is one not as yet in general use, but it is well worth the atten-
tion of clinicians.
Sometimes it is necessary not only to detect the various proteids
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 307
present in the urine, but also to determine the relative quantities present.
For. this purpose the proteids must be precipitated with neutral salts; by
saturating the urine with ammonium sulphate all proteid matter except
true peptones are precipitated. On the other hand, magnesium sulphate
is used to precipitate serum globulin alone, as it does not cause any
precipitation of serum alljumin or of albumoses. AYhen the salts are
used to precipitate proteids from the urine it is of course necessary to
wash the precipitated proteid on the filter-paper with the saturated solu-
tion of the salt used. Thus, a precipitate of albumose obtained with
ammonium sulphate must be washed with a saturated solution of
ammonium suljDhate. At the present time the precipitation of proteid
matter in the urine by these solutions of neutral salts is used more for
the purpose of research than of clinical routine.
Qiutnfitative estimatlo)i of proteid. — For rough estimations the amount of
precipitate deposited at the bottom of the test-tube in twenty-four hours
after heating and acidification with acetic acid is usually sufficient. This
rough method, however, is liable to considerable error, owing to various
conditions of the urine, such as its acidity for example, influencing the
retractility of the coagulum.
If this method is employed, the amount of proteid is usually expressed
in a fraction of the volume of the urine. A more accurate method is that
of Esbach, where the urine is precipitated by a solution containing picric
acid, and the amount of proteid is determined by the bulk of the deposit
precipitated in a specially graduated tube. Esbach's method, although
more accurate than the previous one, is open to a similar fallacy ; and the
only really accurate method is to precipitate the proteid and, after Avashing
and drying the precipitate, to weigh it. The most convenient method of
doing this, if the urine contain a considerable amount of proteid, is to add
5 c.c. of the urine to some 50 c.c. of boiling aljsolute alcohol. The
mixture is allowed to remain in a hot-air oven at 80° C. for some hours,
the precipitate is collected on a weighed filter-paper, washed with alcohol,
ether, and water to remove the salts and fats, dried in the hot oven at
120° C. and weighed; if further control is desired, the total nitrogen in
the precijDitate can be determined by Kjeldhal's method.
Pyuria. — Pus may be present in the urine as the result of diseases
of the urinary tract ; as in suppurative nephritis, pyelitis, cystitis, or
urethritis, or from rupture into the urinary tract of an abscess outside it,
as in perinephritic or prostatic abscesses ; or, finally, the urine may con-
tain pus by simple contamination with a pus-secreting surface, as in cases
of vaginitis. In all cases of pyuria it is important first to see the urine
passed, and, secondly, to have it passed in at least two portions. In this
way it is possible to separate the cases where the pyuria is of renal origin
from cases of pyuria of urethral origin. Further, it is very important to
separate the pus from the urine either by subsidence or, preferably, Avith
the centrifuge before testing the supernatant clear urine for albumin.
In this way it is possible to determine with certainty the presence or
absence of organic renal disease in relation to the disease causing the
3o8 SYSTEM OF MEDICINE
pyuria. In cases of calculous pyelitis it is not uncommon for serious renal
disease to l»e j)resent in addition to the pyelitis. xVljscess of the kidney,
with or without perinephritic abscess, and pyelitis, leading to pyonei)hrosis,
may be and frecjuently are present without the urine containing any pus.
In fact, the absence of pus from the urine is a matter of comparatively
small importance in the diagnosis of pyonc])hrosis in the presence of a
renal tumour. Pus jjresent alone in the urine, unless the amount of it be
very large, does not cause more than a trace of albumin. Hence the
appearance of a considerable amount of albumin in the urine containing
pus is always suggestive of the coexistence of renal disease. The presence
of casts containing renal elements will also assist us in forming this
diagnosis. Urine containing pus may be acid or alkaline ; the former is
more characteristic of the pyuria of renal origin, the latter of that of
vesical oriiiin.
If, however, cystitis be slight in amount the urine may remain acid,
as in some cases of pyelitis ; on the other hand, in pyelitis complicated
with cystitis the urine may be alkaline. Hence, in the differential
diagnosis, too much stress must not be laid on the reaction of the urine.
In acid urine the pus corpuscles are discrete and subside ; in alkaline lu-ine
the pus is ropy and stringy. Pus is best recognised by mioi'oscopical
examination, but the suspected urine, if acid, may be tested by the addi-
tion of liquor potass®, which causes any purulent deposit to become ropy.
Ozonic ether causes an effervescence in urine containing pus.
Glycosuria. — The normal urine contains several reducing substances,
and there has long been a difference of opinion whether these reducing
substances are only urates or kreatinin, or whether traces of sugar are also
present. Now, however, it is admitted that the normal urine contains
carbohydrate material, at any rate in the foi*m of glycuronic acid ; and
that the whole of its reducing power, therefore, is not to be attributed to
the presence of urates and kreatinin. It is possible, but not certain, that
a verj' small amount of dextrose is also present ; but even if this be so,
Avhich is doubtful, the quantity is so small as only to be detected after
concentration of large volumes of urine ; hence, if present, it is of no
clinical importance.
Glycosuria is not infrefpiently seen Avithout the other accompaniments
of diabetes. Thus it occurs in certain circumstances in the apparently
healthy ; and to this the name of fundional ghicosnria has been applied,
analogous to that of the so-called functional albumiiuu-ia described above.
Traces of sugar appear in the urine in certain persons after severe
exercise ; in others, and a much larger grouj), after meals, and more
particularly, perhaps, after meals rich in carljohydrates. The ingestion of
large quantities of milk is not infrequently followed by the presence of
reducing substances in the urine, probably lactose. In the cases where
glycf)suria is observed after meals, a state which has been called "dietetic
glycosuria," the patients not uncommonly have gouty manifestations also.
They are often obese, and hence the name " lij)ogenic glycosuria " has been
used in these cases. It is very probable, however, that no hard and fast
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 309
line can be drawn between diabetes on the one hand and these cases
of more or less temporary glj'cosuria on the other.
Glycosuria, slight in amount, is frequently seen in certain grave
diseases ; and more especially in diseases leading to increased intracranial
pressure, such as meningitis, cerebral haemorrhage, and cerebral tumour.
This is more especially the case in infra-tentorial disease, and in disease
about the medulla oblongata. It is not limited to these cases, however,
and may be present in cases of cerebral haemorrhage in the ordinary
situations ; namely, in the external capsule and in ventricular haemor-
rhage. Glycosuria also occurs after injuries to the head and in epilepsy.
It is rather remarl^able that si;gar does not appear in the urine in cases
of hepatic cirrhosis and in acute yellow atrophy ; more particularly so if we
regard the liver as a " sugar-stopping " organ. On the other hand, if the
liver be a sugar - forming organ, this result would not be surprising
after the extensive destruction of the liver that occurs in these diseases.
Glycosttria is also said to occur after the administration of various
drugs and poisons, more especially of morphia, chloral, opium, chloroform,
and carbonic oxide. It is probable, however, that the reducing substance
in the urine is not dextrose, but a compound of glycuronic acid. This is
certainly the case after the administration of chloral. Slight glycosuria
is also stated to occvir in cases of cardiac and pulmonary diseases, leading
to venous congestion of the kidney ; and it has occasionally been found
transitorily in various acute specific diseases.
The stigars met with in the urine are dextrose, lactose, and inosit,
very rarely laevulose ; and the last is rarely present alone, as dextrose
usually accompanies it. Lsevulose, lactose, and inosit are, however, of no
great clinical importance. It is asserted by some authors that traces of
dextrose are present in the normal urine ; but, as I have said already,
special methods are necessary for its detection ; and it is probable that
the slight reducing power of the normal urine is dependent mainly,
if not entirely, on the presence of kreatinin, urates, and compounds of
glycuronic acid. Benzoyl chloride is an agent that can be used for the
precipitation of carbohydrate material in the urine, and it has been
shown that normal urine contains carbohydrate derivatives ; bttt there is
no evidence of the presence of dextrose in any quantity. The blood
normally contains 0'05 to 0'09 per cent of sugar; and when the pro-
portion of stxgar present rises to some 0"3 per cent this substance appears
in the urine. The amount of sugar passed in the urine in diabetes
mellitus varies from an ounce or two to as much as a pound or a potmd
and a half in twenty-fotir hours ; occasionally even greater quantities
may be passed for a short time, and as much as one pound a day may be
passed daily for considerable periods. The percentage of sugar in the
urine rarely, if ever, rises above 1 0 per cent ; and it is uncommon for it
to reach this high limit, since the excretion of large quantities of sugar
always causes a great increase in the amount of urine passed. In
diabetes mellitus the qttantity is usually considerable and sometimes
enormously increased; thus, 5 to 10 pints a day are quite ordinary
SYSTEM OF MEDICINE
amoiints for a case of moderate severity ; and the quantity may he in-
creased to 15 or 20 pints, hut this is exceptional. "When the quantity is
increased to some 5 to 10 pints the urine is of a pale greenish yellow
colour. Sometimes the quantity is hut slightly increased, and here the
urine retains its normal colour ; hut the quantity of sugar present in
these cases is necessarily not Aery large since, even if the percentage of
sugar he high, the amount of urine is not sufficient to lead to a great loss
of sugar. Glycosuria without polyuria is perhaps more often seen in
the less severe cases of diahetcs in the aged, and in the cases of so-
called gouty glycos\iria. These cases are liahle to he overlooked, as the
patient very frequently does not suflfer from thirst. The specific gravity
of urine containing sugar is usually high. A specific gravity of 1025 or
ahove in a pale-looking dilute urine suggests the presence of sugar ; and
a specific gravity ahove 1035 in such a urine is almost always due to
sugar. The specific gravity does not vary, however, directly and pro-
portionately with the amount of sugar present. Sugar may be present
in the urine when the specific gravity is as low as 1010. It is possible,
however, that some of the cases described as cases of glycosuria with a
low specific gravity have really been cases in which glycuronic acid was
mistaken for dextrose.
In diabetes, other abnormal constituents of the urine, such as cliacetic
acid, acetone and oxj'butyric acid, are usually present with the siigar.
Diacetic acid is the one most frequently present. These bodies, especi-
ally diacetic acid and acetone, are present in the urine in cases of
diabetes even when no symptoms of acetonaemia are present. In diabetic
coma, however, they are usually much increased in amount, and recent
observations have shown that in a large number of cases of diabetic
coma ;8-oxybutyric acid is present in the mine in comparatively large
quantity.
The amount of sugar in the urine in diabetes is not only variable but
not uncommonly fluctuates greatly in the daily excretion, quite apart
from any influence of treatment. Thus, in febrile complications occur-
ring in the diabetic the amount of sugar may diminish or eA^qn disappear
entirely. Further, in diabetes, it is not uncommon for sugar to dis-
appear suddenly and completely from the urine. In many of these cases
coma is imminent, but this is not invariable ; the urine may remain free
from sugar for a few days, and then contain it again in its former
abundance.
The cause of these fluctuations, and still more of the sudden
and spontaneous disai)pearance of sugar, is very obscure. In diabetic
coma the sugar almost always undergoes a diminution, and not
uncommonly disappears ; hence the gravity of a sudden and great
dimiinition in the amount of sugar passed. In diabetic coma, with
the diraiiuition or the disappearance of the sugar, the c^uantity
of urine also undergoes great diminution. In many cases of diabetes
albumin appears in the urine towards the end ; and, if the amount of
albumin be large, the Fehling reaction does not take place satisfactorily
GENERAL PATHOLOGY OF THE RENAL FUNCTLONS 311
unless the albumin be previously removed ; therefore, in testing highly
albuminous urines for sugar the albumin should always be removed before
the sugar test is applied. The presence of albumin, however, does not
prevent the success of the sugar test unless the amount of it be large. The
well-known odour of diabetic urine is dependent on the presence of
diacetic acid and acetone, more fi'equently on the former than on the
latter. When in diabetic coma the sugar disappears or undergoes
diminution, the diacetic acid and acetone are increased in amount ; and
although these bodies are almost always excreted abundantly in diabetic
coma, their presence in the urine is not restricted to this condition.
Sugar teds. — In testing the urine for sugar many precautions are
necessary. Fehling's solution must be freshly prepared, or care taken
that it has not undergone decomposition. The urine should be added in
a small quantity to an excess of Ijoiling Fehling's solution. If a consider-
able quantity of sugar be present, a few drops of urine are sufficient to
yield the characteristic reaction. If only a small quantity be present, a
larger quantity of urine, amounting to a half or at the most an equal
volume to that of the Fehling's solution, must be used. Excess of urine
and prolonged boiling are both to be avoided, especially if the urine is a
concentrated one ; as, under these circumstances, the reduction of the
copper by urates or kreatinin may be attributed to sugar. If copper
sulphate and potash are used instead of Fehling's solution it is neces-
sary not to have an excess of copper present ; since, if the amount of
sugar be small, some black oxide of copper may be formed and may
obscure the formation of the red oxide.
When the reaction is doubtful the reduction occurs only after pro-
longed boiling ; or a yellowish green discoloration is obtained instead of
a brick-red precipitate. Under these circumstances it is not safe to regard
sugar as present without the application of some corroborative test. Of
these, one of the simplest is the fermentation test, and this has the further
advantage of distinguishing glycui-onic acid from sugar. As a test for
the presence of sugar, fermentation is excellent ; but it is not so valuable
for its cpiantitative estimation.
To perform the fermentation test a small quantity of mercury is
placed in a test-tube filled up with urine, to which a fragment of yeast
has been added. The test-tube is then inverted in a small vessel con-
taining mercury and kept for some hours at the temperature of the body,
preferably in an incubator. The test is said to be sufficiently delicate to
reveal the presence of 0 1 per cent of sugar.
The phenyl-hydrazin test. — This test is of value, both from its delicacy,
and that by its use sugar may be recognised in its different varieties. It
depends upon the fact that phenyl-hydrazin with glucose forms crystalline
needles, which are but slightly soluble in water. Hydrochlorate of
phenyl-hydrazin and acetate of soda are mixed together in the proportion
of two parts of the former to three of the latter, and to the mixture some
10 c.c. of urine are added. The fluid is then warmed by placing the test-
tube in a water-bath for half an hour. On cooling, should sugar be
312 SYSTEM OF MEDICINE
present, a distinct crvstallinc deposit is formed, which under the micro-
scope is seen to consist of needles. If the ixi-ine contain a large quantity
of albumin it is better to remove it liefore applying the test.
The picric acid test. — A few drops of saturated solution of picric acid
are added to the urine, to this is added caustic potash, and the mixture
warmed. The presence of sugar determines a deep red colour. This test
has the advantage that it can be performed in the presence of al])umin ;
but it has the great disadvantage that a somewhat similar colour, though
not of the same depth, is yielded by kreatinin : by itself, therefore, the
test is not conclusive of the presence of sugar.
Gli/cnronic acid. — This acid is frequently present in the urine in
appreciable quantities, and probably traces of it are normally present.
It is especially abundant in the urine after the administration of certain
drugs, more especially chloral and camphor. As mentioned al)ove, in
cases of indicanuria the quantity of glycuronic acid is considerably
increased, since the indol and skatol formed in the alimentary canal
appear in the urine in part as compounds of glycuronic acid. This acid
is of carbohydrate origin, and, as it reduces Fehling's solution, it is lial)le
to be mistaken for sugar. It is said that some of the cases where sugar is
supposed to be jiresent in urine of low specific gravity are really instances
of excessive excretion of glycuronic acid. This body, although reducing
Fehling's solution, does not yield carbonic acid on fermentation. Glycu-
ronic acid itself is dextro-rotatoiy, its compounds are Irevo-rotatory, and
it forms with phenyl of hydrazin a compound which melts at 115°;
whereas the corresponding compound formed with dextrose melts at
205°.
Acetone. — Acetone is found in the urine in many conditions, as in
diabetes mellitus, febrile diseases, and the cachexia of malignant disease.
It is stated to occur in starvation, and also after anaesthesia ; but, accord-
ing to Abram, neither the quantity of anaesthetic used nor the duration
of the ansesthesia has any well - marked effect on the amount of the
acetonuria ; it is stated that acetonuria occurs in at least two-thirds of
the cases of anaesthesia. Acetone is also stated to occur in traces in the
urine in health, and more especially in children. In diabetes mellitus
acetonuria alone is certainly not indicative of the presence or imminence of
diabetic coma. Acetone is the cause of the peculiar etherial odour often
noticed in cases of diabetes, both in the urine and the breath.
In diabetes acetonuria is frequently accompanied by the presence of
diacetic acid ; and some of the so-called tests for acetone depend really on
the presence of diacetic acid. If the amount of acetone in the urine is
small, it can only be recognised by distillation ; if large, one or more of the
following tests may be used : — The suspected urine is added to a solution
of iodide of potassium in liquor potassae, and the liquid boiled ; if acetone
be present, crystals of iodoform are formed. A convenient strength of the
solution is 20 grains of iodide of potassium to a drachm of liquor
potassaj.
Another test for acetone is that of Legal. To the suspected urine a
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 313
concentrated freshly-prepared solution of sodium nitro-prussirle and some
caustic soda are added. A red colour is formed, which disappears, and
on the addition of acetic acid is replaced by a purple. Diacetic acid is
recosrnised bv the red colour -which it yields Avith ferric chloride.
/?-Oxy butyric acid occurs in the urine in diabetes, and more especially
in diabetic coma. It is, however, seen in febrile states also. There is
no convenient test for this substance, but it may be recognised by
fermenting the urine with yeast, filtering, concentrating, and distilling
the filtrate with concentrated sulphiu'ic acid. a-Crotonic acid separates
from the distillate on cooling, and may be recognised by the fact that
the crystals melt at 72°.
B. The Kidneys
Physiological considerations. — The kidneys share with the skin,
the lungs, and the intestines the duties of eliminating from the body
substances, either produced in the course of metabolism or introduced
from the outside, which are either no longer useful or positively in-
jurious.
In health the excretion of the urinary pigments may be instanced as
illustratinof the former, and the various nitrosenous extractives and salts
as illustrating the latter. In disease, the removal of sugar in diabetes
illustrates the excretion of a substance no longer useful ; and the toxins
excreted in the urine in microbic diseases afiord an illustration of sub-
stances injurious to the economy. In the course of this process in health
a consideral)le quantity of water is eliminated by the kidney ; approxi-
mately 50 per cent of the quantity ingested. The great bulk of substances
excreted in the urine are formed in other parts of the body, and the
kidneys are only concerned in their removal from the blood -stream.
Some constituents of the urine are, however, undoubtedly formed 'va the
kidney.
The functions of the kidney may be classified somewhat as follows : —
(i.) The excretion of water.
(ii.) The excretion of salts, pigments, extractives.
(iii.) The synthesis of some constituents of the urine.
(iv.) The metabolic activity.
i. The excretion of water. — The excretion of water by the kidney
is intimately related to the state of the circulation in the kidney, and
as yet there is no definite experimental evidence of any kind of influ-
ence of the nervous system on the water excretion, except the indirect
one exerted through the vaso-motor system.
Broadly speaking, the elimination of water depends on the rate of
the flow of the blood through the glomerular tufts, and most substances
normally present in the urine, when introduced into the circulation,
bring about a dilatation of the renal blood-vessels. Some substances,
however, such as digitalis, cause an increased flow of urine, notwithstand-
ing that they produce constriction of the renal vessels. This, however.
314 S YSTEM OF MEDICINE
is depemlent on the fact that, along with the renal constriction, there is
general vascular constriction ; and the heightened blood-pressure so pro-
duced causes an increased flow of blood through the kidney. In pathology-
it is important to bear in mind that the rate of the flow of blood through
the hidney is of more importance in determining the actual amount of
water excreted than the actual blood-pressure. Although there is no
definite proof of the existence oi renal nerves apart from vasomotor
nerves, yet it is possible, if not probable, that such exist. Many opera-
tive procedures, such as the placing of a canula in the ureter, bring
about complete arrest of the urinary secretion. It is difficult to .suppose
that this is due to a vascular efl'ect, as oncometric observations do not
show that such operations produce any direct and sudden efi'ects on the
volume of the kidney.
Some observers have thought that the kidney reabsorbs water ; in
other words, that the urine, as secreted by the glomeruli, is more dilute
than that passed out from the renal pelvis ; and the facts of comparative
anatomy as regards the structure of the kidney in dilTerent animals are
appealed to in support of this opinion.
The amount of water excreted apparently depends also on the
amount of kidney substance. This conclusion is based upon the con-
sideration of the following facts : — If a portion of one kidney be excised,
the operation is followed by an increase in the amount of urinary water.
This increase is not seen after simple incision and suture of the kidney ;
to produce it a portion must be i-emoved, although the effect is seen
when the portion removed is small, weighing perhaps but a few grammes.
If, after the removal of a portion of one kidney, the second kidney be
also removed entire, leaving the animal with less, therefore, than one
kidney, the increase in urinary water is very considerable, amounting
frequently to twice the normal quantity. No other profound efl'ect is
seen, provided the amount of kidney left approximates to one-third of the
previous total normal kidney weight. This increase in urinary water, as
far as my observations go, is a permanent one ; at any rate it persists for
periods of four to six months. The removal of a wedge from each
kidney produces a very great increase in urinary water, often greater
than that seen in the jjrevious series of experiments. In some cases the
flow has been quadrupled. This condition is also very persistent, but is
not followed by any marasmus or marked deterioration in the health of
the animal ; the only striking phenomenon being the abundant dilute
urine, approximating in character to that seen in the human subject in
cases of renal cirrhosis and diabetes insipidus. No cirrhosi-s or inter-
stitial inflammation of any kind is induced in the organ as the result
of these excisions ; therefore tlie increase in the urinary water is in no
way dependent upon any secondary pathological process stai-ted in the
kidney by the operation. Apparently no such increase ensues on removal
of one entire kidney. Division of the renal plexus is not followed, so
far as my observations go, by any permanent increase in the urinary flow ;
and division of the renal plexus has no influence in modifying the results
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 315
produced by the excision of portions of the kidney. It is immaterial
in such experiments whether the renal plexus be divided or not.
I am not prepared to offer any explanation of the increased urinary
flow, but it is possible that the partial ablation of a kidney produces
secondary effects on the blood-pressure, and that this is raised. It is
also possible that there is a greatly increased rate of flow through the
fragment of kidney left, and that in this way the elimination of water is
increased. It is also possible, but not probable, that the increased flow
depends on a diminished reabsorption of water ; but the fact that the
greatest and most marked effects are seen after partial bilateral neph-
rectomy is '\w favour of the dependence of the phenomenon on some
secondary effects produced on the vaso-motor system.
The kidney is enormously vascular, and is one of the most useful
organs in the body for the investigation and demonstration of vaso-motor
phenomena.
The kidney in animals (dog) receiA^es its vaso-motor nerves from the
sixth dorsal nerve to the third lumbar inclusive ; that is to say, from a
consecutive series of eleven nerve-roots, inasmuch as the dog has thirteen
pairs of dorsal nerves. It is, however, only the lower of these nerve-
roots that contain an abundant supply of vaso-motor nerves. Although
the great bulk of nerves distributed by these roots are vaso-constrictor
nerves, yet there is definite experimental evidence that the lower dorsal
and upper lumbar roots contain some vaso-dilator fibres. Further, the
kidney receives from the posterior roots a number of afferent nerves,
the excitation of which, by producing constriction of large vascular
areas, causes a very great increase of the general blood-pressure. It is
remarkable that nerves, the excitation of which causes a fall of blood-
pressure by bringing about general dilatation, for examiDle, the depressor
nerve, the central end of the lower intercostal, etc., do not produce any
marked direct fluctuations in the volume of the kidney.
ii. The excretion of salts, pigments, ete. — Although these are
grouped together, they are excreted by different portions of the kidney ;
thus the salts — and certainly the abnormal pigments — are excreted by
the glomeruli : the urea, on the other hand, is removed by the tubules.
The urea is definitely known not to be formed in the kidney, but simply
to be removed. The blood normally contains (approximately) 0"015 per
cent, and thus the selective activity of the renal epithelium may be
gauged, inasmuch as the urine contains approximately 2 per cent of urea.
Although the renal epithelium has such marked selective affinity for
eliminating urea, the kidney is able to remove a number of substances
introduced into the general blood-stream, especially when such substances
are abnormal constituents ; but, on the other hand, it will also eliminate
normal constituents of the blood-stream not usually present in the urine
in cases of a marked increase in such substances. Thus the abnormal
presence of albumoses in the blood is followed by their prompt excretion
by the kidney. The same applies to the presence of bile pigments in the
blood. A normal constituent of the blood, like sugar, which is probably
3i6 SYSTEM OF MEDICINE
not nniMn;ill\' present in the urine, appears readily in this fluid when
the percentage in the blood increases from the normal 0*09 ])er cent to
0*3 per cent. Nothing demonstrates the selective activity of the renal
epithelium better than the fact that, although there is in the blood some
four or five times as much sugar as there is urea, the lu-ine contains either
no sugar or traces at most ; whereas, as mentioned above, the percentage
of urea is at least one hundred times greater than in the blood. Although
most of the constituents of the urine are derived either from the products
of the metabolism of the tissues, or from the ingestion and absorption of
various food constituents, some of the urinary constituents reach the urine
by a roundabout cour.^.e ; thus the aromatic sulphates of the lu'ine are
derived principally from the decomposition of proteid matter in the in-
testine, and it is certainly remarkable that these substances should be
absorl)ed from the intc-itine aiid subsequently excreted by the kidney.
Hence the eliminating functions of the kidney are not only related to
those of the skin, but are in connection with the intestine also ; so that it
is quite conceivable that, if the eliminating functions of the kidney should
be seriously impaired, an accumulation of more or less toxic materials
might occur in the intestines ; and this independently of the fact that
when the urinary flow ceases, urea, and pro1:)ably other bodies, are ex-
creted by the mucous membrane of the stomach and the bile.
Most substances readily excreted by the kidney produce at the same
time a copious flow of lu'inary water, and oncomctric observations shoAv
that such substances produce vascular dilatation of the kidney.
iii. The synthesis of some of the constituents of the urine. — The
urine contains traces of hippuric acid. In many animals the quantity is
considerable. In man the quantity is greatly increased as the result of the
ingestion of substances containing benzoic acid or its compounds. It is
definitely known that when benzoic acid is ingested, it is excreted as
hippuric acid, and that the conversion of benzoic into hippuric acid occurs
in the kidney. This fact is important, as showing that the kidney is
capable of synthesising complex oi'ganic substances ; and what is true of
hippuric acid may be true for other urinary constituents.
It has recently been asserted (Lufl") that uric acid is formed in the
kidney and not, as is more commonly believed, in the liver or spleen.
This conclusion is largely based on the cliflficulty of determining the pre-
sence of uric acid in the blood, q\qx\ in the cases of animals, such as birds,
whose urine contains large quantities of uric acid. The blood of such
creatures has long been known to contain urea (Garrod), and it has been
supposed that the kidnoy is concerned in the conversion of urea into uric
acid. The removal of the liver in such animals, however, is followed by
a very great diminution in the uric acid excreted, and most physiologists
consider that this fact points to the conclusion that the liver is the organ
in which the lU'ic acid is formed. Further, the removal of the kidneys in
bii-ds, or their destruction by repeated injections of bichromate of potash
(Ebstein), is followed by the deposition of uric acid in various tissues and
organs of the body.
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 317
iv. Metabolic activity. — Recent physiological observations have
shown that the suprarenal, thyroid, and pancreas are glands possess-
ing internal secretions ; and. a series of observations have been made
by myself to see whether the kidneys possess any snch functions. The
object of these experiments was, by diminishing the amount of kidney
substance, to observe whether the resulting phenomena were due to a
deficiency in the excretory function of the kidney. The general result of
these observations was as follows : — The removal of a portion of one
kidney is not followed by any permanent after-effects, except in the case
of the flow of urinary water. The removal of a portion of both kidneys
produces the same excessive flow to a greater amount. The removal of a
portion of one kidney and the whole of the other, again, is followed by
the same eftect, j^rovided the quantity of kidney left amounts to not less
than one-third of the previous total kidney volume. The removal of a
portion of one kidney and of the whole of the other is followed by death,
if the amount left is, approximately, no more than one-fourth of the total
normal kidney weight. The period of survival after this last operation is
very short — rarely more than three weeks, sometimes as short as one week.
In this last series of cases, not only is the quantity of urine greatly
increased, but there is also an increased excretion of urea, absolute or
relative ; by the former is meant that the actual amounts excreted are
greater than those previously excreted on a full diet in health. By the
tei'm " relative increase " is meant a condition in which the excretion of
urea remains at the height at which it existed previously on a full diet,
notwithstanding that no food is taken sulj'sequently to the operation. In
other words, if the animal refuse food, as sometimes is the case, the
amount of urea excreted equals that previously excreted on a full diet ;
whereas if the animal eat, the amount of urea excreted is increased.
This increased excretion of urea is accompanied by great wasting,
especially of the muscles, and great consequent weakness. The marasmus
is accompanied by a great fall of the body temperature. The blood and
tissues contain a large excess of urea and other nitrogenous extractives
at a time when the increased excretion of urea is in full swing. When
the animal is moribund the increased excretion of urea and urine
diminishes. I think it is clear from these observations that the removal
of very large quantities of kidney substance — that is, over three-quarters
of the total kidney weight — is followed by a disordered metabolism of
such a character that the production of urea is increased ; and that the
increased urea and nitrogenous extr;ictives present in the blood and tissues
are dependent on this increased production, and are in no way caused by
any deficiency in the excretory activity of the kidney.
It is most remai'kable to see how these fragments of kidney will
excrete quantities of urine and urea far greater than those normally
excreted from two intact kidneys. The disordered metabolism produced
by these extensive partial nephrectomies is in no way due to a disturb-
ance of the nervous system produced by mutilation, since the division of
the renal plexus has no influence in moderating or increasing the severity
3i8 SYSTEM OF MEDICINE
of the effects, nntl the phenomena are dependent entirely on the qnantity
of kidney substance removed at the operation, and not on the mutilation
produced in removing it. Thus a greater quantity of kidney is removed
by excising a wedge from one kidnej', and subsequently removing the
whole of the second kidnej", than by removing a wedge from eacli kithiey ;
yet the mutilation and severity of the operation are far greater in the
latter case than in the former. The latter operation is never followed
by an increased urea excretion ; the former may be if the quantity of
kidney removed is some three-fourths of the total kidney Aveight. These
observations point to the existence of another function of the kidney
apart from its excretory function ; since the latter is, at any rate, not
abrogated by the procedures, whereas the metabolism of the body is very
seriously deranged. Whether this is dependent on the existence of an
internal secretion I am not ])repared to say, since such a conclusion is not
justifiable until the disordered metabolism produced by the operation can
be successfully arrested by the injection or administration of a kidney
extract. As yet such experiments have not been carried out. Finall}',
whether the kidney possess an internal secretion or not, it is clear, I
think, that the diminution in the amount of the kidney suljstance avail-
able produces a widespread disturbance of the general metabolism, in no
way dependent upon the impairment of its functions as an excretory
organ.
Tre general pathology of renal disease. — The pathology of
diseases of the kidney may be divided into two series of phenomena :
first, the pathological results of diseases of these organs ; and, secondly,
the mode of production of the diseases themselves.
Diseases involving the kidneys tend to produce one or more of the
following pathological defects : —
1. Alterations in the composition of the urine; 2, oedema; 3,
urpemia ; 4, cardio-vascular changes ; 5, marasmus and anaemia ; and
6, liability to septic inflammations, that is, the so-called secondary
inflammations.
1. Alterations in the urine. — The normal floAv of urine depends
upon the activity of the glomerular epithelium, and on the rate of
the l>lood-flow through the vessels. The urinaiy flow is diminished
as the result of morbid conditions affecting one or more of the following
mechanisms : —
(i.) Circulator ij changes in the kidney. — {a) TJie direct action of varions
substances on the renal vessels. — Sul)stances acting on the renal blood-
vessels may bring about a diminution in the cpiantity of urine, or even
actual suppression, by causing vascular constriction. Frequently this
constriction, even if extreme in amount, is followed by dilatation,
depending in many cases upon damage to the vessel wall by the con-
stricting substance, as by turpentine. Many substances which in certain
doses cause constriction of the renal vessels, in other doses cause dilatation
and diuresis ; citrate of caffein is a striking example of this contrast.
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 319
Further, substances like caffein, which produce a double effect — constric-
tion followed by dilatation, if given experimentally in rapidly repeated
doses cause constriction only, and even complete suppression.
This action of substances on the renal vessels is a direct one, as
shown by the fact that division of the renal plexus has little effect on the
phenomena ; and, furthei", that the characteristic effects can ])e produced
in a kidney, excised from the body, through which an artificial circulation
is maintained.
(/>) Indirect or reflex effects 011 the rennl vesseU produced through the nervous
system. — Constriction of the renal blood-vessels produced by reflex excita-
tion is not so likely to lead to diminution or suppression of the urinary
flow as direct excitation ; since on reflex excitation the local effect is
liable to be accompanied by a general constriction, and thus the flow
througL the kidney is not diminished to the same extent. It must be
remembered, however, that substances acting directly on the blood-
vessels have not, as far as we know, any special action on the renal
vessels, and therefore, to a certain extent, the eftects produced in both
conditions will be similar.
Although constriction of the kidney is readily brought about by
reflex excitation of the sensory nerves, it is doubtful whether complete
suppression, lasting for any length of time, can be pi'oduced in this way.
Stimulation and excitation of the central ends of the lower dorsal nerves
produce reflex dilatation of the kidney, along with a general con-
striction.
(ii.) epithelial changes. — (a) TJie changes produced as a residt of the
above circulatory cJmnges.- — Interference with the renal circulation, whether
by the production of constriction or dilatation, is followed very quickly
by changes in the renal epithelium ; and these are undoubtedly largely
responsible not only for variations in the amount of the urine, but also
for alterations in its composition.
(b) Direct toxic action of various substances on the epithelium. — In many
microbic diseases, more especially in diphtheria, anuria is not uncommon ;
and often in fatal cases there are no signs of any very profound lesions
of the vessels of the kidney. It is probable that in these cases suppres-
sion is brought about by the action of the morbid poisons on the epi-
thelial elements of the kidney. This is in striking contrast to the
suppression seen in acute nephritis and scarlet fever, where the changes
in the blood-vessels and circulation are very marked.
(c) The action of the nervous system directly on the lidney cells and on
the blood-vessels. — This action must, at the present time, be considered
purely hypothetical ; yet a number of cases of complete suppression
arise as a result of reflex excitation of some part of the nervous system.
This suppression may last for days ; and it is difficult to suppose that it
depends entirely on reflex effects on the blood-vessels, since, as mentioned
above, although it is possible, experimentally, to cause diminution in
the flow of urine by the reflex stimulation of nerves, yet it is difficult to
arrest the flow completely for any length of time.
320 SYSTEM OF MEDICINE
An increased flow of urine is described above in the section on
" Urine " as a characteristic ijhenomenon in many diseases. In some, as in
diabetes mellitus, the mechanism is comparatively simple, inasmuch as
the increased How probably depends closel}' on the presence of the sugar,
which is a powerful diuretic ; it is not entirely due to this, however, as
the increased flow may sometimes persist Avhen the sugar is largely
diminished. The kidneys in diabetes mellitus are usually considerably
hyportrophicd. In cirrhosis of the kidney the mechanism is by no means
St) clear. The increased flow here has usuall}^ been supposed to be
dependent on the heightened arterial tension increasing the rate of flow
through the remaining kidney substance. The increased flow cannot
very well be due simply to increased blood-pressure favouring filtration,
inasmuch as, physiologically, the flow of the amount of urine is not
de[)endcnt upon the absolute blood- pressure of the renal A-essels, but
upon the rate of flow through the renal vessels.
The increase seen in renal cirrhosis is somewhat similar to the
increase seen after the experimental removal of portions of the kidney ;
and it may perhaps be dependent rather upon the diminution in the
available kidney substance than upon the increased blood-pressure. It
is possible that the increase in the amount of urine may, to a certain
extent, be an indication of the degree of destruction of the kidney
substance. It is certainly remarkable how great are the quantities of
dilute urine sometimes passed by kidneys with very advanced and general
destructive and fibroid changes, a change so widespread and extensive
that but little kidney structure may remain. In amyloid disease the
increased flow is supposed to depend upon the increased [jermeability of the
glomerular tuft. In chronic nephritis, in Avhich the amount of interstitial
change is frequently considerable, the flow is also increased ; and here
the card io- vascular changes are often by no means so well marked as in
cases of so-called grainilar kidney. It is diflicult to say whether in these
cases the increased flow is dependent simply on the increased blood-
pressure, or whether here also it is related to the destruction of the
kidney substance.
In chronic nephritis with dropsy the subsiilence of the dropsy is
always associated with an increased flow of urine.
The other abnormalities of the urine in renal disease arc considered in
the section " Urine."
2. Dropsy is a frequent accompaniment of renal disease, but the
association is not an invariable one. Some diseases of the kidney never
cause dropsy, and no disease of the kidney causes it always. Dropsy is
peculiarly associated with Bright's disease, acute and chronic, but even
in this malady its 0("currence is not invariable, and acute Bright's disease
of the greatest severity may occur without the presence of any dropsy.
In other forms of this malady dropsy may be the most prominent
symptom, and the severity of the lesitni, as judged by the alterations in
the composition oi the urine, may not be any more severe than in cases
unaccompanied by drojjsy. Dropsy is most frequent in the cases of
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 321
Blight's disease dependent on scarlet fever, cold, and alcoholism. It
is remarkably frequent in what is known as the large white kidney ;
not so common in cases of small white kidney. It is also frequent in
the waxy kidney. The dropsy seen in certain cases of granular kidney
is usually held to be associated with some accompanying cardiac lesion.
Dropsy does not occur in cases of suppression of urine from calculous
obstruction, even when this lasts as long as a week or ten days. It is
also uncommon in the partial or complete suppression seen in diphtheria ;
but dropsy does sometimes occur in this latter state. Slight dropsy is
often seen in cases of eclampsia, but here it is probable that the dropsy is
dependent on the coexistence of renal disease. Tuberculous and malig-
nant disease of the kidney do not of themselves necessarily lead to dropsy.
Renal dropsy is associated with the diminution in the amount of
urine excreted, so that an increase in the dropsy is always associated
with a corresponding diminution in the amount of urine voided. And,
conversely, an increased flow of urine is associated with a subsidence in
the amount of the dropsy. Dropsy in cardiac disease is also associated
with a diminution in the amount of water excreted, so that some
observers have considered that so-called cardiac dropsy does not arise
unless, owing to the venous congestion produced by the cardiac lesion,
there is some interference in the rate of the blood-flow through the
kidney, and hence a diminished excretion of urinary water.
. In cardiac diseases, however, it is probable that the relationship is
not one of cause and effect, but simply an associated defect ; the increased
venous pressure leading, on the one hand to anasarca, and on the other
hand to the diminished excretion of urinaiy water.
The dropsy of renal disease affects more especially the subcutaneous
tissues, and is most readily detected over the sacrum, the scrotum, the
eyelids, and the shins. Not uncommonly the patient's attention is first
attracted to the malady by the puffiness of the lower eyelids ; oedema
here, however, is by no means always due to renal disease. The dropsy
affects also the serous cavities, and when the general oedema is at all
marked there are dropsical accumulations in the serous cavities, more
especially in the pleural cavities.
CEdema of solid organs, such as the lungs, brain and larynx, is also
common ; but pulmonary oedema is perhaps the most serious, and at the
same time a very frequent complication of renal disease. Oedema of
solid organs, and more especially of the lungs, is usually found in long-
standing cases of renal dropsy, and pulmonary oedema is frequently
associated with hydrothorax. Pulmonary oedema, however, is not un-
commonly seen in fatal cases of uraemia, when there is no general dropsy.
It is important to recognise that pulmonary oedema in renal disease is
not always a mere accompaniment of general water-logging, but is a fre-
quent, if not invariable, accompaniment of urcnemia. fficlema of the
glottis is by no means so frequent ; and oedema of the brain, although
sometimes very well marked, is likewise by no means an invariable
accompaniment either of renal disease or of uraemia.
VOL. IV Y
322 SVSrEM OF MEDICINE
The fluid found in the serous cavities in renal disease is remarkable
for containing only a small percentage of proteid ; and that found in the
subcutaneous tissue contains a still smaller percentage, frequently not
more than one per cent. The amounts of pi-oteid found in the dropsical
fluids are far loss than those seen in inflammatory exudations, or e^"en
than those found in the dropsical transudations of heart disease. Whether
oedema be caused by cardiac or renal disease, the percentage of proteids
present in the sul)cutaneous fluid is less than that seen in the fluids
found in the serous cavities ; but the amounts present in the transuda-
tions of renal disease are far below those seen in the transudations of
cardiac disease. This is not surprising in renal disease, considering the
continual loss of albuminous substances from the blood plasma, owing to
the albuminuria.
The (h'opsy of renal disease is thus peculiar in its distribution, affect-
ing mainly the subcutaneous tissues; and in its composition, owing to the
small amounts of proteid matter present. The. dropsical fluids in renal
disease contain large (juantities of nitrogenous extractives, more especi-
ally in uraemia ; even when there are no signs of ura?mia, the blood and
dropsical fluids of a patient Avith Brigh't's disease contain a notable excess
of urea and other nitrogenous extractiACS.
By an examination of the pleural and peritoneal fluids in cases of
Bright's disease associated with dropsy, it is possil)le to determine, ap-
proximately, the amounts of nitrogenous extractives present in the l)lood.
The dropsy of chronic Bright's disease conceals, to a great extent, the
general wasting which occurs in this malady, and which becomes very
apparcTit if from any cause the dropsj' subside.
Dropsy is sometimes the first obvious sign of grave and unsuspected
renal disease ; both in acute Bright's disease, and in subacute Bright's
disease of insidious onset. Cases of the general oedema characteristic of
Bright's disease are sometimes seen, however, in which, on examination
of the urine, no confirmation of this suspicion is found.
The causation of renal dropsy is obscure, much more so than in the
case of cardiac dropsy ; and many hypotheses have been advanced to
explain it, none of which is wholly satisfactory. From a pathological
point of view, the dropsical transudations found in renal disease are after
all accumulations of more or less abnormal lymph — abnormal especially
from the presence of a small amount of proteid matter and the large
amount of extractives. The abnoi-mality of the composition of the fluid,
however, is most obvious in chronic cases, and can be accounted for fairly
well by the fact that the blood itself is rich in extractives and poor in
proteid constituents. The inquiry is therefore narrowed down to the
actual cause of the increased transudations of lymph. An increased
transudation of lymph must, as far as is known, be dependent ultimately
either on primary altei'ations in the wall of the capillaries increasing their
permeability, the blood-flow through them and the blood -pressure in
them remaining normal, or else upon an alteration in the blood-pressure
and bloud-flow in the ca])illaries themselves.
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 323
Physiologically, it can be shown that an increased lymph- flow is
readily broiight aljout by any condition increasing the venous pressure,
either general or in the locality affected. Some physiologists have held,
however, that the capillary wall exerts a very special and selective action
on the contained Ijlood ; and that, to a certain extent, the flow of lymph
is to be looked upon as due to the vital selective activity of these cells ;
if so, the lymph -flow is not directly reLated to and dependent upon
pressure changes in the blood-stream. Pressure changes in the arteries
are of small moment in this connection; the essential and important factor
is an increased capillary pressure brought about by venous obstruction.
In renal disease it is not clear how the venous pressure can be afl"ected
to any great extent, whereas the arterial pressure is known to be fre-
quently raised. On physiological grounds there is no evidence to show
that increase of arterial blood-pressure will cause any increased transudation
of lymph ; moreover, in renal disease the occurrence of dropsy and the
presence of an increased arterial pressure are not necessarily correlated.
It has been supposed that a hydrsemic plethora is the direct cause of
the dropsy, and some authors regard the scanty urinary secretion as the
direct cause of hydrsemia and dropsy. It is quite certain, however, that
mere suppression of urine will not cause dropsy, clinically or experi-
mentally. Complete calculous suppression, ligature of the ureters, the
removal of the kidneys do not cause dropsy. It is the suppression of
Erights disease that is intimately associated with the causation of dropsy,
not suppression generally.
It is interesting in relation to this question to note that, although the
injection of large quantities of salt solution into the blood-vessels of an
animal will not cause general dropsy, even after ligature of the ureters,
yet if, previously to this, some vasciilar area be damaged, as the pleura for
instance, by the injection of an irritant, then the hydrsemia produced by
the injection will cause a most abundant exudation. Further, the in-
jection of considerable quantities of salt solution intravenously after
intraperitoneal ligature of the ureters and free venesection will cause an
abundant transudation of fluid, poor in proteid, into the peritoneal cavity.
It is asserted, however, that the peritoneal vessels have been damaged by
the operative procedures necessary to ligature of the ureters, so that
although the blood -state and the transudation produced in this way
closely resemble that seen in renal disease, the distribution of the
transudation is quite different ; seeing that it is characteristic of renal
disease to aff"ect the subcutaneous tissues.
The most plaixsible explanation of the dropsy in certain forms of renal
disease is to assume that the capillary walls have been damaged, probably
by some material in the blood-stream ; and that this, together with the
hydrsemic plethora, leadsto thedropsy. These hypothetical toxic substances
cannot, however, be the toxic substances leading to urpemia ; as uraemia is
so frequently seen, not only without dropsy, but where there has never
been dropsy. The form of kidney diseas3 that more especially leads to
uraemia is not necessarily associated with the presence of dropsy.
324 SYSTEM OF MEDICINE
Cohnheim's view, that the dropsy is a kind of subacute inflammation
of the skin structures, due to <leficicnt excretory acti\ity of the kidney,
is negatiA'ed by the composition of the fluid, and by the facts that the
dropsy is not limited to the skin, and that complete suppression does not
cause dropsy.
It is, perhaps, important, in discussing the pathology of renal dropsy,
to recognise the diflerence between mere hydriemia and hydra:^'mic
plethora. In one case the blood is simply poor in solids, the total
volume remaining the same ; in the other it is not only poor in solids,
but the volume of the fluid present is increased. A condition of hj'drnemic
plethora is readily brought about experimentally by the remo\al of a
given quantity of blood, and the immediate transfusion of a much larger
quantity of normal saline solution.
Heidenhain's ex])ei-iments have shown that a number of substances
injected into the circulation lead to an increased lymph- flow, apparently
by acting on or changing the epithelium of the capillary wall ; and this
observer considers that substances having this action might be divided
into two groups — those the injection of which is followed by the forma-
tion of an abundant dilute lymph, and those the injection of which is
followed by the formation of a very concentrated lymph ; and he con-
sidered that he had definite evidence that the lymph is more or less of the
nature of a secretion, the composition of which largely depends on the vital
secretory activities of the capillary walls. Heidenhain's views have not
received uniform support ; and many experimenters consider that not
sufficient stress was laid by him on the effects produced in his experiments
upon the venous pressure. However this may be, the production of ;rn
increased lymph-flow, dilute or concentrated, l)y the presence of abuornud
substances'in the blood-stream, certainly throws a new light on the mo le
of production of renal dropsy ; but the enigma of its abundance in the
subcutaneous vessels still remains, as apparently all authors are agreed
that, given a general condition favouring the production of an increased
lymph -flow from the lilood, the vessels of the peritoneum and of the
pleura allow an exudation more readil}?^ than those of the subcutaneous
tissues. Further, not only do vessels of diff'erent regions of the body
afford facilities for the production of dropsy, but even when there
is a general cause, such as heart disease, the composition of the
dropsical fluid is different in different regions ; moreover, the fluid in the
subcutaneous tissue is always dilute, showing that the permeability of
these vessels, at any rate for solids (colloids), is far less than that of the
peritoneal and pleural vessels.
[For fuller detail the reader is referred to an article on Dropsy which will
appear in a fol lowing volu7ne.'\
3. Uraemia. — The name urpemia is used for a group of symptoms
arising during the course of many renal diseases ; always grave, not infre-
quently fatal, and dependent mainly, but not entirely, upon derangement
of the functions of the nervous system. In this way the uraemia of renal
disease resembles the acetomemia of hepatic disease.
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 325
■ Uraemia, more or less severe, may occur in almost all diseases of the
kidney ; thus it is seen in congestion — active or passive ; in nephritis,
especially in Bright's disease ; in renal cirrhosis ; in waxy kidney ; in
tuberculous, calculous, and cystic diseases ; in hydronephrosis, and in
consecutive nephritis. Furthermore, patients may sometimes succumb to
urc'emia with complete suppression, and with but few signs of serious
disease of the kidneys. This is sometimes seen after severe injuries to
sundiy parts of the bod}', or after operative procedures on the kidney or
urinary tract.
Fatal uraemia usually occurs either late in the course of chronic
renal disease, or else during the course of acute nejihritis very violent
and severe in degree. Some of the most remarkable forms of urcemia,
however, occur suddenly ; either in the midst of apparently robust
health, or else when the symptoms of some chronic renal disease have
existed for some time, but, owing to their apparently trivial character,
have been either overlooked or neglected. The uraemia accompanying
fatal calculous suppression, and the uraemia of the granular or cirrhotic
kidney, are instances of the latter ; the ursemia of scarlatinal nephritis,
of chronic Bright's disease, and of waxy kidney are instances of the
former.
Uraemia may be classified clinically, according to its mode of onset or
according to the nature of the most striking symptoms produced ; thus,
uraemia may be sudden in its onset and rapid in its course, or it may be
gi-adual in its onset and slow and persistent in its course ; the former is
characterised as acute, and the latter as" chronic. Some cases, however,
are very rapid indeed in their progress. It is advisable, therefore, to
divide the acute cases into two groups, and thus to recognise three groups
in all — the fulminating, the acute and the chronic. If uraemia be
di\dded according to the character of the symptoms produced, two great
groups can be recognised : (ft) the nervous type ; (i) the gastro-
intestinal type. In the former the main symptoms point to disturbance
of the nervous system, such as delirium, coma, convulsions ; in the latter
the principal symptoms point to disturbance of the gastro-intestinal
functions, such as nausea, vomiting, and diarrhoea. The gastro-intestinal
group corresponds fairly well with the chronic or subacute variety of
uraemia ; the nervous group with the fulminating and acute varieties.
This classification, however, is artificial, since many symptoms in the
gastro-intestinal form are probably dependent on the action of poisons on
the nervous system. The symptoms in the gastro-intestinal form are
remarkably constant : nausea, intense and persistent vomiting, hiccough,
and frecjuently, but not invariably, diarrhoea. After the persistence of
these symptoms for days, weeks, or months, according to their severity,
certain nervous symptoms ensue ; such as cramps in the legs, muscular
twitchings, contraction of the pupil, occasional and inconstant delirium,
and gradually increasing dyspnoea — possibly of the Cheyne-Stokes variety,
but more particularly characterised Ijy its peculiar hissing quality. The
delirium gradually gives way to drowsiness and coma, and the patient
326 SYSTEM OF MEDICINE
dies from failure of respiration ; sometimes gradually, sometimes with
remarkable suddenness.
The symptoms in the fvdminating and acute forms are much more
protean in their manifestations, and may be divided as follows : —
1. The er!(fmplic or cpUeptifomi f>/pc. In this form, Avith or without
previous warning, the patient is seized with an epileptic seizure, usually
Ijcginning, like other forms of epileptic seizures, with movements involving
the small muscles, then spreading rapidly to the whole body. The fits are
frequently repeated, and may be of great severity, the patient passing
into a condition allied to the status epilepticus. There is usually un-
consciousness, which, however, is not always absolutely complete, and the
body temperature falls. The pupils are contracted and the knee-jerks
exaggerated ; and often — if the fits are very fre(]uent and severe — the
body temperature rises considerably, and there may e\'en be hyperpyrexia
without the presence of any gross inflammatory lesions in the lungs, or
elsewhere, to account for the height of the fever. This tj^pe of ura3mia
in its pure form is not common, except in eclampsia ; but epileptiform
seizures of a similar type occur in other forms of unvmia.
2. Hie maniacal form. — This, also, is not a common form, but it is
seen occasionally in cases of contracted kidney in 3'oung adults ; some-
times in cases where symptoms of renal disease have existed and been re-
cognised for some time ; in other more obscure forms where the onset of
A^olent mental symptoms has been the first indication of the underlying
malady. The patient is excited, restless, noisy and sometimes very
violent ; in two cases under my own observation very distinct cataleptic
phenomena were present at intervals. The excitement soon gives Avay to
drowsiness, and then to coma and other distinct ura?mic symptoms.
3. The di/spnceic form. — Dyspnoea of a peculiar hissing character, as
noted by Addison, is common in uraemia ; sometimes it is almost the
onl}^ sign present, even in fatal cases. Such patients are seized with a
dyspn(jea so intense as in some cases to suggest laryngeal obstruction, the
patient sitting up and gasping for breath. The breathing is very noisy,
hissing, and asthmatic in type, but there is Aery frequently no great
lividity, and the patient is frecpiently conscious, and his mind clear.
The dyspnrjca much resembles the paroxysmal attacks seen in leukaemia ;
more fref[uently, however, the dyspnoea is only the accomj^animent of
other urremic manifestations, and its pecidiar hissing quality in a drowsy
patient, with bleeding gums, is very characteristic of the urasmic state.
Very violent paroxysms of dyspnoea, so far as I have seen, are most
marked in the acute ursemia supervening in cases of contracted kidney.
The other or hissing variety is more often seen in chronic urfemia, and
greatly resembles the breathing seen after the administration of excessive
doses of salicylates. The respiratory rhythm in ui"emia is often ])eriodic
rather than I'hythmic ; and tlie form usually assumed is that known as
Cheyne-Stokes breathing. The periodicity afiects not only the respira-
tory rhythm, but other functions also ; and in a well-marked case the
following phenomena occur — with the waxing and wain'ng of the respira-
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 327
tory rhythm the pulse-rate is altered in such a way that the rate is
quickened with the noisy breathing, and slows down again during the
period of apnoea ; the periodic variations in the pulse-rate are not Cjuite
synchronous with the periods of respiratory rhythm ; there is, so to speak,
some slight overlapping ; the pupil coiitracts and dilates, the dilatation
occurring with the noisy breathing or just preceding it, and, further,
during the period of noisy breathing the patient is restless, subject to
irregular muscular movements until during the apnocic period he gives
way to complete temporary coma.
These phenomena show that Cheyne-Stokes breathing is something
more than a mere periodicity of the rhythm of the respiratory centre,
and that many other functions of the nervous system are simultaneously
affected. In some cases where Cheyne-Stokes breathing is seen, the
patient is not completely unconscious, and a waxing and waning of con-
sciousness may be observed ; but this is a rare phenomenon in compari-
son with the others described above. Cheyne-Stokes breathing is more
common in chronic urremia and in the acute exacerbations of chronic
uraiuiia than in acute and fulminating cases.
4. The comatose form. — This is the commonest form of uraemia; and
in this form the patient, with or without delirium, passes into a state of
drowsiness deepening into coma. Sometimes the coma is preceded by
cramps and twitchings, and the latter are usually to be observed,
especially in the forearms, during the progress of the case. At other
times the coma is jjreceded by gastro-intestinal phenomena, especially by
nausea and vomiting; sometimes by intense headache or amaurosis,
partial or complete, and there is always a considerable fall in the body
temperature.
Some of the most acute cases of ursemia occur, however, cjuite
suddenly, and without any marked prodromal symptoms ; such patients,
after a short period of delirium, or even without, suddenly become
drowsy and ra]>idly comatose, with contracted pupils, excessive knee-
jerks, and subnormal temperature. During this coma epileptiform fits
may occur, Imt these are by no means an invariable accompaniment
of uriemia. In all forms of urtemia the tongue is apt to become dry,
brown, and cracked.
Other rarer forms of urtemia may be described, and more especially
the following : —
5. The jiarab/tic form. — In this remarkable condition a hemij)legia or
even a monoplegia may occur suddenly without any gross lesion to account
for the paralysis being found after death.
6. A form in which persistent iiiahiliti/ to sleep is the most marked
phenomenon, associated with twitching, cramp and hiccough ; but the
mind remains clear and there is no coma : death occurs rather suddenly
from respiratory failure.
7. Latent urcemia. — This is probably the most remarkable of all ; it
is seen more especially as the result of complete obstructive suppression
of urine, and has been fully described by Sir William Ecberts. It is seen
328 SYSTE.U OF MEDICINE
when both ureters are obstructed simultaneously ; or, more commonly,
■where bihitenil calculous disease has led to the complete destruction of one
kidney in the past, and then the ureter of the sole remaining kidney be-
comes suddenly obstructed, and no uiiiie is passed. Sometimes a very
small quantity of luine is })ent Tip in the renal pelvis behind the obstruc-
tion, and it is not common in a case of complete suppression to find at the
necropsy no urine pent up in this situation. The symptoms in this
class are remarkable fur their sli<i;ht intensity, and for this reason the
term " latent ur;vmia " is perhaps ap})lical)le to such cases. Such
patients will live for seven, ten, or even fourteen days without expelling
any urine. They remain conscious almost to the end ; and all the so-
called ursemic symptoms are conspicuous by their absence. There is but
little headache and nausea, vomiting may be absent, and the ])aticnt com-
plains of little but weakness and drowsiness. The tongue becomes dry
and brown, the pupils contract, and perhaps — after some days of com-
plete suppression — slight twitching of the muscles may lie seen. The
temperature is subnormal, and this and the state of the })upils are the most
frequent and trustworthy signs of a condition, ai)parently trivial, but
really of the utmost gravity. Such patients usually die suddenly from
respiratory failure, with little if any mental disturbance or confusion.
Although vomiting is not usually a marked symptom of this condition,
cases are sometimes seen where the vomiting is not only well marked,
but where it is almost the only symptom present ; and in the absence
of a complete and accurate history of the case, it may be so severe as to
suggest intestinal obstruction : indeed this gi'ave mistake in diagnosis
has been made more than once. This symptom group has usualh^ been
said to occur in cases of calculous suppression only ; but I have seen a
precisely similar state where, owing to endarteritis and thrombosis of the
interlobular arteries of both kidneys, the renal secretion Avas practically
arrested, and the patient lived for seven days without secreting any urine.
The symptoms presented by this patient Avere those descriljcd by Sir
William Koberts as characteristic of double calculous suppression.
The difference between the group of symptoms seen in . calculous
suppression and the ordinary forms of uraemia is veiy great, and has
considerable bearing on the intci-pretation of unemia.
Attempts to explain the nervotis disturbaw:es in wceniia have hitherto been
made on what may he called the mechanical and the chciiiitvl bases. Accord-
ing to one school, the results are due to the excitation or pai-alysis of
the nerA'e structures by the changed physical conditions brought aliout
by cerebral a3dema or cerebral amemia ; according to the other, the results
are due to the action on the nerve-cells of one or more poisons circulating
in the blood-stream.
Cerebral fodcma is seen, no doubt, in cases of fatal ui-a'mia unassociated
Avith general dropsy, but tlie general feeling is that it is rather the result
of atrophy of the cerebral convolutions than an active condition. Cerebral
(jcdcma Avas invoked to explain uraemia, as it affords a possil)ility of account-
ing for localised ui'a'mic disturbances ; modern knowledge, however,
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 329
certainly shows that a poison circulating in the general blood -stream
may pick out but one portion of the nervous system, or even produce a
lesion on one side of the body only. Lead and arsenic afford numerous
instances of such actions. Both may cause symmetrical peripheral
neuritis ; but what is more remarkable is that either of them may cause a
patch of focal myelitis. Arsenic not infrequently causes herpes, which in
all probability is dependent on a nerve lesion, and is generally unilateral in
its distribution. Further, one and the same poison may produce opposite
effects at difl'erent times or in different cases. Thus, lead poisoning may
cause convulsions or palsy. The mere fact, then, that uramic manifesta-
tions are sometimes localised, and are not ahvays uniform, does not
militate in any way against the view that their source is a toxic one.
An active inflammatory ceclema is as familiar to pathologists as a
dropsical cerebral cedema is unfamiliar ; but there is no evidence of the
existence of such a condition in uraemia.
Cerebral anosmia will undoubtedly produce many of the effects so
often seen in urremia. For instance, convulsions, epileptiform fits, Cheyne-
Stokes breathing can all be brought about experimentally by ligature of
one or more of the cerebral arteries \ and it is possible that cerebral
antemia may be responsible for some of the phenomena seen in unemia.
The difficulties in the way of this view are that modern investigation
shows no evidence of any well-developed vaso-motor mechanism su])plying
the cerebral vessels ; and further, that the state of the cerebral vessels is
mainly dependent on the state of the vessels at large. Contraction of the
vessels of the body leads to distension of the cerebral vessels, and cerebral
anaemia is more readily brought about by causing dilatation of the vessels
of the Ijody than by causing active constriction of the vessels of the brain.
In fact, there is no method by which active constriction of the cerebral
vessels can be brought about experimentally. It is probable that even if
the blood were to contain a substance capable of constricting the cerebral
vessels, the vascular constriction and the heightened blood -pressure
produced by its simultaneous action on the other vessels of the body
would overpower the local cerebral effect.
One of the principal reasons for looking upon uraemia as dependent
on physical causes is the fact that uraemia is so often associated with a
granular or fibroid kidney. This condition is one in which, owing to the
existence of extensive lesions in the vascular system producing great
thickening and narrowing of the arteries, it is possible that anaemia of the
tissues might be produced.
Uraemia in these cases is common when the blood-pressure is high ;
and, notwithstanding the thickening in the arteries, the blood-pressure in
this disease frequently varies, and a temporary increase in blood-pressure
and uremic manifestations have long been known to be associated.
Further, venesection, or a spontaneous haemorrhage, such as epistaxis,
will frequently relieve at the same time both the increased tension and
the uraemia. These are the principal reasons that led Traube to form his
celebrated hypothesis of cerebral oedema and anaemia. For the reasons
330 SYSTEM OF MEDICINE
mentioned above this hypothesis cannot now be accepted, although there can
be no doubt, as just mentioned, that high tension is fi'e(]uently associated
with urremia. High tension, and even extensive arterial disease, are not
necessaril}' associated with extensive disease of the cerebral vessels ;
thickening of their walls cannot be inferred by the examination of the
pulse, nor by the absence of marked high tension. It is not uncommon
to see the cerebral vessels extensively thickened without obvious general
disease of the other vessels ; and on the other hand, extensive disease of
the vessels of the body may exist with comparatively little disease of the
cerebral vessels or even none.
For these reasons the majority of observers look upon uraemia as
dependent on the presence of toxic material in the blood, and the excita-
tion of the nervous structures by this poison. Unfortunately, however,
no such poison has hitherto been separated and identified, and the great
variety of ursemic manifestations has suggested the possibility that more
than one toxic body is present.
The toxic substance may appear in the blood under one or more
of the following conditions : (i.) that a body that ought to be and
normally is excreted, is retained ; (ii.) the abnormal decomposition in the
blood or tissues of such a body ; (iii.) the formation of abnormal products
of metabolism by the tissues.
The first is the simplest explanation of uraemia, and one very generally
accepted. In many cases of subacute and chronic unemia, and in the
\aolent uraemia seen in acute nephritis, the quantity of urine excreted is
often very small, and examination of the blood shows the presence of
greatly increased quantities of nitrogenous extractives. The amount of
urea in the blood may be twenty times greater than normal ; and although
this substance may not be directly answerable for the effects produced, its
presence in these large amounts serves as an index to the amounts of
other and perhaps unknown bodies, possessing toxic actions, which may
be present in largo quantities. Bouchard has insisted strongly on the fact
that the urine normally is toxic, that its toxicity depends on a variety of
substances, more especially salts, pigmentary matters, and certain unknown
constituents, and that the nitrogenous extractives present in the urine,
and more especially the urea, possess but little poisonous action. He
conducted a series of observations showing that a certain quantity of urine
injected into the circulation is fatal ; in some cases death wais preceded by
convulsions, in others by coma ; in nearlv all contraction of the puj^il and
failure of res})ii-ation were markcfl symptoms.
By comparing the amount of urine injected with the Aveight of the
animal, he established what he called urotoxic equivalents, and found, as
a mean of a large series of observations, that 25 to 75 c.c. of lu'ine per
kilogi'amme of body weight of the atn'mals used (rabl)it) Avere fatal.
Ligature of the ureters and (lonl)lc c<)m])lete neplu'ectomy is usually
fatal on the third day, and some of Bouchard's observations tend to show
that the amount of urine excreted in three days is toxic if injected at any
one time. Bouchard, however, stated that the urine in many cases of
GENERAL PATHOLOGY OF THE RENAL FUNCTLONS 331
urtemia loses its toxicity largely or in part ; and he deduced from this that
the toxic principles are retained, and produce the well-known symptoms.
The principal difficulties in the way of the acceptance of this view are,
in the first place, that when suppression of urine occurs in the human sub-
ject, as in cases of calculous anuria, the symptoms produced are as described
above, very peculiar, and not those that are usually considered character-
istic of urfemia. Secondly, in a very large number of cases of acute
lU'semia with granular cirrhotic kidney there is often no evidence of any
considerable suppression of urine. Such patients often pass very consider-
able cpiantities of iiriue, containing less urea, it is true, than normal, but
not necessarily less than many patients, suffering from other diseases and
taking but little food, would pass. In my experience it has not been un-
common to find patients dying of acute uraemia with graiuxlar kidneys, and
excreting as much as 10 to 1 2 grammes of urea in the last t^^'enty-four hours
of life. Moreover, as such patients are usually unconscious, it is impossible
to collect all the urine ; hence these quantities do not really represent the
total amount excreted. Many patients suffering from other diseases
with no complication of the kidneys, and even healthy patients, often
do not pass more than 10 to 15 grammes of urea per diem. Such
may be the case in patients who have undergone ovariotomy and have
been kept for twenty-four hours without food.
Patients dying from acute unemia often take little or no food for
many days, and still more frequently reject what they do take ; moreover,
the urine is often highly albuminous, and the proteid thus excreted
represents a nutritive loss ; hence it is unreasonable to expect such
patients to pass quantities of urea at all comparable to those seen in
health, and the mere fact that the excretion may be, comparatively
speaking, low, does not prove that the kidney is unable to excrete the
nitrogenous extractives.
The blood in cases of ordinary uraemia arising from renal disease
contains a large excess of nitrogenous extractives, frequently as much as
twenty times the normal. Again, the blood of patients who have granular
kidneys, and the blood and dropsical exudations of patients with chronic
Bright's disease, contain very considerable cpiantities of urea and other
nitrogenous extractives at a time when the patient is free from obvious
ursemic symptoms. The blood normally contains, approximately, 0"015
per cent of urea. In renal disease without uraemia this may rise to 0"15
per cent, and this at a time when the patient is excreting quantities of
urea within the limits of health. With the supervention of acute uraemia
the quantity may rise in the blood-vessels to 0'4 or even 0'5 per cent.
No experimenter has been able to reproduce all the symptoms of
uraemia, either by the injection of urea or of other nitrogenous extractives ;
and although the blood, in cases of ordinary vn^aemia, contains this large
excess of nitrogenous extractives, such is not the case in eclamjDsia.
Even in fatal cases of eclampsia the blood does not contain quantities at all
comparable to those seen either in uraemia or in cases of calculous sup-
pression, the highest percentage observed by myself being 0"06 per cent.
332 SYSTEM OF MEDICINE
Retention undoubtedly affords the sim])lest explanation of the presence
of these large amounts of extractives in the blood; but I think there can
be no doubt that these extractives are present in increased amount at a
time when there is no evidence of a greatly diminished nitrogenous out-
put ; and further, as mentioned above, the urine contains quite appi-eciable
quantities of extractives, even in the last twenty-four hours of life, since
on the whole it is exceptional to see complete suppression of urine in
cases of acute uraemia in the granular kidney.
Seeing all these difficulties in the way of explaining uraemia as
dependent simply on the retention of some normal constituents of the
urine, many observers have fallen back on the view that, owing to the
diminished excretory activity of the kidney, the retained urinary con-
stituents undergo decomposition, either in the blood at large or in the
alimentary canal. It has been suggested that the urea decomposes into
carbonate of ammonia, and that the toxic phenomena of ura?mia are due
to the presence of this body. Carbonate of ammonia, when injected into
the circulation, will undoul)tedly produce many symptoms characteristic
of uraemia, such as convulsions and dyspncea. Many observers, however,
have failed to detect ammonia in the blood in fatal cases, and for this
reason the suggestion has not received any large measure of support.
Inasmuch as there are these serious difficulties in the way of the retention
and decomposition hj'potheses of uremia, Perls and Schottin suggested
long ago that the toxic substances in uraemia might be derived from
the products of abnormal metabolism. There are some facts in favour
of this view. In the first place, the typical phenomena of uriemia are
not those seen as the result of sim])le suppression. Again, in cases of
uriemia, the quantities of nitrogenous extractives in the blood, and
more especially in the tissues, such as the muscles, are far greater in
percentage amount than in cases of complete calculous anuria. This
suggests that the quantities of these bodies are too great to be accounted
for by retention.
My expeiiments, mentioned above, have shown that when the avail-
able kidney substance is greatly reduced in amov;nt, the excretory functions
of the kidney are not only not seiiously interfered with, l)ut that the
excretion is actually increased ; and that, notwithstanding this, the blood
and tissues of the animals contain very large quantities of urea and other
nitrogenous extractives. In the experimental cases these nitrogenous
extractives must have arisen from increased tissue disintegration, for no
retention occiu-rcd, but a positive increased excretion of urinary water
and urea ; and these experiments suggest very strongly that when the
available kidney substance is diminished beyond a certain amount — roughly
speaking, one quarter of the total kidney Aveight — the proteid tissues
undergo rapid disintegration with the formation of abnormal quantities
of extractives. These expei'iments, then, lend some support to this view
of uraemia, although the classical symptoms of uraemia appeared in none
of the animals.
4. Cardio- vascular changes. — "Widespread changes in the cardio-
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 333
vascular system are common in renal disease, and more especially in
certain forms of it, such as renal cirrhosis and chronic Bright's disease.
The pathological changes produced in renal disease involve the heart and
the large and small arteries ; the former becomes hypertrophied ; the
changes in the arteries, however, are not so simple. In many cases the
large arteries lose their elasticity, but this is by no means a constant
change, and in very far advanced renal disease the lai'ge arteries may still
be very elastic. The inner coat of the larger arteries frequently presents
atheromatous changes, but these again are not an invariable accompani-
ment of renal disease. The medium-sized and small arteries have their
coats very much thickened, and this thickening aflects mainly the
internal coats. In the small arteries the changes are on the whole most
evident in the internal coat. The middle coat of the thickened arteries
shows an increase in the amount of muscular tissue, and this in some
cases is exceedingly well marked. In others, apparently, the increase in
this coat is largely dependent on fibroid change ; but it is unquestionable
that, in many cases of renal disease, there is a true hypertrophy of the
muscular coat. The thickening of the internal coat is largely dependent
on the formation of loose fibrous tissue in the deeper layers, so that the
subendothelial tissue is greatly increased in thickness ; this increase is
not always uniformly distributed, and not uncommonly the endothelium
is thickened also, but this is not so frequent as the thickening in the
subendothelial layers. The thickening of the inner coat decreases the
lumen of the vessel very considerably, and the thickening of the middle
coat — especially when fibroid — is sufficient to be readily recognisable by
the finger in such an artery as the radial.
The arterial changes are frequently widespread, but they are not
uniformly distributed, and they are most marked in the vessels of the
kidney itself : in some cases, perhaps, they are restricted to these vessels.
In addition to the above changes in the arteries miliary aneurysms
are commonly present, especially in the cerebral vessels. These miliary
aneurysms, it is well known, affect more particularly the small arteries,
and they are frequently present in enormous numbei's. \_Vide art.
" Disease of Arteries " in a later volume.] The cirrhotic kidney and certain
forms of chronic Bright's disease are the renal lesions most frequently
associated with the presence of miliary aneurysms, and hence these are
the renal diseases in which cerebral haemorrhage is most prone to occur.
The aneurysms of large vessels, due to atheromatous changes in their
walls, are by no means necessarily associated with renal disease ; although
the high arterial tension existing in renal disease is usually held to be
one of the remoter causes of aneurysm.
Hyaline changes in the capillaries, especially in those of the glomeruli,
are commonl}^ associated with the cardio-vascular changes described above.
The cardiac hypertrophy of renal disease is usually moderate in amount,
and unless there be coexisting valvular defects it does not attain the
degree which is seen in the latter condition. The hypertrophy of renal
disease affects the left side of the heart mainly yet not exclusively ; but
334 SYSTEM OF MEDICINE
unquestionably tlic liypertrojjhy of Aahular disease nffccts the right side
of the heart more than the hypertrophy of renal disease does. Still in
the latter case, if the enlaigenicnt of the heart be considerable, the right
side shares in it to a slight extent.
These -widespread lesions of the vascular system are most extensive
in certain cases of renal cirrhosis ; more especially in that condition known
as red granular kidney, or raspberry kidney, which occurs in middle-aged
persons ; and the greater and more widespi'ead the arterial disease the
greater the cardiac hypertrophy. The vascular lesions are also fairly well
marked in cases of chronic Bright's disease, where the size of the kidney
may be variable, sometimes a little larger than the normal, sometimes a
little smaller, but where there is considerable fibroid change in the kidney.
These cases often occur in the comparatively young, and the arterial
thickening and cardiac hypertrojihy may occasionally in these cases reach
the degree seen in the granular kidney. Snch patients may succumb to
cerebral hoemorrhage. On the other hand, cases of chronic Bright's
disease with the kidneys shrunken and fibroid, the capsule thickened and
leaving a granular surface on stripping, may exist with comparatively
little hypertrophy or arterial change except in the renal vessels. It is
not very uncommon to see cases of death from uraemia with the kidneys
weighing about three ounces apiece, and very granular on the surface ;
but the stripping of the capsule does not tear the cortical sul)stance, and
in such cases the heart may not be appreciably enlarged, and the arteries
generally are not thickened to any great extent.
The amyloid kidney is not associated with any profound arterial
changes except those necessarily associated with the presence of waxy
disease in the body ; and the heart in these cases is not hypertrophied.
Extensive destruction of the kidney substance by hydronephrosis,
even if double, is not necessarily associated with profound cardio-vascular
changes. On the other hand, in some cases, and more especially perhaps
in the double hydronephrosis seen in young persons and probably de-
pendent on congenital abnormalities, the cardiac hypertroph}?^ is a well-
marked phenomenon. Cases of partial hydronephrosis associ;iited with
fibroid change in the rest of the kidney are not uncommonly seen ; the
upper or anterior half of the kidney is little more than a sac, and the
available kidney substance is spread out in the posterior or lower portion.
In such cases cardiac hypertrophy is often a marked feature.
Acute and snbacute Bright's disease lead very rapidly to the pro-
duction of high arterial blood -pressure, and cardiac hypertrophy and
arterial changes, if the malady last so long as six weeks, may be observed ;
that is to say, in this time obvious physical signs pointing to the existence
of hypertrophy can be detected. Many cases of chronic Blight's disea.sc
associated with dropsy exist for long periods without leading to the
marked cardio-vascular changes associated with high pressure.
From the above facts the following dednctions may, perhaps, be pos-
sible. High arterial blood-pressnre is a frequent accompaniment of renal
disease, and more especially of the condition known as the granular
GENERAL PATHOLOGY OF THE RENAL FUNCTIONS 335
kidney occuriing in middle-aged persons. It is also avcII mai'ked in the
contracted kidney occurring in the young, as a sequel to acute or chronic
nephritis ; but it is not an invariable accompaniment of these conditions.
Finally, extensive destruction of both kidneys may take place "without
necessarily producing the graver Avidespread vascular lesions associated
with high blood-pressure.
The explanation of the cardio-vascular changes accompanying renal
disease, and especially evident in certain forms of it, is by no means
simple. It is usually supposed that a condition of what has been called
"functional high tension" precedes the anatomical changes described
above ; that is to say, the blood-piessure is increased as a result of an
increased activity of the vasomotor system with consequent conti'action
of the arteries ; the excitation of the vaso-motor mechanism being pro-
duced by the circulation in the blood of some material capable of exciting
it. In favour of this opinion is the undoubted fact that' the pulse in
renal disease frequently shows the characteristic features of high pressure,
when there may be no clinical evidence of anatomical changes in the
vessel. This is more especially true of acute renal disease. Further, the
degree of pressure is variable, and a smart hamiorrhage, say, from the
nose, will often relieve it greatly. There is, however, no evidence to
identify' the substance or substances that cause this functional increased
activity of the vaso-motor system, and some authors have supposed that
the cardiac hypertrophy is not the result of the vascular obstruction,
but actually the cause of it ; and they consider that the circulation in the
blood of increased amounts of nitrogenous metabolites, such as urea and
its allies, causes an increase in the force of the heart-beat, and that in this
manner the vessels are exposed to an increased strain, the results of which
are the thickening and other changes observed in the arteries.
At any rate, the injection of urea temporarily increases the blood-
pressure, yet this substance has certainly no influence in causing aiterial
constriction ; if therefore the high tension of renal disease depends on the
presence of increased amounts of nitrogenous extractives in the blood, the
effects may be produced T)y a primary action on the heart.
Again, it has been suggested that the high tension of renal disease is
brought al)out by an attempt to maintain an efficient rate of blood-flow
through the remaining kidney substance ; now inasmuch as this area is
greatly diminished in extent, the flow can only be maintained at a normal
rate by an increase in the general blood -pressure produced by con-
striction of other vascular areas causing an increased rate of flow through
the remains of the kidney.
Speaking broadly, the high pressure in renal disease certainly varies
inversely as the extent of kidney substance present ; and it reaches its
maximum in renal cirrhosis. Experimentally, I was unable to reproduce
the characteristic lesioias seen in the arterial degeneration of renal disease
as the result of the removal of lai'ge quantities of kidney, but the blood-
pressure was apparently raised.
In many cases of renal cirrhosis it is probable that the widespread
i36 SYSTEM OF MEDIC LYE
arterial changes are primary, and that the lesions in the kidney, especially
those in the epithelium, are secondary to the vascular lesion ; in other
words, the interference with the circulation through the kidney leads to
the decay of the higher renal elements, and thus the overgrowth of fibrous
tissue subsequently found in the kidney is secondary to this, and not a
primary lesion. [Vide art. "Arteriosclerosis" in a following volume.]
Considerable lesions of the smaller vessels of the kidney, Avith great
thickening of their walls and a narrowing of their lumen, may, however,
exist without the presence of any cirrhosis.
Albuminuric retinitis and thickening and rigidity of the retinal
vessels are common accompaniments of grave renal disease; more especially
in the later stages of chronic Bright's disease and in the granular kidney.
5. Marasmus and Anaemia. — Renal disease frequently produces well-
marked anaemia, and also great Avasting. The extent of the latter may be
very largely concealed by the presence of dropsy. In some renal diseases
emaciation is one of the early symptoms. Tlie wasting of renal diseases is
dependent on many causes. In the first place, such i)atients have an
impaired nutrition, dependent on serious disorders of the gastro-inttstinal
tract : the appetite is poor ; nausea, vomiting, and diarrhoea arc common.
The Cjuantities of albumin lost in the urine are often considerable, especially
in chronic Bright's disease ; and in this way the nutrition of the patient
is still further affected, since such patients frequently pass in the urine
one-quarter or one-third of the total proteid ingested. "Wasting, however,
may be a marked feature of renal cirrhosis, in Avhich the disturbance of
the gastro-intestinal functions may be slight, and in Avhich the albumin-
uria is always slight ; the emaciation in these cases reseml)le3 the rapid
Avasting that is seen experimentally Avhen large quantities cf the kidney
substance are removed, a condition Avhich I have shoAvn — at any rate
experimentally — to be dependent on an increased disintegration of the
proteid tissues, more especially of the muscles.
Anaemia in renal disease is present in almost all cases to a greater
or less extent ; but it is specially marked in chronic Bright's disease
associated Avith dropsy. Such patients are exceedingly p;de. ]\Iany
patients Avith granular kidney, especially in the form of it seen in young
persons, are also frequently very pale ; and the aniemia of renal disease,
like the AA^asting, is often of complex origin. Many patients suffer from
profuse haemorrhages, specially from the nose or from the urinary tract ;
and in the latter case, if very profuse, it not improbably arises from the
pelvis of the kidney. The dyspep.sia and gastritis necessarily present in
this disease Avill also tend to cause anaemia, and it is probable that the
Avidespread disorders of nutrition also tend in this direction.
The anaemia of renal disease may be so seA'cre as to approximate in
character to the anaemia of pernicious anremia ; and many of the vascular
murmurs characteristic of anaemia are A'ery evident in cases of renal
disease.
6. Secondary inflammations. — Inflammatory complications are com-
mon in certain forms of renal disease, and more especially in chronic
GENERAL PATHOLOGY OF THE RENAL FUN OTTO NS 337
Bright's disease associated with dropsy. Such patients often suffer from
septic inflammations of the skin and subcutaneous tissues after incisions
have been made for tlie relief of dropsy ; and it is well known that
formidaljle septic complications are much more apt to ensue after
incisions in the treatment of renal than in that of cardiac drops}'.
Deep-seated inflammations of organs and of serous membranes are also
very frequent ; and low forms of pneumonia are common in uraemia com-
plicating any form of renal disease. Pericarditis is also a very common
complication of renal disease, and it is remarkable that it frequently
assumes a latent form ; other inflammatory comj^lications, such as pleurisy
and peritonitis, are also not uncommon.
It was at one time supposed that these inflammatory complications
are directly dependent on the presence in the blood of the toxic sub-
stances causing uremia. Modern knowledge has shown, however, that
these inflammations have a microbic origin, and that in renal disease
the resistance of the tissues to microbic infection is seriously diminished.
As mentioned above, in the section on " Urine," micro-organisms are
not uncommonly present in the urine of Bright's disease ; it is prob-
able, therefore, that these organisms are circulating in the blood : if this
be the case, it is comparatively easy to understand the frequency
of grave inflammatory complications in this disease. Xot only are
inflammatory' complications common in renal disease, but they rarely run
a normal course : thus inflammations of the serous cavities have a great
tendency to become purulent, and this is especially the case in peri-
carditis.
John PiOse Bradford.
REFERENCES
1. Abram, J. H. " Acetonuria," Journal of Pathology, vol. iii. — 2. BorcHARD,
Ch. Lcs auto-i'iitoxicatioiis, IS87 . — 3. Bradford, J. R. " Influence of the Kidney on
I.Ietabolism," Proc. Roy. Soc. 1892. — 4. Charcot. Traite de m&lecine, vol. v. — 5.
DuxLOP. "Oxalic acid in Urine and Oxaluria," Journal of Pathology, vol. iii. — 6.
Ebstein. Die Natur und Bchandhmg d.er Gicht. 1882. — 7. Garrod, A. "The
Yellow Colouring Matter of the Urine," Proc. Roy. Soc. vol. Iv. — 8. Garrod and
Hopkins. "The Occurrence of Hsematoporphyrin in the Urine of Patients taking
Sulphonal," Journal of Pathology, vol. iii. — 9. Hopkins. "On the Estimation of
Uric Acid in the Urine," Journal of Pathology, vol. i. ; see also Fokker, Pflilgers
Archiv, Bd. X. ; and Salkowski, Virchow's Archiv, Bd. Ixviii. — 10. Leathes and
Starling. "Production of Pleural Effusion," Journal of Pathology, voh iv. — 11.
LfFF. Goulstonian Lectures, R.C.P. Loudon, 1897. — 12. MacMunn. Clinical
Gliemistry of the Urine, 1889. — 13. McWilliam. " New Test for Albumin and other
Proteids," Brit. Med. Journ. 1891. — 14. Roberts. Uric Acid, Gravel, and Gout,
1892. — 15. Salkowski and Leube. Die Lehre vom Ham. — 16. Von Jak.sch.
Clinical Diagnosis.
J. R. B.
VOL. IV
338 SYSTEM OF MEDICINE
NEPHROPTOSIS
Movable or Floating Kidney
Definition. — The kidney is said to be pathologically movable when by
pressure, l)y alteration in i)osture, or liy changes in the distension of the
surrounding parts, it may be displaced from the position which it usually
occupies.
Normal position. — There is a considerable variety in the exact site
of the kidneys in their normal condition as observed in different in-
dividuals ; but, in general, their position may be marked on the anterior
wall of the abdomen in the following way : — The inferior polo of the
right kidney is opposite a spot 3 cm. al)f)ve a point 7 cm. from the linea
alba on the horizontal line drawn through the umbilicus. The level of
the superior pole is marked by a point 5 cm. from the linea alba on a
horizontal line drawn on the altdominal Avail lU em. above the horizontal
umbilical line. The axis of the kidney corresponds to the line Avhich
joins these poles, and its hilum is on a plane internal to and below the
edge of the eighth costal cartilage opposite the middle two-fourths of the
axial line. The organ thus lies at the meeting-place of the hyj)ochondriac,
right lumbar, and epigastric regions as these are ordinarily defined. On
the posterior Avail of the abdomen the upper pole of the I'iglit kidney is
5 cm. external to the tip of the eleventh thoracic spine, and its loAver
pole is at a point 3 cm. above the iliac crest and 7 cm. (^xternal to the
medio-dorsal line. The left kidney lies, usually, 1 cm. higher ; and on
each side the back of the kidney crosses the tAvelfth rilj.
The kidneys are kept in their places to some small extent l)y the
pressure of the surrounding viscera under the constraint of the muscles
of the abdomen. The nature and amount of this constraining inHuence
of the abdominal Avail have been discussed by various authors. Schatz
made the first formal attempt to demonstrate its existence, and its
amount Avas calcubited by Haughton ; but, on account of the insufTi-
ciency of the exjjcrimental data employed, the results ai'rived at are not
of practical value. Weisker (132), in an al)le paper, has demonstrated by
his experiments, made in Ludwig's laboratory, that the intra-abdominal
pre.s.sure in the sense of a retentive force is insignificant. The only
demonstrable intra-abdominal pressure Avhen the al)doininal nuiscles are
not actually contracting is the hydrostatic pressure of the viscera one
upon the other. The viscera during life are soft and ])lastic ; and,
as they are closely packed together, l)y their mere Aveiglit they exercise
a certain amonnt of pressure the one against the other ; so that Avhen
harrlened in situ they are mutually faceted and moulded upon each other.
Till! liglit kidney presses against the l)ack part of the abdominal Avail
posteriorly, and in front against the right lobe of the liver above, the
NEPHROPTOSIS 339
colon below, and the duodenum and coils of the ileum along the mesial
border. The left kidney is similarly compressed by the spleen and
stomach above, by the pancreas medially, and by the jejunum and (to a
small extent externally) the descending colon below.
The adipose capsule, which is the fatty and areolar envelope of the
gland, acts as a semifluid pad around the organ. By dissection it can be
made to appear as having a basis of rather firm connective tissue con-
tinuous inwards behind the kidney with the tunica adventitia of the
aorta, and above with the subperitoneal tissue on the diaphragm. A
layer of areolar tissue, without fat, continuous Avith this below, can be
traced upwards over the ventral face of the kidney, beginning at the
lower border of the gland and joining the deeper layer above. To this
layer Englisch has applied the term " ligamentum suspensorium renis";
but the same structure was indicated, though much more indefinitely, Ijy
Bartholinus as the "fascia renum " tvv^o and a half centuries ago. The
tissue of this capsule, Avhicli in the child is simply areolar, becomes
filled with fat about the tenth year, more especially behind, below, and
external to the gland ; but this fat is much softer during life than it
appears to be in the post-mortem room, and, as a retentive apparatus,
the entire adipose capsule is of itself of but moderate importance.
Tuffier (127) has carefully described this capsule.
The peritoneal reflexions, on the fi'ont of the kidney, act as the most
important factors in the fixation of these organs. On the front of the
right kidney the serous membrane is reflected from each side of the
ascending colon ; on the front of the left kidney, as Landau has pointed
out, the serous reflexions from the upper and lower borders of the
pancreas have a more definitely retaining influence.. These attachments
•taken together, peritoneal and subperitoneal, are in general sufficiently
strong to retain the kidneys in place in an opened abdomen when the
cadaver is raised to the erect posture ; and in only four out of twenty
experiments did they permit of displacement from gravity. Upon the
relations of these peritoneal folds and their retentive function the very
important paper by Weisker (133) must be consulted.
Many forms of misplacement of the kidney, not attended with any
considerable degree of mobility, have been described from time to time.
The most important of these have l)een catalogued by Macdonald Brown
and other authors. These malpositions are, for the most part, of
anatomical rather than of pathological interest ; they are seldom attended
by any marked disturbances of function. In one instance, however,
described by Hohl, a pelvic kidney was an obstacle to delivery. A
similar case is recorded by Albers-Schonberg.
The kidney has normally a certain degree of mobility. Oncometric
experiments show that the healthy organ varies in size with the varying
conditions of blood- pressure, and of vasciilar dilatation and contrac-
tion (35). The surrounding organs are lialile to corresponding variations ;
and, in consequence, the exact contour of the kidney, faceted by the
pressure of neighbouring parts, is by no means constant. The condition
340 SYSTEM OF MEDICINE
ascertainetl in the bodies prepared by Professor Cuniiinghaui's ingenious
method — in which the antero - external surface is trans\ersely ridged
between the hepatic and colic areas — represents a common but by no
means an invariable result of this mutual visceral moulding.
Abnormal positions. — Almost all possible gi-adations in mobility have
been observed, from the normal fluctuations in size due to the condition
of the blood-vessels, and the normal alterations in position in the diH'erent
phases of the respiratory cycle ^ and in different postures of body, to the
extreme condition of " floating," in which the organ can be grasped by the
fingers through the abdominal wall, and moved u])wards and downwards
by external pressm-e. Dr. Fraidvs (37) recommends the following sim})le
method of testing abnormal mobility. The patient being placed on the
back, or else in the latero-prone position, the surgeon grasps the flank with
his left hand, pressing his thumb in front below the costal aich and
the fingers behind below the twelfth rib. If the kidney be abnormally
movable it can be felt at the beginning of expiration below the grasp of
the hand. If the right hand now press on the tiunour when the left
has relaxed its grasp the gland can be felt to slip upwards into its
normal position. This method, however, is not always successful on
account of the conditions of the surrounding viscera. Kuttner regards
the deviations of every kidney which can be felt to mo\e with respiration
as pathological ; but this view has been contested on sufhcient grounds
by Paul ^^'agner.
There are two structural conditions in which the kidney exhibits an
abnormal degree of mobility. The rarer of these is that in which the
kidney is partialh^ or wholly enveloped in a mesonephric fold of peri-
toneum : to this form the name "Floating Kidney" is limited by Jenner
and Newman. This anomaly is generally considered, but with insufficient
reason, to be congenital : the possibility of the secondary production of
a peritoneal fold is too well known to anatomists to exclude the possi-
bility of the mesonephric fold being an acquired condition. Examples
have been described by Girard, Roberts, Crum, Howitz, Priestley,
Hender.son, and Steven. In Steven's case there was undoubted evidence
of displacement from tight-lacing. In an instance noticed in the dissecting-
room, the peritoneum clothed the back of the right kidney and the u{)per
end of the gland, reaching to the lower border of the hilum ; but the
lower Ijorder was not completely enveloped. The ascending colon was
displaced nearly to the middle line, and the renal vessels were elongated
and toi-tuous. Additional cases of the kind have been described by
Franks (38) and others.
Cases of this kind cannot be clinically distinguished from those of the
second form, and the methods of treatment are practically the same
(Bruce Clark). If, however, the existence of a mesonephric fold be
suspected, the method of ojieration should be by anterior abdominal
section and intra-peritoneal fixation.
' Lanilau (p. 244) denies the movement of the kidney with respiration, hut Israel has
both seen and felt these movements in lumbar sections (61).
NEPHROPTOSrS 341
In the majority of cases there is no mesonephric fold of peritoneum,
and the gland moves within a lax areolar capsule. HillDcrt distinguishes
two grades of these cases : in the first only the inferior pole and not more
than the lower half of the kidney can be felt ; this he calls the " palpable
kidney " : in the second the whole kidney can be felt, and can be isolated
with the fingers ; this he calls the " movable kidney." Usually, however,
the name movable kidney is indiscriminately used for examples of both
grades (Jenner),and the condition of mobility has been named Nephroptosis.
This condition is met with at least seven times more commonly in
females than in males. Kuttner asserts that one woman out of every
five or six in the polyclinic of the Augusta Hospital, Berlin, had a patho-
logically movable kidney, Ijut this must be taken in connection with his
definition of mobility ; indeed, this want of agreement as to the limit of
normal and almormal mobility vitiates all the statistics. Niehans finds
it in about the same proportion in Berne. Mathieu found 85 cases out
of 306 women examined in Paris (81). Dietl regards this condition as
more common among the Poles than among other peoples ; but the
statistics given Ijy Skorczewsky do not bear this out, as he only found
movable kidneys in 3-1 j^er cent of 1030 females, and in 0-76 jDer cent
of 392 males. Oser found that 10 per cent of the women whom he
examined in Vienna suffered from this displacement.
Statistics of 300 cases show that the right kidney only was movable
in 82 per cent; the left in 10 per cent; and both in 8 per cent. Of
these 300 cases 87 per cent were females, and 13 per cent were males.
Senator says that movable kidney is as common among the rich as among
the poor, and he estimates that one case exists in every 139 of sick
women. The majority of the Avomen in whom this condition has been
found Avere multipar?e ; but in most of the cases which ha\^e been care-
fully noted the displacement appears to have begun at or shortly after
the first pregnancy. It is most commonly met Anth betAveen the ages
of thirty and forty ; but cases in children have been descril^ed by Hirsch-
sprung, Keppler, Steiner, Wilks, HaAvard, Albarran, Drummond, Gilford,
and others.
The character of the mobility is not always the same ; the gland may
slip up and doAvn Avithin the loose capsule, the motion being compared by
Morris to " cinder-shifting " (86) ; or the kidney and its capsule may move
on the hinder Avail of the abdomen. In this case the gland may slip
beneath the peritoneum, or the serous membrane may be attached to its
surface anteriorly ; but the marginal connections may be lax enough to
alloAv of the gland moving forAA^ards and iuAA^ards, dragging the membrane
AAath it. Cases of this kind, such as those described by Jago and Gilford,
simulate the true floating kidney. Indeed, it is so difficult to draAv the
line between them, that it is probable that some of the examples which
have been referred to that group may really be of this nature.
These conditions are rarely noticed in the dissecting-room, OAving to
the position in Avhich the body is dissected, and to the increased solidity
of the adipose capsule after death. In the records of 6000 autoi^sies at
342 SYSTEM OF MEDICINE
tho Berlin Churito, Landau found four cases only in which a movable
kidney had heen noted; out of IGOO at Guy's, Durham noted two only ;
out of 5500 at Oppolzer's Clinic, liollet found twenty-two; and Sir
Andrew Clark stated that he had met Avith only two examples in the
course of 4000 post-mortem examinations.
The usual direction of the disj)laceMient is doAvnwards, forwards and
inwards ; and, in slipping, the organ usually rotates so that the upper end
and outer border move forwards, and the hilum is directed inwards and a
little backwards; the extent of the motion being apparently limited by
the length of the vessels. Adhesions or alterations in the surnjunding
viscera may lead to modifications in the direction of the displacement.
The records of operation testify to the variety of positions which the
gland may assume, such as those desci'ibed by IJrag and others. JNIosler
found the gland with the hilum directed u])wards, and its convex border
lying horizontally. All forms are usually associated Avith a medial dis-
placement of the ascending colon, and the gland is usually below the
level of the duodenum (Abcrle). In many cases there is a remarkable
absence of 2)erinej)hric fat, l)ut even this is by no means invariable
(Durham).
Causes. — This displacement is not uncommonly associated Avith
others, such as hernia or retroflexion of the uterus ; sometimes it is part
of the general relaxation of A'isceral coiniections named Enteropfous,
which has been described by Glenard, Ewald, and more recently by
Grasset and Eauzicr \tide art. "Enteroptosis," vol. iii. p. 587]. Landau
noticed that in most of his cases the abdominal Avails Avere flaccid ;
but the kidneys ai'c not movable in all cases of pendulous abdomen.
Any conditions Avhich relax the abdominal Avails certainly seem to dispose
to this affection ; and in this manner Ave can explain the mobility of the
two kidneys noted by Siredey after hysterectomy. The range of motion
varies from 3 or 4 cm. to 25 cm. In a case clescribcd by Dr. Bindley
the kidney is described as moving under the peritoneum OA'cr a space
Avhich is called a circle Avith a diameter of 8 or 9 inches.
The predisposing causes are relaxation of the abdominal A\'all,
diminution of the perinephric fat, and congenital elongation of the
vessels. Indeed, it is proba])lc that in most of the cases there has been
some such congenital jjredisposition to the displacement ; possibly, as
Weisker has supposed, Avhere a Avide interval exists betAveen the layers of
the mesocolon, nephroptosis may be specially liable to occur. In the
ancient description of dislocation of the kidney giA'on in Pedemontainis'
edition of Mesiie's Avoi-ks, too frequent Avarm bathing is assigned as a
predisposing cause (1581, p. 74 f.). The immediate cause of the disloca-
tion may be a blow, a fall, a tAvist of the spine, or the carrying of a
Aveight on the back Avhen the body is l)owed for\vards, violent coughing,
or straining in vomiting or ])arturition. Treves has seen a normal kidney
worked out of its place by a vigorous masseuse who mistook it for a
fae'-al mass. There is no doubt of its frequent association Avith jiregnancy,
a change Avhich disturbs the peritoneal relations of so many of the viscera;
NEPHROPTOSIS 343
and most cases are recognised for the first time when the abdominal
parietes are relaxed after parturition. Gueneau de Mussy attempts to
account for its being more commonly met Avith on the right than on the
left by the supposition that the uterus rises more on that side. Landau
belicA-es the dragging influence of a colon distended with faeces to have
some effect in the production of displacement ; but this factor is under-
valued by Champneys, the translator of his monograph (p. 279).
Cruveilhicr long ago pointed out the influence of tight lacing as a cause
of disj)lacemcnt ; and this cause has been reaffirmed by Bartels and
Miiller-Warneck ; the latter blames also the laced bodices iised in some
countries. The objections of Landau (p. 275), who discredits the dis-
placing influence of the stays, have been fully ansAvered by Manassein,
by Kuster of Marburg, and by liertz ; the last-named author shows that,
in most cases, the tight-lace line on the liver is on the same level as the
upper pole of the kidney. Thus pressure on the liver may be transferred
to the right kidney and may dislocate it. The drag of heavy garments
fastened round the waist also exercises a displacing influence ; and
Sophia Chamney has pointed out that this drag is even more injurious
in the woman than it would be in the man ; on account of the smaller
lumbar curve and the greater shallowness of the bed of the kidney in that
sex. The wearing of high-heeled shoes is also blamed by ^'on Koranyi
as predisposing to it by altering the lumbar curve.
Li many cases, falls, fits of coughing, the jolting of carriage exercise,
violent retching, and so forth, have led to the first recognition of the
condition, if they have not been its producers (Henoch, Ferber, Le Ray,
Defontaine).
Symptoms. — Out of 270 cases in Avhich nephroptosis was determined by
palpation, there were no symptoms of distress in 130 ; of the remainder,
72 suffered from various neuroses arising from the uneasiness felt m the
kidney, from slight pressure effects, and from apprehension that this mal-
position might at any time give rise to more serious trouble ; while in
68 the condition was accompanied by symjjtoms of a more serious nature
(Curschmann). The sensation is one of weight and di^agging with occasional
colicky pains, and a sickening feeling when the kidney is pressed ujDon. This
pain increases markedly during the incidence of the catamenia. Some-
times these sensations are intermittent, and have been compared by some
patients to the sensation of quickening ; indeed the symptoms have
actually been mistaken for pregnancy (83). (See also Daranyi.) Li
some cases the symptoms disappear during pregnancy, the enlarged
uterus and the increase in the amount of retroperitoneal fat during
that condition supporting the organ.
The catamenial aggravation of the characteristic sensations has been
pointed out by Becquet, Lancereaux, Sawyer, and Fourrier; and has been
regarded as indicating an etiological connection between the conditions :
but although there is, as Virchow showed, a vaso -motor connection
between the uterus and the kidney, yet it is difficult to see hoAv any tem-
porary increase of blood-pressure can cause permanent mobility. Guyon
344 SYSTE.U OF MEDICINE
describes a case Avhich first became noticeable in the menopause. In this
connection a case pul)lished by Dr. Ferguson of Perth is particularly
interesting.
The more troublesome effects of nephroptosis are twofold, disturbances
of the digestive canal, and obstruction of the ureter or the renal vessel.
Besides these there are certain pressure effects, such as " kidney-pain," in
the knee, heel, or along the outer side of the thigh, and also along the
genito-crural nerve in males, together -with neuralgic pains in circum-
scribed areas of the body- wall ; sometimes on the opjjosite side to that of
the displaced kidney. In rare cases cedema of the right leg has been
seen from pressure on the common iliac vein (Landau) ; while there is at
least one case on record of throml)osis of the inferior vena cava (Girard) (43).
The disturbances affecting different parts of the digestive canal are
sometimes veiy severe. ]\Iathieu states that the percentage of cases of
movable kidney in dyspeptics is very large ; and it is Avell in cases
of unaccountable disorders of digestion to search for the existence of
nephroptosis. The symptoms are gastric pain, loss of appetite, frequent
vomiting, and the other signs of gastric catarrh ; the l)Owels are often
obstinately constipated, the body becomes emaciated, and sometimes
jaundice supervenes, lasting a few days, disappearing and recurring. In
some cases the resulting exhaiistion has almost proved fatal (Fa\dder
White). In other instances intestinal obstruction has been attributed to
renal pressure (Rollet, Dora). In others, again, obstinate faecal accumula-
tions were associated Avith nephroptosis (Kidd). The gastric SA'mptoms,
first described by Dietl in 18G4, are liable to sudden and violent exacer-
bations, or " gastric crises," attended Avith abdominal tenderness, and
sometimes with a slightly raised temperature. These symptoms last a day
or two, disappearing if the patient continue recumbent ; but are apt to
return when the body reassumes the normal upright position. During
the crises there is usually a transitory jaundice such as that descriljcd
in Hale White's cases. In rare cases exacerbations of this nature have
ended in peritonitis Avhich has proved fatal (Berry). The appearance
of the patient in several cases has been suggestive of malignant disease
of the stomach, as described by Lochhead.
The auKjunt of displacement is not necessarily commensurate with the
severity of the symptoms. Edebohls has noticed that sometimes the
cases Avith the most distressing symptoms are those in which the kidney
has comparatively small range of movement.
Another series of disturljances may be met with in cases of nephro-
ptosis. After some rapid or violent movement there is a sudden accession
of inten.se and sickening pain; the abdomen becomes distended; the region
of the kidney becomes excessively tender; giddiness, faintness, and some-
times delirium supervene ; the pulse is small ; the skin i.3 covered with a
cold sweat; the urine becomes scanty, dark in colour, and sometimes con-
tains albumin and tube-casts. The symptoms increase for three or four
days and then subside, recovery being generally accompanied by a copious
flow of clear urine. These violent attacks have been attributed bv Dietl
NEPHROPTOSIS 345
and Ebstein to the wedging of the kidney into the subperitoneal tissue ,
and by Gilewski to acute hydronephrosis from the impaction of the
kidney between the last rib and the vertebral column : and to them has
been applied the name renal incarceration, from a supposed analogy with
the strangulation of a hernia. Landau, however, from his own experi-
ments, as well as from those of Robinson and of Perls and Weissgerber,
has made the suggestion that they are due to torsion of the renal vein,
as the pathological conditions are very like those which result from the
experimental deligation of that vessel. Newman also in the course of
several operations has verified the existence of this vascular torsion due
to rotation of the kidney, giving rise to paroxysmal hsematuria (95, 96).
In these cases temporaiy albuminuria and tube-casts were due to mechanical
hypersemia ; and Newman found in one case that the rotation of the kidney
around its shorter axis had twisted the ureter and blood-vessels round each
other.
Another series of distressing symptoms may arise from obstruction
of the ureter occurring in a like manner from the rotation Avhich
accompanies the descent of the kidney. The same kind of kinking which
has been described as affecting the veins must take place in the ureter ;
and this, by its frequent repetition, leads in process of time to dilatation
of the pelvis of the kidney, and so to hydronephrosis. The process of
dilatation has been carefully worked out by Landau, who has explained
the mechanism of its occurrence. Cases illustrative of this effect have
been described by Hare, Pernice, Ahlfeld, Cole, Clement Lucas, and Morris
(87). In some of the 83 cases described by Terrier and Baudoin it is
shown that the ureter has become permanently distorted by the occurrence
of local inflammatory action, producing adhesions. For recent experi-
ments on the mechanism of these intermitting hydronephroses, see
Tuffier (128).
As a consequence of the interference with the vessels due to displace-
ment, the movable kidney is liable to atrophy, this change being secondary
to the displacement. In other pathological conditions in which the kidney
increases vn size and weight, displacement may take place, but this is only
a secondary consequence of the enlargement. Thus tuberculous, carcino-
matous, and sarcomatous kidneys may become movable and slip down-
wards. Calculi have also been found in displaced kidney, and consequent
pyelitis has been described by Dickinson, Fritz, and Hickinbotham.
While in general there is very little change in the nature and amount
of the urine in nephroptosis (Eosenstein, Henoch) (54), yet sometimes
there is periodic polyuria, as in the case described by Oppenheimer.
Apolant accounts for this by supposing the nerves to be stimulated by
the displacement.
As a collateral reflex concomitant of movable kidney tachycardia has
been noted by Eccles. Certain conditions of the surrounding viscera
have been occasionally found to accompany nephroptosis. The liver
frequen:ly shows deformation from the same causes which ha^•e caused
the renal displacement, especially from tight lacing ; and the kidney may
346 SYSTEM OF MEDICINE
be adherent to the anterior edge of its right lobe. The gall-1)ladder has
been found dilated in a few instances (88).
But the most characteristic of these changes in neighbouring organs
is the dilatation of the stomacli -which Bartcls of Kiel has described, and
attri])Utes to the forward di.splacemcnt of the gland pressing on the fixed
descending portion of the duudenum, and so mechanically obstructing the
normal passage of the chyme. This view is supported by Mathieu (82),
Stiller, and Midler-Warneck. In Franks' case a peritoneal band from the
upper portion of the kidney was attached to the duodenum in such a manner
that, when the kidney was drawn down, the band dragged upon the duo-
denum and kinked it, thus practically occluding its lumen. Similar bands
have been seen by Lenharz and Weisker, and I have been able to demon-
strate the existence of folds of peritoneum of this nature in subjects in
our dissecting-room. This condition, which would have been missed in
Franks' case had the oi^eration been performed retroperitoneally, is, I
have reason to believe, not very uncommon, and furnishes a natural and
adequate explanation of the gastric disturbances. Such l)ands may pass
occasionally from the upper pai't of the duodenum, jjut they are more
comnionly attached to the middle or lower part of the descending jiortion,
'\\\ the position nearly opposite that at Avhich the bile-duct enters. The
drag of the peritoneum on the duodenum is probaljly the commonest cause
of the temporary jaundice which often accompanies the gastric crisis, and
of the dilatation of the gall-bladder. The objections which Oser has
brought against Bartels' hypothesis do not apply to that of Franks ; on
the contrary they rather favour it (100). Edelwhls' opinion that the
gastric crises are due to traction upon the nerves of the solar plexus (loc.
cii.) is unsupported by any evidence, and is insufficient to account for the
gastric enlargement and jaundice. Newman's suggestion that the jaundice
is the result of concurrent biliary colic or catarrh of the bile-duct leaves the
frequency of the coincidence unexplained ; as does that of Lindner that
the jaundice arises from a reflex spasmodic stricture of the bile-duct. It
is improbable that the displaced kidney itself can ever press on the bile-
duct or on the diverticulum Vateri as Littcn supposed. Adhesion of a
moval)le left kidney to the descending colon has likewise been met with
as a result of circumscribed adhesive pei'itonitis.
Weisker, in the paper already quoted, has called attention to the
close connection of the ligamentum hepato-duodenale to the bile-duct,
which lies in its sharp border ; and, as that fold is directly continuous
with the peritoneal capsule of the kidney, it is difficult to imagine any
very great displacement of the kidney taking place without an interfer-
ence Avith the duct. Fischer-Benzon has described the coexistence of a
dilated caecum with nephroptosis.
Diagnosis. — Generally speaking, the diagnosis of movable kidney is
not diflicult ; careful palpation by Franks" method usually suffices to detect
the tumour. The peculiar sickening sensation Avhen it is squeezed, and
the position and form of the swelling, are characteristic. Sometimes there
is a clearer percussion note than usual in the lumbar region (Guttman); l.ut
NEPHROPTOSIS 347
this is a very variable character. I have found the usual dull percussion
note in a case in which the kidney was much displaced ; and Landau has
also noted the untrustworthiness of this sign. The conditions which most
simulate it are those phantom contractions of the recti and internal olilique
or transversalis muscles which appear as oval, smooth, definite tumours ;
but these resolve under chloroform, and although a movable kidney
usually returns to its normal place under an ansesthetic, yet it is easy
in such cases by bimanual palpation to ascertain the mobility of the gland.
There are no pathognomonic symptoms of movable kidney ; but in
cases where unaccountable gastric crises occur, or intermittent hydrone2:)h-
rosis can be diagnosed, a movable kidney may be suspected. As most
of the conditions which are liable to be confounded with it show dis-
tinctive characters, in obscure cases, when the tumour itself is not dis-
tinctly palpable, the diagnosis is generally arrived at by a ■ process of
exclusion. Faecal accumulations, hydrosalpinx, omental tumours, cancer
of the colon, enlarged gall-bladder, the " tight-lace lobe " of the liver,
ovarian tumours, and hydatid disease have all been taken for nephro-
ptosis, but can usually with care be discriminated. On this subject
Landau has made some acute observations. The diagnosis of enlarged
gall-bladder from movable kidney is treated more fully in the chapter
on "Diseases of the Gall-bladder" (p. 229).
Treatment. — The treatment of movable or floating kidney is twofold
—palliative and operative. In cases in which there are no sj-mptoms, or
merely trivial neuroses, the constraint of a well-fitting tight jersej^, put on
before the patient rises from bed, careful attention to the boAvels, and the
avoidance of violent exercises, such as dancing and miming, generally
suffice to avert more serious discomfort. If these prove insufficient to fix
the kidney, some more direct means of support may be used, such as a well-
fitting abdominal belt extending from Poupart's ligament to the seventh
rib, or Landau's abdominal stays Avith busks extending to the pubes.
Massage has been recommended by Landau and by Eisenberg; and
general treatment, especially ferruginous tonics, strychnine, and local
douches or shower-baths, often proves of service.
Many forms of special retentive apparatus have been devised. Gueneau
de ]\Iussy suggested the use of an L-shaped pad beneath the abdominal
binder, the horizontal leg being placed below, and the vertical external to
the gland. Ellinger recommends a special form of bandage. Smith in-
vented a truss with a straight spring — not oblique like that of a hernia
truss ; the posterior end is provided with four small pads which rest two
on each side of the spinal column ; and the anterior pad is a soft rubber air-
cushion which can be inflated to the required degree of tension. A some-
what similar truss is recommended by Niehans (97), and a crescentic rubber
air-pad has been devised by Stifler. A similar pad, invented by Bigg, is
described in the British Medical Journal (11).
For local pains hot fomentations and sedatives may be used. Althaus
has recommended the hypodermic injection of antipyrine ; and the pain
which sometimes supervenes in these mild cases from unwonted exercise
348 SYSTEM OF MEDICINE
generally subsides with rest, fomentations, poultices, and belladonna
plasters.
When, however, the symptoms are severe, and retentive apparatus
does not relieve them, or is not easily borne, surgical interference is called
for. Two operations have been proposed — Nephrectomy and Nephror-
rhaphy. The former has been advocated by Keppler, Avho regards a
movable kidney as a continual menace to life ; but it is a serious opera-
tion, and of the thirty cases recorded between 1870 and 1887 nine were
fatal. The first recoi'ded extirpation of a movable kidney was performed
by Dr. Gilmore of Mobile, Al., in 1870. Of the fatal cases one is
interesting, as the excised gland proved to be the only kidney possessed
by the patient, who in consequence died of uraemia on the eleventh day
(Polk). Meriwether more wisely sutured the solitary kidney in a case of
displacement. Cases like that recorded by Hager arc also calculated to
make us hesitate to advise nephrectomy, except in those instances in
which the displaced organ is hopelessly diseased. Adding in the more
recent cases which have been recorded since the publication of Newman's
list in 1888, the mortality of this operation vip to date has been 23 per cent.
The operation of nephrorrhaphy — suture of the movable kidney to the
abdominal wall — was introduced by Halm in 1881; and ^as first
practised in this country by Newman (94). This is a much safer operation ;
Keen has tabulated 134 cases in which it has been performed, out of
Avhich only four were fatal; Neumann has collected records of 274 cases,
out of which only 1*82 per cent were fatal ; and, still later, Albarran gives
the statistics of 374 cases, showing a mortality of r87 per cent. These
statistics justify the term " simple and safe," which Mr. Clement Lucas
has applied to the operation. The French authors in general call the
operation nephropexia, a name invented by Le Dentu, after the analogy of
the name of hijsteropexia applied to utero-fixation by Trelat.
The different methods of nephrorrhaphy have been experimentally in-
vestigated by Van der Lee and Triomi ; but generally the operation is per-
formed by the lumbar incision. The objects of the operation are to fix the
kidney and its capsule to the abdominal wall, to attach the kidney to its
capsule, and to reduce the size of the ca^■ity in which the kidney moves.
The incision needed is usually a little over 8 cm. long, and is carried from
a point 1 cm. below the last rib close to the outer border of the erector
spinse, obliquely downwards and outwards towards the iliac crest ; the
fatty capsule is to be opened, and if loose a part of it should be cut away.
Herczel, Tillmanns, and Lloyd have recommended the incising of the
fibrous capsule so as to deiuide the cortical substance (9, 22). The operation
requires to be varied to suit the case. ]\I'Cosh points out that, accord-
ing to circumstances, the fatty capsule may or may not be opened ; it
may suffice to pass the sutures through it, or, the fatty capsule being
opened, the sutures may be passed through the fibrous capsule, or through
the parenchyma of the gland ; or the fibrous capsule may be partly
stripped off. The incision described usually gives sufficient room for the
subsequent proceedings ; Ceccherelli, however, found it necessary to resect
NEPHROPTOSIS 349
the eleventh and twelfth ribs, but his patient died from the consequences
of his wounding the pleura. It is seldom necessary to drill the last rib
and suture the gland to it, as was done by Lowson.^ In one of Walther's
cases Avhere a reoperation was required, he found it desirable to suture
the kidney to the costal periosteum. The sutures may be silk, kangaroo
tendon, or silkworm gut ; but they must be strong, as Newman has found
that those Avhich traverse the kidney substance are very rapidly destroyed.
They are most conveniently inserted by the circiilar Hagedorn's needle.
Newman uses a di'ainage-tube ; but Morris recommends packing the
wound with gauze or lint. Two to four stitches are usually enough, the
sutures being inserted as widely apart as possible in the gland (Treves).
In cases where the diagnosis is doubtful, the intra-peritoneal operation
is recommended by some (Herczel, loc. cit.), the incision being made in the
linea semikinaris (Langenbuch). In a case thus operated on. by Sir W.
Stokes, adhesion took place without suture, as a result of the manipulation
to which the kidney Avas subjected.
In all cases the patient must be kept recumbent for about six weeks
after the healing of the wound, and should wear an abdominal belt for
some time afterwards. The results of the operation as given by Albarran's
statistics show that 64 per cent were completely successful, 14 per cent
were partially successful, and 22 per cent were failures. In Neumann's
list, 65'32 per cent are recorded as successful, 10"36 per cent were par-
tially so, and 2 2 '07 failed.
Some modified operative procedures have been recommended by other
authors. Riedel has introduced a method of fixation to the diaphragm
Avhich, although advocated by Keineboth, does not seem to possess any
advantage. Mikulicz, by painting the peritoneal surface with iodoform
collodion, has succeeded in producing a circumscribed adhesive inflammation
so as to fix the viscera together. In case adhesions of the kidney to any
of the viscera are found in the course of the operation, Sulzer recommends
that care be taken not to stretch them unduly ; permanent traction is
apt to be followed by persistent pain. When nephroptosis is a part of a
general condition of enteroptosis it must be treated accordingly (Treves
(125), De Renzi) [see also article "Enteroptosis," vol. iii. p. 587]. The
treatment of hydronephrosis, when complicated by mobility, differs in
little from that occurring when the gland is in its normal site [see
article "Hydronephrosis," p. 430].
Alexander Mac a lister.
^ Albarran recommends that the length of the twelfth rib should be ascertained before
operating, as he believes that if it be nnusiially short there is danger of wounding the pleura.
This, however, is only an occasional danger, as in seventeen cases in which this rib was under
6 cm. in length, the pleura was as far as usual from the track of the needle. Holl and
Lange have, however, found that in some cases the pleura does descend as far in such
instances as in those having the normal length of rib, and Dumreicher has actually opened
the pleura in operation on an enlarged kidney.
350 SYSTEM OF MEDICINE
REFERENCES
1. Abekle. Sahburffcr Dicdic.-chir. Zcitunj, lS-16, iv, 2oS. — 2. Ahlfeld. Archiv
fiir Gyndkoloijic, 1879, xv. p. 114. — ^3. Albauhan. Annules des maladies yenito-
uri)iaires, Any;. 1S95. — 4. Albicus-Schoxbkkg. Ccntr(dblattfurGijnakolo()ie, xviii. 1894,
No. 48. — 4(1. Aliiiaus. British Medical Journal, 1893, vol. i. — 5. Apolant. Deutsche
mcdiciiiischclVocIunischrift, xii. 1886, No. 41. — 6. Baiitels. Journal de iMdecine et de
chirurfjie pratiques, 1884, Iv. p. 394. — 7. Bakiholinus. Anatomic, 1673, p. 177. — 8.
Becquet. Arch. (jin. demdd. Paris, 1865, v. p. 5. — 9. Beitrdge zur ktinischoi Chirurgic,
1892, ix. p. 648. — 10. Behuy. Ncio Orleans Medical aiul Surgical Journal, July 1889,
p. 45. — 11. Bico. British Medical Journal, 1896, i. p. 1368. — I'J. liiNULEY. Trans-
cu'tioiis oftlie I'athological Society of London, xxvii. p. 473. — 13. Brown, Macdonald.
Jouriud of Anatoniii, xxviii. p. 194 — 14. Ciccchekelli. liivista Clinica, April 1884.
— 15. Chamn ICY, Sophia. Iiuiugural Dissertation. Berne, 1893. — 16. Clakk, Bkuce.
British Malical Journal, 1895, i p. 577. — 17. Cole. British Medical Journal, 1874, i.
p. 453. — 18. CuxNiNGH.AM. Journal of Anatomy, July 1895, p. 501. — 19. Cukslii-
MAXN. Schmidt's Jahrbiicher, ccxxviii. 1890, p. 115. — 20. D.-i.UANY[. Gy6gyiiszat,
Budapest, 1880, xx. p. 382. — 21. Defontaine. These sur la Pathologic dcs reins
vuihiles. Paris, 1874. — 22. Deutsche Zeitschrift fur Chirurgic, 1892, xxxiv. \>. 627. — 23.
DicKixsox. Renal and Urinary Affections, \o\. in. — 24. Dii;tl. JFien. med. JFoch.
xiv. 1864, p. 563. — 25. Dora. Philadelphia Medical and Surgical Reiwrter, 1879,
xl. p. 502. — 26. Drummo.xd. Lancet, 1890, i. p. 68.-27. Durham. Guys Hos-
pitcd Reports, 1860, p. 404.— 28. Eccles. British Medical Journal, 1890, i. ]>. 1250.
— 29. Edep.ohi.s. American Journal of Medical Science, cv. 1823, No. 4. — 30. Ellixgrr.
Wiener medicinischc Wochensehrift, 1881, xxxi. No. 17, p. 1315. — 31. Excjli.sch.
Deutsche Zcitschrift fur Chirurgic, '\je\\ydg, 1879, xi. p. 28.-32. Ewai.d. Berliner
klinixhe Wochensehrift, xxvii. 1890, No. 12. — 33. Feubicii. Virchow's Archiv, lii.
1871, p. 95. — 34. Ferguson. Glasgow Medical Journal, 1889, xxxi. p. 348. — 34a.
Fischer-Bexzox. Thesis zur Anatomic d. hcwegl. Niere. Kiel, 1887. — 35. Foster.
Physiology, 6th edit. iii. p. 689 sqq. — 36. Fourrier. Bulletin gJadrale de I'h-Sra-
pcutique, Ixxxviii. June 1875, p. 481. — 37. Fr.\xks, Kexdal. British Medical Journal,
1895, ii. p. 895. — 3S. Idem. Transactions of tlte Royal Acculemy of Medicine cf
Ireland, 1893, p. 392.-39. Fritz. Archives gentrales de midecine, 1859, ii. p.
158. — 40. GiLEWSEi. Wiener medicinisclic Wochensehrift, 1865, xv. 596. — 41. Gil-
ford. Lancet, 1893, ii. p. 1559. — 12. Girard. Gaz. mid. de Paris, 1837, p. 89. —
43. Ibid. Journal hebdomadaire de progres des sciences midicales, 1836, iv. p.
445. — 44. Gi.itN.^RD. Lyon medical, 1885. — 45. Grassict and Rauzier. Malculies du
systeme lurveu.c, Paris, ii. 404. — 46. Guttman. Physical Diagnosis, Sydenham Soc.
1879, p. 364. — 47. Gi'YO.v. Jouriud de medecine ct de chirurgic pratiques, 1888, p. 441.
— 48. H.A.GF.R. Berliner klinische Wochensehrift, Aug. 1889, xxvi. — 49. Haiix. Cen-
tralblatt filr Chirurgic, 1881, viii. July 23, p. 449. — 50. Hare. Medical Times and
CascWc, xvi. 1858, pp. 7, 112. — 51. Haughtox. Animal Mechanics, 1873, p. 218.
— 52. Haward. Med. -Chi. Tr. 1888, Ixxi. p. 81.— 53. Hexdersox. Medical Times
and Gazette, 1859, ii. 501. — 54. Hexoch. Klinikder Unterleibskrankheiten, iii. ji. 367.
— 55. Hertz. Abnormitdten der Bauch-organc. Berlin, 1894.- — 56. Hickixbotham.
Quoted hy Greig Smith, Abdominal Surgery, 1891, \\ 523. — 57. Hilbkrt. Archiv
fiir klinische Medicine, 1. 1892, p. 483. — 58. Hirschspuuxg. Hospital- Tidende,
Copenhagrn, 1879, vi. 949.-59. Hohl. Meckel's Archiv, 1828, p. 355.-60. Huwnz.
Hospital- 7" idewle, xvi. 1873, 14, p. 53. — 61. Israel. Berliner klinisclie Wochen-
sehrift, xxvi. 1889, Nos. 7, 8. — 62. Jago. Medical Times and Gazette, 1872, ii. p. 328.
— 63. Ji;xxER. British Medical Jownal, 18(}9, Y>. 43. — 64. IvEitn. Transactions of the
American Surgical Associtdion, 1890, p. 197. — 65. Ki".ppli".i:. Archie filr klinische
Chirurgie, xxiii. 4, 1879, )>. 520. — 66. Kidd. Lancet, 1894, ii. p. 131 ; 1895, ii. )). 1564.
— 67. KoK.xxYi, vox. Berliner klinische JFoehcnschrift, 1890, No. 31. — 68. Kustkr.
Lancet, 1895, i. 1077. — 69. KurTXKR. Berliner klinische Woc/icnschrift, xxvii. 1890,
Nos. 15-18. — 70. Landau. Now Sydenham Soc. 1884, ex. p. 278. — 71. Laxdau and
Eiskxbep.g. Wiener med. Presse, 1891, xxxii. No. 36. — 72. Langexbuch. Deutsche
medicinischc Wochensehrift, 1889, xv. No. 16, p. 325. — 73. hv.v., VAX Dicit. Lcyden
DisserUdion, 1893. — 74. LiXDNER. Deutsche medicinischc IVochenschrift, 1884, x. p.
230. — 75. LiTTEN. Berlin CliarM Annalen, 1880, p. 10. — 76. Lochhicad. Glasgow
Medical Journal, 1896, xlv. p. 420. — 77. Lowsox. British Medical Journal, 1893, i.
NEPHR 0 PTOSIS 3 5 1
p. n. — 78. Lucas, Clement. British Medical Journal, 1891, ii. p. 1343. — 79.
M'CosH. New York Medical Journal, March 1.'), 1S90, p. 281.— 80. Mana.ssein.
Vratch, 1887, viii. p. 206. — 81. Mathiku. Ann. de^vudad. r/enito-ur. xii. 1894, p. 70. —
82. Idem. Progres medical, Oct. .29, 1892. — 83. Medical Times and Gazette, 18G9, ii.
32. — 84. Meriwetheu. Annuls of Sure/cry, Sept. 1891. — 85. Mikulicz. Zeitschrift
fur Gyncikologie, 1890, xix. jj. 358. — 86. Morris. British Medical Journal, 1892, i. p.
1009. — 87. Idem. Medico- Chirurgical Transactions, lix, p. 227. — 88. Idem. 1895,
i. p. 238. — 89. M0.SLKR. Berliner klinische JFochenschrift, 1866, iii. No. 141,
p. 393. — 90. MuLLEu- Waiineck. Berliner klinische JFochenschrift, xiv. 1877,
No. 30, p. 429. — 91. Mu.ssy, Gueneau de. Clin. vied. 1875, ii. p. 1S7. ^
92. Neumann. Inaugural Dissertation. Berlin, 1892. — 93. Newman. Glasgoiv
Medical Journal, 1883, xx. p. 85. — 94. Idem. August 1883, p. 121. — 95. Idem. British
Medical Journal, 1896, i. 149. — 96. Idem. Lancet, 1896, ii. p. 1758. — 97. Niehan.s.
Centralhlatt f. Chir. xv. 1888, No. 12. — 98. Oi'PENHEIMEr. Deutsche medicinische
Wochenschrift, xvi. 46, 1890. — 99. Orum. Gynak. og Obstet. Meddelelser, Copen-
hagen, 1879, ii. pp. 307-388.— 100. Oseu. Wiener vied. Klinik. 1881, i. p. 4.— 101.
Peknice. Deutsche viedicinische Wochenschrift, 1879, No. 9. — 102. Polk. New ^
York Medical Journal, 1882, voh ii. — 103. Priestley. Medical Times and. Gazette,
1857, p. 263. — 104. Ray, Le. These dcs reins viohiles. Paris, 1876. — 105.- Reineboth.
Inauqural Dissertation. Jena, 1892. — 106. Renzi, de. liiforma Medica, Dec. 22, 1894.
—107. RiEDEL. Berliner klinische Wochenschrift, 1892, xxix. No. 28.— 108. Roberts.
Urinary and Benal Diseases, 1885, p. 672. — 109. Rollet. Pathologic und Therapic der
beweglichen Niere. Erlangen, 1866. — 110. Rcsenstein. Niereiikrankheiten, p. 374. —
111. Sawyer. Birmingham Medical Review, 1872, i. p. 116. — 112. Schatz. Archiv
fUr Gyndkologie, in. 1,1871,}^. 174. — 113. Senator. Deutsche Medicinal-Zeitung, 1883,
p. 479. — 114. Siredey. Bulletin et vievioires de la societe medicale des hopitaux de
Paris. October 26, 1893. — 115. Sk(')RCZK\vsky. Przeglad Lekarski, Krakow, 1882,
xxi. 3. 20. — 116. Smith. New York Medical Journal, 1883, xxxvii. p. 183. — 117.
Steineu. Compendium der Kind.crkrankheiten, 1872, p. 314. — 118. Steven. Glasgoiv
Medical Journal, xx. 1883, p. 307. — 119. Stifler. Miinchener medicinische Woclicn-
schrift, 1892, xxxix. No. 28. — 120. Stiller. Wiener viedicinische U ochensclirift,
1879, xxix. No. 4. — 121. Stokes, Sir W. British Medical Journal, 1895, i. p. 853.
— 122. SuLZER. Deutsche Zeitschrijt filr Chirurgie, xxxi. 1891, p. 506. — 123.
Terrier and Bauuoin. Eevue de chirurgie, 1891, ii. 719. — 124. Treves.
Lancet, 1896, i. 17. — 125. Idem. British Medical Journal, 1896, i. p. 1. — 126. Triomi.
Mercredi viedical, May 23, 1894. — 127. Tuffier. Eeviie de chirurgie, x. May, 1890,
p. 390. — 128. Idem. Annales des Maladies genifo-urinaires, 1894, xii. p. 14. — 129.
Urag. Wiener viedicinische Wochenschrift, 1857, No. 3. — 130. Virchow. Monat-
schrift filr Geburtskunde, 1857, x. p. 242. — 131. Walther. Revue de chirurgie, 1893,
X. p. 273.-132. AVici.sker. Schmidt's Jahrbiicher, ecxix. 1888, p. 277.— 133. Idem.
ccxx. 1888, p. 249. — 134. White, Faulder. British Medical Journal, 1895, i. p.
1376.— 135. Whitic, Hale. British Medical Journal, 1892, i. p. 223.-136. Wilks.
Lancet, 1862, ii. 139.
137. Abbott. Boston Med. and Surg. Journ. 1864, p. 439. — 138. Le Dentu. AJfec-
tiones chirurgicales dcs reins. Paris, 1889. — 139. De.sme. Thise dcs reins Jlottants.
Montpellier, 1885. — 140. Duvet. " Du traitement des reins mobiles par la nephror-
rhsi\Aufi," Bull, de V Acad. Roy. Med. de Belg. v. 1888, p. 440. — 141. Guyon. " Les
deplacements renaux," Gazette des Hopitaux, 1892, Ixv. 103. — 142. Hare. "Report of
Pathological Society on Movable Kidney," Tr. Path. Soc. 1875, xxvii. p. 467. — 143.
Hkrr. Die wandernde Niere. Frankfort a M. 1871. — 144. Keen. "Nephrectomy,"
Philad. Med. News, Ivii. 18, 1890. — 145. Idem. " Nephrorrhaphy," ^os/wi J/cd and
Surg. Journ. 1890, cxxii. 23. — 146. Martineau. Des reins flottants. These, 1868. —
147. PiEi'ER. Ueber Cystenbildungen bcvxglicher Nieren. Berlin, 1867. — 148. Schultze.
Zur Casuistik der bewegJ. Niere. Berlin, 1867. — 149. Serres. De rene qucm dicimvs
errantem. Greifswald, 1866. — 150. Thun. Ueber bewegliche Niere. Berlin, 1869. — 151.
TzscHASCHEL. Ueber beioegl. Niere. Berlin, 1872.
A. M.
352 SYSTEM OF MEDICINE
DISEASES OF THE KIDNEY CHARACTERISED BY
ALBUMINURIA
The present article deals with the diseases of the kidney which are
ordinarily indicated by the presence of albnmin in the nrinc. The name
albnminuria is too comprehensive, for it is nut proposed here to include
functional or cyclic albuminuria, or that of adolescents, or any of the con-
ditions of which haemorrhage is the essential characteristic though all)umin
may at times be present without the other constituents of blood. Nor does
the term Bright's disease exactly fit. This description covers much of the
subject, but not the whole. The denomination has by common usage,
for which the public are mainly responsible, become restricted to the
more chronic and persistent varieties. To say of a person with a
temporary nephritis that he hus Bright's disease would give a false
impression, create unnecessary alarm, and convey a sentence of death to
one not doomed to die. The topic in hand cannot be more tersely
defined than as diseases of the kidney characterised by albumimnia.
These may be broadly divided into three groups, though the demarcations
are not sharply defined, for the conditions run more or less into each
other and present a certain amount of intermixture. The broad divisions
are as follow : —
I. Nephritis, tubal, diffuse, and glomerular. — AVe have
here the immediate results of inflammation, which may afiect the
tubes only or involve also the interstitial tissue or the Mal]jighian
bodies. This state of the organ is generally attended with con-
gestion and increase of bulk, the latter chiefly in the cortical tissue.
The congestion is most marked in the early stages, the swelling in the
later. The surface long remains smooth, at any rate until contractile
changes are superadded which may eventually give rise to, superficial
uneveiniess and remove the condition into the second class, that of the
granular kidney. The climax of the first class is reached in the large
white kidney of nepliritis.
II. The granular or cirrhotic kidney. — This may arise as
the sequel of acute interstitial inflammation ; or, what is more common,
may present itself as the result of gradual, insidious changes, no
doubt inflammatory in their essence, but so obscure in their beginning
and latent in their progress that no inflammatory outbreak can be
discerned in their origin or course. The leading characteristic of this
organic state is contraction, of which superficial granulation or minute
nodulation is the sign. The contractile process may lessen or su})er-
sede an antecedent increase of bulk, or, as more often happens, may
occur without it, the organ beginning to shrink from the first.
HI. The kidney of lardaceous disease, otherwise described
DISEASES OF THE KIDNEY 353
AS WAXY OR AMYLOID. — This commonly occurs together with changes
of the same nature elsewhere. The essential fault is a deposition
within the organ of a peculiar substance which is different from all the
normal comjDonents of the body, and is best detected by its reaction
Avith iodine. The alterations in the kidney present a great variety, and
have already been described. [See vol. iii. p. 259.]
The lardaceous process is apt to set up in the kidney various inflam-
matory and fibrotic changes, Avhich consequential complications impart
to the organ many of the characters Avhich belong to nephritis and
granulation.
It will be observed that I have not mentioned the fatty kidney as a
substantive or independent condition. The renal epithelium may become
charged Avith oil in a variety of circumstances ; it is often so, even to a
considerable extent, without any interference with the renal functions, in'
connection with states which concern the whole body. With tuberculous
disease, such as phthisis, it is often so. With many conditions which
affect the kidney locally the epithelium often displays this state to
an extreme degree. It is often so with nephritis, particularly when this
is due to cold ; after scarlatina there is little tendency to fattiness.-
With the granular kidney the fatty change may be presented, and with
the lardaceous the epithelium is sometimes loaded Avith oil to the extreme
of possibility, while at other times it is free. There is a close association-
between fatty and lardaceous change, as is often seen in the liver.
Alcoholic drinks, particularly beer, tend to make the kidneys fatty,'
whether in connection with other renal alterations or Avithout them. The
peculiar action of phosphorus in producing fatty degeneration of the
kidney, as Avell as of other oi^gans, need not here be dAvelt upon.
I. Nephritis. — Morbid anatomy. — Before proceeding to clinical con-
siderations, I Avill say as much concerning the morbid anatomy of the
disease as is necessary for the understanding of its course and symptoms.
Many pathological details, Avhich need not be recapitulated here, will
be found in another part of this Avork. Unlike many other diseases, the
definition of nephritis lies in its morbid anatomy, Avhich may therefore
be properly considered before its clinical manifestations.
The more closely we regard the results of this disease the less simple
we find them to be. Inflammation, which notably involves the tubes-
and is revealed to us only by their means, is apt to be shared by the
interstitial tissue, and to display after death a complex condition. It is
not possible, therefore, to deal Avith the varieties of nephritis Avith academic
distinctness, nor can Ave assume exact limitations Avhich natiu-e does not
present.
Nephritis may be acute or chronic, Avith many degrees of intensity or
protraction.
To take, first, the acute form, as commonly presented tAvo or three
weeks after its outset, the result of cold, scarlatina, or diphtheria, the
kidney may be thus described. It is increased in weight and bulk, but
VOL. lY 2 A
354 SYSTEM OF MEDICINE
not to the extent attained by the large Avhite kidney of chronic disease.
In an extreme case, particularly of the congestive variety, the Aveight may
be doubleil or even more ; bat usually the increase is in much smaller
proportion. The surface remains smooth, and the capsule thin and
unadhercnt. The organ is everywhere, even including the pelvic mucous
membrane, In'perieraic. The capsular surface is injected especially as to
the minute intertubular network ; stellate veins belong to a later period.
The whole organ on section exudes blood freely, and the cortex is uniformly
besprinkled with conspicuous red specks, which are injected ]\Ialpighian
bodies ; the hypera3mia of the cortical substance is to a certain extent
masked by its infiltration with a pale or buff material which chiefly
consists of a superabundance of epithelium.
The most striking change, as viewed with the microscope, is the
obstruction and distension of the tubes, which are stuffed with epithelium,
granular matter, and often blood and fibrin ; to the more or less oblitera-
tion of their channels. Sometimes the fibrin is so abundant as to
occupy most of the tubes to the exclusion of their epithelial lining, lying
in immediate contact with the basement membrane — the situation sug-
gesting that the adventitious material is an exudation from the tube walls
rather than an escape from the Malpighian bodies. The general sealing
up of the renal exits which results is necessarily attended with corre-
sponding diminution of urine.
In many of the more intense, the more protracted cases, and often the
scarlatinal cases, the intertubular substance shares in the inflammatory
process, and displays hj-pernucleation and new fibroid growth. The new
growth is more or less uniformly distributed between the tubes, in which
respect the fibrosis of acute nephritis differs from that of the chronic
granular kidney, where it presents itself in processes.
There are many grades in the condition of nephritis, and much
variation in the amount of change which appeals to the naked eye.
Sometimes this is so little conspicuous that though the renal disturbance
may have been sufficiently evident during life, yet after death it might be
overlooked by a careless observer. In other cases the disorder leads to
organic alterations so obvious that it is a marvel that they so long escaped
record. I have preferred to place first the conditions most frequently
met with ; I now come to one which is less common but more striking.
Sometimes, particularly when the attack is the result of a definite ex-
posure to cold, and the subject middle-aged and intemperate, an acute
form of nephritis manifests itself which is characterised by extravagant
congestion, even to chocolate or purple, and groat and rapid swelling of
the gland ; so that, as I have seen at least in one instance, the kidneys
have burst their capsules. Short of this exceptional result, the whole
organ, but chiefly the cortical tissue, is enormously swollen, the cortex
changed to a deep coffee colour, and the cones to jmrple, while the tubes
are distended chiefly with epithelium and blood. If the blood be removed
by washing, the cortical tissue will show, what before -was obscured, a
finely-divided superaddition of a buff colour. An admirable reprosenta-
DISEASES OF THE KIDNEY 355
tion of this form of kidney is to be seen in Bright's classical work.
I have elsewhere recorded in detail the case to which I have already
referred, in which the capsules were torn open by the swelling of the gland.
It will be seen by the illustrations which I have elsewhere published
that the interstitial tissue, both in the cortex and cones, was profusely
charged with a new corpuscular formation. It was not impossible that in
this case the intense nephritis may have been associated with htemo-
globinuria.
It must not be passed without notice that in certain cases of diffuse
nephritis, particularly of scarlatinal origin, the Malpighian bodies are
especially involved to the extreme diminution of the urine, and the name
glomerular nephritis is applied to the condition. This is characterised by
urjemia rather than dropsy. The change may occur in the course of
scarlatinal nephritis, while as yet the inflammatory process is but incipient
in the tubes and general interstitial tissue. There is a copious nuclear
formation within the Malpighian capsule by which the contained vessel
may be compressed, the capsule is thickened by a similar growth, and
there is hyaline degeneration of the Malpighian coil. The change
conveys the suggestion that Malpighian structure is early and intensely
aff'ected by some irritating propeity in the scarlatinal blood or in the
urine which here takes its origin from it.
Passing from the acute to the chronic we reach the large white kidney
of nephritis. "The large white kidney," and that in a most typical
shape, may also be a result of lardaceous disease ; the term, therefore, is
not distinctive unless the qualification " of nephritis " be added. The
large white kidney of nephritis is a sufficiently striking manifestation of
renal disease. The organ is increased even to three times its normal
weight. The surface as yet remains smooth. It is abnormally pale, the
pallor of the surface relieved by stellate veins or indefinite patches of
congestion. The cortex on section is seen to be similarly pale and
greatly increased in bulk. The cones are likewise increased, but to a less
extent ; they retain much of their normal red colour, so that the contrast
between them and the pale or buff" cortex is far beyond what the healthy
kidney presents. The condition is the issue of a general or diff"use
nephritis which aflfects both the tubes and the intertubular substance.
The tubes are variously distended and obstructed, and the material between
them hypertrophied, hypernucleated, and beset with the fibrillar of new
fibroid tissue.
The next phase, which is one of slow and infrequent attainment, is
the conversion of the large smooth kidney into the contracted and
granular. The ^QVf fibroid tissue gradually contracts, as its manner is,
draws in the surface at numerous points of attachment, and narrows and
strangulates the tubes which it involves. The resulting condition, one of
contracting fibrosis, is essentially the same as that of the granular kidney
of gradual accession, though there are diff"erences of appearance which
point to the diff'erences of origin. With the ordinary granular kidney
the change begins upon the surface with a fine and regular granulation,
356 SYSTEM OF MEDICINE
and slowly reaches the inner parts, •\vliioh long retain much of their
natural colour and texture. As the sequel of acute disease a superficial
unevenness in the shape of scattered indents or depressions is super-
imposed upon the preceding general change. The unevenness may in
course of years attain to something of general granulation, but this is
•seldom so regular as in the contrasted condition. Even then there
remains much of the original white or buff colour, and of cortical excess,
particularly in the deeper parts ; so that many of the internal characters
of the large white kidney are still to be found in association with the
gi'anulated surface of contracting fi1)rosis.
For purposes of classification, dealing with the kidneys as displayed
post-mortem, nephritis is better defined by naked -eye observation than
by microscopic. The microscope will show various forms of disturbance
in the tubes and their contents ; it may or may not display the
results of interstitial inflanmiation in hypernucleation or overgrowth,
since they may be present or absent according to the cause and
intensity of the attack. The question whether the inflammation
is confined to the tubes, or affects also the intertubular substance, does
not enter into the definition. The kidney of nephritis must be
defined partly by negatives : it gives no lardaceous reaction ; it is not
contracted, or at least not so much contracted as to entitle it to be
classed as contracted and granular, Avhich state nephritis may ultimately
lead to. The surface remains smooth, or nearly so ; the cortex is incrc^-iscd,
often greatly. The disease attains its extremes, as the swollen chocolate
kidney of acute inflammation, and the large white mottled kidney of
chronic disease ; beside and between which there are a variety of
intermediate states characterised by increased cortex and smoothness
of surface.
Sex and Age. — First with regard to aex — all forms of albuminuria are
more common in males than females. With nephritis this difierence exists
at the earliest periods and increases as age advances. In early life, when
ne})hritis is lai'gely due to scarlatina, the difierence is apparent. Dr.
Tripe, writing of scarlatinal dropsy, gave the proportion of males to
females as GO to 39. Of 105 cases of nephritis from all causes in
children under 12 years of age, at the Hospital for Sick Children, 58
concerned boys, 47 girls. Later the pre])onderance is on the same
side. Taking adults, that is, persons over the age of 16, and appealing
to 54 cases under my own observation, I find that there were 33 male
subjects, 21 female.
The greater prevalence of albuminuric disease, connected as it so often
is with infiannnatory action whether acute or chronic, in the male is
only what would be expected. An organ is perhaps liable to disease of
this nature in some sort of proportion to its activity of function ; it is
certain that it is so liable in jiroportion to its sulijcction to morbid
stimulation. The man habitually throws more work upon the kidney in
eating and drinking than does the woman. He is more exposed to
weather than she is, he has a greater propensity to gout, and he is more
DISEASES OF THE KIDNEY 357
conversant with lead. There is one cause of renal disease which affects
the female only, to wit, pregnancy ; but this is not enough to counter-
balance the other causes of renal disease.
Next as to af)e. The disease preponderates in early life, though
perhaps no age can claim exemption. It is nearly unknown in the first
year, rare in the second, afterwards common up to the beginning of old
age. The frequency with which it happens in children as the con-
sequence of scarlatina or cold must have struck every one who is familiar
with the diseases of childhood. As to its occurrence in later life it may
be stated to be rare after 40, not unknown after 50. The cases admitted
into a general hospital like St. George's do not fairly present the pro-
portion of children affected, since so many of these find their way into
hospitals special to them ; the following figures, therefore, understate the
occurrence of the disease in childhood. With this qualification they may
be of value. Of 44 fatal cases of nephritis at St. George's under my own
observation, all of them certified by post-mortem examination, the ages
at death were as follows: — under 10 years, 12 ; from 10 to 19, 7 ; from
20 to 29, 10; from 30 to 39, 9 ; from 40 to 49, 4; from 50 to 59, 2.
The oldest patient was 56 years of age.
Causes. — As j/redisposing causes several present themselves — climate,
heredity, drink, and mental or nervous exhaustion. Climate has a para-
mount, oveiTuling influence. Inflammatory conditions of the kidney are
more frequent in temperate climates than with the extremes of either
heat or cold, so that a medium temperature may be held to conduce to
inflammation of the kidney, as a temperature of the tropics conduces to
that of the liver. At the same time a hot climate is by no means a
preventive, for I have known acute nephritis to have been brought on in
hot weather in India by keeping on wet clothes or long sitting in a cold
bath. With regard to heredity, I may refer to a remarkable instance in
which chronic albuminuria declared itself in four generations and fifteen
individuals of an ancient family. From such post-mortem evidence as
was obtainable, and from the fact that one of this stricken race ^ got
completely rid of his albuminuria after having had it for many years, it
was inferred that the disease was a very chronic form of nephritis. It
might be debated whether in this case the hereditary tendency should
not rather be called the exciting cause than the predisposing, for at least
one of the subjects presented albuminuria at birth. Leaving the verbal
question as of no importance, it is certain that heredity is a potent factor
in the production of nephritis.
The especial liability of drunkards to be attacked \Aath acute nephritis
on exposure to cold, seems to warrant the placing of alcoholic intemper-
ance among the predisposing causes of this disease. Among the cir-
cumstances which, I think, predispose to nephi'itis are mental depression
and nervous exhaustion. I have known this disease to come on under
such circumstances from causes which would seem otherwise inadequate,
' Occasional Papers on Medical Subjects, W. H. Dickinson, p. I.0O.
3S8 SYSTEM OF MEDICINE
that I cannot doubt that the renal susceptibility is increased by nervous
or constitutional depression.
I have satisfied myself that the tuliercular diathesis has no special
association with nephritis. Before lardaceous disease was differentiated,
it was conunon in the post-mortem room to hear a large white kidney
called scrofulous. There miglit be some excuse for thus characterising
the kidney of this type when it was lardaceous, and the result of scrofu-
lous disease ; but the kidney of nephritis proper is not more apt to
present itself in tuberculous persons than in others.
Coming to the exciting or innnediate causes of nephritis, it would be
possible, were we to include the more chronic varieties, to give a list which
should contain most of the causes of the granular kidney, as well as of
what is generally recognised as nephritis, for the granular kidney is
virtually a late result of nephritis in a chronic form. But I will restrict
myself to nephritis in its more acute form according to the general
use of the term. This limitation will exclude gout, which appears to
have little to do with tlie acute forms of renal disease, however much it
may l)e concerned Avith the chronic.
The exciting causes of nephritis may be briefly classed as unnatural
or excessive stimulation of the glandular function, irritation of the organ
possibly not directed especially upon the secreting function, undue
determination of blood to the organ, or retention of blood in it.
In detail the causes may be thus S2:)ecified : —
1. Circumstances which throw upon the kidney the work of other
glands. Cold to the surface of the body, by checking perspiration,
directing upon the kidney what should escape by the skin, and driving
the blood from the surface inwards. Obstructions to the escape of bile,
whence this irritant has to be vicariously eliminated by the kidney.
Diabetes, which pours sugar, which is a renal irritant, upon the channels
of urinary elimination. Destruction of one kidney, whereby double
work is thrown upon the other.
2. Diseases which develop a renal irritant — scarlatina, measles,
diphtheria, er^Tsipelas, septic disease, typhus, pneumonia, cholera ,(?), acute
rheumatism (?).
3. Mattel's taken from without which act as renal irriUmts : turpentine,
cantharides, alcohol, lead, arsenic, etc.
4. Conditions which act directly upon the renal circulation. Preg-
nancy, by obstructing the venous exit ; that this state interferes with
the kidney in some other Avay is probable, the mechanical process
admits of no doubt. Valvular disease of the heart, by causing venous
congestion — less renally mischievous than pregnancy. Malarial disease,
by driving the blood from the surface to the deep organs.
Before considering these causes in detail I annex two numoncal
statements, which display the frequency of the several causes of nephritis
at different periods of life : —
DISEASES OF THE KIDNEY
359
Supposed Causes of Nephritis in 86 Children between the Ages
of 2 and 1 2, from the Hospital for Sick Ch
Scarlatina .
Measles
Cold
Erysipelas .
Acute rheumatism .
Eczema
Idren.
75
3
5
1
1
1
86
(?)
23
6
6
7
3 (?)
MX'Ip
ng on loins
I have collected from my own notes 50 cases of nephritis in adults in
which the causes appeared to be reasonably clear. The preponderating
influence of cold is apparent. This agency, alone or Avith others,
iiccounted for 30 of the 50.
Supposed Causes of Nephritis in 50 Adults (Ages from 20 to 53).
Exposure to cold or wet
Cold or wet togethei- with diink
Drink
Scarlatina .
Acute rheumatism .
Malaria with exposure
Sleeping in newly-painted house
Pregnancy .
Destruction of one kidney by tube
Heavy weight (sack of coals) lalliug on
50
Some of the causes of nephritis may be considered in further detail.
Cold in the adult is the most frequent of all the causes of the disease,
definitely accounting for more than half of the cases. Among children
cold is far less common in this relation than scarlatina. To produce the
result the cold must be applied in a temperate or warm climate. Nephritis
or renal dropsy is not a disease of the arctic regions. I suppose the
active combustion required for the maintenance of vital heat consumes
matters which in other circumstances might be thrown upon the kidneys
to their detriment. The tropics afford no constant protection from
nephritis, however generally infrequent are inflammatory aflfections of
the kidney in these regions. I knew an instance where a young officer
was immediately attacked with severe nephritis during hot weatlicr in
India, after getting wet through in a thunderstorm and afterwards
long sitting in a cold bath. Cold to produce nephritis is usually long or
repeatedly applied, often during perspiration, and often during exhaustion
or in connection with alcoholic excess. The cold, to be eff'ective in the
manner in question, is usualh'^ applied for some honi-s, often for days or
weeks. A walk of several hours in snow, a long drive in cold weather,
a day's work in cold and wet, may be cited as examples, as also may be
a shorter exposure, as in the case of a drimken man who refrigerated
himself by swimming in the Thames. Protracted cold bathing, apart
from alcoholism, was presented not only in the case of the officer I have
36o SYSTEM OF MEDICINE
just referred to. Sometimes repeated exposure, day after day, in the
course of out-door occupations, has been assigned as the cause, and in
other cases the disorder has come on as the result of habitual or long-
continued exposuie. A Cornish quarryman worked for six months under
a clitf, Avhich formed the side of the quarry, from which water dripped ui)on
him, so that he was generally wet all day, and got home wet through in
the evening, often not changing his clothes. This was followed by gradual
loss of health, pains in the loins, and chronic oedema, Avith urine albuminous
to three-fifths. I knew an officer in whom an attack, at last fatal, followed
upon a month's exposure to cold and snow in Armenia. There are many
instances in which the attack has declared itself, usually by facial dropsy,
almost immediately after the exposure, as on the evening of the same day ;
in other cases it has come on later and more insidiously. A very intense and
rapidly fatal varict}^ is apt to present itself in middle-aged drunkards who
take cold in some accidental manner, perhaps connected with their vice.
The passing of bile with the urine is a definite cause of nephritis.
The epithelial cells of the kidney become intensely yellow, and a tubal
inflammation is set up, which imparts to the urine albumin and epithelial
casts. Nephritis of this origin is temporary when the cause is so ; it is
seldom severe, and not usually productive of constitutional symptoms.
Diabetes also is apt to set up nephritis and make the urine albumin-
ous. The irritating quality of the saccharine urine, which is seen in
its action upon the mucous membrane Avith which it comes in contact,
may be the reason ; but I have sometimes asked myself whether both the
allmminuria and the glycosuria may possibly have to do Avith the same
cerebral irritation. Enough changes have been found in the brain of
diabetes to indicate morbid action in it, though not enough to fix the seat
or display the steps of the morbid process. It Avas long ago shoAvn by
Claude Bernard that Avhile irritation of one part of the medulla made
the urine saccharine, irritation of another part made it albuminous. It is
conceivable that a morbid change may produce both results at the same
time. But I Avill not dAvell on speculative considerations. The albumin-
uria of diabetes is of the nature of nephritis. This condition is more
serious and lasting than Avhen due to the elimination of bile, but only in
exceptional cases gives rise to marked constitutional symptoms. A great
physician, no longer Avith us, used to say that a man had better have
both albumin and sugar in the urine than one without the other. It is
true that the al])uniinuria in these circumstances is not usually of a very
active or mischievous kind. But I have seen cases in Avhich, Avith mai'ked
diabetes, there has been equally marked renal disease, Avith albuminuria,
dropsy and cardio-vascular changes, and in Avhich it Avas difficult to
determine which Avas the primary or Avhich the more important disease.
I have known albuminuria and glycosui'ia to concur apparently as the
results of inheritance ; or rather, glycosuria to present itself together
Avith albumirmria in certain members of the family to which I haA'e
already alluded in which albuminuria was hereditary. The connection
between the tAvo conditions under tsuch circumstances is not obvious
DISEASES OF THE KIDNEY 361
Witli regard to the loss of one kidney as the cause of inHammation
in the other, it has sometimes happened, though rarely, that after the
destruction of one of these organs the other has been found to be in the
large white state of chronic nephritis. It is not within my experience
that acute renal inflammation has ever been attributed to this cause. It
sometimes comes to pass, and need be noted as a source of error, that
after the destruction of one kidney by a suppurative process the other is
found to have become the suljject of lardaceous disease, which in former
times was not suihciently distinguished from nephritis.
One of the most important causes of renal disease must be held to be
scarlatina, whether we have regard to the frequency of the organic
inflammation from this cause or to its too often endiu'ing character.
Unlike the nephritis of diphtheria, which is relatively more frequent,
that of scarlatina is peculiarly apt to involve the Malpighian. bodies and
the interstitial tissue, and to leave lasting mischief. The difterent results
of these two diseases suggest that in scarlatina the poison is especially
discharged by, or has a special relation to the Malpighian vessel ; while
in diphtheria the part so selected is the epithelium. But so long as the
scarlatinal poison itself is only a matter of hypothesis, speculations upon
its demeanour are idle.
Not only does scarlatinal nephritis continually prove fatal as acute
renal dropsy, but it is no uncommon experience to trace the chronic
granular kidney to an attack of this fever many years before. In such a
case it is possible that there may have been no early dropsy, even no
dropsy at any time ; though the broken health may with suflftcient prol)-
ability be followed back to the remote disorder of which the renal result
was imperfectly evident in the recent stage. At the same time, it is to bo
fully recognised that a lai-ge proportion of attacks of scarlatinal nephritis
pass off" in the recent stage and leave no wrack behind. It is certainly
the exception for a person, Avhatever his age, to pass through an attack
of scarlatina without the presence of albumin in the urine ; though there
may be only a trace, and that for a short time, in which case there may
be no other sign of renal disease. The late Dr. Hillier found albumin
in about half the cases of scarlatina under his care at the Hospital for
Sick Children ; my own experience would fix the ratio higher, thou-ji it
is to be recognised that the frequency of nephritis varies in difterent
epidemics. \_Fide art. "Scarlet Fever," vol. ii. p. 154.] How large
a proportion of children who suff"er from renal dropsy owe this to
scarlatina will be apparent from the table at page 359, where it is
shown that of 86 cases of nephritis, of which the causes were recognised,
75 were traced to this. Scarlatinal dropsy is rare under a year old,
though I have known it at the age of ten weeks. The number of
deaths from this aff"ection,^ as might be expected from the incidence of
scarlatina, increases from the first year to the fourth, after which it steadily
diminishes. Among grown people the proportion of dropsy, or nephritis,
^ See Dr. Tripe's table, deduced from the reports of the Eegistrar- General referred to in
my book on Albuminuria.
302 SYSTEM OF MEDICINE
which presents itself ns the result of scarlatina is comparatively small,
though it is an item whicli has to he reckoned with. The table at page
359 shows that in the adult nephritis is attributed to scarlatina far less
often than to cold, perhaps less often than to drink ; though the inter-
mixture of the alcoholic with other morbid influences makes it difficult to
speak exactly.
Scarlatinal nephritis may come on at any period after the first appear-
ance of the febrile symptoms. With malignant scarlet fe\er the urine is
often bloody, scanty, and albuminous almost from the first. Where the
fever is ver}' mild, so as to be })ossibly uruioticed, the renal affection may
be the first ostensible sign of illness ; though in such a case inquiry will
probably show that the child has been exposed to the infection, was after-
wards feverish, and })erhaps had a sore throat. According to Dr. Tripe,
the drop.sy most often appears on the fourteenth day, but may be delayed
even to the eighth or ninth week. Dr. West assigns the second week
of the disease as the most common time for the commencement of the
renal sequels, and believes that if delayed later they are usually mild.
Of 60 cases at the Hos])ital for Sick Children 5 showed dropsy Avithin a
week of the appearance of the rash. In 42 the dropsy began between
the end of the first week and of the fourth ; in the remaining 13 it came
on in the second month ; in 2 near the end of it. Speaking generally,
the probability of renal mischief lessens much after the first month, but
is not over until after the second. It is to be fairly inferred that the
kidneys are among the selected loci of the scarlatinal poison, or are
especially irritated by it as it makes its exit ; but the state of the skin
has also a l)oaring upon the renal manifestation. It is impossible to
dissociate cutaneous desquamation from scarlatinal nephritis ; the time
of desquamation is especially that of nephritis. Exposure to cold particu-
larly during this time is apt to bring it on, insomuch that in convalescence
from scai'latina greater care is necessary in this respect than in the corrc-
s|)onding period of perhaps any other febrile affection. In the critical
state of the scarlatinal kidney it is obviouslj^ inadvisable to throw upon
it more than can be helped of what should escape by the skin. It was
once the vogue to anoint the peeling surface with a mixture of olive oil
and lard, l)y way of preventing the scattering of the scales which Avere
thought to be the chief vehicles of infection. Bvit it is to be doubted
whether these are the chief agents in carrying the disease ; and at any
rate the stopping-up of the j)ores with grease cannot but further embarrass
the cutaneous functions already impaired by the desquamating process.
These considerations were suggested to mc by observing, as I thought, a
disproportionate amount of renal disease in patients so treated.
The next cause of nephiitis which calls for especial mention is
diphtheria. The albuniirnu'ia, oi- in other words the nephritis, of diph-
theria differs from that of scarlatina in these important particulars; it is
almost always present, it is early, and it is for the most part harmless.
Albumin is so constantly found in the urine with diphtheria, and that so
early, as to constitute a valualtle indication as to the nature of the affec-
DISEASES OF THE KIDNEY 363
tion of the throat. The albuminuria is rather an accompaniment than a
sequel. Dr. Hillier, at the Hospital for Sick Children, found the urine to
be albuminous in all but five of thirty-eight cases of diphtheria ; and in
thirteen, where the urine was examined daily, there were seven in which
it was found so before the fourth day of the disease. In the remaining
six the advent of the albumin was between the fourth day and the
nineteenth.
Lasting renal disease seldom ensues from this cause. If the patient
recover from the diphtheria, so as a rule does he from the renal complica-
tion. I have known renal dropsy to be thus produced and even prove
fatal, but such results are very infrequent. The nephritis appears to be
chiefly tubal, as must be inferred from the abundance of epithelial and
hyaline casts in the urine and the infrequency with which persistent
disease is left behind.
The evidence of acute I'heumatism as a cause of genuine or general
nephritis needs to be carefully weighed. It is not unknown for blood,
albumin, and casts to present themselves in the urine in the course of
acute rheumatism, but it is to be borne in mind that renal embolism is a
concomitant of rheumatic endocarditis, and may be the source of these
additions. Renal embolism is not attended with dropsy, and cannot
account for this symptom should it be present. But rheumatic endo-
carditis may give rise to dropsy, and also to renal congestion, which may
make the urine bloody and albuminous, and thus simulate nephritis in so
many particulars that the distinction is not always easy or possible. Be
this as it may, I have known dropsy and albuminuria with the characters
of nephritis to come on with, or closely upon, rheumatic fever and be
attributed to it. But Avith the sources of mistake to which I have re-
ferred, and the obvious infrequency of rheumatic nephritis, if such a
thing there be, I am rather sceptical as to the existence of any direct re-
lation between the febrile and the inflammatory disease.
Alcohol, as a cause of renal disease, has given rise to some difference
of opinion. Enormous, almost inconceivable quantities of alcoholic
liquor are often taken without any such result. As a cau^e of the
granular kidney alcohol occupies a very subordinate position. But with
regard to nephritis, and that of a somewhat acute kind, we have evidence
that the cause is by no means an infrequent one, though far less frequent
than cold. I have already adverted to the efficacy in this respect of cold
and alcohol acting together, but alcohol alone is efficient. A kept woman,
aged twenty-eight, having been deserted by her protector, took to furious
drinking. Brandy and gin were her liquors, a bottle of brandy a day
her habit, and intoxication more or less continuous. After two months
of this she became generally dropsical, with marked urinary evidences of
nephritis. A soldier, aged thirty-eight, who had served in India, received
£68 as his share of the Banda and Kirwee prize-money. This he spent
in drink, in seven months. Porter was his liquor, three or four pots
daily his ordinary limit, according to his own statement, while occasionally
he had a "bellyful," which he expl:iined as five or six pots. After five
364 SYSTEM OF MEDICINE
und a half months of this process renal dropsy set in, for which, about
the time liis munc}' was exhausted, he became my patient in St. deorge's.
I was consulted in regard to a young lady, I think of about the age of
nineteen, who acquired renal dropsy, and I doubt not a hopeless white
kidney, after a long course of port Avinc in company with a vinous and
unwise grandfather. Alcohol as a cause of nephritis is generally some-
what acutely administered ; the result is more apt to follow a definite
period of great excess than more moderate and habitual indulgence.
It is not possible to do moi-e than einmierate, and that incom])letoly, the
other irritants foreign to the body, by which various degrees of nephritis
are produced. Among these may be mentioned cantharides, turpentine,
phosphorus, lead, arsenic, silver, and mercury. The resulting inflam-
mation is often brief and charactei'istically tiibal, as in the cases of
cantharides and arsenic. With lead the disease early assumes an
interstitial position and permanent character.
Symptoms. — The symptoms of nephritis present themselves Avith
varying degrees of acuteness, sometimes abruptly, sometimes insidiously.
To take, first, the more acute form, which is usually due to cold, the symptoms
which first attract notice are facial oedema and scantiness of urine, which con-
tains albumin and casts, and often blood. ^ These urinary changes, together
with puflfiness of the face, may appear within a few hours of the exposure
or on the next day. There may be dull pain or sense of weight in the
loins and a general feeling of illness, but there is no acute pain or active
distress ; the disease makes its own sedative. There is often vomiting in
the beginning of the disease as well as in its course, and there is total
want of appetite. There is sometimes at the beginning, especially when
the disease is the result of cold, a certain amount of febrile action, witlj
dryness of the skin, but rigors are exceptional, as also is a continued
high temperature ; though the temperature is often raised l)y the various
complications Avhich are apt to occur in the coiu-se of the disease. Hard-
ness of the pulse and dropsy begin and continue together. A time
may come, after the acute disease has become chronic, Avhen with a
further increase of vascular tension and the superaddition of hypertrophy
of the heart the dropsy will lessen or cease ; but I refer now only to
the acute or recent condition. This is chiefly charactei-ised by dropsy
and the state of the urine, though there are many complications which
will modify the course and shape the end of the disease. The
dropsy, as oedema, is general and especially conspicuous in the face,
legs, and loins, though not so extreme as it is apt to become in cases
which run a slower course than those now under consideration. The
urine may be reduced to two, three, or four ounces in the twenty-four
hours, and, especially when the attack is due to cold, may be black with
blood, atul will deposit not only blood coipu.scles, but nniltitudes
of large casts containing blood, renal epitheliima, and fibrinous matter.
The secretion is, of course, albuminous Vjeyond what the blood explains.
' III niy work on Albuminuria I liave considered the causes of nephritis in more detail
than is possible here.
DISEASES OF THE KIDNEY 565
Blood is not always present, for there is a rapidly fatal form of nephritis
which sometimes follows scarlatina in which there is no blood, though
much albumin and a great abundance of large casts, chiefly fibrinous, but
containing also renal epithelium. In such a case the urine may be almost
suppressed as if the tubes were sealed up with the exudation. It may be
found in such a case that the glomeruli are aflfected as well as the tubes.
The diminution of the urine aflbrds a rough measure of the severity and
danger of the case, and its increase one of the most important signs of
improvement. The less urine the more dropsy is a general but not a
constant rule, for it sometimes happens that, as in such a case as I have
referred to, the urine may be almost suppressed and oedema absent or
only in traces. In these circumstances I have witnessed much vomiting,
exhaustion, and feebleness of pulse, want of arterial tension rather than
excess of it, and have associated the absence of dropsy with this condition.
The urgent vomiting giA-es notice of ureemic poisoning, and forewarning
of head symptoms. Absence of blood from the virine is not a good sign ;
it is probable that the bleeding relieves the congested organ, and does
good rather than harm. Such cases as I am now discussing tend to
death by cerebral uraemia most often displayed by repeated epileptiform
convulsions variously intermingled with degrees of coma ; a condition of
semi-coma being finally succeeded by nearly complete vniconsciousness
and stertor, though the unconsciousness is seldom 50 profound or the stertor
so guttural as ensues upon cerebral haemorrhage.
It is not possible to make a definite separation between the acute
cases and the subacute or chronic. A scarlatinal case, to M'hich I have
already alluded, proved fatal on the fifth day after the appearance of the
albumin. An intense attack from cold ended fatally on the nineteenth
day after the exposure. A similar attack from the same cause recorded
by Bright lasted three weeks, the fatal issue having been, as we may
suspect, hastened by the depleting treatment which was inevitable in the
year 1827. The more rapid cases gi-adually merge into the more pro-
tracted, Avhich we have presently to consider. When death takes place
in the acute stage the condition of the kidney presents several variations
which are determined largely by the cause of the attack. The organ is
always swollen, smooth, and congested, and the congestion more con-
spicuous in the cones than the cortex, where it is more or less masked
by the inflammatory products which in this situation are the more
abundant. The appearance varies according to the degree of congestion
and the contents of the tubes. The most striking variety is the chocolate
or cofFee-coloured kidney, which drips with blood when cut, and belongs
chiefly to the intensely congestive form of the disease which comes on most
often from cold. AVhen from scarlatina the cortex has a pale or parsnip-
coloured basis, which shows through the blood which the organ abundantly
contains and exudes. The injection may be so abundant and so fairly
distributed as to give a general pink colour to the section.
When nephritis takes its slower and more ordinary course, but is never-
theless severe, the urine becomes less bloody, supposing it to have dis-
366 SYSTEM OF MEDICINE
played blood at the outset, and it increases in amount, though not to its
normal quantity. The urine sometimes increases to much beyond the
normal amount. If this happens early in the disease, before renal fibrosis
and secondary cardio-vaseular changes are established, it is a good sign,
part of the natural process of recovery ; the kidneys are responding to
the diuretic action of the retained excreta, and all promises well. But I
am considering a case which promises ill. The most conspicuous symptoms
are usually dropsy and ansemia.
The dropsy, as general dropsy, is as extreme as any we know ; though
possibly some local dropsies, such as hepatic ascites, may lie more intense
within their limits. The areolar tissue is the first part to become
infiltrated, though the serous cavities soon become similarly occupied.
I have known the thighs and back to become so distended as to discharge
large quantities of serum through visible pores' in the skin. I have
known the abdomen to become so stretched partly from peritoneal and
partly from integumental fluid that the true skin gave way, leaving,
when the patient recovered, which she happily did, a liberal pattern of
scar-like exaggerations of the linea alha of pregnancy. I could give
other instances where, under similar circumstances, the skin has been
variously injured by distension. The dropsy sometimes includes con-
junctival oedema, a striking but not a common complication. As parts
of the general drop.sy, fluid frequently collects in the peritoneum and
pleurae, less often and in relatively smaller quantity in the pericardium.
These accumulations belong rather to the later than the earlier stages of
the disease. Of all renal conditions that of nephritis with the large
white kidney tends most to dropsy. The outflowing may to a certain
extent relieve ursemia, but is a source of danger in itself. The hydro-
thorax causes dyspnoea, to which the ascites contributes ; beside which
erysipelatous inflammation is apt to ensue upon the excessive oedema, and
various local evils — cellulitis and abscess — often follow upon the siu-gical
measures employed to relieve it. The dropsy and the amemia which
goes with it give visible characters to the disease, the bloated pallor and
the water-logged carcase.
Beside the dropsy, which is the most frequent and conspicuous symptom,
the course of the disease is varied, and often concluded by intercurrent
attacks of an inflammatory nature, especially such as affect the respiratory
organs. Pneumonia, broncho -pneumonia, bronchiti.-^, and pleurisy are
common, especially in the earlier stages, and more in young subjects than
old. These occur without any recognisable external cause, as if the
products of the disease acted as irritants to the organs of respiration. In
the majority of fatal cases one of these conditions assists to bring about
the final result. Pericarditis sometimes occurs, but far less frequently
than with the granular kidney. A condition of the larynx, which may
probal)ly 1)6 termed intiammatory cedema, sometimes presents itself.
Laryngeal dyspnoja comes on somewhat suddenly with alteration or
loss of voice. The mucous folds above the epiglottis are swollen and
puffy, and the epiglottis may be felt with tlie finger to be thick and
DISEASES OF THE KIDNEY 367
prominent. Should the case terminate fatal!}', a general submucous
infiltration will be found above the true cords, involving the epi-
glottis and arytseno-epiglottidean folds. Croupy breathing is the most
obvious sign of this condition, Avhich not infrequently precedes and
contributes to the fatal ending. I may here interpose a word to the
eflfect that this complication is often successfully treated by liberal
acupuncture of the parts affected and the inhalation of steam. Mem-
branous inflammation of the larynx — true croup — has sometimes been
known to occur under such circumstances as I am considering, especially
in hospitals 5 but I think that this has been truly diphtheritic and the
result of infection, not a simple result of the renal disease.
Ursemic attacks, usually convulsive in nephritis, frequently occur in
the advanced stages of the disease, or in intense forms of it not of
long standing. Epileptiform seizures present themselves, often, but not
always, preceded by vomiting or headache ; and may recur at short
intervals and in great numbers, j^erhaps sixteen or seventeen in as many
hours. The intervals are occupied by drowsiness or incomplete coma.
The attacks are often fatal, but not necessarily so. When they occur in
acute disease, in young persons, and when the kidneys are capable of
recovery, they often pass off under treatment and leave the patient none
the worse. To show the frequency of ursemic head symptoms under
nephritis, and the preponderance among them of convulsive attacks, I
may state that of 63 cases of nephritis under my care in which recovery
took place, convulsions occurred in 5 ; coma without convulsions not at
all. Of 57 fatal cases, convulsions occurred in 17; coma without con-
vulsions in 2. Thus it appears that of 110 cases of nephritis, inclusively,
convulsions occurred in 22 ; coma without convulsions in 2. Thus,
speaking of nephritis in general, it appears that convulsions occur in one-
fifth of the cases. ^
Nephritis is usually attended from the first with an mcrease of arterial
tension, and as a consequence Avith the cardio-vascular changes Avhich
ensue upon it, hypertrophy of the heart and thickening of the arteries ;
and in advanced cases the retinal alterations which belonc; to the same
process. I have distinctly recognised hypertrophy of the heart as a result
of nephritis of not more than six weeks' duration. I need not dwell on
these changes at present, as they will receive fuller consideration in
connection with the granular kidney. It is to be borne in mind that the
kidney of nephritis is not divided from the granular kidney by any
abrupt separation or essential difference in the pathological process by
which the two are produced. One may pass into the other. The
cardio-vascular changes are of the same nature in both, their establish-
ment being chiefly a question of time. It may be mentioned in connection
with the vascular changes that epistaxis sometimes occurs with nephritis,
though not so frequently as with the granular kidney.
The dupation of nephritis cannot be expressed in absolute terms. Of
^ I have given further particulars in my book on Albuminuria, to which I have already
referred.
368
SYSTEM OF MEDICINE
those who completely recover, the vast majority do so within a year. Of
those who die, the majority do so within six months, though there is a
small but very conspicuous minority in which the acute condition becomes
chronic, and the chronic condition ])crmanent, lasting in one shape or
another for many years, possibly with a delusive interval of apparent
health between the beginning and the end. I found that of 50 fatal
cases of all ages the termination in all but one occurred within the first
six months ; but the wdiole story is not revealed by this comparatively
limited record. There are many cases, particularly after scarlatiiia,
wlien fibrosis is peculiarly apt to assert itself, where the later stages take
the almost indefinite chronicity of the granular kidney, Avhich is the
organic condition ultimately attained to.
The causes of death in nephritis vary according to age. Under
sixteen the fatal issue, in more than half the cases, is brought about by
some inflammatory affection of the organs of respiration. After sixteen
this cause accounts for only about a seventh. Cerebral urfemia takes
the second place before sixteen, and the first after that age. Dropsy and
Fig. 1. — Pulse-tracing in acute nephritis of 14 days' standing in a boy aged 14.
Marey's sphygniograph. 150 grammes jjressure.
its direct consequences at both periods come next to urjemia, next to this,
at both periods, peritonitis, and then pericarditis, which is very infre-
quent with nephritis as compared with the granular kidney.
The urinary changes of nephritis may be briefly indicated ;
within the space to which I am limited it is impossible to do more. The
urine is usually diminished in quantity at the outset, sometimes nearly to
suppression ; wliile during recovery, should this occur, it is often greatly
in excess of the normal amount. It often, at the very beginning, gives
traces with the guaiacum test of the blood crystalloids, Avhile at an early
period corpuscular blood generally presents itself, sometimes in large
<piantity. Much albumin is early present, which diminishes with the
stress of the attack. AU^uminuria with nephritis is so nearly constant
tliat an exception has the interest of a curiosity. I will mention one.
A male child of the age of ten months had what could not be otherwise
legarded than as acute; renal dropsy. Tliere was no history of scarlatina
or of other cause. Wlien he came under notice tlie disorder had lasted ;i
fortnight. There was then much general a'dema, which became extreme
until the eyes were nearly closed by the surrounding swelling, the limbs
distended, tense, and shiny, and the hands and feet nearly globular.
DISEASES OF THE KIDNEY 369
After two convulsive attacks he died ten days after he was first seen.
Tlie water, whicli was extremely scanty, could be obtained only on one
occasion. It was ammoniacal. There was a doubtful trace of opacity
after heat and acid, leaving the presence of albumin equally a matter of
doubt. The kidneys were buff-coloured and firm in texture; the pair
weighed one ounce and half a drachm. The tubes were generally
occupied, and in some places distended with epithelium and fibrinous
cylinders. Prepared sections failed to display any interstitial change.
The case was one of intense tubal nephritis.
Tube-casts of various kinds and renal epithelium seldom fail to show
themselves in great profusion.
To revert in brief to one or two particulars : the diminution of urine
at the outset furnishes a rough measure of tiie severity of the attack. I
have often known the urine to be reduced to less than two ounces in
the twenty-four hours, and occasionally to about half an ounce. Such
diminution is generally a fatal omen. It is generally dependent either on
nearly universal stopi)age of the tubes or the extensive participation of
the Malpighian bodies in the inflammatory process. Diminution to a less
extent, for exam})le to half or a quarter of the normal amount, is con-
tinually followed by recovery, this process being often attended with
diuresis. I knew an instance in which this salutary flow amounted to
240 ounces in twenty-four hours. The specific gravity gives an average
of about 1019 ; in the most acute conditions, where the secretion is very
scanty, the specific gravity may be much higher; in the later stages it is
often as low as 1010, or even lower. In the early stages, and sometimes
for long afterwards, the urine may be black with blood, or it may present
only an almost invisible trace, or none. The total absence of blood,
particularly in an acute case, is not a good sign, 1)ut the reverse ; the
haemorrhage appears to relieve the organ. Epithelial cells, sometimes
fatty in the later stages, are usually found. Early in the disease these
may be so abundant as to form a sediment conspicuous to the naked
eye. Casts of the tubes are generally present, the abundance of which
is usually commensurate with the activity of the disease. The special
cast of recent tubal nephritis is the epithelial, a delicate cylinder of
fibrin embedding epithelial cells. Sometimes the cells are so massed
together that nothing else is visible. Blood appears in the casts, or may
even chiefly compose them during the hsemori'hagic process. In the
advanced stages of the disease the tubes sometimes lose their epithelial
lining, and discharge casts of large diameter and strongly-marked outline,
consisting chiefly or entirely of transparent fibrin. During recovery the
casts diminish and ultimately disappear.
There is a condition to which the term acute nephritis applies, though
the inflammation appears to be limited to the interstitial tissue ; with
this there may be little urine, much albumin, acute and general dropsy,
and all the constitutional symptoms of ordinary diffuse nephritis, such as
results in the large white kidney ; but with all these evidences of acute
renal inflammation there may be no casts from first to last. Such cases
VOL. IV 2 b
370
SYSTEM OF MEDICINE
are rare, and, so far as I liavc seen, fatal. They ma}'' be described by the
term acute interstitial nephiitis.
It may suflice to tjive a brief sumnuuv of the chemical changes in the
urine in nephritis. Albumin is almost always present, sometimes in amounts
which are greater than are found in any other renal disease. The
maximum is about 35 grammes, or an ounce and a quarter in twenty-four
Fio. 2. — Casts of nopliritis cnntainiiip fibrin, epithelial colls and pranular matter. One large cast
includes othcns iu its interior. (From Dickinson's Albuminuria.)
4
hours. The loss of even half this amount would )>robal)ly tell, by way of
impoverishment, u]ion the system at large. All the normal constituents
are diminislied — the water, the urea, and the chlorides — to a greater extent
than occurs in an}'^ other disease of the renal sub.stance. The phosphoric,
sulphuric, and uric acids are reduced in a less marked manner ; of these,
the uric acid apparently suffers least. In some cases, indeed, during the
process of recovery, uric acid is di.scliarged in abnormal abundance ; and
a similar statement may be made Avith regard to the urea and the water.
I
DISEASES OF THE KIDNEY 371
Treatment. — In treating nephritis \\q may generally hope that we have
to do with a disease which has a natural tendency to get well, so that our
endeavours must be not so much to cure the patient, as to place him in
favourable circumstances for recovery. Certain complications may, how-
ever, present themselves in which active interference is called fur. The
primary considerations which must guide our conduct are these — to abate
renal hypera^mia, and to avoid whatever may produce it in tlie shape of
renal irritants ; to relieve the kidneys of work so far as is consistent with
maintaining an abundant flow throu2;h the tubes : to ensure this flow,
without irritating the gland, so as to keep the tubes clear ; to keep the
skin active and the bowels free, and thus direct into other channels
matters which might otherwise be thrown upon the kidnej^s to the injury
of these disabled glands. The keeping down of ura^mic accumulation is
a secondary though important pui'pose which the measures indicated will
subserve. The diet in an acute and recent case should be wholly liquid
or only with the admission of a little farinaceous food. Arrowroot may
be commended as both liquid and farinaceous, but more solid foods of
this class may be given in the early pi'ogress of the disease. Milk may
be given freely, but the diet shoidd not wholly consist of it. Light
animal broths should be included ; no concentrated essences, but thin beef-
tea or thin broth of other kinds. It is essential that water should be
freely introduced, either pure or sophisticated. Lemonade and barley
water serve the purpose, but perhaps pure water is best of all, especially
distilled water, such as may be ol>taine,d under the name of Salutaris.
Malvern Avater is nearly equally pure and is more palatable. Water,
whether pure or only slightly modified, is the best of diuretics ; not only
is it without irritating properties, but it lessens by dilution any irritating
quality which the urine may possess. Alcohol should be entirely
inhibited unless there be some special reason for its employment. The
patient should be kept in a warm bed in a warm room, at a temperature
not high enough for discomfort, but higher than is common in a hosj^ital
ward or sick chamber. Hot-air baths may be called for by any threaten-
ing of ura?mia, but are not generally necessary. It is essential that free
action of the bowels should be ensured. I am accustomed to begin with
a mercurial purge, calomel with compound jalap powder or haustus
senn?e, and to follow it up with a saline laxative. Sulphate of magnesia
is perhaps the best purgative in such cases as I have in view, while one of
the alkalising salts of potash should be in some way superadded. We
must not forget that sulphate of magnesia is decomposed by the vegetable
salts and carbonates of the alkalies. A small dose, 2 or 3 drachms,
of the sulphate may be given every morning, and a drachm of i)otassio-
tartrate of soda, or of tartrate or citrate of potash, three or four times a
day. A drachm or half a drachm of sulphate of magnesia may be given
in an ounce and a half of water, together with a drachm of tartrate of
potash ; the solution decomposes, but does not at once precipitate.
After a time iron becomes desirable. In the later stages I have been in
the habit of giving at bed-time and on rising some such mixture as this —
372 SYSl^EM OF MEDICINE
a drachm of sulphate of magnesia, a drachm of aloes wine, and ten niininis
of the tincture of perchloride of iron. If it be desired to include an
alkalising salt, tartrate of potash may be given with tartrate of iron and
a little decoction of aloes. Digitalis must receive especial mention as
demanded whenever the urine is very scanty, as it usually is in the early
stages, and when dropsy is present. This invaluable remedy may be
introduced as infusion or tincture into an}^ of the mixtures which I have
mentioned.
Some of the complications require special treatment, others none.
The horizontal posture must be strictly maintained when the legs are
affected, which is usually the case. Tlie paramount effect of digitalis
has already been adverted to. If other measures are needed, })eriodical
hot-air baths, best to the legs only, are of great service ; they not only
remove the fluid, Imt by purifying the blood they correct the condition
on Avhich the dropsy essentially dejiends. Hydragogue purgatives at
regular intervals are of service for similar reasons, but neither sweating
nor purging must be too energetically enforced, since they may injuriously
increase the an:Bmia which is one of the factors of dropsical effusion.
Puncture of the legs should be avoided when possible on account of the
local inflammations which are apt to ensue, and are often fatal. Anti-
septic precautions should be strictly employed, notwithstanding the
apparently trivial nature of the opei'ation. The belly may be tapped
with less danger, and generally with advantage, and with relief to the
legs as well as to the abdomen. I have often thought especial and
general relief to follow from tapping one of the pleura^ Avhen it contains
much fluid ; not only does this relieve the breathing, but b}' taking
pressure off the lung it releases the general venous outlet and promotes
absorption. Urajmic convulsions, or the threatenings of them, must be
met promptly and vigorously with eliminants, hot-air baths, and
hydragogue purgatives. The hot-air bath may be up to the neck, if the
circumstances are pressing ; and if it fail to produce free sweating, the
patient may be immersed for two or three miiuites in a bath of very hot
water, say 108^, and the hot air again applied. If the blo'od-jn-essure
be high and regular, the hot air nuiy be j)receded by a subcutaneous
injection of pilocai-pin ; but this dangerous dosing must be used with
great caution, and at the initial dose should not be more than one-tenth
of a grain. Of purgatives, elaterium is the most effective ; calouiel
is also of use, coml)ined with some quick aperient, and may generally
be given with safety if not repeated. Should the convulsions be violent
and alarming, chloroform, chloral, or bromide of potassium may be used
as a palliative, tliouL'li it is with some unwillingness that one poison is
thus a<l(ied to another. Inflamuiatnry attacks must Ite treated on general
principles with a general avoitlance of opium and mercury. (Edema of
the glottis usually yields to the inhalation of steam and acupuncture.
Pericarditis is little under tlic influence of nuMlicinc.
When the disorder has assumed a chronic and quiescent form it is
necessary, among other precautions, to guard against anaemia. The
DISEASES OF THE KIDNEY 373
rigidity of diet may be relaxed, and a little meat and fish allowed, perhaps
one meal of each daily. Iron is generally called for, which, as a rule,
should be associated with some laxative so as to ensure two actions of
the bowels a day, or three in two days. Other medicines being now put
aside, it will suffice to give morning and night, or in the morning only,
such a mixture as I have already referred to, containing iron, sulphate of
magnesia, and aloes, the doses being adjusted to produce the desired
efTect. In the later stages of chronicity a resort to a warm climate
especially in winter, may be of great service.
II. The Granular Kidney. — Pathology. — The pathology of the
granular kidney may first receive attention. The essential alteration
is an overgrowth of tlie interstitial intertubular or fibroid tissue as
the result of a slow process akin to inflammation, or amounting to it
in its most chronic form. The overgrowth is succeeded by contrac-
tion and the compression of the tubes and Malpighian bodies to
their gradual atrophy and jjartial extinction. The morljid change is
analogous to that which in tlie liver leads to cirrhosis. There are two
modes by which the contractile renal fibrosis wliich eventuates in the
granular kidney may be produced, Avhich, however different in their
beginning, are virtually the same in their results. Most frequently the
granular kidney comes on insidiously, with no early symptoms, by way
of chronic and long unnoticeable change in the interstitial tissue. Less
often the mischief is set going by an acute attack of difi'use nejjhritis, such
as follows scarlatina, or may be due to other causes.
The granular kidney of gradual origin may be traced in its patho-
logical progress by putting together jjost- mortem observations relating
to different stages. In this condition the intertubular overgrowth is of
gradual production and in small amount ; the contractile process follows
closely in the wake of the hypertrophic, so that the organ shrinks from
the first. The contractile overgrowth shows itself as a fine hyper-
nucleation which begins under the capsule and about the blood-vessels,
and works its way inwards so as to involve in time the greater part of the
cortical tissue. The hypernucleation usually presents itself in wedge-
shaped regions, with the base at the surface, the apex pointing inwards,
and slowly extends to the intermediate and deeper parts. The tubes are
separated, variously constricted, and in places practically destroyed, though
remnants may be discovered with the microscope. The Malpighian
bodies surrounded with new contractile tissue are in like manner com-
pressed and sometimes obliterated.
The naked -eye changes are at first slight, the capsule becomes
thickened and adherent, the surface loses its smoothness and its even curve,
and becomes beset with small i)rojections which are but faintly indicated,
and which look like exaggerations of the minute subdivisions into which
the surface is normally subdivided by the blood-vessels. The projections
are not actual outgrowths, but are made by the drawing in of the inter-
granular intervals by the contractile process. The separating vessels are
374 SYSTEM OF MEDICINE
often eiilaviiC'd and somewhat stellate. The colour cm surface ami section
is as yet little altered, or may be of a somewhat deeper tint than natural.
In time the superfi(;ial granulations become more declared ; the cort^'X
first, then the whole organ, shrinks and cysts are developed, notwith-
standing which there is much loss of bulk, so that ultimately the
weiuht of tlie onran may be reiluced to half Avhat it was. In the
advanced stages the superficial granulations are often large, pale, and
conspicuous, and sliarjily contrasted with the vascular depressions which
lie between them. They are more or less hemispherical, or at least
present the shape of segments of spheres. The cortical layer between
the cones and the capsule may now be no thicker than a shilling,
while the deeper parts are also reduced in bulk, the cortex more
than the cones. The general colour of the organ on surface and
in section may be more or less btiff, or it may retain nuich of the
reddish or brick-dust colour with which it started. In a practical
outline of this kind it is needless to follow the minute changes in
detail. The leading factor is the development of the intertubular con-
tractile growth, to the strangulation of the essential elements of the
gland. Large regions of the tuhtilar structure are virtually destroyed,
the tubes being reduced to attenuated and useless remnants, or even
entirely replaced by fibrous tissue. The epithelium is variously atrophied,
compressed, and distoi-ted l)y the contractile process. The ]\Ialpighian
bodies I'esist longer than the tubes, and sometimes groups of them may
be seen close together or in absolute contact, all the intervening structures
having disappeared while these only remain. In time many of the
Malpighian bodies are destroj^ed, or reduced to a small size by com-
pression. Sometimes they imdergo a cystic transformation as a result of
the obstruction of the tubes with which they are connected; fluid collects
between the capsule and the vessel, with dilatation of the one and com-
pression of the other. Together with the tuln'S the intertubixlar
ca[)illaries are obliterated or rendered impervious, and thus an obstacle is
put in the way of the escape of the blood from the stu-viving ]\Ialpighian
bodies. This cannot fail to enhance the blood-pressure in the Malpighian
coil, and thus increase the watery discharge from it, a consideration
which maj'- help to explain the ])olyu.ria of the granular kidney. The
arteries, large and small, are tliickened. The primary renal arteries are
measurably thickened in both their coats, but their calibre is not con-
siderably or constantly diminished. I have taken some pains to ascertain
the point by measuring with the rota meter, with the help of enlarged
outlines, the internal circumference of the ren;d artery in granular and
healthy kidneys. I find that though the artery of the granular kidney is
more various in size than that of he.dth (2), yet that the average calibre of
the two is practically the same ; I found it to be exactl}' the same in the
male, nearlj' the .same in the female. This point has its interest as con-
cerns the renal circulation. !M:iny years ago I ascertained, by directing
water through the renal vessels, that the granular kidney on an average (18)
transmitted less than a quarter of the amount transmitted by the healthy
DISEASES OF THE KIDNEY 375
kidney under corresponding circumstances. Thus it seems that there
is a great obstruction in the renal circuhition, and that this is not in the
large arteries. It must be phnced in the minute vessels of the gland, the
arterioles of which are visibly thickened and narrowed, while it is
obvious that the capillaries are extensively destroyed.
Small cysts are very often found in the cortical tissue of the granular
kidney and displayed upon the surface. These are made out of the tubes
which are cut into segments bv the contractile tissue outside them. An
occasional but not a necessary change in the kidney of this kind, as of
that of nephritis, is a general fatty degeneration of the epithelium.
This sketch of the morbid anatomy of the granular kidney of gradual
and concealed origin will serve in most of the later respects for that
which conies on as the sequel of acute nephritis. But the early stages
are different, and to them a few woids of separate description must be
given unless this outline is to be left conspicuously incomplete. The large
white kidney of nephritis is usually fatal as such, with the kidney large
and smooth, or only Avith a few dimpled depressions to indicate the
beginning of contraction in the still excessive bulk. It must not be
forgotten that Avith the large white kidney the inflammation involves not
only the tubes but the interstitial tissue, which with time and opportunity
may take upon itself the contractile process wliich is the essential agent
in the making of the granular kidney. AY hen nepliritis proceeds to
granulation it maybe presumed that the inflammation is ])rotracted rather
tlian intense, and that the large white stage, though more or less
accomplished, has not been as fully declared as when death has been its
immediate result. The granular kidney of this origin, though it may
have become smaller, even much smaller than natural, still retains on
surface and section mucli of the pale or parsnip tint which belongs to
nephritis. The shrinking is most marked under the surface ; the retention
of the nephritic character is most conspicuous in the deeper parts between
the cones, which are often compressed in their centres to the well-known
Avheat-sheaf shape. The longer the disease lasts the more the characters
approximate to the oi-dinary type of the granular kidney, so that after
a time it may be difficult to decide whether the disorder have been of
chronic or acute orisiin.
For clinical purposes the granular contracting kidney, putting aside
that of lardaceous disease, may be dealt with as one and indivisible,
Avithout any attempt to distinguish the symptoms according to the origin
of the disease, Avhether in chronic change or as the result of nephritis.
Sex and Age. — As to the suljjects of the granular kidney, sex may be
considered first. It Avould be easy to midtiply evidence on this head, but
it may suffice to say that of 250 cases collected from the post-mortem books
of St. George's Hospital, 165 related to male, 85 to female subjects, and
that this pro])ortion of tAvo to one is found generally to apply. It is
obvious that some of the causes of this condition, notably lead and gout,
affect males more often than females. This may partly, but probably does
not Avholl}', account for the difference.
376 SYSTEM OF MEDICINE
The age at which the disease proves fatal, or of •which evidence is
found after death, ranges, according to my experience, from 5 years to
82, and no chnibt wider information would extend the limit in both direc-
tions. It is rare before 20, but I could mention cases fatal at the respective
ages of 5, 10, 11, 12, and 14, and many between 14 and 20. The
follo'.ving statement compiled from the post-mortem books of St. George's
Hospital gives the age at which death took place in 242 instances : —
Deaths.
1
. 17
. 38
, 73
. 55
. 43
15
Age.
0to20
21 „
30
31 „
40
41 „
50
51 „
60
61 „
70
Over
70
242
Ca,uses. — The frequently obscure origin of the disease invites a
particular inquiry into its antecedents. Of these the following are ascer-
tained as causes of the granular kidney, or at least have to be considered
in relation to its origin : —
i. Climate, Avhether predisposing or exciting, but at any rate exert-
ing an overruling influence with regard to the origin of the disease, ii.
Long prex;edent acute nephritis, or scarlatina possibly without ostensible
nephritis. iii. Gout. iv. Lead. v. Alcohol, vi. Valvular disease of
the heart. vii. Pregnancy. viii. Malarial fever. ix. Obstructions to
the exit of urine, x. As part of general fibrosis, xi. Heredity. xiL
Mental depression.
I will now pioceed to consider some of these causes in detail. The
overruling influence of climate cannot Ije dealt with here, excepting in
general terms. I may refer for particulars to the cliapter on "(liinate
in Relation to Renal Disease" in my work on AlhuminurUx. For the
present purpose it may suttice to say that the disease in question prevails
most in the temperate zone ; that it is more common in Etigland, Holland,
Germany, au<l the Northern States of America, than in the South of
France, Italy, the islands of the Mediterranean, and ])laces still farther
to the south. Coming to causes of less general and more definite
application, the first consideration must be given to antecedent acute
nephritis as a cause of the granular condition ; not that this is a frequent
cause in comparison with others, but it forms a link of connection
between the sul)ject of the present section and that of the preceding.
In old days there was much dispute whether the granular contracted
kidney was a sequel of the large white or was of independent origin.
The fact is that both modes of origin occiu", the independent frequentl}',
the consequential infrequently. Scarlatinal nephritis is es])ecially apt
to involve the interstitial tissue, and to l)e succeeded, as has been already
stated, by granular contraction. A boy died in St. George's Hospital
under the care of Dr. Ogle. He had had scarlatina severely three years
DISEASES OF THE KIDNEY 377
previously, and never been well since. He manifested the symptoms of
the granular kidney in a marked manner, and after his death displayed
tlie pathological appearances "with equal distinctness. A woman died
under my care at the age of twenty-one of chronic albuminuria, which
was apparently contiinious with an attack of scarlatinal dropsy eleven
years previously. The immediate cause of death was pericarditis. The
kidnevs, which wei<rhed together but three ounces, were characteristic
examples of the granular and fibrotic. A boy, of the age of fifteen when
last seen, was frequently luider my care in St. George's Hospital with
chronic albuminuria traceable to scarlatina seven j'ears before. His heart
was hypertrophied, and no doubt his kidneys granular. 1 lost sight of a
young woman at the age of sixteen in a similar condition, which was
apparently the result of scarlatina at the age of three. The granular
kidney may be a late result of scarlatinal dropsy, or, as there is reason
to believe, it may be a remote sequel of scarlatina Avithout the inter-
vention of dropsy, or of any of tlie outward and visible signs of acute
nephritis. AYhen chronic renal disease follows acute renal dropsy the
diopsy disappears as the heart hypertrophies, so that in the ultimate
stages dropsy may be only a matter of history.
Gout., Lead., and Alcohol are so intermixed as causes of disease that
they may be conveniently taken together. The granular kidney is so
coniTnonly associated with gout that the " gouty kidney " has become
another name for the granular. It is evident that the gouty disorder
precedes the renal, and may be presumed to be the cause of it. Gout is
one of the results of chronic lead poisoning, which toxic condition may
cause the granular kidney either together with gout or independently of
it. Given the lead, it may be said Avithout fear of over-statement that
no other cause of the granular kidney is as efficacious, though as only a
minority of the population are subjected to the influence of this powerful
poison, other causes taken together may produce the result more numer-
ously. Of 45 men who died in St. George's Hospital Avith granular
degeneration, 10 had been concerned with lead in the way of trade. Of
•i2 workers in lead who died from disease or accident in the same insti-
tution, 26 Avere found after death to have granular kidneys — in other
Avords, the painter or plumber, be his end Avhat it may, is more likely
than not by the time he has reached it to have acquired this organic
impairment. Lead is knoAvn to be excreted by the kidnej's, and it is
probable that the morbid action of this metal is as a renal irritant. This
usually acts sloAA'ly Avith the residt of the granular kidney, though
instances occur less frequently in Avhich acute nephritis is produced by
the same cause. Alcohol is a renal irritant of less effect than lead.
Some alcoholic liquors, notably beer and Avines, the sugar of AA'hich is not
completely exhausted by fermentation, cause gout, of Avhich the gouty
kidney may be a part ; but, on the Avhole, alcoholic drinks have a less
influence in causing renal disease than has often been supposed. The
kidneys and the liver are very differently circumstanced as regards
drink. The liver receives i:; from the stomach at first hand; as much as
378 SYSTEM OF MEDICINE
survives hepatic action has to be passed through the lungs before it can
reach the kidneys. jNIucli of this A'olatile substance must be got rid of
by evaporation and expiration, so that the proportion which remains for
renal elimination must be small. Alcohol has indeed been recovered
from the urine by distillation, but only in small quantities and when
much has been taken ; and it may be believed that of the amount
introduced into the stomach the proportion which reaches the remote
renal exit is under ordinary circumstances insignificant. A drunken
debauch, as has been prt;viously stated, is capable of causing acute
nephritis. There is a large, smooth, somewhat congested kidney,
partly tubal and partly interstitial, which is begotten of beer, upon the
persons chiefly of draymen ; and alcohol in general has at least some
influence in causing granular contraction. The activity of this cause
may be roughly measured by a comparison wliicli I formerly instituted
between the kidneys of persons whose employment made them conversant
with liquor (draymen, potmen, and the like), and those of others who
had no such association.^ Of 149 persons to whom drink Avas presented
in the way of dutj', 31 were found after death to have granular kidneys;
of the same numV)er of persons to whose occupations drink bore no
relation, 27 displayed granular kidneys. The ditterence is le.«s than
would have been presented had alcohol any such overpowering influence
upon the kidney as it has upon the liver. I nia}' mention by way of
illustration that in the same series cirrhosis of the liver was found in 22
of those employed about liquor, in only 8 of tliose employed otherwise.
As bearing upon the exaggerated views which have ])cen taken with
regard to the effects of alcohol upon the kidneys, it may be stated that
persons who have died with delirium tremens piesent no larger propor-
tion of kidney disease than persons who have owed their deatli to
accident Avithout any such complication. In the course of thirty-one
years at St. George's Hospital 58 jX)st-mortems were made after delirium
tremens. In 28 the kidneys were healthy, in 15 congested, in 7 granular
or C3'sted. In the same number of examinations after death from accident,
without delirium tremens, the kidneys were found to be healthy in 24,
congested in 7, gianular or cysted in 15. Delirium tremens may be
accepted as a proof of alcoholism, but before drawing conclusions it must
be stateil that the average age at death after delirium ti'emens was
thirty-eight, after death witliout it forty-one. We may at least infer that
such an alcoholic habit as suffices to produce delirium tremens does not
do so much to make the kidneys granular as three years of additional life.
VaJcular disease of the Jieart and disease of the kidney are often found
together. Tiie relation is a double one ; each may cause the other under
circumstances which will presently appear. Cardiac hypertrophy dilata-
tion and consequent mitral regurgitation are consequences of renal
disease, particularly of the granular kind. j\Iitral regurgitation from
this cause is a late and not very frequent consequence, but nevertheless
is a very real one. The mitral disease, for such it must be called, con-
^ See notes at end of chapter.
DISEASES OF THE KIDNEY
or.
sists only of dilatation without any morbid change in the flaps, Imt it is
enough to give rise to murmur and all the clinical resuls of mitral regur-
gitation. The evidence that the granular kidney is sometimes a cause of
endocarditis may be accepted, but for practical purposes it need not be
greatly regarded. On the other hand, there is evidence in abundant
detail that valvulai', especially mitral disease habitually causes renal
change wliich may proceed to the granular kidney. Habitual venotis
congestion of a solid organ — the liver, the spleen, or the kidne}' — causes
induration of its substance. As a result of valvular imperfection par-
ticularly mitral, general venous congestion is produced and maintained.
As regards the kidneys, they become full of blood, red, hard, and some-
what increased in size ; the capsules adhere more firmly than natural, and
after a time the surfaces become finely granular and give evidence of
contraction, Avhile cysts sometimes present themselves in the cortical
tissue. An early change, as revealed by the microscope, is accumulation
of epithelium in the cortical tubes ; increase of the interstitial tissue and
fibrosis occur later, and are of slow and scanty development as compared
with what takes place when the renal disease is of different origin.
Though fibroid thickening and hypernucleation are superadded in process
of time in a considerable proportion of cases of prolonged mechanical
congestion, I have often failed to find them even when the peculiar hard-
ness of tissue has led me to expect them. In the course of five years I
made post-mortem examinations of 153 persons with valvular disease;
29 of these had the kidneys hard, congested, and increased in bulk, but
still smooth, 67 had granular surfaces and contracted cortices. Thus
valvular disease is frequently a cause of renal, and it may be added that
renal disease of the granular kind is sometimes a cause of valvular ; not
onl}' by way of dilatation of the orifice, as has been already stated, but
occasionally by setting up endocarditis.
AYhen albuminuria and mitral regurgitation concur, as they often do,
the inexperienced may doubt which is the pi'iraary disorder and which
should give the chief direction to the treatment. What is to be deter-
mined is whether the albuminuria is due to independent renal disease or
to congestion of cardiac origin. In advanced cases of renal disease,
where the cardio-vascular changes are conspicuous and the heart greatly
enlarged, it is probable that the regurgitation is brought about by the
disease of the kidney ; but more often, when cardiac and renal
symptoms present themselves together, the cardiac is primary, the renal
secondary. The distinction is of great practical importance, for if the
albuminuria is merely the result of mechanical congestion, it will be got
rid of or made better by treatment directed to the heart. The results of
digitalis and mercury in such a case are often such that the physician is
glad to make a diagnosis Avliich suggests their employment. On the
Avhole, the kidneys are tolerant of the congestion of heart disease.
Persistent change is slow to establish itself. The urine, after being
albuminous, may, under treatment, cease to be so. Uraemia seldom
declares itself. Dropsy, when present, is more cardiac than renal.
38o SYSTEM OF MEDICINE
Far otherwise is it Avitli prerjiMncii as a cause of renal disease. Here,
as with licart disease, we recognise mechanical venous obstruction, but
whether because it is applied in a manner especially injurious to the
kidney, or because it is conjoined with other circumstances which are so,
it is apparent that tlie puerperal state is one of the most active causes of
renal disease to whicli woman is subjected.
It has long been known that in a considerable proportion of cases the
urine is alltuminous during the later months of pregnancy, a condition
which may be merely transient, or may eventuate in lasting renal disease.
The uriue usually becomes alljuminous in the later months, after the
fcetus has attained a considerable size, and moved from the pelvic to the
abdominal cavity. It is obvious that this change of position and increase
of bulk must be attended with compression of the vena cava, and possibly
also of the renal veins, and it is a matter of observation as well as ot
inference that congestion of the kidneys is a consequence. In many
cases the mechanical nature of this process is shown by the limitation of
the wdema to the lower extremities, and the absence of constitutional
symptoms of renal disease. In other cases the constitutional results
declare themselves ; the face becomes dropsical, dropsy indeed may be-
come more or less general ; and, together with other renal symptoms, there
is frequently that variety of uremic convulsion which from its circum-
stances is known as puerperal. There has been some diflerence of
opinion as to the immediate cause of the disorder of the kidney which
ensues upon pregnane}'. The probability is that the cause is com[)lex or
at least dujjlex. I\Iechanical congestion is a certain factor, but there is
in all likelihood something more. The kidney, as h;is been already
shown, is tolerant of mechanical congestion Avhich is slow to produce
active disease. The kidney disease of pregnancy is far more actively
mischievous than that of heart disease, it more rapidly takes on serious
organic change, and quickly gives rise to renal consequences.
The changes which occur in the kidney as consequences of pregnancy
may be briefly indicated. They are the changes of heart disease and
something more. To passive congestion is superadded an active inflam-
matoiy })rocess. In an early stage there is much hyperaeniia with obvious
fulness of vessels, general redness, and some increase of size. In a case
destined to further trouble, a somewhat peculiar form of diffuse nephritis
succeeds ; the tubes become loaded with epithelium, which early takes on
fatty change and imparts a yellowish colour in streaks or otherwise to
the section. The fatty change is not limited to the epithelium, but may
be somewhat general. The tubal change is accompanied or quickly
followed by interstitial nucleated contractile growth, with consequent
compression of the tubes, particularly near the surface, and sujierficial
granulation. The condition is one of general nephritis, iipon which
granular contraction ensues Avith inordinate rapidity. So early does the
contractile process become superadded to or intermixed with that of in-
flammatory swelling, that the more bulky results of renal inflammation
are excluded ; the large white kidney does not, under these circumstances,
DISEASES OF THE KIDNEY 381
present itself. The early access of • inflararuatory cliange would seem to
imply that other causes are at work beside the mechanical, and that these
are analogous to those to which other forms of nephritis have been traced.
It has been suggested that the kidneys are irritated by some product of
pregnancy, possibly an excrementilious result of fcetal nutrition. The
conjunction of the two morbid agencies, the mechanical and the vital,
may account for the greater activity of the disease as compared with the
granular kidney of other origin.
I think I have observed that women of slender frame more often
contract renal disease under pregnancy than those of more liberal outline.
Tlie mischief usually presents itself in the first pregnancy, at the end of
which it may prove fatal by way of puerperal conx'ulsions. Should this
not happen, the renal symptoms rapidly become mitigated after delivery,
to be aggravated with every recurrence of pregnancy. The disorder,
unless re-initiated by repetition of the cause, may long remain quiescent, or
even undergo slow improvement. It by no means follows thut, because
the urine be albuminous and the legs dropsical, permanent disease will
result ; these may be simply mechanical ; if, however, the face be also
swollen, we must infer enough renal change to produce constitutional
results, and regard the condition as one of gravity. Although, in this
place, I am dealing only wath the causes of disease, not with its results, I
may conveniently interjiose a few words of more general bearing. The
puerperal kidney has a mixed nature ; it is one of diffuse nephritis, upon
which granular contraction is rapidly superimposed ; the nephritic char-
acter is early evinced by dropsy, whicb may be widely spread and even
extreme ; the results which more especially belong to the granular state
are declared later, but are even exaggerated as compared with the common
consequences of this condition when it is of other than puerperal origin.
The tendency to acquire the retinal and other secondary lesions appears
to be disproportionately great. As to treatment, prevention is the great
desideratum. If a first pregnancy has declared the danger, it is much to
be desired that there should be no recurrence of it. "When it is ordered
otherwise, and renal symptoms become pressing, the induction of prema-
ture labour may be an absolute necessity, the only measure w^hich is
capable of affording the relief needed.
Malarial fever, especially of tiojMcal origin, is frequently succeeded by
persistent or chronic albuminuria, which we need have no hesitation in asso-
ciating with the granular contracting kidney. I have frequently recog-
nised this condition in persons who have returned from India after having
suffered repeatedly from the effects of malaria. It is probable that the
disorder is brought about by the recurrent attacks of intense congestion,
to which the kidney, together with other abdominal organs, notably the
spleen and the liver, is subjt-cted under the malarial influence. As com-
plicating and intensifying this influence is the fact that the same malignant
agency is a frequent cause of hasmoglobinuria, or " intermittent hsema-
turia" as it is also termed ; and that this is capable of acting locally upon the
kidney as a cause of nephritis and probably of its remote sequels. Most
382 SYSTEM OF MEDICINE
of the cases of renal disease of presumed malarial origin which I have
seen have been in returned Indians. The syni})toms have been such as
to indicate the fibrotic kidney, mostly very chronic or quiescent, and com-
paratively harmless. There has been little or no tendency to dropsy,
more to the cardio-vasculur chanire. A distinguished Indian medical
officer, who had seen much service, and suffered long and severely from
malarial fever, returned to England in the ye;ir 1872 with urine albumin-
ous to a third, and some indications of cardio-vascular change. The
albumin diminished with occasional periods of increase, and at last ceased
to be constantly present. He has led a ver}' active life since his return,
and is now (1896) in the enjoyment of good health, excepting that he is
slightly gouty, and that the urine sometimes displays albumin.
I call to mind two instances which ended fatally with renal symptoms.
One of these did so after sixteen years in England, most of which were
spent in active professional work. The disorder long remained without
apparent progress, l)at ultimately was succeeded by urtemic asthma and
convulsions. In neither of the cases mentioned was a post-mortem ex-
amination practicable.
Ohstrudion to the exit of urine, or the irritation which some cause of
obstruction has set up, is sometimes to be traced among the antecedents
of renal fibrosis. The liver occasionally becomes fil)rotic or cirrhotic, in
consequence of obstruction by gall-stones, and the kidney apj^ears to suffer
in a similar manner from a similar cause. Two of the most marked and
pathologically complete cases of the granular kidney which I ever witnessed
in early life — they proved fatal at the respective ages of twelve and
fourteen — gave evidence at death that tlie escape of urine from the
kidneys had at some bygone time been hindered. In the younger there
was dilatation of one kidney and of the other ureter ; the elder had been
operated on for stone at the age of three, and after death one kidney was
found to be dilated and atrophied. ]\Iore or less fibrosis of the kidney,
together with glandular atropliy, is indeed not seldom to be recognised as
a consequence of long-standing retention of urine. It is probable that
this iiritating fluid, probably made more so by ammoniacal deconijjosition,
being detained at high pressure in the renal cavities, soaks into and irri-
tates the renal structure and sets up inflammatoiy action.
The granular or fibrotic kidney lias been thought to ])e but a part of
a general or airdio-vascular fibrosis, and herein lay the contention of Gull
and Sutton which it is not needful in this place to follow in detail. It
must be allowed that with age, alcohol, and possil)ly other circumstances,
the arteries deteriorate and the fibrous skeletons of the solid organs
increase at the expense of their more actively vital constituents ; but it is
not necessary to reiterate, what has been abundantly shown, that the
granular change in the kidney is chiefly ])rodnced by causes which act
especially, and in the first instance, ui)un this organ and not indillerently
upon the body as a whole. The granular kidney frequently succeeds
upon inflammation limited to the organ. It often presents itself at an
age so early that it is impossible to credit the arteries with any general
DISEASES OF THE KIDNEY 383
deterioration or fibrosis unless it be the result of the renal mischief. And
there is ample clinical evidence that the caidio-vascular change associated
with the renal is, as a rule, not a contemporary and parallel alteration,
but is subsequent to that in tlie kidney and presumably j^roduced by it.
That the renal fibrosis, of which a granular surface is the outward expres-
sion, is local to the kidney and not general to the body is shown, as I have
elsewhere insisted, by the pathological independence of the liver and
kidney. Cirrhosis of the liver and granulation of the kidney have little
tendency to occur together. I found that in 250 cases of the granular
kidney the liver Avas cirrhotic but in 37, or 1 in 7. Valvular disease
may act conjointly on both organs, and j^roduce a lesser degree of fibroid
thickening in both : alcohol may thus affect the liver much and the
kidneys a little ; but tlie rule is that each of these organs is acted on by
morbid causes proper to itself, and not shared by the others ' or common
to the whole Ijody.
The heredity of the granvdar kidney stands on the same basis as that
of the chronic form of diffuse nephritis, of which it is a sequel (see Nephritis,
p. 357).
It has been thought that the form of renal disease under consideration
is sometimes consequent upon mental depression. There appears to be a
double relationship in this respect ; advanced renal disease of this nature
is sometimes attended with lachrymose depression, and there are instances
in which this disease has come in so immediately upon depressing circum-
stances that it may be conjectured to owe its origin to them (Allbutt).
Mental disquietude is a diuretic of no mean efficacy, and it may pos-
sibly be a cause of organic renal change. If it be so, the relation is by
no means singular; cancer and tubercle are both invited by mental
distress.^
Finally, there are mnny cases of granular degeneration, probably the
majority, without ostensible cause, or only the tendenc}' of race, or the
infiuence of climate.
Symptoms. — In describing the symptoms of granular degeneration I
Avill briefly indicate the common course of the disease, and then touch upon
its deviations. The ordinary form is that which begins gradually and
insidiousl}', not that which succeeds upon acute nephritis. The patient,
commonly a man between forty and sixty, loses his health by such
imperceptible degrees that it is usually imjDossible to say when the
disease began, or what was its cause. If gout or lead is in the record
the cause is ready to hand, otherwise it is likely to be douljtful. The
earliest obvious indications are usually hardness of the pulse or slight
oedema, perhaps amounting only to pufiiness. The urine is now dis-
covered to be albuminous, though perhaps only to a trace ; the heart is
found to be hypertrophied, and tlie conclusion is obvious, not only that
the kidneys are diseased, but that they have been so for a considerable
time. Dropsy may be totally absent for long or altogether, particularly
if the heart be much hypertrophied and little dilated. The cardio-
1 See paper by Professor Clifford Allbutt, Brit. Med. Jmirnal, Feb. 10, 1897.
384 SYSTEM OF MEDICINE
vascular changes, togetlier proLably witli some alteration in complexion
ami aspect, may even for a long course of years be the only outward
signs of the disease. The patient, or rather the affected person, for he
may not as yet be a patient, acquires a dirty i)all()r, perhaps something
of p'ltliness, or sometimes a blotchy look such as is associated with
free living. The urine will probably be pale and superabundant, will
be passed Avith some frequency, especially at night, and will display
albumin, — very little at first, perhaps only a trace, afterwards more ;
especially when in i)rogress of time the interstitial change becomes
complicated with tubal. AVith this the urine lessens in amount, and
some degree of dropsy usually presents itself, though not to the extent
wliicli characterises nephritis of acute origin. Pain in the back in the
renal region is occasionally present, but more often not. It is, however,
sometimes severe, and made worse by shaking. When this has been so,
it has happened to me to observe after death an unusual amount of
adhesion about the capsule and cellular tissue.
Sometimes ilropsy is absent from first to last. Occasionally there is a
good deal in the later stages, especially when the liy[)ertrophicd heart
has become dilated so as to permit of regurgitation through the mitral
orifice. Tiiis may be accompanied with a definite mitral muruuir,
though the valve-Haps may be perfectly healthy. In such a case there
may \)Q pulmonary apoplexy with hLTemopt3sis, and the dropsy may take
manj' of the characters of that of cardiac origin, which, indeed it partly
is, become considerable and general, and affect not only the legs, but the
pleurse and peritoneum.
Various symptoms ma}^ intervene during the progress of the disease,
and possibly some of them may have been the first means of calling atten-
tion to it. Among these are vomiting and various forms of dyspepsia.
The vomiting is no dotd:)t generally excited by the secretion of uraemic
matter into the stomach. It occurs independently of food, often iu the
morning before breakfast, and results in the production of a little slimy
matter, which often has an alkaline reaction. "When the renal disease is
associated with the special form of ulceration of the bowel which, as I have
shown, goes with it, then is the vomiting most urgent. I have known it
to be haljitually provoked in such a case by the sotuid of the dinner-bell.
Vomiting is more characteristic of the granular kidney than is diarrhcea,
"which in my experience is rare in this connection, more so than con-
stipation. Before the diffcrrntiution of lardaceous disease diarrhoea Avas
sominvhat generally attributed to albuminuric affections; but without
being quite unknown in other conditions, it is the especial accompani-
ment of the lardaceous form. Among other symptoms are headache,
dimness of vision, and asthmatic attacks. Ila-niorrhages of various
kinds occur more particularly when the heart has become liypertrophied
anil the arteries deteriorated. Epistaxis is not infrequent, and may be
obstinate. Cerebral haemorrhage has its association with the granular
kidney, though when it occurs it is more often found that the kidneys
are slightly than extremely affected. Of all ha^morrhagic affections, that
i
DISEASES OF THE KIDNEY 385
of the retinae, which will be presently dealt with separately, is the most
frequent, and diagnostically the most significant. More fatal and less
obvious is the albuminuric ulceration of the bowel which is of
haemorrliagic origin. To this I shall revert presently ; I have already
mentioned hcemoptysis as a late result of the granular kidney. Other
evils beset the long course of the disease before it reaches what may be
considered its normal ending in cerebral uraemia. Many inflammatory
affections occur; broncliitis is exceedingly common, pneumonia and pleurisy
are frequent, peritonitis occasional (vol. iii. p. 635). Pericarditis is fre-
quent; it comes on insidiously, often without noticeable symptoms, and is
almost invariably fatal. It is not unusual for it to remain undiscovered
until after death. The brain participates, though perhaps less than might
be supposed, until it is violently overcome by the ura^mic poison. The
patient sometimes becomes lachrymose, sometimes restless and irritable ;
and occasionally, especially in the advanced stages, there is transient
delirium or temporary mental failure with delusion. These are bad signs.
The idle comments foretell the ending of mortality. Among the later and
less frequent complications is a scaly skin disease — a form of dermatitis.
This formidable catalogue of possibilities must not be allowed to give
too discouraging a prospect. ]\Iany or most of them may never be
encountered, the patient may pursue the eA^en tenor of his way almost
undisturbed by his disease, and may live almost indefinitely, fairly useful
and reasonably comfortable. The disease for many years may give no
sign of its presence excepting to the medical observer, and to him only
by the albumin in the urine and the changes in the heai't and vessels.
Though the foregoing outline is intended to relate to the disease of
gradual development, a few words will suffice to make it apply equally
to the kind which succeeds upon acute nephritis. The granular kidney
sometimes declares itself years after an attack of scarlatina, as in cases to
which I have already referred. Sometimes the later affection is in
obvious continuity with scarlatinal nephritis, shown by oedema and
albuminuria, or possibly the connection of the renal disease with the
exanthem may be indicated only by an intermediate period of indefinite
bad health. Nephiitis of other than scarlatinal origin may be similarly
followed, though with more infrequency. As the acute disease becomes
chronic the heart enlarges and the dropsy disappears. It is an instructive
fact, as bearing on the direct causation of the cardio-vascular changes
by the renal, that these consequent alterations attain their most typical
development in young persons, often children, in whom the renal fibrosis
is an obvious result of acute inflammation. The granular condition
having been fully attained, it matters little whether the beginnings were
in chronic change or acute disease ; the symptoms and issues in the later
stages are what have been already indicated.
The duration of the granular kidney is difficult to limit, since the
beginning is usually unrecognisable. In hospital practice the disorder does
not come under notice until it has reached an advanced stage and mani-
fests the symptoms which belong to it. From private sources it would
VOL. IV 2 C
386 SYSTEM OF MEDICINE
not be (litiicult to collect cases which have endured for ten or twenty
years. I know a gouty gentleman who enjoys fair health at the age of
seventy-two, whose urine has been allmminous for fifteen years. He has
much cardiac hyperti'ophy, and has had h;einoptysis, no doubt of renal
origin. That he is a subject of the granular kidney is beyond doubt.
Ou the other hand, instances occur, though rarely, in which the renal
fibrosis takes an acute form with symptoms resembling in most respects
those of tubal or diffuse nephritis. I will subjoin an instance of what
might be called acute interstitial disease of the nature of fibrosis, though
scarcely amounting to it.
A married lady, aged forty-four, Avhom I saw frequently with Dr.
Buzzard, furnished an example of this form of disease. She had had
several children, the last five years before her attack. She had never
had any dropsical symptoms with her pregnancies ; there was no record
of gout, no history of scarlatina, or exposure to cold, or of anything else
which could be assiu-iied as the cause of her disease. The be<rinninsr was
sudden. She was perfectly well, as far as was known, until one day early
in October 1894 the feet were found to he greatly swollen, and in three
or four days, without any feeling of illness, the whole of the lower
extremities were oedematous. The urine was tlien found to be highly
albuminous. Throughout the subsequent course of the illness it remained
so, and was generally much reduced in quantity. The urine never con-
tained blood ; no casts nor any other morbid deposit were found. I
examined the urine on many occasions with the result that casts were
uniformly absent. The dropsy increased upon the limbs, and invaded
the peritoneum and pleurae ; acupuncture of the legs and paracentesis of
the abdomen were repeatedly called for. The skin assumed in its most
characteristic form the ivory pallor of renal dropsy. Vomiting was
latterly a distressing symptom, and there were two or three convulsive
uniemic attacks. Towards the close the dropsy spontaneously diminished,
until at last little remained. Death was brought about by gradual loss
of strength connected Avith the inability to take or retain food. She died
on 9tli Octoljer 1895, her illness having laste<l almost exactly a year.
Her mother, it is stated, died of dropsy supposed to have been of renal
origin. I am indebted to Dr. Colman for the account of the post-
mortem, and also for some sections which I examined as well as him-
self. Both kidneys were in much the same condition ; small, hard,
slightly granular on the surface, and with adherent capsules. The
cortices were much diminished. The renal arteiies were atheromatous ;
the left renal vein contained a firm, old throndius, which however did
not cf)mpletcly obstruct the channel. Under the microscope the chief
murbid apjx'arance was universal, and profuse hypernucleation of the
interstitial tissu<', by which its bulk was notably increased and the tubes
often widely separated. The increase was of young nucleated material
rather than of old fil)rons tissue. The ]\Ialpighian bodies showed nothing
special. A large numl)er of the tubes were natural, some contained Jilugs
of amorphous sulwtance.
DISEASES OF THE KIDNEY 387
Secondary changes. — Tlie foregoing outline of the course of the
disease may be filled in with a somewhat more particular account of
one or two of its more important consequences, pathological and clinical.
Tlie comprehensive change in the heart and arteries must receive thi;
first consideration as common to the whole body and to almost every
case. It has its physiological and its pathological aspect, its uses as well
as its disadvantages ; it obviates some of the symptoms and causes others.
It will suffice for the present purpose to describe briefiy the damages in tlie
drcidating system tvhich occur in counedion with the gramdar kidney, and to
lefer also with brevity to the clinical consequences which follow upon them.
I shall avoid as much as possible matters in dispute, but shall deal chielly
Avith simple observations and practical issues. It has already been shown
that the changes of which I am about to write are not confined to the
kidney which has acquire<l or attained to the condition of granular
contraction (see p. 367), but are manifested as the same in kind if less
in degree, as the results of nephritis upon which granulation has not
yet ensued. As the renal changes advance, so do the card io- vascular,
until the incipient changes of nephritis pass into the general hypertrophic
thickening which goes with the granular and contracted kidney.
Taking a well-marked instance of the granular kidney, the following
changes are to be recognised in the circulatory system. The heart and
the arteries together become hypertrophied ; the heart in both ventricles,
and the arteries in both muscular and fibrous coats, and of every size.
The hypertrophy of the heart is nearly invariable with the granular kidney,
but not quite. I have estimated that, not including cases where peri-
carditis is superadded, in which cases renal hypertrophy of the heart may
be reckoned as almost surely present and often extreme, this cardiac
change occurs in a decided form in 74 per cent of the fatal cases of the
granular kidney. If cases with pericarditis had been included, the per-
centage would have been larger. It is, indeed, exceedingly I'are to find this
form of renal disease without some evidence of the associated cardiac change.
But, however infrequently, cases do occur in which the cardiac complication
(salutary adjustment it may be called) is absent, and it has been observed
that they pursue a more unfavourable course than when it is present.
The heart displays the hypertrophy most obviously in the left ventricle,
but the right shares in the same process. The weight of the heart may
be doubled or trebled. I may mention incidentally that when the hyper-
trophy is extreme, pericarditis is very apt to occur as the finishing stroke.
I have before me a series of thirty -one cases illustrating the cardio-vascular
changes of renal disease ; in nine of these the heart and pericardium together
weighed between 20 and 39 ounces. The heaviest without pericarditis or
pericardium Aveighed 23 ounces. In addition to liypertrophy the left
ventricle in course of time often dilates, with the result of insufficiency of
the mitral valve and all the results wliich follow this lesion; mitral murmur,
increase of dropsy, pulmonary apoplexy. The dilatation marks the begin-
ning of the end. So long as the heart holds its own, the hypertrophy-
appears to be beneficial. Under its influence, or at least together with it,
o
3S8 sysTE^r of medicine
it is continually found that the dropsy, if there have been any, diminishes
and often entirely subsides, to reappi-ar, as I have said, when the heait
gives way ; the last form of dropsy being worse than the first. How the
beneficial action is brought about may be open to discussion, but one way
seems clear. The ventricle has a double action ; it not only drives but
it draws. By its expansion it must tend to suck the blood out of the
lungs, and thus clear the way for the emptying of the veins and relieve
the venous circulation. It is manifest that this suction power, ])robably
not very important in healtli, must be greatly enhanced by thickening
of the ventricular walls, particularly when their stiffness is not impaired
by increase of the cavity.
The systemic arteries, as has been stated, are thickened throughout
their whole course from the heart to the cajHllaries, and it is to be
inferred from the hy})ertropliy of the right ventricle that the pulmonary
arteries are similarly affected, though probably to a less degree ; with
regard to these vessels, however, observations are wanting. The systemic
arteries, more especially those of smaller size, are thickened ])Oth in their
muscular and fibrous coats, and Gull and Sutton believed that they found
a thickening also in the capillaries, not of course muscular, where no
muscle is, but what they termed hyaline. As to the arteries, there is no
doubt as to the general thickening of their walls, and as to both muscular
and fibrous coats being thus affected. I need not detail o1)servatii)ns
which are accessible elsewhere ; but I may briefly say that I have ascer-
tained that not only are the arterioles thus changed, but also, though
to a loss extent, the larger arteries — to wit, the aorta, the innominate,
the common femoral and the renal. The changes are therefore universal
to the systemic arteries. The hypertrophy of the arterioles is often
succeeded by fatty degeneration, which affects chiefly the muscular coat
but is not confined to it. Sometimes small vessels are seen which are so
disorganised by fatty change that little else can be made out. This is
most often seen in the pia mater, probably because the vessels in these
situations are more easily examined than elsewhere. The arteries are
thus weakened, while the force Inought to bear ujwn them by the ventricle
is increased, a coml)ination which explains the frequency of haemorrhage
under the circumstances.
The clinical signs of tlie cardio- arterial changes have become ■svell
known, and need not here be discussed at any length or in technical
detail. From the outset of nephritis, before any increase in the size of
the heart is recognisable, the i)ulse is hard to the touch, and gives
evidence under the sphygmograjth of increased pressure. This implies
some difficulty in the emptying of the arteries, which is the cause of
their over-tension, and ultimatel}' of the thickening of their walls and of
the vejitricular hypcrtro]ih3'. Taking a case of long standing, where the
granular contraction of the kidney is well marked, the pulse changes are
more pronounced. Two alterations are now to be discerned — increase of
tension and thickeiu'ng of the artery, both contributing to increase the
hanlness of the pulse. The educated finger, or I should say finger.s, are
DISEASES OF THE KIDNEY 3S9
as instructive as the sphygmograph, or even more so. The artery is
usually large and permanently tight, the difference between systole and
diastole only to be appreciated by firm ])ressnre. If a finger be lightly
passed across the vessel it will feel like a cord which knows no variations
iif size ; and it will be found abnormally difiicult to stop the current
in it ; it may even be that this cannot be done by any amount of pressure
which can conveniently be brought to bear upon it. To judge of the
force or " stopability " of the pulse it is best to use two fingers and both
hands in feeling it, make pressure on the vessel with one hand, and with
the other estimate the stream which emerges. It may be found that a
pulsation of thread-like smallness will pass in spite of almost any pressure
which the finger can apply. The sphygmograph gives similar evidence, and
enables the increased force of the pulse to be accurately measured.
As to the heart, the signs of hypertrophy scarcely need. to be dwelt
upon. These chiefly relate to the left ventricle, the apex beat being
disjilaced downwards and outwards, even to the extent of an inch outside
and two inches below the nipple. Occasionally, though the heart is
Fio. 3. — Pulse-traciug in a case of granular kidney in a painter aged 05. Marey's sphygmograph.
150 grammes pressure.
greatly enlarged, the apex beat is so distributed as to be scarcely per-
ceptible owing to the rounding of the lower end of the organ. The first
sound is muffled and prolonged ; it may be nearly indistinguishable
owing to the thickness of the muscular wall through which it has to
come. Cases of this sort furnish a convincing proof that the first sound
is made in the interior of the heart and not within the wall ; it is intra-
cardiac and not muscular ; were it muscular it would be increased, not
diminished, by the thickness of the muscle. Beside the signs of hyper-
trophy are those of intra-arterial tension, one of which is accentua-
tion of the second sounds. It is to be noted that, contrary to what
might perhaps have been expected, the pulmonary second sound is more
accentuated than the aortic. Accentuation of these sounds is due to
the increased blood -pressure in the great vessels. There is also under
the same circumstances, but by no means constantly, a reduplication of
the first sound, or some approach to it, Avhich indicates a want of syn-
chronism between the ventricles.
The damages in the circulatory system which have been indicated are
manifested clinically by man)' haemorrhagic accidents, which give its
leading character to the disease, and are more vitally important than
anything in its course excepting the uraemia with which it normally
390 SYSTEM OF MEDICINE
terminates. Some of these accidents have not yet been noticed ; others
roquire more notice than they have 3'et received, ruhnonary apo^ilexy
and lia^moptysis of renal origin need not be further dwelt upon, nor is it
needful i'uither to mention epistaxis. Willi regard to apoplexy of the
brain, the frequency of renal disease as a concomitant has been already
referred to. Of 75 persons who were examined at St. George's Hospital
after death from intracranial extravasation, 31 were described as having
kidneys in a decided state of granular degeneration. This enumeration
docs not include slight decrees of renal chaufre, which were luunerous.
Under this association cerebral apoj)lexy has been known to occur at an
age to which it does not commonly belong. I have elsewhere related
the case of a girl who died at the age of twelve with an extravasation in
the brain as large as a goose's egg. The kidneys were in an extreme
condition of fil)rotic disease ; the heart was hyi)ertrophied to the weight
of 8i ounces, and the arteries were characteristically thickened and
affected with fatty degeneration. That the arterioles should often give
way under the circumstances which have been descril)ed is no marvel ;
while the vessels are weakened the heart is strengthened, intra-arterial
pressure is increased, while the power to resist it is diminished.
Next to the brain in position, and perhaps in importance, comes
the retina. With regard to this I gladly avail myself of the special
knowledge of Mr. Brudenell Carter, who has und(irtaken this sub-
division of the subject, and who writes as follows : — " The frequent
occurrence of impaired vision during the progress of 'dropsy' has been
known to physicians from a verj^ earl}' period ; and Dr. Bright, when
conducting the researches by which he connected ' dropsy ' with disease
of the kidney, was not uimiindful of the fact. In an article on renal
dropsy, which he contributed to the volume of Guy's Hospital Reports
for 1836, he mentions, in the introductory portion, dimness or failure
of sight as a common symptom or comj)lication ; and he also men-
tions it specifically as having been present in sonie of the instances
which he describes ; although, in an ap]>endcd tabular account of
100 fatal cases, the principal post-mortem ap])earances in which are
set forth with some fulness, neither the state of the vision nor the
presence of morbid changes in the eyes is referred to. The eyes, indeed,
do not seem to have been examined in any of these cases; and the
impairment of sight received onl}' a small degree of attention, probably
because, at that time and for some years afterwards, it was regaixled
as a conspicuous example of alteration of nei'vous function, due to the
nerve being suj){;lied with ' imperfectl}' de])urated blood.' In 18.^)0,
Tiirck discovered, by jtost-mortem examination, that the retinae of a
patient who had died from renal dro])sy were studded with spots of
fatty degeneration. A similar condition was afteiwai'ds found by
Virchow and others; and, in 1856, Heymann ])ublished the fir.st account
of the ophthalmoscopic appearances which have since become so familiar.
The issue, in 1863, of Liebreich's ,///r/.s- dcr Ophfhdhnosropie carried the
matter a step farther, and rendered a highly-coloured picture of what he
DISEASES OF THE KIDNEY 391
described as ' retinitis albuminurica ' accessible to many physicians who
had not yet learned to use the ophthalmoscope for themselves. The
characteristic feature of this form of 'retinitis' was said to be the pre-
sence of a group of white spots, arranged in a conspicuous stellate figure
around the macula lutea ; while other spots of the same general appear-
ance, but usually larger and more isolated, and often accompanied by
patches of effused blood, were irregularly distributed over the fundus. This
particular combination of appearances, or even the presence of the stellate
figure alone, was long thought to be pathognomonic of kidney disease ;
but more extended experience has shown not only that the stellate figure
may be absent in renal cases, but also that it may be present in cases
which are not renal. In 1872, for example, a young woman who might
have sat for Liebreich's jMcture of 'retinitis albuminurica' was admitted
into St. George's Hospital, and died there, with healthy kidneys, of
tumour in the cerebellum. A boy was admitted into the same hospital,
at about the same time, with typical 'choked discs,' but Avith no stellate
figures, no scattered patches, and no haemorrhages, whose eyes led many
highly-skilled observers, including several members of the International
Ophthalmological Congress, then assemljled in London, to form the ojtinion
that he was the subject of an intracranial tumour. He died of pleurisy
supervening upon advanced kidney disease, and no primary brain lesion
was discovered by the most careful examination. A case similar to the
former had previously been described by H. Schmidt and Wegner; and
a few others of both kinds have since been recorded. Notwithstanding
these, however, it is incontestable that a combination of haemorrhages
and of white patches in the retina, either with or without the central
stellate figure, will, in the great majority of instances, indicate the pre-
sence of renal disease with a very near ap})roach to certainty.
" As soon as the ophthalmoscopic examination of renal patients became
general and systematic, it was discovered, as might have been expected,
that the typical albumimiric retina represented an advanced stage of
changes which were recognisable at a much earlier period, and M'hich
commence, in some cases, by the appearance of small and scattered white
spots, in others by the occurrence of minute effusions of blood. In the
experience of the writer, bleeding has been the more common initial
phenomenon ; and it has usually been first observed on the temporal side
of the nerve, between the disc and the macula. The first haemorrhagic
patches are almost invariably seated in the fibre layer, and the distribu-
tion of the effused blood is governed by the anatomical conditions of the
tissue. The blood makes its way among and between the nerve fibres,
which are often visible in front of it as a delicate white striation ; while
the general outline of the patch assumes a brush -like or flame -like
character. As the case proceeds, fresh bleedings occur in parts of the
retina more remote from the centre, and white patches of varying outline
and magnitude are formed in increasing numbers. In the majority of
instances the optic disc itself, and the unaffected portions of retina, for a
long time preserve nearly their normal aspects ; while, in others, the disc
392 SVSTEAf OF MEDICINE
may become swollen, its margin obscured, and the portions of retina
between the spots and the blood patches dimmed and cloudy, as if from
the j)resence of albiiininous fluid in the meshes of the tissue. If we dis-
regard minute anatom\', and consider the retina as a structure roughly
divisible into two layers, an anterior and a posterior, the Ibrmer of which
derives its nourishment from the arteria centralis, and the latter from the
vessels of the choroid, we may ascertain, even by the ophthalmoscope,
that the changes associated with albuminuria are, as a rule, almost con-
fined to the former. Sometimes, however, the choroidal circulation
becomes implicated in the general disturbance, and then some displace-
ment of the retinal pigment, and a greater degree of impairment of
vision than is usual, are liable to occur.
" The general apj)lication of the word ' retinitis ' to the changes seen
in albuminuria has led many persons to conjecture that these changes
must always be ushered in by some increase of blood -supply to the
affected parts ; and hence a preliminary stage of ' hyperaemia ' has more
than once been described. It is exceedingly difhcult to ascertain the
presence of ' hyperasmia ' of the fundus oculi, the conditions of its blood-
supply being liable to vary within rather wide limits ; and, in the opinion
of the writer, the changes are essentially degenerative, and only assume
certain sub-inflammatory characters in comparatively rare cases, possibly
as a result of the disturbance of tissue by the eff"usion of blood or by the
deposit of fat. The latter occurs as an infiltration with fat cells, which
are found most abundantly in the granular and intergranular layers of
the retina, but which, in advanced cases, extend into the fibre layer also.
Aggregations of these fat cells constitute the white patches ; in which,
moreover, the nerve fibres are often found to be swollen, and to be
studded with irregular nodosities.
" The presence of the characteristic retinal changes does not afford any
indication of the natui'e of the kidney disease, or of the stage which it
has reached. These changes are found in every malady which is attended
by albuminuria ; not only in ' Bright's disease,' but also, for example, in
the albuminuria of pregnancy or of diphtheria, or in that consecutive to
scarlatina. The retinal changes, in the experience of the writer, never
precede the albuminuria ; but, in Bright's disease, it is quite common for
them to give rise to the first symptoms which direct attention to the
kidneys. Both in hospital and in private practice patients who consider
themselves in good health will seek advice on account of im.pairment of
vision, and an examination of their retiuixj will at once .suggest an
examination of their urine. On the other hand, cases of albuminuria are
met with in which the retinae remain unaffected to the last.
" Apart from the olwious indication to treat the eyes indulgently, and to
])rotcct them from attempts at overwork or fi'oni other niunifestly injurious
influences, the treatment of allnmiimu'ic retinal degeneration resolves
itself into that of the affection upon which the allnimiiiuria depends. In
the ca.sf'S which depend upon diphtheria, upon scarlet fever, or upon ]ireg-
nancy, it is not uncommon for the retime to clear up, and for normal
DISEASES OF THE KIDNEY 393
vision to be restored, as one part of the process of general recovery. In
the cases of chronic kidney disease from which no recovery can be expected,
the impairment of vision Tisually increases with the increasing amount
and area of degeneration, but it seldom leads to complete blindness."
Analogous to the retinal changes, connected as they are with haemor-
rhage, are some which affect the bowel, and produce a special and fatal form
of ulceration which, like the change in the retina, is essentially albuminuric.
I have elsewhere fully described and exemplified this condition, to which
I drew attention in the Croonian Lectures for 187G. I will therefore
now content myself with referring to it somewhat cursorily. Under
advanced renal fibrosis, together with its cardio-vascular accompani-
ment, submucous haemorrhages are apt to occur in many parts of the
alimentary canal, in the stomach rarely, in the intestines frequently,
more particularly about the ileo-caecal region. This is succeeded by a
form of ulceration which often leads to peritonitis, perforation, and
death (vol. iii. p. 902). The ulcers are small, circumscribed, and sharply
cut ; they are usually few or even solitar3^ They are not connected with
any of the glandular structures of the bowel, nor do they resemble the
ulcers of typhoid or tubercle, or of any other sort, except to a certain
extent those due to ftecal irritation. Evidences of hiemorrhage are usually
to be seen in their neighbourJiood, and it is aj)parent that submucous
extravasation is the process to which they owe their existence. The usual
symptoms are diarrhoea, griping, abdominal tenderness, vomiting, and
finally those of perforation.^
The ha^morrhagic tendency shows itself in places other than have
been mentioned. Epistaxis is very frequent ; sometimes it occurs com-
paratively early in the disease, in the later stages it is apt to be profuse
and alarming. Menorrhagia is not uncommon. Hsematemesis occurred
three times in 68 fatal cases. Purpura and bleeding from the mucous
membrane of the mouth are late and infrequent, but genuine renal issues.
Next to haemorrhaares, among the results of the form of renal disease
under consideration may be placed inflammation. Of these, bronchitis
is the most common, occurring in over a third of the cases. Pneumonia
and pleurisy are about equally frequent, much less so than bronchitis.
Next to bronchitis in frequency comes pericarditis, which was found in
a recent state after death in 16 of 68 cases. This complication is more
frequent with the granular kidney than with any other kind, and is almost
invariably fatal, though often latent. There is usually no accompanying-
endocarditis, though endocarditis with or without pericarditis is to be
recognised as an occasional result of the same renal condition. In the
^ Since this was in type I have learned that the concnrrence of intestinal ulceration with
i-enal disease has not entirely escaped notice, though I believe that I may claim to have been
the first to point out the nature of the connection. Wilks and Moxon, in the second edition
of their Pathology, 1875, speak of duodenal ulcers as, like gastric ulcers, due to the acids of
the stomach, and, like gastric ulcers, often associated with Bright's disease ; tliey also refer to
diphtheritic colitis as met with together with a similar inflammation of the stomach and with
Bright's disease. I have ventured to regard the intestinal lesion as specially connected with
the renal, and that by way of cardio-vascular change.
394 SYSTEM OF MEDICINE
68 post-mortem cases already referred to, recent endocarditis was
observed in 4. Erysipelatous inflammation or cellulitis sometimes occurs,
particularly as an attendant of droj)sy ; but is less common than with
nephritis. Other eruptions of an inflammatory nature have been noticed
in connection witli Brights disease, wiiich I venture to refer to in this
place, though they do not all especially belong to the granular kidney or
that of interstitial nephritis. I have seen a marked form of eczema,
together with nephritis, in course of recovery. Dr. Pye Smith has given
(|uite a catalogue of eruptions which aie apt to occur with renal disease.
One of them has been termed erythema leve, and others described as
roseolous or ])apular. A severe form of dermatitis has, during recent
years, been ad<led to the catalogue of renal inflammations, and is particu-
larly associated with the graiuilar kidney. The eruption first appears as
a sort of erythema; vivid red blotches, which rapidly become ])a])ular,
present themselves on the extensor surfaces of the limbs, and after-
wards on the palms, soles, and face. The mucous membranes are at the
same time aff'ected, as is evident by soreness and congestion of the throat,
and sometimes by inflammation of the auditory meatus. The cutaneous
papulae rapidly become confluent, and may be succeeded by various
degrees and admixtures of desquamation, eczema, and pustulation. These
eruptions are attended with much itching and irritation. They occur late
in the course of the granular kidney, are preceded by evidences of urteniia,
and are usually followed by a fatal issue. Dr. Le Cronier Lancaster,
to wliom we are indebted for an early, if not the earliest notice of this
condition, while house ph3'sician to St. George's Hosj)ital, collected eight
cases of this kind ; one was followed by recovery, seven by death. Post-
mortem examination was made in six, in five of which the kidneys were
granular, in one lardaceous. One of the cases in this series was that of
a man aged twenty-five, who was a patient of mine. He had albumin to
a sixth, much hypertrophy of the heart, and increased arterial tension,
vomiting, diarrhoea, headache, and bronchitis ; no dropsy. A reddish,
elevated, papular eruption appeared on the man's legs and body, and
afterwards on the face, which was accompanied with a burning sensation
together with much itching. He had also red, smooth, tender patches on
the throat, running at the nose and eyes, and discharge from the ears,
both of which were swollen. The eruption became scaly, then pustular,
and several superficial absces.ses formed on the limbs, broke, and dis-
charged fo'tid pus. He died fort\'-one days after the appearance of the
rasli. The kidneys were found to be in a marked condition of granular
contraction, weighing together only six ounces. The usually fatal issue
of the condition leaves little hope for treatment, but I would venture a
suggestion in this view. Tiie j)resumed cause, satiuation of tlie skin by
urajmic products, seems to indicate a simple measure wliith, in the only
ca.se in which I have as yet employed it, was highly successful. I would
suggest long soaking of the body in a bath of water at blood-heat, say 98°
or thereabouts, wliirh could scarcely fail to dissolve out much that it would
be desirable to get rid of. This might be preceded by a brief immersion
DISEASES OF THE KIDNEY 395
in a weak solution of bicarbonate of potash, which would appeal especially
to the uric acid, if, as is likely, this takes part in the morbid process.
Supposing the patient with interstitial nei)hritis to have escaped all
the pitfalls by the way, his course will terminate in cerebral uraemia,
which may l)e said to be the normal ending of his disease. It is obvious
that as the kidneys fail in eliminating various constituents of the urine,
these must remain behind unless they are expelled by other channels.
The kidneys may fail in many ways as regards their excretory function.
Obstructive suppression may forbid the exit of the urine as a whole after
it has been completely formed by the kidneys, or at least while the
kidneys are structurally able to form it completely. With Bright's
disease the urine is not arrested, but rather is not formed, or formed only
imperfectly. These differences of morbid procedure are attended with
different results ; the urpemia of obstructive suppression is different in
many respects from that produced by disease of the renal substance.
And with regard to diseases of the renal substance, differences are to be
observed both in the impairment of the urine and the ur?emic results
which ensue. With acute nephritis it is common to find both water and
solids diminished ; with the granular kidney it is often found that while
the solids are diminished the water is increased. The blood must therefore
be differently affected in the two cases, and the results are not quite the
same. Coma occurs in both. With nephritis there is generally convulsion \
Avith the granular condition convulsion is often, but not always absent.
Ursemia. — Before proceeding to the consideration of the uraemia of the
granular kidney, I will briefly discuss the nature of ursemia in a somewhat
general sense. The chief function of the kidneys is to separate from the
blood certain matters already existent in it in the form in which they are
excreted. The chief constituent of the urine, the urea, appears not to be
made by the kidney as the bile is by the liver, but to be simply removed
by the kidney after having been made elsewhere. With regard to uric
acid, there is some uncertainty as to its place of origin, whether renal or
extra-renal. Whether any excrementitious compounds are constructed
by the kidney as Avell as expelled by it is not known ; but it M-ould seem
improbable that so complicated an epithelial arrangement as exists in the
kidney should not be constructive as well as selective. Whether the
renal exit be obstructed, or the kidney itself diseased, urea accumulates in
the blood, and probably the same is true with regard to uric acid.
But the question of urtemia is not limited to these simple considerations ;
it is complicated, and we must admit that it is but partially understood.
What we require is examination of the blood under a variety of circum-
stances and in further detail than has yet been accomplished. It may be
presumed that the blood in renal disease varies inversely as the urine ;
thus what the urine wants the blood abounds in, and conversely. The
blood is deficient in albumin ; it contains a notable quantity of urea and
uric acid, and, according to some pathologists, ammonia ; it holds an excess
of mineral salts, probabl}^ of many as yet indeterminate matters, and
generally of water. With regard, first, to the toxic effect of urea, this is
396 SYSTEM OF MEDICINE
now known to be less than was formerl}'^ supposed. It may be introduced
into the stomach or veins of animals with little result excepting increase
of urine. \Vhen the kidneys, from disease, are unable to respond, the case
may lie ditl'erent. A large amount of urea is known to accumulate in the
blood as a consequence of obstructive suppression, but the attendant
symptoms are not those which ensue upon disease of the renal substance.
AVith ol)structive suppression there is heart failure, some degree of som-
nolence, some degree of muscular twitching, but not general convulsion
or coma. To produce these, something different from urea, or something
in addition to it, is presumably necessary. The blood has been thought
to contain ammonium carbonate due to the decomposition of urea, and the
symptoms of ur:emia have been attributed to this salt. In advanced kidney
di.:easc ammonia can be detected in the breath in more than normal
quantity, and convulsions have been found to follow the injection of the
ammonium salt into the veins of animals. But it has been objected that
the free exhalation of ammonia which occurs with ex})iration must make
it difficult for this volatile substance to accumulate in the blood. As
somewhat contrary to the ammonia theory the alkalinity of uraemic blood
has sometimes been found to be diminished, and importance has been
attached to this deficiency. Much has been attributed to the toxic effect
of retained potash salts, and food and physic regulated so as not to
introduce them in large amount. Hydrtemia has been thought to play
an essential part in the morbid process. This condition is no doubt
generally present, though Dr. Carter has shown that after fatal
uraemia the brain substance contains a no larger percentage of water
than in health. Hydroemia may be confidently put aside as playing no
necessary, though possibly it takes a subsidiary part. It may be noted
in passing that disastrous results may ensue if the treatment of uraemia
comprise the Avithholding of water from the diet with the purpose of
les.sening the wateriness of the blood. Water is the best of diuretics
and depuratives, and a remedy for urjemia, not a cause of it. It has
been supposed, but probably erroneously, that increased intravascular
tension is a necessary agent in bringing about the results of uraemia. It
is not to be disputed that when tliis condition is advanced nwre or less
over-tension is commonly present, but it is collateral rather than essential.
With the unemia of obstructive suppression, which, however it may differ
from that of substantial renal disease, is tridy toxic, tension is lessened
rather than incieased, and lardaceous disease occasionally ends in unemia
though the tension may have undergone no exaggeration.
It is sufficiently apparent that the condition of uraemia is not to be
more narrowly define<l than as one depending on the retention of urinary
excreta ; which excreta are es])ecially injuiions, or Avhat changes any of
them undergo to become so, are questions for the future.
I will now briefly indicate the symptoms and results of the uraemic
state so far as it depends on the granular or fibrotic kidney, or, in other
words, upon disease of long standing and not lardaceous.
Many of the results of renal disease — the vomiting, the inflammations,
DISEASES OF THE KIDNEY 397
the asthma — must be held to depend on toxic retention, and be truly
uremic in their nature ; certain conditions, not necessarily of nervous
origin, may be first touched upon as indicating advanced ursemia, and
apt to precede the cerebral manifestations. One of tiiese is a brownish
discoloration of the skin, especially of the face, which gives a sort of
tropical look very different from the pallor of the less chronic varieties
of renal disease. Itching of the skin is a late uraemic manifestation.
It has been found in rare instances that crystals of urea have formed
on the skin and hair in advanced cases of uraemia. This condition
is associated with abnoi'mal sweating, but the opposite condition some-
times presents itself, morbid dryness of the skin which refuses to perspire
even under baths and other sudorifics. This is a late result and a bad
indication. Another bad sign is advancing poverty of urine, which may
be of low specific gravity, pale colour, often feebly acid or alkaline in
reaction and of a fishy smell. The breath, under similar circumstances,
a,ssumes a characteristic, somewhat ammoniacal odour, and gives an
ammoniacal reaction when brought in contact with hydrochloric acid.
A late ursemic manifestation of more than ordinary interest and more
than ordinary distress is urcemic asthma. The patient, who probably has
a hard 2)ulse and a large heart, but whose breathing at ordinary times is
normal or nearly so, is suddenly seized in the early part of the night,
perhaps after having slept soundly, possibly without having slept at all,
with agonising dyspnrea. The attack is like one of bronchial asthma
with cardiac superadditions. There is agonising want of breath, with
violent inspiratory effort and imperative orthopnoea. There is much
palpitation and cardiac distress, apprehension, and a sense of mortal
struggle. The patient perhaps clutches at the furniture, his face is
bedewed with sweat and wears an expression of agony. Under such an
attack I found in one case, together witli much exaggeration of cardiac
action, an intense blowing murmur, at the apex and systolic, which was
not present before the fit and suljsided soon after it. In another case I
found during the attack a marked reduplication of the first sound which
was not there before. After a term of agony and terror lasting, perhaps,
two hours, the difficulty yields with wheezing, coarse crepitation, and the
expectoration of frothy fluid, sometimes blood-tinged or accompanied with
separate sputa of bloody mucus. With this the dyspnoea and distress
subside, the respiration resumes its former tranquillity, and nothing
remains of the paroxysm but the prostration which it leaves behind it.
The foregoing sketch is drawn from cases of exceptional severity ; many
lesser degrees of the same condition are not infrequently met with. In the
post-mortem examinations which I have seen after such attacks there has
usually been emphysema, with injection and thickening of the bronchial
membrane, and frothy or muco-purulent secretion in the tubes. In one
instance the lungs were numerously beset with punctiform extravasations
of blood. It is clear that these attacks are not ordinary asthma ; they
occur in persons who have not hitherto been asthmatic, and without any
ostensible reason excepting tlie renal disease and its cardio-vascular compli-
398 SYSTEM OF MEDICINE
cations. The bronchi may take some })art in thi-m, as is suggested by the
bronchial secretion with whicli they terminate, but it cannot be doubted
that the cardio-vascular system is essentially concerned, and uraMuia the
essential cause. I ventured, in the second edition of my book on
Allmmbmna, published in 1877, to suggest that spasm of the pulmonary
artery was the modus operandi of the attacks under consideration ; tiiis
hypothetical explanation has found favour with later obftervei's, and may
be regarded as prol)al)le, though not ])roved. The vascular contraction
may be ])resumed to be in the smaller ramifications of the pulmonary
vessel. It is known, but not always sufficiently regarded, that dyspnoea
as intense as ensues from any obstacle to the admission of air to the lung
may be produced by the cutting oif of the blood from it. This is some-
times witnessed in cases of jmlmonary embolism.
Proceeding to the specially nervous results of uraemia, one of the first
to be observed is headache, which is often of a neuralgic ty})e, intermitting,
and sometimes of agonising severity. This often ])resents itself long before
the fatal issue, and may constitute the chief ostensible symptom of the
disease. Various other disturbances may occur towards the close of the
malady, some peculiarity of or change in manner or temper, a lachrymose
tendency, a feeling of stui)idity, drowsiness, sometimes sleeplessness, and
occasionally a horrible restlessness which is more distressing than any actual
pain. Speech is now and then slightly affected in the way of indistinct
articulation or clipping of words before the final overthrow of the nervous
system, and sometimes, though rai'ely, there are at the same period symp-
toms, such as squinting or inequality of the pupils, which would seem
to indicate, what may not be apparent after death, some localised change
in the brain. As the scene approaches its close and the ciirtain is about
to fall, other disturbances of intellect and nervous function may befall the
actor. Such are many degrees of transient mental failure, to which such
terms as "wandering" and "ram])ling" are applied. Occasionally there
are hallucinations, brief delirium, or what must be regax'ded as transient
insanity, delusions without fever. Among the consequences of advanced
uriemia must be mentioned what has been termed Bright's lilindness,
partial or complete loss of sight, which ma}' be temporar}', which occurs
independently of any retinal change or any alteration to be discerned
with the ophthalmoscope, and cannot as yet be further defined than as a
profound and ill-understood manifestation of the ura'mic state. Various
muscular agitations accrue and are often heralds of epileptiform convulsions,
twitching of the face and limbs, subsultus, and tremor of the tongue.
The end is now in sight, it occurs with coma sometimes, but not always,
])receded by or accompanied with epileptiform convulsions. The "head
symptoms " with the granular kidney do not differ materially from those
which occur in nephiilis, excepting that with the more chronic condition
they are more uniformly fatal, and convulsion is relatively less frequent.
Of 33 stxch cases convulsions were noted in 14, coma without convulsion in
19. The final iu;emic attack sometimes comes on with little or no notice.
It is not unknown for a man to fall in the street in what ap]»ears to be
DISEASES OF THE KIDNEY 399
an ordinary epileptic fit. Tiie lu'ine is then found to contain albumin, and
he may die comatose, and the kidneys be found in a state of advanced
granular degeneration ; though no sign of renal disease had as yet attracted
attention. Such a man probably belonged to the labouring class, members of
which are not keen to take notice of what they consider to be slight ailments.
With the final nervous disturbance there is often delirium, sometimes
of a violent character. There is often dyspnoea of the astlimatic type,
and sometimes bronchitis. Cheyne-Stokes' breathing is often present,
sometimes in a very marked form. With the development of the cerebral
symptoms the pulse, probably formerly hard, loses its force, and often
becomes extremely feeble before the close. The coma is less profound
and less stertorous than that which is produced by cerebral haemorrhage,
and the muscular failure commonly aff"ects both sides alike, so that hemi-
plegia is absent. The temperature is usually subnormal, though excep-
tionally, sometimes after a hot-air bath, it has been known to. go up even
to 103"^. It is worth noting that urajniic attacks, whether asthmatic or
convulsive, are sometimes determined, in persons sufficiently charged with
the poison, by mental emotion.
After death the brain is found to be anaemic, the large vessels empty,
the gray matter pale, the white colourless and bloodless. There is
generally a slight excess of watery fluid in the cavities and interstices.
The ventricles contain a little more than usual, but not enough to cause
pressure on the cei-ebral substance ; the sulci are generally deep, and the
convolutions prominent. In former times, when uremic coma was not
recognised, this condition was, no doubt, often described as serous apoplexy.
The brain is generally firm as in health. I have already referred to an
observation of Dr. Carter, to the effect that the brain substance in this
condition yields no excess of water.
The urine, with the granular and contracting kidneA-, differs from that
of acute nei)hritis in certain striking particulars. With the granular or
granulating kidney (excepting when this condition is the sequel of acute
nephritis) the urinary change is exceedingly gradual and insidious, not only
long unnoticeable by the patient, but such as to escape routine medical
observation. In the next place, contrary to what happens with acute
nephritis, the urine is superabundant at first, scanty at last. Diuresis, a
trace of albumin, few casts or none, loss of colour and specific gravity,
and the disappearance or diminution of urates, are urinary characteristics
of the early stages.^ Later, particularly when intratubal changes ai"e
superadded to the interstitial, the albumin increases, the urine diminishes,
and casts multiply. Towards the close the urine often becomesvery pale and
of very low specific gravity, deficient in acidity, and often of a fishy smell.
The urine occasionally contains blood, or gives evidence under the
guaiacum test of blood crystalloids. Rarely the secretion is profusely
and continuously haemorrhagic. This, I believe, occurs chiefly when there
is much tubal inflammation together with the interstitial — Avhen, in short,
the pathological state is mixed. To conclude these general statements, it
must be added that all the normal excreta except the water are diminished.
4CX3 SYSTEM OF MEDICINE
To revert somewhat more in detail to a few of tlie pf)ints wliich have
been touched upon, the quantity of urine, or in other words the secretion
of water, is in some cases so excessive as to amount to a sort of dial)etes
insipidus (90 ounces per diem is not an unknown quantity), with resulting
thirst. In the advanced stages the quantity usually falls below normal,
possibly to 6 or 7 ounces, or even on the approach of death to total sup-
pression. Diuresis may be looked upon as salutary, and thirst as a natuial
demand to be satisfied rather than endured. The specific gravity varies
inversely with the urine; it may be as low as 1007, or even lower,
when the urine is very abundant ; if the urine become scanty it may
become even higher than normal, 1030 being the maximum of my ex-
perience. Next as to albumin, this averages much less than with the
kidney of acute or subacute nephritis. The more uncomplicated is the
interstitial change the less the albumin ; when the kidney, in addition to
having a granular surface, is large and congested there may be scanty
urine with a large proportion of albumin. The more atrophic the organ
the more abundant, as a rule, is the water and the less the all)uinin. This
may be only a trace, and that more apparent with nitric acid in the cold
than with heat and acid. It is worth noting in especial that though the
cardio-vascular changes may be declared, and the fatal issue not very
distant, it is possible that the urine may be absolutely free from albumin.
Among the normal solids of the urine the urea, as has been said, is
diminished. This diminution aflfords a rough test of the deterioration of
the gland, and of the peril of the patient. The disease may last for a
long time with but slight lessening of urea, yet as it progresses the
urea diminishes. In a case under my own care the urea gradually fell
from 23 grammes to 8"7 grammes in the twenty-four hours ; and instances
have been recorded by trustworthy observers in which the daily amount
has been as low as 3 '5 grammes, or even 1"0 gramme. The uric acid
follows a similar rule ; little reduced at first, latterly extremel}'' so. The
mineral acids and the chlorine are lessened, the j)hosphoric acid more than
the sulphuric acid or the chlorine. The alkalies and earths are reduced,
but have received less attention than they deserve. The validity of the
kidneJ^s should be roughly indicated by the amount of solids passed, ex-
clusively of the albumin, in twenty-four hours. But there are individual
differences of food and physiological habit which make it unsafe to draw
conclusions except from great or very persistent departures from the
normal standard.
The urinary sediment with the granular kidney is less abundant and
less constant than with the more acute disorder. Putting aside urates
and crystalline deposits as constitutional rather than renal, casts are the
chief microscopic products which have to be considered. In quiescent
cases these may be entirely absent. The less the tubes are involved the
more simply interstitial the disease, the fewer the casts. Their absence
is a sign of little morbid activity, their relative abundance a measure of
it. Renal diagnosis caiuujt be founded on casts alone, though the}'^ may
be helpful to it. The casts whicii are most frequent with the granular
DISEASES OF THE KIDNEY
401
kidney are coarse, dark, and of granular texture. Casts retaining the
translucent appearance of fibrin are present as in other forms of renal
disease. Epithelial casts are also occasionally found, and must be held to
indicate the intercurrence of tubal catarrh. A similar statement may
be made with regard to detached renal epithelium. Blood is passed with
less frequency than with the more acute disorder. About one patient in
ten was found to pass enough blood to be evident to the naked eye.
Treatment. — In the treatment of the gramdar kidney there is more to
be done than might have been expected, considering that the disease is not
to be cured, nor has any tendency to recovery. At best it may remain
Fig. 4. — Casts obtained from cases of granular kidney. Most contain coarse dark granular matter,
others granular matter of tlner texture ; a few contain blood -globules or epithelial cells. (BYom
Dickinson's Albumi)iuria.)
stationary, or advance no more rapidly than age advances to the inevitable
and natural end. Our primary guide must be physiological, and our
endeavour must be so to modify the circumstances and habits of the
patient as to minimise the work of the irritated gland, and enable the
system to do with a minimum of renal relief. Diet, warmth, exercise,
and elimination by organs other than the kidnej's must all be brought
under regulation. I will deal first with the quiescent condition and in
regard to diet. Nitrogenous food, which supplies the bulk of the renal
excreta, should be reduced to the lowest amount compatible with health,
having regard to the fact that though ursemia threatens on one side,
antemia is to be feared on the other. The rule I have found beneficial is
one meal of flesh, one of fish, and one of neither. Every kind of
"vegetable food may be allowed, more particularly the farinaceous : the
VOL. IV 2 D
402 SYS TEA/ OF MEDICINE
patient may eat potatoes with the Irishman, oatmeal with the Scot, rice with
the Hindoo, or pulse with the Prophet. Regard must of course be had
to individual taste and suitability. As to liquids, the liberal use of water
or aqueous drinks should be enjoined. Milk may be employed freely,
though I liave not found quiescent cases to do well on a purelj' milk diet.
Alcohol should be avoided, or used with extreme parsimonJ^ Next, as to
the temperature to which the body should be exposed. As long ago as
1867 I advocated resort to a warm climate as a remedy in chronic
albuminuria. Cold to the surface is a renal stimulant, and warmth a
condition in which the kidneys are comparatively at rest. In subtropical
regions albumiiuu'ia, excepting perhaps that which depends on lardaceous
disease, is infrequent as compared with what occurs in the colder })arts of
the temperate zone. Thus England is more albuminuric than the soutl
of Europe or the north of Africa. The desiderata are warmth, dryness of
air, and equability ; of these equability is of less importance than warmth
and dryness, as the valetudinarian may keep Avithin doors after sunset.
To speak meteorologically, what should be sought is a high mean
temperature within temperate limits, a low relative humidity, and a small
daily range. I have elsewhere discussed renal resorts in more detail
than is possible here ; to condense the conclusions they are these : If the
health and means of the patient are such as to alloAv him to make a long
journey, let him go to the north of Africa, Egypt, or Algiers. The
Riviera is disappointing, occasionally cold during the day, and always so
after sunset ; the latter disadvantage is, however, shared, and even to a
greater degree, by many other subtropical places. If the patient cannot
go farther than the Riviera, I think he may as well stay within the
circumference of Great Britain, within Avhich, on the whole, I think the
best winter resort is Falmouth. The daily range is here very slight, the
nights oidy about seven degrees colder than the days, while the humidity,
though consideral)le, is less than at Penzance, a town which will necessarily
be taken into comparison. To minimise the cold of the Avinter without
leaving England it is necessary to go to the west, so as to be within the
influence of the Gulf Htream, and to the south Avhere high land interposes
between the selected spot and the north Avind. It should be endeavoured,
also, to obtain similar protection from the east — often a matter of some
difficulty. Other matters beside climate Avhich concern the Avarmth of
the body must not be lost sight of, notably the enq)loyment of Avarm
clothing and. the avoidance of cold bathing. Habitual ex])osure to cold
may result in the clironic aggravation of the disease. Incidental ex-
posure may give cold to the kidneys, or, in technical language, set up
intercnrrent nephritis — an accident especially to be guarded against.
Touching intercurrent nephritis I may r«'call Avhat I have already said,
that there is reason to believe that foul smells are capable of giving rise
to it. P^xercise must find brief mention. Walking is the best. Cycling,
I think, is less suitable, at least I have known a temporary attack of
alljuminuria of thf nature of nephritis to folloAv a day's bicj'cling.
The use of drugs Avhen the disorder is quiescent takes a secondary
&
DISEASES OF THE KIDNE V 403
place. It is well to give none unless there be some especial indication.
It is essential, however, by their means or otherwise to secure regular
and somewhat full action of the bowels, which should be moved freely
once a day, or perhaps three times in two days. An occasional morning
potion of sulphate of magnesia, or one of the effervescing salines which con-
tain it together with an alkali, answers well. This may be varied with a
nocturnal dose of compound rhubarb, colocynth, or cascara. If the urine
be over-acid a little tartrate of potash or potassio-tartrate of soda may be
given twice a day. Iron has its use and also its abuse. It should not be
given as a matter of routine, but when an obvious condition of antemia
suggests it. When given it should be, as a rule, associated with enough
of some aperient to rather more than overcome the constipating action.
Ten drops of the tincture of the perchloride, with a little sulphate of
magnesia, of soda, or of potash, to w^hich may be added ten or fifteen
minims of aloes wine, will generally serve the purpose. Sulphate of
potash is ixseful in this relation, l)ecause a little of it suffices; Ten grains
are generally enougli togetlier with the aloes. If it is desired to produce
an alkalising effect, two or three grains of ferrum tartaratum may be put
with a little tartrate of potash or the potassio-tartrate of soda, and
perhaps a drachm of the compound decoction of aloes. I have found it
expedient to give such a mixture as I have indicated at bed-time and on
rising. The nocturnal dose insidiously prepares for what the morning
dose completes.
Should dropsy appear, it must be treated as recommended in nephritis.
For oedema the horizontal posture when at rest ; though moderate walk-
ing may often be permitted with advantage. Digitalis, intermitted from
time to time, need not again be insisted on as a prime necessity in renal
dropsy. A drachm, or less, of the infusion, or ten drops of the tincture,
may be given with a little perchloride of iron and one of the sulphates.
Acupuncture can generally be avoided. In the advanced stages of the
disease, if dropsy of the cavities present itself, tapping either of the
pleurse or the peritoneum may be employed with little danger and mi;ch
advantage. Should pulmonary apoplexy or haemoptysis occur, it should
not be treated with ergot or styptics, but with laxative salines, especially
sulphate of magnesia. Having regard to the hardness of the pulse,
should this be excessive it may be modified by moderate purging, but
under no circumstances should tlie attempt be made to reduce the pulse
to the softness of health. The circulation is carried on under difficulties,
and more than normal pressure is essential. If any of the lesser mani-
festations or threatenings of ursemia present themselves, headache,
vomiting, ursemic smell, or extreme poverty of urine without any com-
mensurate increase of quantity, much may be done by periodic sweating.
The best way of accomplishing this is by Turkish baths, one every ten
days or fortnight. But these are not always available. The best
substitute is the leg-bath of which I have already spoken, which may be
applied weekly or at intervals of ten days. The medicinal diaphoretics,
excepting sometimes pilocarpin, are of no great use ; the acetate of
404 SYSTEM OF MEDICINE
ammonia is possibly injurious, as tending to increase the ammonia in the
system, which, if we may judge by the breath, is aheady too abundant.
The therapeutics of renal asthma must be directed to two ends :
the immediate relief of the spasm and the mitigation of the uraemia with
as little delay as is ])racticable. The spasm may be notably reduced by
vaso-dilators and etherial and alcoholic stimulants. The inhalation of
nitrate of amyl is of the greatest use ; I have had less experience of
nitro-glycerine, but cannot doubt that this also is useful. I have used
also opium and stramonium, but am satisfied that these are less
beneficial than vasodilators and etherial stimulants. But measures
which purify the blood and at the same time reduce the arterial tension
are of more permanent effect than antispasmodics. Purging and sweating,
calomel, elaterium, hot-air baths, and pilocarpin are the agents and the
instruments from which the most lasting good may be expected. By
such antiuraemic treatment the attacks can often be held at bay with
long intervals of peace until the patient finds leisure to die quietly in
some other way.
The ursemic convulsions, which are too often fatal, though not neces-
sarily so, and the ur?emic coma of quiet onset which is generally fatal, must
be met energetically in modes which have been referred to in connection
with nephritis. Prompt purging and sweating must be had recourse to,
and possibly, if the pulse be extravagantly hard, venesection may be
indicated. If the convulsions are very violent there is no objection to
the inhalation of chloroform, or the use of chloral by the mouth or the
rectum. Of late the inhalation of oxygen has been recommended.
Theoretically this seems worth trying. I have had little experience of it
in uraemia, though I have frequently employed it in diabetic coma, but
without benefit. Finally, opium and its derivatives should be rigidly
avoided in the convulsive and every other stage of organic albuminuria,
save only with the lardaceous kidney, where they are permissible and
sometimes useful, but not when this condition is productive of convulsion
or any other ursemic symptom.
III. Lardaceous Disease of the Kidney. — Lardaceous renal disease
has already been so far discussed in relation to lardaceous disease in
general (vol. iii. p. 259), that it is not necessary to say anything with
reference to j)athology or etiology beyond what has already found men-
tion. It only remains to add a few clinical details bearing upon symptoms
and treatment.
Nothing further need be said as to the sex and age of the subjects of
the disorder in question. It is not necessary to repeat that lardaceous
disease, whether of the kidnej' or of other organs, is always secondary,
always gradual in commencement, and always chrcmic in jn'ogress ; though
it may undergo the superaddition of tubal or diffuse nephritis which may
convey to it originally for the time as much acuteness as belongs to renal
inflammation of other origin.
The detection of the disease is generally easy, even obvious, though
DISEASES OF THE KIDNEY' 405
occasionally a searching inquiry has to be made before its nature is
apparent. The question will probably be raised by the discovery of
albumin in the urine, or the presence of oedema or diarrhoea. What we
then have to search for is evidence of suppuration or of syphilis. The
suppuration may be present or past ; if any chronic suppurative disorder
still persist, it will at once convey a suggestion, as also will any deformity,
deficiency, or cicatrisation which a bygone suppurative process has left as
its record. Signs of phthisis, a crooked spine, a defective joint, an
absent limb, or extensive scars may all be instructive in this relation. A
tropical complexion may give a hint ; the disease is readily produced
under the influences of the tropics, the traveller is likely to have had
dysentery in these regions, and he may even have had, and survived,
abscess of the liver. Signs of syphilis will be equally indicative,
eruptions, nodes, and evidences of old specific ulceration. It is obvious
that there must be some cases, however few, in which the airencies in
7 7 0
question may have done their work and left no mark. Suppuration may
take place from the bowel as the result of dysentery or some other
ulceration, and leave no external sign ; the same may be said of the
kidneys, one of which may be destroyed by a suppurative process which
may have come to an end before the constitutional result is recognised,
so that then there is no ostensible evidence of the primary mischief.
Syphilis also may leave its effects on the constitution in the form of
lardaceous disease without any conspicuous external mark. However, I
need not here dwell on the causes of lardaceous disease, which have been
already given in detail ; my present object is only to point to the external
signs which may lead to its detection. A worn and cachectic look is very
significant, though it may not at once be apparent on what it depends.
Putting aside evidences of antecedent disease the lardaceous state is
early productive of an increase in the quantity of urine, which is slightly
albuminous. The increase may amoiint to morbid diuresis, and be
attended with thirst. Diarrhoea is a frequent symptom, important not
only diagnostically, but as a source of danger Avhich contributes largely to
the fatal issue. This is generally painless, the motions watery and free
from mucus. It is due to extension of the disease to the intestine.
Vomiting due to a similar participation on the part of the stomach is
often distressing and sometimes dangerous. The enlargement of the
liver and spleen has been sufficiently referred to in the general account
of the disease. These enlargements, when present and palpable, are great
helps to diagnosis, but are less productive of symptoms than might have
been expected. The enlarged liver is seldom attended with obstructive
results, and the enlarged spleen does not usually give rise to marked
leucocytosis. Dropsy is present at some time or other, more often than
not. I reckon that oedema occurs in about two-thirds of the cases,
ascites in about a fourth ; hydrothorax rarely ; dropsy of every kind
may be absent from first to last ; diuresis and diarrhoea are antagonistic
to it. Though there may have been considerable swelling in the course of
the case, diarrhoea towards the close may completely carry it off, and leave
4o6 SYSTEM OF MEDICINE
the patient attenuated and sliarp-featured, with dropsy, so to speak, a minus
quantity. CEdema is jnost apt to come ou when, with tlie advance of
the disease, the profuse and slightly albuminous urine has become scanty
and highly albuminous. I have often noticed the a>dema to present
more tlie characters of heart disease than of renal ; absent from the face,
and collected in a peculiar baggy manner about the ankles.
As with other renal maladies there is a tendency with lardaceous
disease to certain intercurrent affections. Pneumonia, pleurisy, pericar-
ditis, and peritonitis occur in this relation, but less frequently than with
nephritis or the granular kiilney. These inflammations are probably due
to a uremic state of the blood, a condition Avhicli is less apt to be developed
in lardaceous than with other renal disorders. They are more frequent
when the lardaceous state is chiefly renal than when the stress falls
mainly on other organs. In forty-eight cases of lardaceous disease, in
whicli the renal change was productive of marked sj'mptoms, pneumonia
was found in nine, pleurisy in five, peritonitis in four, and pericarditis in
three. Bronchitis is seldom present. Ha^morrhagic complications are rare.
Of these, epistaxis is the most frequent. Purpura is uncommon, but not
unknown. Sanguineous apoplexy and the albmnimu'ic retinal affection
present themselves but rarely in connection with lardaceous disease, and
then only in cases of long standing where the fibrotic change has been
superadded. Apoplex}- has been recorded in this relation, though this
event does not chance to have come within my ex})erience. I have
known a case, however, in which well-marked retinal hpemorrhage
occurred in connection with advanced renal disease of the kind in ques-
tion. As to albuminuric ulceration of the bowel, I knew, and have else-
where related, an instance in which this affection and lardaceous disease
were conjoined; but in this case the ulceration, and an abscess to which it
gave rise, were the causes of the lardaceous disease, not its consequences.
The absence of hemorrhagic results is explained by the general
absence in lardaceous disease of increase of arterial tension and cardio-
vascular hypertroph}'. The heart in this disorder gives an average
weight of lOf ounces for adult males, one of 8i ounces for adult females,
which are so nearly the weights in health that it is clear that hyper-
trophy is generally absent. The left ventricle is somewhat thinner than
in health, and the cavity of full size or somewhat dilated. The heart is
weakened rather than strengthened, and the cedema, since it affects the
ankles rather than the face, is sugscestive rather of a cardiac than a renal
origin. It must be added that in certain cases, as has been already
noticed, the fibrotic renal change may be superimposed ujion the
lardaceous with some decree of the cardio-vascular thickening which
belongs to renal fiVjrosis. I could instance a man who died of lardaceous
disease consequent on dysentery. He eventually had urnemic symptoms.
The heart was distinctly but not greatly hypertrophied, weighing 13 oz.
The general absence of cardio-vascular hypt'rtr(>])liy in the lardaceous
state may be associated with the condition of arterial tension, which is
■Kually diminished rather than increased. This may be traced to two
DISEASES OF THE KIDXEY
407
causes : there is often some exhausting discharge, suppurative or
diarrhoeal, which keeps the tension down ; the tendency to uraemia is
Fig. 5. — PuUe-tracing in lardaceous disease of kidney. Dudgeon's spliygniograph. 100 grammes pressure,
comparatively slight, so that the vascular obstruction due to this morbid
state of blood is absent. In connection with the general freedom from
Fig. 6.— Casts from the lardaceous kidney. These are much the .same as occur in nephritis ; some
simply fibrinous, others embedding epitlielial cells. (From Dickinson's AWitmiiiiiria.)
over-tension in the circulating system may be mentioned the infrequency
of renal asthma with lardaceous disease.
4o8
SYSTEM OF MEDICINE
While upon the heart in lardaceous renal disease, I may add that
endocarditis is relatively frequent. Vegetations recent at death were found
in five of eighty-three cases, and old valvular thickening in twenty-one of
the same series. The vegetations are often ragged, and liave been
known to present the special reaction with iodine, as also have embolic
blocks to which they have given rise. This tendency to fibrinous
deposition on the valves must probably be attributed rather to the state
of the blood in the general lardaceous condition than to any action
belonging especially to the renal localisation.
Not only does renal fibrosis ensue upon the lardaceous state, which
may be said to be the rule when the disease is of long continuance, but
it sometimes comes to pass that acute nejihritis with much tubal catarrh
is superimposed upon it. In such a case there may be an exacerbation of
dropsy, with scanty and highly albuminous urine, abundance of epithelial
and other casts, and a copious deposit of renal epithelium.
The duration of lardaceous disease is exceedingly variable, sometimes
it approaches in rapidity all but the most acute forms of tubal or diffuse
nephritis, sometimes it imitates the slow progress of the most chronic
forms of the granular kidney. From the necessarily gradual operation
of the causes on which it depends, it is obviously difficult to mark the
beginning with exactness. The cause in every case must have been in
existence for some time before the effect was produced. I have before
me a collection of post-mortem cases representing the experience of St.
George's Hospital from the year 1876 to 1894, of which an abstract is
appended. It must be borne in mind that as the recognition of the
lardaceous state was post-mortem, not clinical, there were many in which
it had not progressed far enough to cause symptoms.
Table of 78 Cases in which Lardaceous Disease was found after Death,,
showing the Time between the Commencement of the Disease by
which it was caused and the fatal Termination.
Time.
Xuinber of Deaths in stated time.
Kidneys affected.
Kidneys not affected.
ToUl.
From 2 to 3 montlis
Over 3 uiouthsiiot above (i
,. t5 „ „ 12
,, 1 year ,, 2
,, 2 years ,, .'>
„ » „ n 10
„ 10 ,. ,, 20
,, 20 ,, ,, 30
„ 30 „ „ 32
1
5
20
16
8
9
5
1'
2
1
4
2
3
1
2
5
24
16
10
12
5
2
2
It is apparent that in the majority of cases the fatal termination was
' This case was apparently due to cougenital syphilis.
DISEASES OF THE KIDNEY 409
within two years of the origin of the disease. In some the disorder
appeared to have originated only two, three, or four months before death.
The shortest time, two months, was presented by a single instance in
which the cause was phthisis ; the overt manifestations of this disease, from
which the history was dated, may have been preceded by changes which
were unnoticed or unrecorded. To pass to the other end of the scale
there were some cases Avhere the presumed source of the morbid con-
dition dated as far back as twenty or thirty years. One patient in
whom the disease was presumably due to congenital syphilis lived to the
age of twenty-one. The longest interval between the beginning and the
end Avas exemplified by a man who died at the age of fifty-seven, with
cerebral syphilis and many manifestations of lardaceoUs disease, in whom
the specific history was traced back for thirty-two years. It was not
known when he began to be lardaceous.
In the earlier and possibly in the longer part of its course lardaceous
disease may be latent or without symptoms. When these jDresent them-
selves it may be presumed that the organic change has already made
considerable progress. How long it may last after it has been declared
by albuminuria, diuresis, thirst, or dropsy is a matter of much variation,
but it may be said, as relating to the majority of cases, that the end of
the complicated process is not far oft", the interval to be measured by
months more often than by years. In some cases, however, the larger
measure of time is required to express the duration of the symptoms.
A boy, a frequenter of the Hospital for Sick Children, had a profuse
discharge in connection with disease of the pelvis and hip-joint, and a
year afterwards displayed evidences of lardaceous disease in enlargement
of the liver and spleen, slightly albuminous urine, and some oedema.
Under the influence of tonics and Margate the liver gradually resumed
its normal size, the urine ceased to be albuminous, and he lost the cedema.
The spleen remained greatly enlarged, but he improved so greatly in
general health that his complete recovery seemed not improbable. He
was, however, attacked with haemoptysis, with a return of the dropsy,
and died eight years after the commencement of the lardaceous symptoms.
A man, in whom the disease was of syphilitic origin, became my
patient in October 1866 with hepatic enlargement, albuminous urine, and
oedema. He improved under specific treatment, and lived until June
18G9.
A boy, in whom tlie disorder was due to disease of the pelvis, lived
for nineteen months after the legs had become oedematous, the liver
having enlarged previously. These instances of protraction might be
multiplied and extended, but, nevertheless, it may be fairly stated that
commonly the duration of the symptoms ranges from about two months
to a year and a half. It will be evident to the reader that the fore-
going statements are based entirely on fatal cases, in which the evidence
may be taken as complete and conclusive ; but it is not to be inferred
from the exclusion of others that all cases are fatal.
The immediate causes of death under lardaceous disease in general
4IO
SYSTEM OF MEDICINE
have already been stated in detail (vol. iii. pp. 274, 275) ; it only remains
to add a few Avords in reference to the renal localisation. Of persons
shown after death to have been the subjects of lardaceous change, a
greater number, as has already been shown, owe their deaths directly
to the primary lesion rather than to the lardaceous consequence. Having
regard only to the lardaceous consequence, the chief difference between
this and other renal diseases is in the relative infrequency in this of
uri>3mia, and the almost total absence of the disorders of over-tension,
especially of hjeraorrhage, cerebral, retinal, and of the nature of pulmonary
apoplexy. Tlie annexed statement, derived partly from my own experi-
ence and partly from the St. George's records, will furnish sufficient
evidence on the jioints in question. It is here seen that the chief cause
of death in lardaceous disease is diarrhoea ; this is not strictly renal, but
due to the participation of the bowels in the disease. Diarrha^a was
jirominent as a cause of death in 29 of the 74 cases, about a third.
Vomiting was prominent as a cause of death in 9.
Inflammatory affections of the lung are of frequent occurrence, as
■with other forms of renal disease. Cerebral uraemia occurred in 13 of
the luimber, about 1 in 6, a small proportion compared to what
holds in other forms of renal disease. The iittacks take ])lace some-
times with convulsion, sometimes as coma without convulsion. It is
not necessary to add anything to what has been said with regard to
unemia under other circumstances. The condition of the kidneys is
not such as to offer much hope in treatment, beside Avhich the state of the
l^atient is usually such as to forbid very energetic or exhausting measures.
Table showing the apparent Causes of Death in 74 cases of Lardace-
ous Disease, in which the Kidneys were affected. No symptoms
are given excepting such as were mainly concerned in the I'atal
issue : —
Diarrhoea
23
Diarrlii fa + vomiting
4
l)iarrlifea + dropsy .
1
Dianliiia + erj'sipelas
1
Yoniitini,' ....
3
UnBinia (convulsions or coma)
13
Pneumonia ....
9
Broncho-pneumonia or bronchitis .
2
I'lcurisy ....
2
General dropsy
3
Ascites (tajiping) . . . .
4
Peritonitis
5
Enteritis . . . . .
1
Thrombosis
2
Suppression of urine
1
74
I have already pointed out the fact (see vol. iii. p. 276) that
lardaceous disease has to a certain deirree a tendency to recovery ; this
will be furtlier seen when I come to consider the results of treatment.
Section of a lardaccous kidney showinj; casts /» s/ht, presenting the icxline reaction, which casts
rarely show. (From Dickinson's Ai/'u»iinuria.)
DISEASES OF THE KIDNEY 4"
I have it on the authority of the late Dr. Moxon that lardaccons organs
may recover themselves under the influence of typhoid fever, as if the
material were consumetl by the febrile process.
The urine in lardaceous disease of the kidney resembles in many
particulars that of granular degeneration. The first change is increase of
quantity, which varies from little above the normal to about four times
as much. Sir. T. Grainger Stewart has found as much as 200 ounces in
twenty-four hours. The common range is from 50 to 90 ounces. The urine
thus increased is pale and clear and of low specific gravity, from about
1015 to 1006. When the increase becomes obvious, or soon afterwards,
a trace of albumin appears. Commencing always in small quantity, it
gradually increases to a decided precipitate while the quantity of urine
diminishes. Towards the latter periods, particularly when a certain
amount of tubal catarrh is superadded, the urine may fall below normal
even to 8 or 10 ounces in twenty-four hours, and will noAV be highly
albuminous. On the approach of death the secretion may be totally sup-
pressed, though this is exceptional. The acidity of the urine is usually
decreased. Blood is but rarely present ; when present it is sometimes
in considerable quantity. Casts make their appearance early and increase
in number as the disease progresses. The most common are cylinders of
fibrin, often dotted with oil, which do not differ from what are shed in
other renal disorders. They may be large or small according to the state
of the tubes in respect of dilatation and the retention of their epithelial
lining. Besides these there are often others which contain or chiefly
consist of epithelial cells ; these indicate tubal catarrh, and may be
associated with much loose renal epithelium. As a very exceptional
occurrence, but as one which admits of no doubt, it must be mentioned
that casts have been known to present the iodine reaction in a marked
manner. I have witnessed this both in casts which have been passed
with the urine, and also in those which have been exposed in situ in the
kidney by section after death. I have given a coloured illustration of
this phenomenon in the second edition of my book on Albuminuria.
It is by no means rare when the urine is scanty to find a deposit of
uric acid or amorphous urates.
The chemical changes in the urine may be briefly expressed. All
normal ingredients are reduced excepting the water, about which no more
need be said. The urea is but slightly reduced so long as the urine is
superabundant ; afterwards it is more sparingly secreted, but seldom
reaches the degree of diminution to which it falls in extreme cases of
other forms of renal disease. The ordinarj^ range is from two-thirds to
half the normal quantity; 7"37 grammes and 3 "6 grammes have been
recorded — the first by myself, the second by Rosenstein — as examples of
unusual diminution. The uric acid is sometimes normal in quantity,
more often diminished. The phosphoric acid, the sulphuric acid, and the
chlorine are all lessened, the phosphoric acid with the greatest regularity.
The alkaline salts, as estimated by incineration, are below the normal
amount ; especially during the presence of a purulent discharge. Nothing
412 SYSTEM OF MEDICINE
need be said about the albumin but -what has already found jilace. It
may be observed that in lardaceous disease the precipitate is sometimes
more soluble in excess of nitric acid than is usual with other forms of
renal disease.
In the treatment of lardaceous disease it has to be premised that the
disorder, as already stated, has a tendency to recovery which, however, is
to be little relied upon when the disorder is advanced, and of the kidney.
The superaddition of fibrosis stamps the disease with ])ermanency, though
the lardaceous character may be on the wane or even a thing of the past.
If the cause is apparent, but the effect not j^et manifest, j)revention must
be aimed at by removal of the cause. If the change be noticeable, but
as yet only incipient, its further progress may be arrested, and even the
mischief undone, by directing salutary influence upon the primary disease.
The paramount measures are the arrest of suppuration and the coiuiter-
action of syphilis. Of late years we have seen much less of lardaceous
disease than formerly ; this is owing, in the first place — speaking in order
of time — to oiu" having learned the use of iodide of potassium ; and in
the second place, to the introduction of antiseptic surger}^, which has
made operations possible which formerly were not so, and has prohibited
suppuration under circumstances in which it used to be uncontrolled.
The first question in the treatment of lardaceous disease is to which
of its two causes it is due. Supposing it to be due to i)resent suppura-
tion, we must take counsel with a surgeon, and put an immediate stop, if
it be possible, to the source of the discharge and of the disease. The
expedients of surgery must be pushed to the uttermost in the assurance
that if the primary mischief be allowed to continue, the secondary
misciiief Avill probably kill if the primary do not. On the other hand,
we have warrant for believing that if the organic change be not far
advanced, it may be undone by the processes of nature if the cause be
removed. The subjects of lardaceous disease have a considerable power
of recovery after operations, and will bear much in the way of what is
necessary to arrest suppurative processes. Together with appropriate
surgery, or without it when this is not practicable, nmch may be done by
general restoratives. If we cainiot stoj) the discharge, we may com-
pensate for it. Nourishing food, cod-liver oil, iron, and quinine are all
of value towards this end.
In the presence of suppuration I am sure it is harmless, and I think
it is beneficial, to compensate the inevitable loss of potash by the
administration of this alkali. This to be effective must be in its most
active form, that of liquor ])otassa3, and be given on an em])ty stomach.
The amount thus introduced is small, but it carries with it active
affinities. Some of the old belief in liquor j)Otassa} as a resolvent may be
ilue to its action under such circumstances as I have indicated. Pure
and bracing air is of particular efficacy.
Margate has obtained great and deserved repute in cases of suppura-
tive disease ; it seems both to control the suj)puration and to mitigate its
effects. I have known lardaceous cases with present suppuration, which
DISEASES OF THE KIDNEY 413
had been practically but not wholly checked by operation, to derive un-
doubted h>enefit from the local influences, and I have referred to one in a
former page (vol. iii. p. 276). Other places beside Margate may have
similar effects, but of all such Margate may be taken as the example.
In treating established lardaceous disease it may be a matter of
rejoicing to the physician to be able to trace it to syphilis. The great
remedy is iodide of potassium in large doses and for a long time ; the
results, though slowly brought about, are eminently satisfactory. Such
patients do not bear mercury well, and my experience has led me to
avoid it. I have elsewhere given instances of the effects of iodide of
potassium in these circumstances which I need not here repeat. It
will suffice to sa}', under the persevering use of this remedy, that I
have known marked lardaceous disease of syphilitic origin, with highly
albuminous urine and much dropsy, to eventuate in recovery apparently
complete. Given for a short time it is useless, and the good effects I
have seen have been from large doses. It needs to be given with
occasional intermissions for from two to five years, and perhaps in doses
of from ten to twenty grains three times a day. Iodide of iron can often
be usefully associated with it. Such treatment will be more than
equally serviceable in relation to lardaceous viscera other than the
kidneys when of syphilitic origin. I have known the enlarged liver to
lessen rapidly, and ascitic fluid to become quickly absorbed. The spleen
loses its abnormal bulk more slowly than the liver. Of all lardaceous
organs the kidney is the most obstinate. There are few diseases which
are attended with as much organic change as the lardaceous effect of
syphilis and which are impressed by treatment so satisfactorily.
It remains only to add a word or two as to what should be done for
some lardaceous symptoms which have not been dealt with in this view.
It is not necessary to repeat much that has been said with regard to other
forms of renal disease which may be applied with modification to this.
It is to be borne in mind that arterial tension is more often below than
above par, and that the treatment in general must be less exhausting and
more sustaining than with other renal disorders. There is less tendency
to uraemia, and less need for stimulating the secretions which is often
overdone by the disease itself. For dropsy iron is generally required, and
digitalis often beneficial. Intercurrent inflammations should be treated
on general principles, but with a light hand. Diarrhoea, as one of the
most fatal of lardaceous affections, is one over which medicine has little
control. Ferruginous styptics may be employed, one of the best being
iron-alum. Vegetable astringents may be used, including the red gum of
Australia. And it is to be particularly noted that opium and its deriva-
tives are not counter-indicated, or not to the same extent, as in other
varieties of albuminuria. Opium, in the guise of compound kino powder,
or with sulphuric acid or sulphate of copper, may be employed. It is well,
perhaps, to avoid acetate of lead in such circumstances, as lead is a renal
irritant, and lardaceous kidneys especially amenable to irritation.
W. HowsHip Dickinson.
414 SYSTEM OF MEDICINE
REFERENCES
1. Allbutt, T. C. " Mental Anxiety as a Cause of Grauular Kidney, " 5ri7. Med. Jour.
Feb. 10, 1877. — 2. Baillie Lecture, Lancet, July 20, 1895. Reprinted in Occasional Papers
on Medical Subjects, 1896. — 3. Biac;HT. The Reports of Medical Cases, \o\. i. plate 5. — -1.
Carteii, W. Bradshaw Lecture, Lancet, 25th Auo;ust 1888. — 5. Dickinson. Allu-
miniu-ia, 2nd ed. p. 79, illustrations, pj). 30, 169, 310. — ^6. Idem. Mcdico-Chirxirgical
Transactions, vol. xliii. — 7. Idem. "On the ilorbid Eflects of Alcohol," J/crf.-CVi//-.
Trans. 1872, vol. Ivi. Republished in Occasional Tapers on Medical Subjects, 1S96, j).
65. — 8. Idon. "The Cardio- Vascular Changes of Kenal Disease," Lancet, 20th July
1895. Reprinted in Occasional Papers, p. 190. — 9. Idem. " On Albuminuric Ulcera-
tions of the Bowels," Med.-Chir. Trans, vol. Ixxvii. Reprinted in Occasional Papers,
p. 161. — 10. Idem. Croonian Lectures, British Medical Journal, April 22, 1876 ; Med.-
Chir. Traits. 1891, vol. Ixxvii. Reprinted in Occasional Papers, 1896. — 11. Idem.
"Case of Uric Acid obtained from the Brain in a Case of Renal Disease," Path. Trans.
vol. xviii. p. 19. — 12. Idem. "Places and Connnonplacos in Renal Disease," Zrt/ur^,
10th February 1894. Reprinted in Occasion-rl Papers, p. 178. — 13. Idem. "Renal
Dro|)sy," Med.-Chir. Trans, vol. Ixxv. p. 365. — 14. Klein. Path. Trans, vol. xxviii.
J). 430. — 15. Lancaster, Le Cronier. "On Eight Cases of Ur;«inic Eruptions of the
Skin," Transactions of the Clinical Society, vol. xxv. p. 49. — 16. Dickinson, W. H.
Pathological Transactions, vol. xl. p. 145.— 17. Ibid. vol. xxx. pp. 543, 545. — 18.
Medi^o-Chirurgical Transactions, vol. xliii. — 19. Smith, Pye. " Ail'ections of the Skin
occurring in the Course of Bright's Disease," British Journal of Dermatology, vol. vii.
p. 284, 18tJ5. — 20. Tripe. See Dickinson's Albuminuria, 2nd edit. \t. 35.
W. H. D.
OTHER DISEASES OF THE KIDNEY
Perinephric Extravasations
Air. — Air is occasionally found in considerable quantity around the
kidney after injury to this organ. The source of the air is not always
traceable. In one case it appeared to have gained admission through a
perineal incision which had been made on account of a rupture of the
urethra, which complicated a fracture of the pelvis. Wounds of the loin,
groin, and perineum, whether complicated by wounds of the bowel or
not, and fractures of the lower ribs, Avith injiuy to the lung, may be the-
causes of this form of exti-avasation. Retroperitoneal abscess opening
into the bowel may give rise to it.
Blood may be effused around the kidney from a ruptured artery or
vein, or from capillaries as a result of violence. The clots so formed may
ultimately break down and lead to suppuration. Fractures of the pelvis
or lumbar vertcbrjB, ruptures of muscles, and the bursting of an aneurysm
of the abdominal aorta, have been causes of considerable circunncnal
haemorrhage. The kidney may be pushed forward so completely by the ex-
travasated blood as to present a tumour anteriorly in the hypochondrium.
The si/iii/ifo)iis vary with the cause and extent of the extravasa-
tion. When the blood is confined to the cellular tissue of one loin.
PERINEPHRIC EXTRA VASA TIONS 4 1 5
it causes a tumoui', sometimes difficult to diagnose from a distended
kidney. If the source of the bleeding be a superficial laceration of the
kidney, or a rupture of an artery (say one of the kimbar arteries), some
weeks may elapse before the effusion is sufficient to give rise to any swell-
ing or increased dulness in the loin, and no sign of faintness is noticed at
any time ; then, after some time longer, the effused blood becomes more
solid, and the tumour more irregular, and by degrees, perhaps, it is
absorbed. On the other hand, the blood -clot may disintegrate ; under
which circumstances the symptoms of suppuration will arise.
Recovery may take place after very extensive traumatic haemorrhage ;
but retroperitoneal haemorrhages due to ruptured aneurysm are almost
certainly fatal, though, it may be, tardily so.
If the haemorrhage increase, or suppuration occur, and surgical aid is
not brought to bear upon the case, death may follow from peritonitis, due
to tension upon the peritoneum or rupture of it ; or the colon may be pene-
trated and faeces and flatus enter the blood tumour, and give rise to de-
composition, septic absorption, and death.
When haemorrhage is due to aneurysm, little or nothing in the way of
treatment will avail ; when due to injury, the treatment must be based
upon the principles stated in dealing with injuries to the kidney.
Urine is extravasated into the loin behind the peritoneum from a rup-
ture of the kidney involving the calyces or renal pelvis, from direct
penetrating wound, the result of operation or accident, or as a con-
sequence of ulceration of these parts. Ulceration of the ureter, due to
injury or the joressure of a tumour, may cause urinary extravasation into
the loin or .iliac region. The inflammation of the cellular tissue, result-
ing from urinary infiltration, may run on to suppuration, giving rise to a
lumbar or inguinal abscess. Healthy urine alone is but little irritating ;
it is the mixture of blood and urine which tends to decomposition and
suppuration. If the quantity of urine efTused is small, the cellulitis,
stopping short of suppuration, may become chronic, spreading towards
the iliac fossa, and causing contraction of the ilio-psoas muscle. In some
instances the effused urine becomes encapsuled within a thick-walled cyst
of inflammatory origin, Avith the cavity of which the kidney communi-
cates at the point of rupture or ulceration. Sometimes phosphates
accumulate in the space occupied by the effused fluid to sv;ch an extent
as to form deposits which block the drainage-tubes used in treatment
by lumbar incision.
Treatment. — When the diagnosis is uncertain, but from the fulness and
dulness of the loin there is reason to think urine is escaping behind the
peritoneum, a lumbar incision and drainage are needed. Suppuration
must be dealt with by early free incision. If the kidney be greatly
damaged, nephrectomy will be requisite.
4 1 6 SVS TEM OF MEDICINE
Renal Fistul.e
Fistulse which communicate with the kidney and pelvis of the
kidney.
Caufr.'!. — Kenal fistula? are caused, in the great majority of cases, by
calculi in the i)elvis of the kidney or in the ureter. Other causes are
gun-shot, punctui-ed or incised wounds, injuries inflicted by surgical
operation, and abscess of the kidney. The opening into the cavity of the
kidney or ureter is usually single and connected Avith the posterior aspect
of the organ. Renal fistula may open at the loin or groin, into the colon
or duodenum, into the pleural cavity or lung, or into the peritoneum. It
is comparatively rare for a fistula to open into the peritoneum. If the
fistula be the result of a wound or a ruptured hydi'onephrotic cyst, urine,
sometimes in large quantity, will escape from it ; if the effect of pyo-
nephrosis, due to ureteral obstruction, pus will be mingled with the urine ;
if caused by the conversion of the kidney into a scrofulous abscess cavity
the discharge will consist of pus and broken-down tuberculous material.
Renal fistula opening" in the loin. — When fluid of a urinous
character escapes from a fistula which followed suppurative nephritis or
injury to the kidney, the diagnosis of the renal origin of the fistula is
certain. It must be remembered, however, that a lumbar fistula, instead
of communicating with the kidney at all, may be the result of disease in
the ureter, the bladder, or even the urethra.
Treatment. — The skin around the orifice must be kept clean, and free
from irritation. If, after a fair length of time has been allowed for spon-
taneous closure, the fistula persist, an incision, such as to lay open any
sinuous track, vivify callous edges, or remove spongy granulations or
calculous deposits, must be tried. The injection of iodine solution some-
times will stimulate the sinus to healthy action.
If the other kidney be sound, and a permanent fistula communicating
with a diseased organ, threatening the life and sacrificing the comfort
of the patient, resist other treatment, the best plan is to perform
nephrectomy.
Renal fistula opening into the stomach. — This is of extremely
rare occurrence. In one case of communication of the left kidney with
the stomach, pus \irine and calculi are said to have been vomited ; but
there is much uncertainty as to the genuineness of the symptoms and the
accuracy of the diagnosis. In a case of gastro-renal fistula due to scrofulous
pyelone])hritis, admitted under my care into the Middlesex Hospital
in 1884, there was a hi.story of "inflammation of the bladder" and of
" pus in the motions," as well as in the urine. There were four sinuses
in the back discharging pus. Careful examination of the chest and ab-
domen di.sclosed nothing a1>normal. No phy.sical signs of pelvic cellulitis or
circumrenal abscess could be made out. Complete anuria jireceded death.
On post-mortem examination the only communication between the kidney
PERINEPHRITIS AND PERINEPHRIC ABSCESS 417
and the gastro-intestinal tract was a fistula of the diameter of a crow-
quill, opening into the left margin of the great curvature of the stomach.
Renal fistula eommunieating- with different parts of the intestine,
and renal fistula opening' into the lung, are of very rare occurrence.
Prompt surgical treatment might in some instances have prevented their
formation.
Ureteral fiitulse are almost invariably the results of operation
wounds.
Perinephritis and Perinephric Abscess
Perinephritis is inflammation of the cellular and adipose tissues sur-
rounding the kidney. It may occur at -my age, having been met with in
quite young children ; it appeal's in three forms : the sclerosing, the
fibro-fatty, and the phlegmonous.
The sclerosing variety results in the formation of a thick Avhite firm
fibrous capsule, which occupies the site of the circumrenal fat and may also
extend into the neighbouring parietes in the lumbar region, even to the
skin. This sclerosis of the adipose tissue round the kidney leads to com-
pression of the vessels and subsequent atrophy ; the organ having been
removed in some cases without there being any necessity to ligature the
contracted vessels.
The fibro-fatty variety consists in the over-development of the normal
envelope of the kidney associated with a certain amount of induration,
so that the organ may be concealed in large masses of fat and fibrous
tissue which may even penetrate into its substance, rendering its recogni-
tion extremely difficult.
The phlegmonous form, which constitutes perinephric abscess, includes
all kinds of pus-formation in these tissues. It is rare before pubert}'.
Perinephric abscesses are : (i.) Primary extrarenal abscesses, or those
which are independent of any fistulous opening into, or other disease of
the kidney. These may depend upon injuries, chills, etc., or may follow
the acute exanthems ; or the abscess may have extended from a distant
part, as the spine, pelvis, etc.
(ii.) Consecutive extrarenal abscesses ; in which inflammation of the
kidney has spread to the cellulo-adipose tissue (a) by contiguity, but
without urinary infiltration ; or {h) as a result of a renal fistula communi-
cating with the surrounding cellulo-adipose tissue. This form is usually
due to sitppurative pyelitis ; or to tubercle, cancer, hydatid or other form
of cystic disease ; or to calculus of the kidney.
(iii.) Consecutive to disease of an organ other than the kidney, as of
colon, testis, liver, or one of the pelvic organs.
The pus is situated usually behind the kidney or at one or other ex-
tremity of it. In the latter varieties it lies between the kidney and the
diaphragm ; or between the kidney and the colon, with a tendency to
extend towards the iliac fossa. In most instances extension takes place
so that all these sites are occupied at once, and the limiting wall is made
VOL. IV 2 E
4 1 S 5 YSTEM OF MEDICINE
lip of the iiciglibouriiig viscera agglutinated together and protectetl by
false ineni1)rancs, while the enclosed area is broken up into separate
suppurating foci. The contents may be thick creamy pus or a thin
serous or glairy fluid, often Avith a feculent odour ; and in the midst may
lie the immediate cause of the abscess in the form of calculi, hydatids,
or intestinal matters. The kidney may be free froTU disease or ma}'
contain suppurating points, not necessarily in direct communication with
the abscess, but often situated immediately beneath the capsule, and
sometimes constituting the proximate cause of the abscess.
Suppuration may extend to the liver, spleen, or pancreas, and the in-
testine may be closely adherent; but the peritoneum is rarely, involved
beyond being adherent and thickened.
In one case, recorded by Coupland, the pleura and lung were involved
and the pus was discharged by a bronchus. In others j)yothorax has
resulted. Below, the abscess has extended to the pelvis and found vent
through one of the various natural openings or into one of the i)elvic
viscera, or has tunnelled along the psoas muscle. Posteriorly it may
open superficially in the loin through the triangle of Petit.
Sijmptoms. — These varj'' with the cause and acuteness of the disease.
"When the inflammation is secondary to some distant disease, such as
pelvic cellulitis, the symptoms of the primary aff"ection may disguise those
of the perinephritis. Extensive sclerosis gives a firmness and immolulity
to the circumrenal tumour which, taken in conjunction with its position
and relations, are quite characteristic.
The constitutional indications of pus in the circumrenal connective
tissue are the same as those excited by deep-seated suppuration elsewhere.
The febrile temperature in some cases runs continuously high ; in others
it is intermittent and suggestive of malaria or pyaemia. Obstinate con-
stipation is almost invariable.
Of the local sj^mjitoms, those clue to pressure are more marked in
perinephric abscess than in perinephritis. Pain, deep-seated and often
paroxysmal, ushers in the disease ; sometimes dull and aching, at others
darting, it courses along the distribution of the lumbar plexus. The
pain is greatly intensified by bi-manual compression of the loins.
The aflfectcd side will impart a sense of increased resistance and
weight long before i)us has formed, or the abscess is large enough to alter
the contour of the part in any way. The skin in the loin is often waxy
and n?dematous. Fluctuation is frequently A'cry remote, owing to the
thickness of the parietes ; and in one case, in which six pints of pus were
pent up, on account of the great depth of the subcutaneous fat no fluctuation
could be detected. CEdema of the foot and ankle has preceded for many
weeks every other sign of perinephric abscess. A pecidiar lameness, due
to the flexed position in which the thigh of the aff"ected side is retained
in order to relieve tension, is often an early symptom. There is usually
also distui'bance of the diirestive organs manifested bv anorexia with
nausea and vomiting, and either diarrhoea or constijxition.
In perinephritis before suppuration has occurred the spinal column is
PERINEPHRITIS AND PERINEPHRIC ABSCESS 419
preternatiirally stiff, and the body in walking is inclined to the affected
side ; stooping is difficult ; in the recumbent posture the patient will not
extend the corresponding thigh beyond 160^, or in severe cases 130°;
and there is sometimes pain in the knee. These conditions together cause
the case to resemble the second stage of hip disease, especially when the
thigh is rotated outwards, so that the heel of the affected side during
standing rests on the dorsum of the opposite foot. In simple peri-
nephritis there is no tumefaction to be felt in the loin, as in perinephric
abscess.
rrognosis. — In a few cases perinephritis ends in resolution before the
suppurating stage has been reached. When suppuration occurs, the
prognosis depends chiefly on two things, the early and free evacuation of
the pus, and the cause of the disease.
When the abscess is primary, that is, not dependent upon renal or
other visceral or spinal disease, an opening into it is soon followed by
convalescence. If the abscess burst into the peritoneum, rapidly fatal
peritonitis ensues.
The abscess may open through Petit's triangle ; or by way of the
pleura, lung, or pericardium above; by the groin or pelvis below; forwards
beside the umbilicus ; or inwards by the intestine. In any case the
persistence of sinuses and the establishment of lardaceous disease usually
lead ultimately to a fatal I'esult.
Etiologif. — Perinephritis is most commonly secondary to a suppurative
lesion of the kidney. It may, however, arise primarily in the cellular
tissue ; or be secondary to suppuration in some neighbouring organ ; or
propagated from some distant one, such as the uterus or caecum.
Perinephritis occurs more often in men than Avomen ; it complicates the
specific fevers, septic diseases, and puerperal fever. It occurs also after
exposure to cold, and in some cases after operations on the lower genito-
urinary organs, independently of any affection of the kidney. Among
local causes are contusions, strains, and Avounds, including infection from
an unclosed ureter after nephrectomy for pyonephrosis. The greater
number of instances, however, are secondary to disease in the kidney.
Arising by infection from neighbom-ing organs, circumrenal abscess
may be secondary to biliary or intestinal calculus, perforation of the
colon, pneumonia, empyema, or pulmonary abscess ; infecting vixais being
conveyed by the veins or lymphatics.
Diagnosis. — The affections which may be mistaken for perinephritis or
perinephric abscess are lumbago, various organic diseases of the kidney,
spinal caries, splenic tumours, fgecal accumulations in the colon, morbus
coxcG, and psoas abscess.
The high situation of the pain ; the tenderness in the loin ; the fact
that passive flexion is painless in itself ; the free, painless mobility of the
hip-joint ; the absence of tenderness and fulness over the upper end of
the femur; absence of pain on percussion of the thigh, and the less
rigidity of the adductors and rotators, serve to distinguish perinephritis
from hip disease.
420 SYSTEM OF MEDICINE
The symptoms of perinephritis are very closely allied in many points
to those Avhich accompany appendicitis ; but the characteristic featui-e of
perinephritis is that the pain, tenderness, and SAvelling are first observed
and most pronounced in the ilio-costal interspace behind ; whereas in
appendicitis they are most frequently located in the iliac fossa and in
front.
7'reatment. — Primary perinephritis may sometimes l)e checked in its
early stages by local blood-letting by means of leeches or the cupping-
glass, hot baths, and hot emollient poultices or stupes.
When the acutcness of the sym])toms has passed, or the inflammation
is of the subacute or chronic character, disappearance of the inflammatory
products may follow blistering, or hot fomentations applied over some
absorbent ointment such as iodide of potash or iodide of lead. The
bowels should be Avell opened at the onset by a brisk purgative, and kept
acting moderately by enemas or mild laxatives.
Pain must be relieved by morphia given in suppository or by the
mouth. The diet should be milk, beef-tea, or something equally simple
and as readily digested.
As soon as pus is suspected, it should be searched for at once by an
exploratory incision in the loin ; and when found must be evacuated by
a free incision in this region.
There should be no Araiting for fluctuation ; the increasing fulness,
hardness, and tenderness, and perhaps the commencing redness and
oedema of the skin, are ample signs to warrant an incision, and even to
demand it. Trousseau, among others, pointed out the difficulty of
detecting fluctuation, which he says is almost always deep, requiring
great experience to make out; but the doughy feel of the lumbar region,
the increase of the fever and other general symptoms, and perhaps
the oedema of the skin in the loin, are indications for a free incision
which the surgeon must not hesitate to act upon with promptitude.
The incision may be either vertical, oblique, or transverse ; and after
dividing the integument and muscles with the knife, the suppurating
area should be entered by the finger. The abscess cavity and kidney
should be examined Avith the finger in search for a stone ; should a renal
fistula exist, it must be laid open, especially if the preceding symptoms
indicate calcidous pyelitis.
Any loose sloughs of cellular tissue should be removed by the finger
or dressing-forceps. The abscess should be washed out with a solution
of iodine or carbolic acid, and a drainage-tube should be inserted.
The loin should then be enveloped in a large hot fomentation of
cotton-wool soaked in equal quantities of water and carl)olic acid solution
(1-40) ; or, if there is redness or oedema, equal parts of lead lotion and
carbolic acid solution (1-40). Absolute rest in bed should be enforced
throughout convalescence.
Consecutive abscesses, and also some of the less acute forms of
primary abscess which do not soften down very quickly, must not be
allowed to close too early. On the contrary, the drainage-tubes should
I
TRAUMATIC NEPHRITIS 421
be retained until, by the granulating process in the wound, they are
forced out by degrees. If in these cases the wound is allowed to close
too early, inflammation recurs and pus is formed afresh, which will need
a second incision to prevent burrowing far and wide. When a fistulous
opening remains, astringent or iodine solutions may be injected, or the
hot wire introduced ; but a fistula may persist in sjDite of the most per-
severing measures employed to close it. A lumbar hernia may follow
the incision for the evacuation of an abscess, or for the examination of
the kidney, but excessively rarely does so.
Whilst suppuration continues, nutritious food, tonics, and possibly a
regulated allowance of stimulants should be given. The record of cases
in which eai'ly and free evacuation of pus has been accomplished is very
favourable, nearly all ending in recovery. On the other hand, peri-
nephric abscess left to itself almost always ends fatally ; except in the rare
instances in which the matter finds vent by the bowel, bladder, or
bronchi, or opens externally.
Traumatic Nephritis
Causes. — Wound or contusion of the substance of the kidney, violent
muscular strain, the contusions caiised by the presence of a calcvdus.
When blood has been extravasated into the cavity of the kidney, and
the urine retained there in consequence of impaction of a blood-clot in
the ureter, pyelitis and pyelonephritis may arise.
Symptoms. — Rigor ; fever ; pain not constant, and very variable in
degree, deep-seated and referable to the loin, sometimes diffused over a
considerable area of the abdomen, and rarely of a throbbing character
unless the perinephric tissue be also involved. Nearly all movements
aggravate the pain. If the disease sets in soon after an injury, the urine
always contains a trace of blood. Subsequently, in a few cases, pus may
be found in the urine.
There is a disposition to the formation of gravel and calculus — and,
as a consequence, to renal colic — after wounds or concussions of the
kidney.
Traumatic nephritis is not usually serious, provided the damage
inflicted on the kidney be not great and the large vessels be not
ruptured. If severe, the kidney may be softened into a mere pulp.
Treatment. — If the pelvis of the kidney has been penetrated, urine
will drain away by the external wound. If the organ has been opened
by subparietal laceration or rupture, the chief danger when the large
vessels are uninjured is from infiltration of urine mixed with blood into
the cellular tissue. Then it may be necessary to lay open the loin by a
free incision down to the injured kidney, so as to provide for the free
drainage of the extravasated urine and inflammatory products.
When there is no extravasation, small quantities of fluid diet, the
application of cold or leeches, relief of the bowel by one good purgative
422
SYSTEM OF MEDICINE
dose or an enema, and opium to relieve pain constitute the usual neces-
sary details of treatment.
Suppurative Nephritis, Pyelitis, and Pyelonephritis
One of the most frequent of the secondary affections of the kidney
(secondary, that is, to obstruction to the outflow of urine, to reflex
irritation, or to decomposition of urine in the bladder) is suppiuation in
the pelvis, or in the substance of the kidney, or in both.
In by far the greater number of such cases chronic dilatation of the
pelvis and calyces precedes suppuration of these parts ; and, later, numerous
small scattered abscesses occur throughout the renal substance.
It is to this general afl'cction of pelvis and substance of the kidney
from obstruction in the lower urinary })assages, or disease of them, that
the name suppurative pyelonephritis has been given. It is to this condi-
tion that the name surgical kidney has also, but very inaptly, been applied.
Su})purative nephritis, or, in other words, " acute interstitial nephritis,
■with scattered points of suppuration," occasionally occurs alone, Avithout
any affection of the ureter and pelvis of the kidney ; this, however, is not
commonly the case. Usually acute pyelitis and suppurative nephritis
exist simultaneously ; but if suppui'ative nephritis happen to be uncom-
plicated with p3'elitis, the nephritis is prone to be overlooked, because then
the urine contained in the pelvis of the kidney, and drawn off by a
catheter immediately after washing out the bladder, is acid and without
the odour of decomjiosition. Nevertheless the temperature and other
constitutional symptoms ought to correct the fallacy.
EtioJogij. — Infective lesions of the kidney may aiise from the upward
extension of inflammatory affections of the lower urinary apparatus, which
are by far the most frequent cause of them. In other cases the infection
is conveyed to the kidney directly by the blood-vessels, and thence
descends along the ureter to the bladder : these are much less common.
A more important distinction consists in the presence or absence of
distension of the renal pelvis. Pyelonephritis without distension admits
of medicinal treatment, and shows itself by high temperature and other
symptoms ; jjyelonephritis with distension manifests itself by definite
physical signs also, and, generally speaking, needs surgical methods.
In the causation of su})purative disease of the kidney the influence of
sex is prominent ; the very much greater number of cases occurring in
men being consequent upon the greater frequency of diseases of the bladder
in them ; whereas in women similar changes occurring in the kidney are
usually associated with morbid conditions of the utero-ovarian system.
Arterio-sclerosis, associated with interstitial nephritis and eidargement of
the prostate, is a frequent predisposing cause of bacterial infection of the
kidneys in men. In women such infection results from inti'apelvic com-
pression of the ureters resulting from fibroma, cancer, peritonitis, or
prolapse of the uterus.
Penal congestion, due to reflex changes in connection with cutaneous
SUPPURATIVE NEPHRITIS, PYELITIS, AND PYELONEPHRITIS 423
impressions, over-distension of the bladder and particularly to the vaso-motor
paralysis accompanying injury to the spinal cord, is an important pre-
disposing cause, to which may perhaps be added the influence of albumin-
uria and defective nutrition of the tissues.
Among exciting causes may be mentioned pysemia and puerperal
fever (which more often induce abscess of the kidney than pyelonephritis),
and the allied blood conditions which accompany erysipelas, burns and
osteomyelitis. Of the more immediate local causes are injuries to the
kidney or ureter, pelvic celkditis, cystitis due to septic catheterisation,
and frequent over-distension of the bladder from various causes.
Pathologij. — The ascent of micro-organisms to the kidney is assisted by
the failure of peristaltic contraction and the dilatation which are associ-
ated with retention of urine ; and again by the contractions of the
bladder which are provoked by the obstruction to the natural escape of
its contents.
Congestion of the kidney renders it more vulnerable on the entry of
micro-organisms ; these develop more readily in an albuminous fluid,
and the arrangement of the blood and lymphatic vessels of the kidney
and ureter aftbrds a direct means of invasion in cases of urethritis.
Ureteritis leads sometimes to thickening and sometimes to dilatation of
the tube, and in a few cases to a sclerosis of the vesical extremity with
impairment of the valve -action there. The pelvis of the kidney is
subject to similar pathological changes, the walls being either thickened
and contracted or thinned and dilated. In acute inflammation the
mucous lining is vascular and swollen, covered with glairy muco-pus or
false membrane, a deposit of phosphates often being added.
Without distension, the kidney may be enlarged, soft, oedematous,
grayish in colour, and showing no distinction between cortex and medulla.
The parenchyma may contain cysts, collections of fat, and (in the acute
cases) miliary abscesses or areas of necrosis.
With distension of the jjelvis and calyces, the kidney may attain the
size of the human head. It is closely attached to the neighbouring
organs, tissues, and vessels. The fatty envelope is usually sclerosed and
adherent, as is also the capsule. A quart or more of pus may be con-
tained in the cavity and all appearance of the gland substance may be
lost, nothing remaining l)ut an apparently fibrous membrane with septa
completely or incompletely dividing the cavity. The lining membrane
is continuous with that of the ureter, and often ulcerated or gangrenous.
In other cases many separate abscesses of the renal substance may be
present, and the cavity of the pelvis may be occupied by primary or
secondary calculi.
Microsco[iically the substance of the kidney may display disseminated,
cortical, or radiating medullary abscesses, with granular and fatty changes
in the convoluted tubes, and proliferation of the epithelium of the
glomeruli, accompanied by general hypersemia and the presence of
haemorrhages ; in chronic cases sclerosis and suppuration may be found.
Symjjtoms. — These are wasting, loss of appetite, furred tongue, and
424 SYSTEM OF MEDICINE
disturbed digestion and loss of strength. The skin becomes diy, pale or
jai'iidiced. There is more or less fever. The symptoms, however,
exhibit wide variations, and in some cases are so sliglitl}' marked that
the}' attract no notice.
The acute form is ushered in by fever and rigors often accompanied
by delirium; emaciation with severe disturbance of the digestive functions
and sweating ensue. The disease may prove fatal by hyperpyrexia or
exhaustion in this stage, but more often lapses into the chronic form.
This, however, may be estal)lished without the initial acute phase. The
bulk of the sjmptoms then are manifested by the digesti\e system, so that
most of the patients are regarded as dyspeptics ; and this mistake is
the more likely, as the temperature is but little raised. The mouth
and pharynx are dry, o^nng to deficiency of saliva, S})eech and degluti-
tion are interfered with, and the patient will swallow nothing but
liquid. There are vomiting, fiatulence, tympanites and commonly con-
stipation, though this last may give place in the later stages to foetid
diarrhoea.
The patient suffers much from cold, from great depression, and
muscular weakness. Walking becomes diHicult, and the inability may
amount almost to paraplegia. Sleep is disturbed, and there may be
nocturnal delirium. The skin is dry, cold, and rough, with detached
epidermal scales ; it is often irritable and affected with various
eruptions. The circulatory system is commonly not atfected, until in
the latest stages of the affection the heart becomes weak and irregular. In
cases of a mild form the symptoms are little marked, and the patient may
be able from time to time to resume his occupation. Nevertheless, pro-
gressive loss of flesh and strength and congestion of the internal organs,
especially of the lungs, become apparent, and the patient is liable under the
influence of chills or fatigue to manifest the more acute s3^mptoms, or
to relapse ultimately into the more severe chronic condition mentioned
above, dying of urinary cachexia without actually presenting the definite
symptoms of uraemia.
Locally the signs vary according as there is pyelonephritis with or
without distension, and according as this is permanent or intermittent.
There is pain in the region of the kidney, and tenderness on deep palpa-
tion, or pain elicited by movement when calculus is present. Pyelo-
nephritis without distension occurs mostly in old i)eople, often in the
course of chronic cystitis, and directly on exposure to chill or catheterism.
The onset is marked by fever, or may supervene gradually with pain in
the lumbar regi(jn and polyuria, accompanied b}' albumin and casts.
The daily secretion of urine is increased to from four to eight pints. It is
pale and of low specific gravity, and presents a grayish-white deposit of
pus with a supernatiint cloud of mucus or li(]Uor puris on standing. On
expulsion, the urine is uniforndy opalescent or may be slightly denser
towards the end of micturition ; early in the disease it has an acid re-
action, but later it becomes neutral or alkaline.
The urea is diminished, albumin is present independently of the pus,
SUPPURATIVE NEPHRITIS, PYELITIS, AND PYELONEPHRITIS 425
and the tendency to putrefaction and ammoniacal change is more marked
than in healthy urine. Slight haemorrhage occasionally occurs ; but when
it is abundant, and influenced by movement, it probably depends on the
existence of a renal calculus.
Microscopical examination reveals epithelial cells derived from the
tubules, hyaline casts, and casts made up of pus cells, imbricated epi-
thelium from the pelvis and sometimes fragments of renal tissue, triple
phosphate crystals, and various forms of micro-organisms.
Pyelonephritis with distension, which may ensue, is chai'acterised
by the presence of a renal tumour and by intermittence of the pyuria.
The swelling is generally smooth and rounded, occupying the loin and
yielding a resonant note on percussion in front. There is pain and tender-
ness, and very often perinephritis supervenes, increasing the size and
firmness of the swelling.
With the appearance or increase of* the tumour there may be dis-
appearance or diminution of pus from the urine ; and when the tumour
subsides, pus reappears in increased quantity, and the symptoins are
temporarily alleviated. The further course of the case may be that of
pyonephrosis ; or of renal abscess complicated by secondary calculi, with
pain and haemorrhage on movement ; or of perinephritis either of the
sclerosing or suppurative variety, the severity of the symptoms being
accentuated by the probable implication of the opposite kidney.
Diagnosis. — When no tumour exists, but only constitutional symptoms,
with pyuria, the disease may easily be confounded with chronic cystitis,
or with tuberculosis of the urinary organs. In chronic cystitis there
would probably be no polyuria, the urine would be alkaline and glutinous,
and the distribution of pus in the urine would be less uniform than in
pyelonephritis.
Tuberculous disease of the kidney is usually associated with recog-
nisable lesions in other organs, and the characteristic bacilli may be found
in the deposit in the urine. Haimorrliage is more frequent, and the febrile
exacerbations are less marked. The rapid failure of the patient's strength
is sometimes an important sign.
When a tumour is present, the disease may simulate tuberculosis or
hydronephrosis ; in the latter case fever and septic manifestations are
usually absent.
Prognosis. — Attacks of the primary affection due to irritant drugs,
such as cantharides, or to cold, are usually transitory. Thos'e that
follow disease of the bladder or other pelvic organs, those affecting
both sides, and those that develop acutely, are more formidable, threaten-
ing death by urinary toxaemia. Chronic cases with free discharge of
pus have the most extended course, lasting often for months or years ;
and the outlook depends largely on the condition of the digestive
organs.
The most formidable cases are those of retention of pus, which
distends the renal pelvis and destroys the parenchyma, leading to
toxaemia or to the rupture of the sac and the establishment of a fistula.
426 SYSTEM OF MEDICINE
Treatment. — In suppurative nephritis and pyelonephritis the treat-
ment is essentially the same as that for acute or subacute nephritis
without sujipuration. Every precaution should be taken to prevent
their recurrence. Any obstruction to the outflow of urine, or any
incapacity to empty the bladder completely, should be remedied or
counteracted ; stricture of the urethra should be dilated or divided,
vesical calculus removed, and the effects of enlarged prostate combated
by earl}' and re!j;ular catheterism. If chronic cystitis exists, daily irriga-
tion of the bladder will be necessary to obviate decomposition of the
urine and to restore the mucous membrane to a healthy state. The
impaction of a stone in its course between the kidney and bladder calls
for its removal either by the bladder, loin, or abdominal route ; according
to its position in the ureter. Confinement to bed is necessary as soon as
inflammation has once set in.
With the object of avoiding the severe and dangerous onset of
pyelonephritis, as well as the slighter forms of urinary fever, catheterism
should never be employed except when the |)atient during and for some
hours after the introduction of the instrument is in a warm and equable
temperature, preferably in his bed.
The bowels should be kept Avell opened, and for this purpose warm
abundant enemas are of special serA'ice.
The diet should be light and moderate, and should consist chiefly of
fish, milk, chicken or game, light farinaceous or milk puddings, and
Avell-cooked vegetables : uncooked vegetables and fruits as avcU as
butcher's meat should be avoided. Stimulants shoidd be taken, if at all,
in very small (juantities ; and if, during their administration, the pulse
is quickened, the temperature raised, or the urine becomes more puru-
lent, they should be discontinued at once.
Liquids should be taken in moderate quantity only, if the amount of
urine secreted be abnormally large ; but where cystitis exists, and nnich
mucus is passed in the urine, barley water, triticum repens, and linseed
tea are useful adjuncts in slaking thirst and relieving the irritation of
ammoniacal urine.
Little can l^e said in favour of medicines ; a mixture of one grain of
quinine with 5 niin. of tincture of opium and L'O grains of citrate of
potash in mucilage has proved of benefit in some cases ; and 5 grains of
salol (jr bil)orate of magnesia in doses of i-1 drachm have been given,
with a view of controlling the septic changes in the urinary tract. AVhen
constipation exists, and a large quantity of urine is secreted, I have seen
gi'eat benefit accrue from a few doses of ergot of rye. This drug, hy
acting upon the involuntary muscle fibres of the gut, overcomes the con-
stijiation, and by its influence on the coats of the blood-vessels constricts
and gives tone to the renal circulation. The consti])ation, flatulence,
atony of bladder, and general arterial and muscular feebleness, suggest
remedies which will give contractile force to the muscular fibres of the
viscera.
When the febrile attacks t.ake the remittent form, 5 gr. of quinine
RENAL ABSCESS 427
in 1 oz. of lemon juice, and \ drachm to 1 drachm of liquor morphinse,
are sometimes very efficacious in checking the rise of temperature.
Traube obtained good results from injections into the bladder of
acetate of lead, from \-\\ gr. in 4 oz. of distilled water, and the internal
administration of pills of tannic acid (l-ll gr.) every two hours. He
recommends both of these remedies because of their antiseptic and anti-
phlogistic action.
Drugs like tannin, alum, acetate of lead, and perchloride of iron,
which act as astringents upon the blood-vessels of the mucous membrane,
and so lessen the excessive secretion of mucus, have been recommended,
and certainly deserve fair trial. When the urine is alkaline, benzoate of
ammonia in 10-grain doses may be tried and often with benefit.
Eenal Abscess
Abscess of the kidney is one of the varieties of suppurative diseases of
the kidney. It is not intended here to refer to any of those forms of
suppurative nephritis characterised by the development of minute and
scattered points of pus, the origin of which may be infection carried by
the ureter, vessels, or lymphatics ; nor is it intended to include miliary
abscesses due to the irritation of calculous matter in the kidney or to the
decomposition of urine in the renal pelvis resulting from any of the
numerous causes of obstruction to the outflow of urine. What we have
now to describe is that form of suppuration which results in the formation
of one or more abscesses of considerable size in the substance of the
kidney.
Etiology. — It must be stated at once that renal abscess of large size,
involving the greater part or even the whole of the kidney, occurs as the
result of the fusing together of a large number of miliary abscesses.
Suppuration of this kind may be limited to one kidney, the other being
quite unaffected. Metastatic and secondary abscesses of large size may
be also formed otherwise. Thus, in pycemia, or in cases of embolism
derived from ulcerative endocarditis, instead of a number of minute and
scattered emboli followed by minute and scattered points of inflammation
and suppuration, one large vessel may be obstructed by an embolus and
a large abscess may ensue. Sometimes, as a result of stricture or other
disease of the lower urinary organs, a circumscribed abscess may form in
the tubular substance of the kidney. AVounds, contusions, and lacerations
of the kidney, and kicks, blows, or falls, involving the loin or renal
region on the front of the abdomen, are occasional causes of suppuration
and abscess of the kidney. INIore usually when renal abscess occurs as the
result of injury to the loin, whether attended with immediate injury to
the kidney or not, the suppuration of the kidney has been preceded by
suppiu^ation in the circumrenal cellular tissue ; so that the abscess involves
the kidney by spreading from without, and is not primarily a renal abscess.
Injuries which cause obstruction in the renal pelvis or ureter are especially
428 SYSTEM OF MEDICINE
likely to be foUowetl by more or less suppuration of the renal tissue ;
moreover, injury to the kidney, from its tendency to excite the formation
of renal calculus in the injured organ, may be in this way an indirect
cause of renal abscesses of large size. A calculus which originates in a
renal tubule, or one which becomes more or less shut oft" by inftannuatory
adhesions from the general cavity of the pelvis of the kidney, is the most
likely to give rise to an abscess in the substance of the kidney ; the
impaction of a stone in the renal pelvis or ureter leads more frequently
to calculous pyelitis and thus to pyonephrosis.
Foreign bodies other than calculi may give rise to a large renal
abscess. A piece of bone, a fragment of clothing, or a bullet, may
gain entrance to the kidney ; and, instead of becoming quietly encysted,
or passing through the natural channels out of the body, it may give rise
to extensive suppuration in the organ in which it rests.
Irritant drugs, such as cantharides and turpentine, have been known
to cause renal abscess. A kidney illustrating this change is preserved in
the ^luseum of the College of Surgeons. Cantharides was the drug
administered, and death occurred in three Aveeks.
Pathology. — Circumscribed abscess usually affects one kidney only.
There may be one or several abscesses in the same organ. In size, they
vary from that of a hazel-nut to that of an orange. They may connnuui-
cate with the pelvis of the kidney, or through the capsule with the
circumrenal cellular tissue. When they open through the capside they
lead either to a circumscribed perinephric abscess, or to dittused and
burrowing retroperitoneal suppuration. When they open into the renal
pelvis they may empty themselves partially or entirely through the ureter
and bladder. When two or more abscesses aftect the same organ they
may communicate with one another or remain distinct ; and one ma}'^ dis-
charge in one or other direction, the others remaining unopened. This
isolation of several abscesses should be borne in mind in exploring the
kidney for suppuration.
In a very considerable number of specimens of renal abscess, the
whole organ, including the pelvis, is involved ; and very little, if any, renal
substance is left.
It is not easy in some of these cases, especially when the ureter of
the aflfected side is pervious, and the opposite kidney and lower urinary
organs are not diseased, to say whether the morbid process began as a
pyonephrosis or as abscess in the renal substance. It is undeniable that
many of the cases reported in the journals and elsewhere as renal abscess
are really far advanced cases of pyonephrosis.
Symptoms. — These may be either acute or chronic. In the acute cases
there is pain in the region of the diseased organ, with fever and rigors.
The rigors are sometimes marked and frequent ; at other times only one
or two occur throughout the course of the disease, and these at uncertain
and irregular periods.
Haematuria often precedes the formation of abscess when the cause
is traumatic. The absence of pus in the urine is no test ; in many cases
RENAL ABSCESS 429
there has been none whatcA^er throughout. In other instances, if the
abscess have broken into the ureter or pelvis of the kidney, pus, it may be
in large quantity, will be seen in the urine.
If a tumour has been formed in the loin, the discharge of pus by the
bladder will probably be followed by diminution or subsidence of the
tumour. It is not often, however, that any tumour perceptible during
life is formed by a circumscribed abscess of the renal substance. If a
tumour do exist, with the history or symptoms suggestive of suppuration,
dilatation of the cavity of the kidney may with fair certainty be predicted ;
or else it may be that the whole organ is in a state of general inflamma-
tion with several foci of threatening or actual suppuration.
When the abscess is chronic in character, it forms Avithout causing
any definite symptoms. Indeed, the abscess may be found at the post-
mortem examination without having caused a suspicion of its existence
during life. In some cases, however, general impairment of health,
occasional chilliness and rigors, obscure aching in the loin, gradual
emaciation and increasing sallowness or duskiness of skin indicate some
grave disorder, but do not point with any distinctness to its nature.
In acute cases a fatal termination may occur in a fortnight to three
weeks. The cause of death will most probably be typhoid prostration.
Occasionally, however, the abscess bursts into the cellular tissue, the
intestine, or the renal pelvis or ureter ; and then life may be prolonged
for a time, till ended by exhaustion or hectic.
Possibly recovery may ensue ; in some cases it is pretty certain that
the contents of the abscess, instead of escaping in any of the directions
mentioned, become inspissated and remain quiescent for the rest of
life.
Treatment. — The treatment of the early stages of a renal abscess will
depend largely on the cause. If it be due to external violence, restricted
diet and fluids, rest, anodynes, leeches, or cupping on the loin, the
application of an ice-bag, and, after the first day or two of the inflamma-
tion, the constant application of hot fomentations, is the treatment that
must be followed. If caused by renal calculus, the treatment suitable
for the varying phases of this disease will be I'cquired. In any case in
which there is clear indication of a renal abscess, the pus ought to be
evacuated through an incision in the loin.
Indeed, in the absence of a tumour, but with the history and symptoms
suggestive of suppuration, to make an exploratory incision down to the
kidney is the right treatment. If, Avhen the kidney is punctured, pus
is found, it is not sufficient to evacuate it with a trochar and canula ; a
free incision should be made into the abscess, and the wall of the
abscess cavity, if a large one, should be stitched to the edge of the wound.
When the finger in the kidney enters a space which does n<~>t communicate
with the general pelvic cavity of the organ, or does so only by a small
orifice, the rest of the surface of the organ should be carefully manipulated,
and if fresh pus be found, a second or even a third inc^won of the renal
substance should be made so as to open the other abscesses. If the kidney
430 SYSTEM OF MEDICINE
be very much destroj'ed, it may be best to remove it at once through the
lumbar incision.
The kidney is very much more tolerant of interference than it is
generally l)elieved to be ; and the fear of ha'morrhage is I'eduecd to a
minimuni by restricting incisions to the periphery. In cases where
nephrotomy has revealed either local or disseminated disease with areas
of healthy parenchyma between the foci, and especially if tht^re be a
probability of bilateral distribution, it is bettor, instead of removing such a
kidney, to treat each focus independently by scraping or by the excision of
a wedge. This plan may be resorted to in cases of multiple abscess or of
multiple tuberculous deposit, and may be combined with nephrolithotomy.
AMien operative measures have to be taken in connection with the second
kidney, the surgeon has a much freer hand if the active and healthy part
of the organ first operated upon is still discharging its function.
It is remarkable, too, what a powerful influence on the secretion of
iirine even small portions of renal substance e.vert, and Avhat a capacity
for recovery they evince after the removal of some condition interfering
with their functional activity ; such as pressure, or ol)struction of the
uretei'. Evidence of this is met Avith in the quantity of urine (often of
low specific gravity, it is true) passed after relief of hydronephrosis, where
the organ has l^een distended and thinned to a mere capsule ; and not
frequently at necropsies mere remnants of kidneys, weighing but a few
drachms, are found, which had been activp and serviceable for man}'
years between the occurrence of acute disease and the ultimate death of
the patient.
Hydronephrosis
This name is given to over-distension of the kidney with urine, the
result of mechanical obstruction, no matter whether the cause be in the
urethra, bladder, or ureter. Probably one-third of the cases of hydro-
nephrosis in which a palpable tumour is formed have a congenital origin.
Congenital causes. — Twistings, undue obliquity, contractions, and other
anomalies of the ureter. This duct is in some cases a mere fibrous
cord ; or its vesical orifice may be of pinhole size ; or minute cysts may
be developed in its mucous membrane ; or the angle of its junction with
the kidney may be so acute as to impede the descent of the urine.
Acqnbrd causes are cancer of the pelvic organs, fibro-myoma, pelvic
inflammation with contraction of the cellular tissue. On account of its
frequent dependence on pelvic disease and upon movable kidney, hydro-
nephrosis is very much more frequent in women than in men. Calculus,
either by its impaction in the ureter, or by the idceration and subsequent
contraction at some spot in this tube excited by its passage to the
bladder, is a frequent cause. Other causes are inflammations, tumours,
or abscess of the bladder causing contraction of the vesical orifice of the
ureter. A papilloma of the bladder has been the cause ; or, again.
HYDRONEPHROSIS 431
enlarged lymphatic glands, adhesions or bands of fibrous tissue, enlarged
prostate, and stricture of the urethra. Hydronephrosis may affect both
kidneys or only one, or may be limited to a part of one kidney. Cases
of double hydronephrosis of congenital origin are not very uncommon.
The proportioii of cases in which hydronephrosis produces a palpable
abdominal tumoiu' is very small compared with the frequency of the
disease.
~ PalhoJogy. — The pelvis of the kidney first becomes converted into a
spheroidal sac, then the calyces are widened and stretched in eveiy
direction, and at length the capsule of the organ is expanded, and what
remains of its cortical and medullary substance becomes still further
compressed and alxsorbcd until nothing is left but' a loculated cyst,
the septa of which are inextensible. The size of the hydronephrotic sac
may not exceed that of a normal kidney, it may even be smaller; or, on
the other hand, it may be suificiently large to form a swelling occupying
a great part of the abdominal cavity. The contained fluid is water
holding: a larcrer amount of sodium chloride than exists in urine and a
few epithelium cells. Its Cjuantity is sometimes enormous, reaching
sev^eral gallons. Urea is often all but absent. The reaction is acid or
neutral, and it may be dark in colour and colloid in consistence. AVhen
the seat of obstruction is in the lower urinary organs the ureter is
dilated, and commonly the change is bilateral. When the obstruction is
in the lu'ethra, pui'ulent infection is more common, and pyonephrosis
succeeds to hydronephrosis. As regards the communication with the
bladder, it may be open, closed, or valvular.
My experience in operations on the kidney has led me to classify
cases of hydronephrosis into (i.) Simple hydronephrosis with atrophy
without expansion ; these are the small, flaccid, shrivelled kidneys : (ii.)
Simple h}'dronephrosi3 with atrojDhy and expansion ; these often enlarge
into huge cysts : (iii.) Hydronephrosis with atrophy of the pyramidal, and
thickening and sclerosis of the medullary substance ; these kidneys have
generally been the seat of inflammation and are prone to suppurate.
Sijmptoms. — Hydronephrosis may occur at any age, and is twice as
frequent in females as in males. When the dilatation is insufficient to
give rise to a tumour, there are generally no signs characteristic of
hydronephrosis. Out of a series of 142 cases at the Middlesex Hospital
an abdominal tumour was formed in but very few. In some advanced
cases in which no tumour exists, thirst, pain in the back, frequent
micturition, partial, total, or intermittent anuria, and obscure or pro-
nounced abdominal pains are present.
A hydronephrotic tumour is dull on percussion, sometimes lobulated
in contour, and frequently fluctuates. It has all the characters of a renal
tumour, being situated in the flank, pressing the ilio-costal parietes back-
wards and outwards, having the colon in front of it, and the small intes-
tine either in front or thrust over to the opposite side of the abdomen,
according to the bulk of the swelling. If of no great size, it may be
painless ; if large, it may give rise to excruciating suffering.
432 SYSTEM OF MEDICINE
"When it arises from some innocent cause, such as pregnancy or
uterine flexion, its formation is unattended l\v an}'^ constitutional or local
disturliance ; but Avhcn from some painful cause, such as impacted
calculus, or sudden kinking of the ureter, the symptoms incidental to the
particular condition will occur before the tumour makes its appearance,
and may cause it to be overlooked.
There are instances of the tumour intermittin(f, that is, being pro-
minent at one time and not distinguishable at another, the disappear-
ance of the tumour being sometimes associated with polyuria, the urine
being accompanied by blood, pus, or mucus. In some cases constipation
results from pressure on the colon ; in others, no recognisable symptoms
occur till uraemia sets in.
Diagnnsis. — "When of moderate size, the tumour has to be dis-
tinguished from renal or perinephric abscess and perinephric extravasa-
tion. When it forms a palpable tumour, it may be mistaken for
pyonephrosis, or for a hydatid or serous cyst of the kidney, liver, or
spleen. AVhcn of great size, it may simulate ascites or parovarian
cystoma. If the subsidence of the tumour is followed by an increase in
the outflow of urine, the diagnosis of its hydronephrotic nature is well-
nigh certain. PerineiDhric abscess is cpiicker in its course, and excites
much more pain and constitutional trouble in its early stage. Between
hydronephrotic and pyonephrotic tumoui's the diagnosis is often im-
possible and indeed immaterial.
Purulent urine, rigors, and fever indicate pyonephrosis as a rule ;
but such diagnostic symptoms may be absent. Hydatid and serous cysts
of the kidney are best diagnosed by their history.
From ovarian tumours the diagnosis is often very difficult. These
are, as a rule, more mobile than renal cysts, and enlarge upwards from
the pelvis, not forwards from the loin. Moreover, the intestines are
behind an ovarian and in front of a renal tumour. When the tumour is
renal, the uterus is neither displaced nor fixed. In the case of an ovarian
or parovarian cyst, on the other hand, it is displaced upwards and to one
side.
Prognosis. — This depends in great measure upon the distension, but
chiefly upon whether oiie or both organs are in\olved. If only one
kidney is affected, and the tumour not large, life may be indefinitely
prolonged. There is always, however, the fear that calcixlus or other
disease of the opposite kidney may cause death by suppression of urine
or uraemia ; oi- that suppui-ation may occur in the cyst. If the distension
increase, death may result from pressure on neighbouring organs,
rupture into the peritoneum, or suppression of the urine.
Treatment. — Medical remedies are of no avail. Surgical measures
should be directed against the cause of the hydronephrosis, whether it
be in the pelvis or due to the mobility of the kidney. When of small
size and painless, these hydronephrotic tumours may be left alone.
When they cause troul:»le by pressure, they should be treated by
nephrotomy or nephrectomy.
HYDRONEPHROSIS 433
Eegular friction of the tumour has proved successful, in at least three
cases, by overcoming the obstacle to the passage of the urine, and so in
emptying the cyst into the bladder. If paracentesis be decided upon,
and there is nothing to indicate any spot for puncture, the best point to
tap a tumour of the left kidney is just anterior to the last intercostal
space ; but if the right kidney is affected this is too high, and the
puncture should be made half-way between the last rib and the iliac
crest, and two inches behind the anterior superior spine of the ilium.
Eepeated tappings Avill probably be required. Nephrotomy is the proper
operation, and should be preferred to aspiration. Drainage and anti-
septic irrigation are effected by means of a large rubber tube, which
should be fixed in the cyst.
After nephrotomy for hydronephrosis search should be made with
the finger through the lumbar incision with the object of detecting a
stone, and the ureter should also be tested by passing a long probe or
small sound along it from the interior of the kidney downwards. Lumbar
nephrectomy is required when the kidney is so much damaged as. to be
incapable of performing its function, or where there is a free continuous
discharge from the loin after treatment by nephrotomy ; except in cases
where the opposite kidney is defective.
Congenital hydronephrosis. — In by far the larger number of
cases of hydronephrosis found in the foetus and new-born, both kidneys
are involved ; the most common cause being imperforate urethra. It
may be due to minute cysts, to membranous septa in the urethra, or
to cysts in the ureter or pelvis of the kidney. The subjects of this
disease may be born dead, or may live for a few weeks, months, or even
years.
The urine removed from some of the cases of congenital hydro-
nephrosis has contained little or no urea. The size of a hydronephrotic
foetus has proved a serious impediment to labour in several cases, and
has rendered parturition impossible, until the abdomen of the child has
l)een reduced by tapping.
Congenital hydronephrosis is frequently associated with some other
congenital deformity, such as hare-lip and club-foot.
These cases prove that the secretion of urine goes on to a very
considerable extent during the latter half of intrauterine gestation ; and
that when any obstacle to the outflow of urine exists, the same per-
nicious effects of distension of the bladder, ureters, and kidneys occur
I'efore birth as are commonly known to arise from phimosis, urethral
stricture, calculus, and other causes of obstruction after birth.
VOL. IV 2 F
434 SYSTEM OF MEDICINE
Pyonephrosis
This term implies dilatation of the pehis and calyces of the kidney
with pus, or pus and urine. In advanced cases the suppuration and
dilatation extend beyond the calyces, and go on to compression and
disintegration of the medullary and cortical substance, converting the
organ into a hu'ge loculated sac, the nature of the contents of Avhich
depends upon the cause of the ol)struction.
Hydronephrosis becomes pyonephrosis as soon as suppuration
occurs ; and therefore the causes of pyonephrosis are similar to
those which generate hydronephrosis. When an obstruction causes
pyonephrosis at once, it is more complete in its character, and more rapid
in its irritative effects upon the kidney, than when it causes hydro-
nephrosis first. In some cases of pyonephrosis, the pyelitis, instead of
following, has preceded the obstruction. A small mass consisting of blood-
clot, inspissated pus or mucus, as a result of pyelitis ; or the detritus
from a calculus, new growth or tuberculous deposit may block the ureter,
and so lead to distension with urine and pus ; to Avhich may be added, in
some instances, blood, mucus, phosphatic deposit and detritus from the
disorganised kidney or ncAv growth.
Etuilofiij. — The most fretjucnt cause of pyonephrosis is calculous
pyelitis ; indeed, renal calculus is so largely in excess of other causes that
it has been implied, if not explicitly stated by some writers, that pyo-
nephrosis and calculous pvelitis, when they assume the dimensions of a
renal tumour, are one and the same thing. This, however, is not the
case. Definite and even fatal pyonephrosis may exist without giving
rise to any palpable tumour during life ; and without doubt may be caused
by many conditions other than stone. Such other causes are pyelitis from
extension of septic inflammation from the lower urinary orgajis, arising
in stricture, gonorrhcwa, spinal disease, and cystitis however produced ;
obstruction of the ureter by pressure or infiltration of tumours or in-
flammation in the pelvis; tuberculous and pyaemic deposits in the kidney
or renal pelvis ; the pi-esence of such parasites as Hydatid, and Eustron-
gylus gigas in rare instances ; or the occurrence of direct injury.
Morbid amxtomy. — When pyelitis, whether acute or chronic, is
associated Avith retention of urine within the renal pelvis, the mucous
membrane l)y degrees assumes a dull white colour, is markedly thickened,
and secretes a quantity of pus. The pent-up urine .soon becomes alkaline
from admixture with pus, urea is converted into carbonate of amnu)nia,
and calculous material is often deposited upon the lining membrane of
the organ. As the distension of the cavity of the kidney proceeds, the
orifices by which the calyces and pelvis commtxnicate often become nanoAv
and even entirely closed, the pyramids, and then the cortex of the kidney,
become more and more atrojHiied, until at length all the glandular tissue
is completely removed, and the oi-gan is transformed into a multilocular
or many-chambered cyst. Its relations and connections with the sur-
PYONEPHROSIS 435
rounding structures vary. Sometimes it forms adhesions on all sides.
Ulceration of the cyst wall, or suppurating tracts formed through what
remains of the renal substance, may end in fistulous openings through
which the purulent urine escapes and gives rise to perinephritis, periton-
itis, or the discharge of pus and lu-ine by the mouth or rectum, or through
the loin.
The fluid contained in the distended kidney is occasionally pus with
blood, or pus so concentrated that there is hardly a trace of urine. If it
has become changed l)y decomposition and the development of ammonia,
it is more or less thready and glairy ; at other times it is a soft mortary
material, of a white or buff colour ; in other cases it is of. the consistence
of butter. "When a calculus is formed in the kidney, it often assumes
a branched form which exactly fits tlie pelvis and calyces. Sometimes
independent calculi occupy the pelvis and calyces. Incomplete and
persisting or complete but interrupted obstruction to the escape of urine
or pus from the kidney pelvis gives rise to the greatest degree of expan-
sion of the organ. When the obstruction is complete and persistent, the
parenchyma of the kidney atrophies rapidly and before the calyces and
renal pelvis expand to any great degree. In some cases the kidney
becomes completely sacculated, and left without a trace of glandular
tissue ; subsequently it shrinks to much below the normal size.
Sipnptoms. — In the early stages the symptoms are those excited by
the cause of obstruction, whatever that may be ; and in addition those of
pyelitis.
If the obstruction be not complete, there will be pus in the urine ; if
intermittent, there will be times during which more pus is discharged than
at others ; if complete and permanent, there will be an entire absence of
pus in the urine. There will be constitutional symptoms of suppuration,
and, when the pyelitis is very chronic, all the characters of hectic. W hen
a tumour forms in one or other loin, it possesses the same characters
as a hydroneiihrotic tumour. It is elastic or fluctuating, or nodulated
and hard, and bulging the flank as well as occupying more or less of the
abdomen. W^hen the tumour is not of great size, there may be a line of
resonance above it, but if it Ite of considerable dimensions it may have
formed adhesions with the under surface of the liver or spleen, and so
simulate a tumour or hypertrophy of one or other of these organs. If
very large, the tumour has almost always a more or less nodulated or
lobulated outline, and the resonance of the distended colon may be
elicited on the outer side ; when this is the case, and fluctuation is also
distinct, hydro- or pyo-nephrosis is cleaidy indicated. The pain ex-
perienced depends greatly on the size of the tumour ; in some cases there
are paroxysms of great severity. Pressure over the front of the tumour
nearly always aggravates pain, or provokes it if it were not present before.
Pressure over the flank, in some cases, is not only well borne, but actually
gives relief.
When the cause of the obstruction is intermittent in its action, the
lumbar tumour will diminish, or may even disappear altogether after the
436 SYSTEM OF MEDICINE
(lischai'ge of jms. It is always iieccssaiy, therefore, to watch the urine
continuously and carefully, having the total quantity passed during
twenty -four hours collected and measured.
If the ureter be completely blocked, the total quantity of urine
excreted, for a short time at least after the occlusion, will be markedly
diminished in quantity. If partially blocked the quantity of pus and
urine will A'ary from time to time, even dining the same day ; and if the
cause of the obstruction shift so that the ureter, from being quite
blocked at one period, becomes patent at another, large quantities of
purulent bloody urine will be passed during the patency periods ; the
urine in the intervals of occlusion being nearly or quite clear and natural,
provided the opposite kidney be healthy.
Diagnosis. — The tumours which may be mistaken for pyonephrosis
are thus enumerated by Kayer : — "On the left side of the al)domcn, all
those which result from morbid enlargement of the s})leen ; on the right
side the tumours of the liver and gall-ltladder ; on either side the various
renal tumours of another nature, such as hydronephrosis, haemorrhage
into the cavity of the pelvis, cancer of the kidney, tuliercle, kidney's con-
taining hydatid cysts ; extrarenal abscess, eithei" idiopathic or consecutive
to perforation of the kidney or of the colon or ca?cum ; abscess arising
from caries of the spinal column ; tumours of the suprarenal capsules ;
aneurysms of the aorta ; encysted tumours of different contents, hyd:itid
or otherwise ; and lastly, f.^cal tumours from the accumulation of fiecal
matter in the colon or caecum."
Pyonephrosis is nearly always preceded and accompanied by febrile
symptoms ; the tumour is more or less painful, and the pain is increased
by pressure over it, and by movements of the trunk ; and when the
ureter is not absolutely occluded, there is the presence in the urine of
pus. In hydronephrosis there is an absence of febrile symptoms and
of pus in the urine. In perinephric abscess there is even more pain
than in pyonephrosis, the course of the fever is more severe and
rapid, and fluctuation succeeds to ill-defined hardness about the loin
and iliac region, and not to a gradually developing circumscribed tumour.
In this condition there is extreme tenderness before there is any sign of
fluctuation or elasticity ; the thigh is often flexed upon the abdomen, and
cannot be extended without much pain ; there is generally redness and
oedema of the skin of the loin ; there is no pus in the urine ; and when
pus has formed in the circumrenal tissue, fluctuation is more easily made
out, and is more superficial than in pyonephrosis.
Inasmuch as nephrotomy is the appi-opriate treatment for this last
condition as well as for hydro- or pyo-nephrosis, the exact difterentiation
})etween these conditions is not so important as it would otherwise be ;
for when the incision is made the exact state can be made out, and the
appropriate course of action adopted. It is sometimes im])ossil)le to
diagnose ascending suppurative ])yeloncphritis with general enlargement
of the kidney, fiom pyonephrosis. Tumour, high fever, rigors, and pus
in the urine are common to both diseases.
URETERECTOMY FOR DISEASES OF THE URETER 437
Prognosis. — In cancer of the pelvic organs, suppuration in the vesical
walls, the impaction of a calculus on one side with disease of the opposite
kidney, the fatal prognosis is determined by the nature of the cause.
When pyonephrosis, of one side only, is produced in persons, with pre-
viously healthy kidneys, by some cause which occludes the ureter and
does not interfere with the opposite kidney, the prognosis, as regards
life at least, is good, if early relief to the pent-up urine and pus be
given.
Treatment, in the early stages, consists in the removal, if possible, of
the cause of obstruction and distension, and the improvement of the
pyelitis.
If the cause be a removable or a remedialjle one, such as stricture of
the urethra, or prostatic enlargement, attention must be addressed to
that. Tumours of the ovary, uterus, and of the bladder should be
removed when possible. If a calculus is felt in the vesical orifice of the
ureter, it should be extracted ; and in certain cases in which there are
strong grounds for believing that the cause of the obstruction was a
calculus impacted in the ureter, too high to be felt from the bladder and
too low to be reached through the kidney, abdominal section, followed by
the excision of the impacted calculus, will be justifiaV)le and correct treat-
ment. When the cause of the obstruction has not long existed, and is
probaljly due to a small calculus or a plug of mucus, pus, blood, or false
membrane in the ureter, it may be displaced hj friction or manipulation
of the tumour, if one exists, liy freely drinking hot liquids, such as tea,
or by active and jolting exercise, if such can be taken.
Palliative treatment of the tumour is permissible where there is not
complete obstruction, and the pus and urine can escape by the ureter.
In most instances, however, the proper treatment is nephrotomy,
palliatives being useless, and delay dangerous. The circumstances which
indicate nephrotomy are : constant pain, increasing size of the tumour,
continued fever, severe gastric and intestinal disturbance from irritation
or direct pressure of the tumour ; inflammation of the surrounding tissues
or adhesion of them to the tumour ; and a threatening of rupture or
ulceration of the tumour.
Ureterectomy for Dise^^ses of Ureter
The ureter, though lying deep in the abdominal cavity, may be reached
for purposes of diagnosis, or for the treatment of certain diseased states in
various parts of its course, without opening the peritoneal cavity. The
upper extremity of the tube, immediately below its junction with the
renal pelvis, lies at the level of the lower extremity of the kidney. On
the anterior abdominal wall this point may be arrived at by drawing a
horizontal line at the level of the lower border of the last rib, and
a vertical one at the junction of the inner and middle thirds of Poupart's
43S SYSTE.M OF MEDICINE
ligament. Tlie commoncement of the ureter is at a point six centimetres
below the point of intersection of these two lines.
It is here that a narrowing exists which has been called the npper
neck of the ureter, and here the passage of a stone, that found room
enougli to move freely in the renal pelvis, is arrested in the first
instance. This, the point of Tourneur, may be palpated in thin persons
from the front of the abdomen ; and in case of oj)eration for stone can
be reached hy the finger inserted into the lumbar Avound Avith the
support of the other hand on the al)donien.
The ureter between this point and the entrance to the bladder is of
uniform calibre ; so that a stone passing the neck at the upper end is
usually capable of making its Avay as far as the bladder, though it may
be arrested by the narrow intravesical portion, or lower neck. In this
part of its course the ureter lies between the peritoneum and the psoas
muscle, the vessels and nerves of the pelvis being in relation with it
posteriorly below, until it lies in close relation witli the I'cctvuu or vagina
(2i cm. below the os uteri) l)efore joining tlie l)la(lder.
The point at which the ureter dips into the pelvis is indicated,
according to Halle, by the intersection of a line joining the anterior
superior spines of the ilia with one drawn vertically through the
junction of the inner and middle thirds of Poupart's ligament. It is
here that tenderness may be elicited in septic or tuberculous infection of
the ureter ; or comjDression may be used to arrest the flow of urine
on one side, in order to collect the secretion from the opposite kiilney.
Should it be necessary to reach the ureter in its lower abdominal or
upper j^elvic part, this may be accomplished through a semilunar
incision, as in the case of the ligature of the common iliac artery ; the
dissection being carried outside the peritoneum, which, with its contents,
is pushed towards the middle line. A continuation of the incision to a
point a little below the end of the last rib enables the entire upper part
to be exposed. A stone impacted at the lower neck of the ureter at the
commencement of the intravesical portion is within reach of the finger
inserted into the rectum or vagina ; and it may be removed through the
bladder, after dilatation of the urethra in the female or median
urethrotomy in the male, by dilating or incising the orifice of the ureter
from within the cavity of the bladder.
Tuljcrcnlous or infective ureteritis may call for removal of the ureter
subsequently to extirpation of the kidney ; and in wounds, fistula, and
hydrosis of the tube, secondary to obstruction, dii-ect surgical treatment
of the ureter may be required, either to re-establish its lumen or to
provide an outlet for urine or pus, if not to remove completely the cause
of oljstruction, as has now been repeatedly done in impacted calculus or
simple stricture.
Following the operation there may be various alterations of sensation
and temporary anuria ; but the ultimate issue in the cases recorded has
been satisfactory
RENAL CALCULUS 439
Eenal Calculus
If the ciystaUoid substances, normally held in solution in the
urine, are deposited in excess, become cemented together around a
fragment of organic matter such as mucus or blood-clot, and are subse-
quently added to by fresh depositions from the urine, a calculus is con-
structed which may either be discharged with the urine, causing more
or less renal colic in its transit along the ureter, or may remain behind
in one of the calyces, or in the pelvis of the kidney, there to grow by
fresh accretions, until it attains a size altogether in excess of anything
Avhich can pass along the ureter. Calculi may originate in the urini-
ferous tubes, or in one of the calyces of the kidney.
The formation of a stone in the kidney is the result of some defect
in general metabolism, and is occasionally preceded by a deposit of
crystals, granules, or gravelly deposit which escapes Avith the urine.
The tendency (hereditary in many cases) shows itself about equally
in the two sexes, in childhood anrl after middle life. It is aggravated
by a sedentary life, by insufficient fluid, and by an excess of nitrogenous
or saccharine food, and possibly of the salts of lime. Renal calculus
occiu-s with peculiar frequency in certain localities, such as in Scotland,
Norfolk, Moscow, and the Delta of the Nile.
The deposition of solid matter depends, in the first instance, either
upon the presence of an abnormal and insoluble product of tissue change,
or of a normal product present in such excess as to be insoluble in the
urine, or precipitated on account of alteration in the reaction of the
fluid, which may be alkaline or excessively acid. In a great many
instances the deposit is found to accrete around a foreign body or a
small nucleus of organic matter ; such as a mass of epithelial cells, a
blood-clot, or a parasite.
The most common form of renal calculus in the adult is the Tiric acid,
the next most common the oxalate of lime; but carbonate of lime, phosphate
of lime, a mixture of phosphate and the ammonio-magnesian phosphate
(the fusible calculus), cystine, xanthine, mute of ammonium, or the mixed
urates, are occasionally, though rarely, found as the nuclei or chief con-
stituents of renal stones. Alternating calculi of uric acid, oxalate of
lime, and phosphates in distinct layers, are not uncommon. Renal
calculi are fomned at all periods of life.
The nucleus in the case of an infant is usually formed of ammonium
urate ; that in a person of about fifteen or sixteen years of age consists of
uric acid, whilst after the fortieth year oxalate of lime constitutes the
nucleus. One or many calculi may be formed in the same kidney ; when
composed of lime oxalate the calculus is usually but by no means invari-
ably single.
A renal calculus may be a small, round, smooth body, or a large
rough branched mass filling all the pelvis and calyces. A stone as large
440 SYSTEM OF MEDICINE
as a marble, sluiipl}^ mamniillated on its surface, may remain confined
to one of the calyces for years without giving rise to more change than
induration of the whole organ, tlue to slight or chronic interstitial in-
flammation. On the other hand, quite a minute stone in the tubular
structure of the kidney, not much or any larger than a mustard seed or
grape seed, Avill excite congestion, and even acute inflammation and.
abscess.
Renal calculi do not attain to such large dimensions, as a ride, than
those which occur in the bladder. They dilfer much in size as well as in
shape and colour, varying from that of a hemp seed to that of a small
walnut ; but in excej^tional cases they may be very much larger. The
large branched phosphatic calculi have been known to weigh as much as
1500 grains ; and in one instance (Pohl, recorded l)y Le Dentu, p. 106) a
calculus Aveighed even 5 lbs. They are usually rounded or oval, unless
moulded to the pelvis or calyces, when they may be irregular or
branched and coral-like.
The surface is usually rough or mammillated. The colour differs
with the constitution of the calculus, and may vary in different layers.
It is mostly purplish broAvn in oxalate of lime, reddish yellow in uric
acid, and grayish white in phosiDhatic calculi, exceptional specimens being
yellow, pink, green, or blue.
The liability of the kidney to calculus is equal on the two sides, and
in about 15 per cent of the cases both organs are affected at once.
Pathology. — The presence of a calculus in the kidney does not
necessarily provoke immediate and extensive changes in the organ. It
may exist for some time at least without even exciting recognisable
symptoms, especially Avhen it is ffxed in such a position as not to interfere
Avith the function of the gland.
Atrophy of the kidney is found in some cases, chiefly post-mortem,
in association Avith calculus ; the kidney being reduced to a mere
fibrous capsule around the stone. It Avould appear that in these cases
the calculus has been loose, or so situated as to oltstruct the xireter or
pelvis ; Avhence folloAved more or less distension of the kidney, absorption
of the secreting substance, and subsequent contraction of the sac.
In other cases, Avhere the calculus has caused obstruction of the
pelvis and ureter, there ensues gr-eat distension of the kidney, beginm'ng
in the pchis and extending to the ciilyces and parenchyma. Dilatation
of the renal pelvis is frecjuently associated with interstitial oedema, and
dilatation and contortion of the tubules.
The glomeruli atrophy, the cells of the conncctiA'e tissue proliferate,
and the vessels become thickened by the development of ncAv muscular
fibres. At the same time both the fibrous and nmcous layers of the
pelvis are much thickened; and it depends on the ratio lietween secretion
with obsti'uction, and sclerosis, Avhether the kidney l)ecomes distended
into hydronephrosis or ends in contraction and atrophy. The in-
troduction of septic orgain'sms determines the develoj)ment of suppura-
tive nephritis, pyonephrosis, or even perinephritis ; and, by inducing
RENAL CALCULUS 441
alkaline decomposition of the urine and secondary deposit of phosphatic
salts, may lead to a very rapid increase in the size of the calculus.
Destruction of one kidney is usually associated with hypertrophy of
the opposite one.
SijinjAams. — A small stone may form, travel down the ureter, and
escape without giving I'ise to any symptom ; and a stone of moderate or
even large size may exist for years without giving rise to any recognis-
able symptom. As a rule, however, there is at some time blood or
albumin mixed with the urine, and some lumbar pain or aching ; this
may be Avorse at night, but is especially excited by jolting or shaking of
the body, and when long continued may lead to lateral flexion of the
thorax from muscular spasm.
The importance of pain about the kidney involved, as a symptom
of renal calculus, depends on its position, persistence, and direction of
radiation, together with the accompanying phenomena. In addition there
may be pain (so it is said, but I am sure with insufficient proof) referred
to the opposite kidney or ureter, or to the bladder, with painful and
frequent micturition, and at times with some pain in the testicle. If
the stone have existed some time, pus, mucus, or albumin will be found
daily in the urine in a minute, moderate, or considerable quantity.
As soon as a stone enters the ureter, or is being propelled along it,
renal colic sets in, the attack coming on suddenly, lasting a few hours, or
two or three days, and suddenly subsiding to recur at some future
period if the stone, instead of escaping at the lower end of the ureter, is
simply displaced from the upper orifice into some less important point in
the renal pelvis. Recurring attacks of colic arise also fi'om fresh forma-
tion of renal calculus. The paroxysmal pain shoots down the course of
the branches of the lumbar plexus, and is felt in the bladder, groin, or
thigh, if not in all these parts ; and is intensified by the spasmodic con-
tractions of the ureter. Collapse and faintness are not uncommon ;
the bladder is irritable, and the urine blood-stained and loaded with
urates. The attack is often ushered in with a rigor, and generally
accompanied by vomiting and profuse perspiration.
When the patient is very thin, and the stoi>e large, it may sometimes
be detected on palpation of the loin. The hsematuria is not often
profuse or constant, and usually subsides with complete rest in bed ; it
is not proportionate to the size, number, or chemical nature of the
stones, though it may be remembered that oxalic calculi have the rough-
est and therefore most irritating surface.
AVhen several stones are present at one time, crepitus may be
obtained. Microscopic examination of the urinary deposit may disclose
casts of the urinary tubules composed of blood corpuscles, or crystalline
masses Avhich have become detached from the surface of the calculus.
Movements such as those caused by carriage exercise, running, or
walking, are not in all cases needed to cause exacerbation of the lumbar
pain ; on merely turning in bed, or even when lying asleep, the patient
may be aroused by a sudden agonising seizure.
442 SYSTE.V OF MEDICINE
Apart from the attacks of renal colic, lumbar and renal pain is a very
common symptom of stone in the kidney. Owing to the wide nerve-
connections of the kidney, the pain of renal calculus is often transferred
to a dista,nce, for instance, to the testicles along the spermatic plexus
and the gcnito-crural nerve ; to the iipper part of the thigh by the
same nerve, to the leg and inside of the foot by the anterior crural
nerve. Paroxysmal, lumbar, and sciatic pains, accomi)anied or not by
retching, are liy no means rare. Sometimes the sciatica is severe
enough to keep the sufferer within doors for Avecks or months ; and
though the pain will be on the side of the calculous kidney, there may l)e
nothing to indicate the cause of it. In all such cases it is prudent to
institute a careful examination of the urine for blood, albumin, or
crystals, and carefully to review the clinical history, esjjecially as to any
past attacks of htximaturia.
At the same time it must be remembered that uric acid in excess and
oxalic acid in the mine are often attended by hivmaturia, crystals in the
urine, and wandering, transferred, and paroxysmal pains in the back,
thigh, calf of leg, and solo of foot.
Prout states, and Dickinson agrees with him, that uric acid calculus
produces the least pain, and that of a dull oppressive character, with a
sense of weight ; oxalate of lime produces an acute pain referred to a
particular spot, as well as shuoting to the ureter, shoulder, and epigas-
trium ; and phosphates give rise to great and unremitting 2)ain, attended,
however, with exacerbations.
Another symptom which results from transference of nerve influence
has reference to the stomach : nausea, vomiting, and dyspepsia are veiy
common, not only at the times of actual colic, but also dui-ing the periods
of less acute suftering. These symptoms are explained through the con-
nection of the pneumogastric with the renal plexus. The retraction of
the testicle, the irritability of the bladder, and the jiain referred to the
thorax, sometimes thotight to be due to plein-isy, are all explained in the
same manner as the gastric disturbance and the jDains in the lower limb ;
jiamely, by transference of nerve influence.
As is the i)ain, so the other conmion symptoms of renal calculus are
largely due to the actual contact of the stone with the mucotis membrane
of the kidney or ureter. These other sj^mptoms are hannatiu-ia, pus in
the urine from inflammation of the pelvis of the kidney, and the occa-
sional sense of fulness or puffiness caused by the mechanical obstruction
to the outflow of urine.
Pus is a conserpience of inflammation of the mucous membrane of the
pelvis and calyces of the kidney. [Sometimes, as the first sign of pyelitis,
before pus cor])usclos are seen, the microscope reveals graiuxlar cor-
puscles and epithelial cells or scales mixed in fibrous threads of mucus,
as well as a few 1)lood corj)uscles. JNIucus occurs more freijucntly when
the calculus is of oxalate of lime. The pus of pyelitis occurs in acid urine,
is not stringy, and separates readily from the urine on standing. The urine
is not offensive, except in those rare cases in Avhich docomposition has
RENAL CALCULUS 443
occurred in the pelvis of the kidney, associated with considerable destruc-
tion of the parenchyma, and material affection of the patient's health.
Tenderness over the affected kidney will often be complained of by
^Dressing on the loin or over the front surface of the organ. The peculiar
attitude and gait of a patient with a renal calculus ai'e due to an eftbrt
to relax all jDressure on the kidney as much as possible. Thus, as in
perinephric abscess, hydronephrosis, and other renal afifections, lateral
inclination of the trunk and flexion of the thic-h are usual.
Among the serious complications of renal calculus may be mentioned
renal colic, suppression of urine from obstruction of the ureter, hydi'o-
and pyo-nephrosis and pyelonephritis.
Diagnosis. — Probably the greatest difficulty in diagnosis is between
early strumous kidney and renal calculus. When frequency of micturi-
tion and slightly purulent urine are met with in a person of strumous
habit, and are unaccompanied by a history of hsematuria, the strumous
nature of the disease is indicated ; but when they are associated with a
history of hajmaturia and sharp lumbar or testicular pain in an otherwise
healthy-looldng person, calculus is much more probable.
Lumbar pain may be due to neuralgia of the parietes or of the kidney
itself ; but there is not the local tenderness on examination which is met
Avith in renal calculus.
Biliary colic is accompanied by jaundice or distension of the gall-
bladder. Affections of the urinary bladder, Avhich might be confused
with renal calculus, may be cleared up with the sound or the cystoscope,
or by digital examination. General diseases like locomotor ataxy,
malaria, and hysteria, are sometimes accompanied by pain which might
be confounded with that of renal calculus ; but the other features of
these diseases are characteristic of their origin.
The haimaturia of renal calculus holds an intermediate position as
regards quantity between that of malignant disease of the kidney and that
due to tubercle : in the former it is extremely free, while in the latter it is
little more than streaks incorporated in the mucus or pus present in
the urine. Moreover, in these cases the haemorrhage is spontaneous, and
not usually associated with any increase in pain ; whereas in calculus the
attacks of haemorrhage are provoked by movement or jolting, and are
immediately relieved by rest, which is not observed in the other cases.
Paroxysms or exacerbations of pain also are a usual accompaniment.
Tumour in the lumbar region, due to distension of the kidney by
obstruction, may be more rapid in formation and rate of increase, and is
accompanied by more pain than the tumour due to tuberculous or malig-
nant disease ; and there may be antecedent symptoms pointing to the
existence of calculus, or to calculous diathesis, before swelling begins.
When anuria occurs, the probability of its being due to calculus is
great if the onset be sudden, and if pain or sv/elling be limited to one
loin, and tenderness be discovered along the course of the corresponding
ureter. This indication is strengthened by a previous history of calculus
on the other side.
444 SYSTEM OF MEDICINE
Treatment. — Tliis may be prophylactic, palliative, and surgical.
(i.) Prophylaxis. — The food must be moderate in amount, and care-
full}' selected ; animal diet is to be used in moderation ; an excess of nitro-
genous food avoided, and diluents taken liberally.
(ii.) ralliative treatment. — Alkaline drinks or distilled Avater are to
be used freely ; and saline aperients as re(iuired. During an attack of
renal colic, the hot bath, opium or belladonna fomentations, subcutaneous
injections of morphia, or suppositories of belladonna and morphia are the
means of relief. In very severe cases the inhalation of chloroform has
been of use. Warm diluent drinks may be given, and the patient
should lie Avith the shoulders and thighs raised.
(iii.) Surgical treatment. — When the symptoms of stone are severe,
and are not removed or rendered bearable by several months of medicinal
treatment and rest ; M'hen, in order to diminish pain or liajmaturia, the
patient is compelled to confine himself to the recumbent posture ; or
when anuria supervenes upon the symptoms of calculus in one or both
kidneys, neplirolithofoinii is indicated. The object of this operation is to
save the kidney. If, however, the organ is in great part destroyed, if
there is calculous pyelitis, or calculous hydronephrosis or pyonephrosis,
nephrotomy and extraction of the stone are the necessary measures.
If, after the kidney and ureter have been thoroughly explored — not
only over the outer surface, but by digital examination of the interior
of the renal cavity — a stone cannot be detected, and yet the symptoms
point definitely to the presence of stone, and the patient's life is insuper-
able from pain or hsemorrhage, nephrectomy is the last resource.
In infants Dr. E. A. Gibbons has described the effects of uric acid
concretions in their passage down the ureter. The testicle is drawn up ;
there is evidence of gj-eat pain and tenderness on the cori-esponding side
of the abdomen ; the urine is clear, scanty, and passed frequently in
small quantities with considerable jiain, accompain'cd by niiiuite cayenne-
pepper-like grains of uric acid, and sometimes a little blood. This con-
ditioji is the cause of more or less incontinence of urine, the child fre-
quently Avetting itself, both by night and day.
True calculi, according to Henoch, are as common in children as in
adults ; but in tlieir passage doAvn the lu^eter the child suffers much less
pain than the adult. The stone is composed of uric acid, and the sub-
jects of stone are ahvays the offspring of gouty parents, and for the most
part are males. The attacks of renal colic occur Avith remarkable sudden-
ness, and Avithout any premonitory signs of illness.
In treating these cases hot baths are to be employed, followed by
poultices or fomentations to the loin on tlie affected side, and the ad-
ministration of a mixttu'e containing bromide of annnonium, sal volatile,
and compounfl tincture of camphor. In older children it has Iteen found
that a mixed ordinary diet combined Avith tonics and an abundance of
fresh air afford the most effective means of combating the defective
metabolism Avhich results vi the excessive formation, and separation, of
uric acids and urates.
MORBID GROWTHS 445
Morbid Growths
The kidney is liable to many morbid growths of a cystic and solid
character, both benign and malignant. Several of these do not attain to
any great size, or cause the kidney to become appreciably if at all en-
larged. Thus adenoma, which occurs in two forms in the kidney (the
papillary and the alveolar), is usually the size of a hazel-nut or walnut, and
seldom, if ever, so large as an egg or small orange ; angeiomala cavernosa,
though distinct formations, or new growths of reticulated cavernous tissue,
are of quite small size, not exceeding that of a marble, and, though called
tumours, the parts which they aflect are often shrunken, rather than
projecting or enlarged ; leuhcmic tumours are small, scattered, roundish
})atches of lymph-cells following the course of the capillary vessels, and
looking not unlike extra vasated white blood-cells, though they are some-
times actively growing tumours of a truly malignant character ; li/mph-
adenoma is found in the kidney, associated with similar disease of the
glands, liver, and intestine; fibroma occurs "in the form of small white
knots of fibrous tissue near the bases of the pyramids " (Moxon), but
occasionally a very large simple fibrous tumour has been found in the
kidney ; sypMlitic (/ummata occur occasionally, but do not attain such a
bulk as greatly to increase the dimensions of the kidney ; various-sized
and numerous cysts, as in granular kidney, may be present without add-
ing to the size of the organ.
Though pathologically of the nature of "tumours," yet, clinically
speaking, some of the above-mentioned formations never give rise to
actual tumours ; others do so but rarely.
Clinically, any enlargement of the kidney, which can be detected by
physical examination at the bedside, is spoken of as a tumour of the
kidney. Some of these enlargements have been considered already,
namely, hydronephrosis, pyonephrosis, renal abscess, and the enlargement
of the kidney caused by scrofulous disease.
I may here mention, incidentally, that the comparatively rare condi-
tion brought about by hiemorrhage within the capsule of the kidney is
liable to be mistaken for tumour or other renal enlargement, or for
calculous disease of the kidney. Subcapsular haemorrhage may result
either from direct traumatism or indirect strain ; the quantity of blood
effused varies from a few drachms to a pint or more. The symptoms
produced are local pain, tenderness or discomfort, and undue frequency
of micturition. They are in fact very similar to those resulting from
the presence of a renal calculus, with or without the haematuria ; and
in those cases where the blood effusion is large it is not at all unlikely,
by its bulk and renal contour together with the hardness and nodu-
lation which result from coagulation, to simulate a renal tumour very
closely.
The subsequent effect of organisation and contraction of the clot is
446 SYSTEM OF MEDICINE
to compress the organ and seriously to impair its function, so that early
relief by operation is of importance ; and the difficulty of distinguishing
between it and calculous pyonephrosis or other form of tumour, except
by exploration, becomes of less moment. The history of the ailection
may be a guide in some instances, the symptoms occurring suddenly,
and dating from a blow or wrench. Such an accident, however, so
readilv calls attention in the first instance to a ti;mour, or causes
sudden pain and enlargement by hivmorrhage from a previously existing
new growth, that too much reliance must not be placed upon it.
Malignant disease of the kidney. — rafknlnr/i/. — ^lalignant tumours
of the kidney include several diilerent forms of new growth. The larger
number are sarcomata, which appear at the extremes of life. Of G 7 cases
of malignant disease collected by Sir William lioberts, 25 occvirred in
children under ten years, 3 only of these after five. These infantile
tumours are almost invariably sarcomatous, and are remarkable for the
rapidity of their growth and the enormous size to which they attain :
Sir Spencer Wells recorded that a tumour removed from a child of
four weighed nearly 1 7 lbs., and others have been found exceeding 30 lbs.
in weight. Sometimes both organs are invaded at the same time. Of 67
instances quoted above, 60 Avere unilateral, and in 3 only Avas it clear that
the disease Avas primary on both sides. According to Guillet, from ob-
servations chieHy made after death, only 7 out of 72 cases were bilateral.
In 1880 Dr. Abercrorabie exhibited three cases at the Pathological Society
in Avhich both kidneys in children Avere invaded from the hilum by
sarcoma. The incidence of malignant disease appears to be pretty
equally distributed on the tAvo sides ; but as regards the influence of sex
there is a remarkable preponderance in faA'our of males ; the proportion
being as 47 to 19 (64: to 35, according to Guillet). This dis})roportion in
distriljution is not so Avell marked in the case of children ; the pro-
portion of males to females being as 1 5 to 9 in those atiected up to ten
years of age.
Iji children, groAvth is extremely rapid, metastasis occurs eai'ly, and
death usually results within a year. The distriljution of the secondary
growths takes place Avith nearly equal frequency in the lymphatic glands,
the lungs, and liver.
Sarcoma supplies by far the greatest number of malignant tumours ;
it occurs either before the age of five, in Avhich case the disease may be
bilateral, or at any subsequent age Avhen they are unilateral and of
somewhat slower growth.
In infancy, sarcomata are usually encapsuled, and for the most part, in
causing enlai-gement, do not alter the shape of the gland. Their growth
is A'ery rapid and the size attained enormous. The glandular substance of
the kidney is almost completely destroyed. These tumours are composed
either of round or spindle cells Avith groups of tuliuk's lietween ; and in
most cases there are present also large fusiform cells Avith cross striation,
having under the microscope the appearance of muscle fibre. The enlarge-
ment is painless, hoematiu-ia is rare, and secondary nodules form early in
MORBID GROWTHS 447
Other organs. Eemoval of the tumour is not to be recommended, as young
children do not bear interference with the viscera well, and those who
have survived the ojieration have died from recurrence or other mishap
Avithin a year.
Sarcoma in adults is for the most part composed of fusiform cells, and
from the admixture of large striated fibres in bundles is in some instances
called myosarcoma. One side only is attacked ; ha?maturia occurs fre-
quently, and large quantities of blood are lost at a time. The tumour
rapidly attains a large size and is accompanied by consideraljle pain,
Avhile secondary deposits occur in other organs. The results of operation
haA^e until recently not been A'ery much better than in children, death
commonly occiuTing Avithin a year of nephrectomy. This has nevertheless
been performed in many instances on account of the pain and incon-
A'enience of the sAA^elling.
In a recent series of five cases, reported by Dr. James Israel of Berlin,
there Avere three complete recoveries in female patients aged respectively
fourteen, forty-three, and six years ; the tumours being ah'eolar sarcoma,
myxosarcoma, and spindle-celled sarcoma respectiA'ely : Avhile tAvo males,
aged five and fifty-one, from Avhom round-celled and cysto-sarcomata Avere
removed, died of recurrence and metastasis Avithin a feAV months.
Other allied forms — such as melanotic sarcoma, in which melanuria
occurs ; myxomrcoma, in Avhich the tumour is soft and jelly-like and cf
very rapid growth ; and hjmplwsarcovia, Avhich is scarcely ever limited to
the kidney — are all extremely rare.
Carcinoma for the most part affects the kidney in the encephaloid form.
It arises in the cortex and iuA^ades the rest of the organ, usually
beginning at one jjole ; the groAvth is of the consistence of normal brain
substance, pale, not very Avascular, and generally encapsuled. The mass is
seldom quite uniform, being occupied by areas of liquefaction, of colloid
degeneration, or extensive haemorrhages ; and in rare instances by indura-
tion of the nature of scinhus.
Carcinoma attacks the kidney tAvice as often in men as in women, and
usually in the latter half of life, nearly all the cases occurring after fort}'-
five. Cancer has a more protracted course in the kidney than it
generally runs in other abdominal organs, lasting in some cases four or fiA^e
years or even longer, and resulting in a tumour of enormous size, Aveighing
15 to 20 or more lbs. In the Middlesex Hospital jMuseum there is a
cancerous tumour Aveighing 31 lbs. from the left kidney of a boy aged
eight years.
The symptoms are hsematuria, often copious and most marked in the
early stage ; the appearance of a tumour in the luml^ar region, Avhich
groAA^s steadily ; and the occurrence of aching and neuralgic pains or of a
sense of Aveight in the side. Varicocele is present sometimes on the left
side as a remote sign due to obstrrction of the spermatic vein ; and the
wasting, anaemia, and loss of strength common to cancer in other parts
are present here, nor is evidence of secondary deposits wanting, at all
events in the later stashes.
44S SYSTEM OF MEDICINE
As regards treatment, most of the cases offer no hope of cure, the
disease not being discovered till too far advanced for eradication. In
cases which are diagnosed early, before secondary infection has occurred,
nephrectomy may be performed with some hope of cure. Dr. James Israel,
in 189-4, reported six cases so treated, of which three ended in recovery.
Epithelioma is met with in rare instances. The cells of which the growth
is corajjosed are more often cylindrically arranged, and are columnar in
shape, with rounded free extremities and a clear protoplasm. Both the
cells and their arrangement resemble very closely what obtains in the
convoluted tubes, even to the maintenance of a central lumen ; and this is
accurately repeated in the secondary deposits.
Instances are upon record of squamous epithelioma attacking the
kidney primarily. In a case published h\ Robin, and quoted by Roberts,
the cells resembled the pavement variety, and were remarkable for their
size, measuring ^V*'^ ^^ ^ millimetre in length. Xo nests were found
as in an ordinary cutaneous ei)ithelioma.
In another case, recorded in the Middlesex Hospital Report for 1892,
the tumour of the left kidney Aveighed 28 lbs., the bulk being due largely
to calculous pyonephrosis ; there was in addition soft new growth arising
in the pelvis of the kidney, and secondary deposits in the lungs, liver, and
retroperitoneal glands, all of Avhich possessed the microscopical features
of squamous epithelioma. The patient was an old wom:in of eighty-two.
In this case the origin of the new growth appears comparable to that
arising in the gall-bladder in connection with gall-stones.
Benign tumours. — Mi/xoma sometimes attacks the kidney and rapidly
develops into a large soft tumour. A case of this sort, occurring in a
man of thirty-nine, causing death within a year from the first discovery
of the tiimour, Avithout metastasis or haematuria, and with symptoms
only of pressure and wasting with some abdominal pain, is recorded in
the Middlesex Hospital Report for 1895.
Villous papilloma is found in the renal pelvis in rare instances. Like
this disease in the bladder, it causes severe hematuria sometimes accom-
panied by fragments of detached villi. Enlargement of the kidney is not
marked, biit, as in other cases of renal hi^morrhage, there may be casts
of the ureter to indicate its .source.
Adrenal tumours and Accessory adrenal tumours, which have a
superfici d resemblance to sarcoma and are frequently mistaken for it, arise
in the suprarenal body, or in disconnected portions lying cither free in the
immediate vicinity or embedded in the cortex of the kidney beneath its
capsule. They contain fat, and have been described as renal lipoma ; but
when the fat is removed by solution in ether, the identity of the structure
with that of the fascicula reticulosa of the suprarenal is evident enough,
and from analogy with similar developments in connection with the thyroid
gland. Virchow has proposed for these tumours the term " struma supra-
renalis," and the accessory forms are referred to in modern German
literature as malignant struma of the kidney. When either the entire
gland or one of these included portions takes on rapid growth, a tumour
MORBID GROWTHS 449
is formed Avhich, both on account of its size and tendency to metastatic
development, becomes dangerous to health and life.
An excellent example of this uncommon form of tumour was removed
by me from a managed forty -three. Many unsuspected secondary nodules
were observed in the liver during the operation, and there was also a hard
nodule attached to the temporal region of the skull. The case was
published in the first volume of the British Medical Joanial for 1893 ; and
I there drew attention to the analogy of this form of tumour to the rare
variety of goitre, associated with secondary deposits structurally identical
with the thyroid gland in the bones and viscera ; I published an instance
of this kind in the Tpmsadicns of the Pathological Societij, vol. xxxi.
Diagnosis and Treatment of renal tumours. — Tlie recognition of
adrenal or accessory adrenal tumours as solid growths of the kidney is
not, as a rule, a matter of difficulty ; but to distinguish between them
and other renal tumours without microscopic examination is at present
impossiljle. Adrenal growths, however, do not run so rapidly fatal a
course as sarcomata ; tlicy are not bilateral like some of the congenital or
infantile forms of the latter disease, and when affecting the suprarenal body
itself do not cause hsematuria. These tumours may be removed with a fair
prospect of cure, and a successful case is recorded by Dr. James Israel in
a man of forty-two who Avas reported well a year after the operation.
Malignant gi'owths of the kidney are for the most part rounded,
smooth, or lobulated, and without the sharp edge possessed by the spleen
or liver ; in the infiltrating forms the tumour retains something of the
original shape of the kidncj^, though no trace of the glandular substance may
remain. With the exception of the comparatively rare cases in which the
kidney is invaded by sarcomatous growth from the hilum, the new
development almost invariably begins in the cortex and spreads thence to
the pyramids ; sometimes it invades the pelvis, ureter, or renal vein, or
even the vena cava. In this way, or by pressure on or infiltration of the
walls of the vena cava, or aorta, obstruction is caused which may lead to
oedema or gangrene of the lower extremities, or to eflfusion into the
peritoneal cavity.
As a general rule the tumour is contained within the proper capsule of
the kidney, which may be thickened and covered with dilated veins, or may
be continued hj fibrous tracts and dissepiments into the substance of the
new growth, rendering attempts at intracapsular enucleation dangerous or
impossiljle. In exceptional cases the capsule is perforated, and neigh-
bouring organs, or the parietes, are infected by continuity. The consistence
of the mass is affected by caseous, fatty, or colloid degeneration of its
substance, or by extensive hsemorrhagic effusion.
Tumours of the kidney occupy a characteristic position deep in either
lumbar region, for the most part high up within the cavity of the abdomen;
but when small and non-adherent, they descend with inspiration : when
large, they extend towards the pelvis and across the middle line of the
abdomen. There is, often some bulging in the loin, and in any case the
mass should be more easily felt from behind, and should play freely
VOL. IV 2 G
450 SYSTEM OF MEDICINE
between the hands placed over the abdomen and the loin. The descent
of a renal tumour on inspiration, though distinct enough to distinguish
it from a swelling of pelvic origin, is very much more limited than in the
case of the liver, spleen, or stomach, or growths connected Avith them ; and
lateral movement is practically not permitted at all. The intestines lie
towards the centre of the abdomen, the tumour being close up to the fianlc,
with the colon in front ; and, if the mass be not too large, there is an area
of resonance above and below it, separating it from the liver above, and
continuous with the resonance in the liypogasti'ium l)elow.
Very large tumours on the left side may displace the spleen and stomach
towards or beyond the middle line ; and on the right side may I'each the
diaphragm, displacing and tilting the liver, so that its edge occujoies a
verticjd instead of a horizontal position near the middle line of the
abdomen.
In the majority of cases the growth begins at one or other
extremity of the kidney, more often at the upper. The mass formed
is then definitely encapsuled ; and when small and situated deep
under the margin of the thorax is very difficult to make out. But
as these are the cases which are most favoural^le for operative treat-
ment, the tumour and kidney being usually readily separated and un-
attended, in the early stage at least, by secondary growths, it is of the
utmost importance to diagnose them earh'. Their presence is indicated,
before the recognition of a tumoui', by ha'maturia, often very profuse and
coming on independently of shock or exertion ; and by pain, tenderness,
or discomfort in one or other loin. With the aid of a thorough examina-
tion, under an anaesthetic if necessary, even a small swellinc: can be made
out through thin abdominal walls ; and this, together with the other
symptoms, is sufficient to warrant an exjjloratory incision which may
finally show the necessity for removal of the kidney. This opinion has
been illustrated by two cases diagnosed and operated upon by Dr. Jamea
Israel of Berlin (the growth being no larger than a cherry in one instance),
both of which ended in complete recovery : the patients reported them-
selves three years after operation.
Cysts of the Kidney
Simple or serous cysts, which are met with for the most part in the
kidneys of elderly people, may attain considerable size, and so constitute
a troublesome disease. They cause no symptoms except those due to
their size and to the pressure they exert on surrounding organs.
These simple cysts arise in the cortex of the organ, and project in
relief from its surface, the rest of the kidney l)eing healthy and function-
ally active ; or it may Ijc granular, or more or less atrophied from the
pressure of the cyst itself. Sometimes a communication is established
between the cyst and one of the calyces of the kidney.
The contents of the cyst are fluid, containing a small (piantity of
CYSTS OF THE KIDNEY 451
albumin and a little saline matter ; but rarely, if ever, any urinary
ingredients. Occasionally they contain blood from the rupture of blood-
vessels in their walls, and sometimes a jelly-like or colloid material.
Their exact mode of origin is uncertain.
Symptoms. — Simple renal cysts begin insidiously, grow slowly,
present themselves first in the loin, or in the lumbar area of the fi-ont of
the belly, and may be so hard at first as to be mistaken for solid growths.
As they increase, they gradually encroach upon the greater part of the
abdominal cavity ; their point of attachment ceases to be even approxi-
mately ascertainable ; and in woman they may give rise to the
suspicion of ovarian tumour. As they grow they tend .to spread out the
renal substance, so that a good part of the kidney may be stretched in a
thin layer over the attached part of the cyst wall.
Diagnosis. — The difficidties which surround the diagnosis of these very
rare cysts are extremely great ; for not only may tht-y be mistaken for
hydatid of the kidney, hydronephrosis, and other renal tumours and
perinephric fluid collections, but it may also be almost impossible to
distinguish them from solid tumours in the parietes, from hepatic or
splenic cysts, or cysts of the omentum, mesentery or pancreas, from
malignant cystic tumours springing from the pelvis or elsewhere within
the belly, and, sometimes in women, from ovarian cysts.
Treatment. — When they become so large as to be inconvenient they
should be tapped ; if they refill, they should be laid open and the edges of
the cyst stitched to those of the wound : the cyst will then collapse, and
probably close. Smaller cysts should be excised from the kidney.
General cystic degeneratfon of the adult kidney. — This is
the result of a degenerative process. The whole kidney is converted into
a vast number of conglomerated cysts of varying size, which leave scarcely
any portion of the glandular structure unchanged, and give a greatly
increased bulk to the organ, which, while retaining the renal shape, may
be ten times the bulk of the normal kidney.
The cortical and medullary portions are alike replaced by the cysts
which bulge the capsule and protrude on the surface as translucent sacs.
The cysts vary in size from microscopic dimensions to that of a grape or
walnut ; the largest being often in the centre of the organ.
The fluids contained are clear, pale straw-coloured, dark vellow,
purplish, or deeply blood-stained. In consistence these contents are lim-
pid, serous, viscid, colloid ; or turbid, caseous, and almost solid. Occa-
sionally they are purulent; sometimes even solid, in which case they consist
of molecules of fat, epithelium, and crystals of cholesterin, uric acid, or
triple phosphates. The cysts do not communicate with the pelvis or
calyces, nor with each other. They are closed cavities, whose walls are
excessively thin, and lined by a delicate layer of epithelium. They
probably owe their origin to expansion of parts of the uriniferous tubules
and atrophy of the interstitial tissue. The original renal substance is in
some places wholly removed, in other places small portions between the
cysts remain unchanged.
452 SYSTEM OF MEDICINE
Sometimes the renal pelvis, l)Ut not the ureter, is much dilated. The
dilatation is due, not to obstruction, but to dragging. In one of my
cases the pelvis was enormously dilated. Both kidneys are commonly
affected. Dr. Dickinson found only one case out of twenty-six in which
the disease was confined to one kidney. A patient from whom I removed
a kidney of this kind nearly four years ago is still alive and well.
" Congeries of Kenal Cysts " are sometimes congenital, and lead to
enormous abdominal distension of the ftetus in utcro, with serious
difficulty in parturition. Cystic degeneration is a cause of death of the
f(jctus in utero or during birth ; and it is sometimes found associated with
various malformations, such as talipes, cleft palate, and imperforate anus.
The observations of Naunyn led him to regard the condition as one of
adenoma. Courbis would prefer to call the condition epithelioma, but for
the meaning usually associated Avith that word. " In the early stages the
cyst walls have a membrana propria, and are lined with tesselated epi-
thelium, which in advanced specimens is difficult of detection. "When the
disease is not far advanced, the renal pelvis is easily recognised ; but in the
later stas-es it becomes filled with fattv tissue." The ureter is narrow and
the vessels are small. " jMinor degrees of the affection are not incom-
patible Avith life, and several instances are known in which such kidnej'^s
have been found in adult individuals." Mr. Shattock has advanced the
opinion that in these kidneys there is a combination of mesonephros
(Wolffian body) w'ith the mctanephros (true kidney) ; and that the cysts
may be regarded as arising in remnants of the mesonephros embedded
in the true kidney. It cannot be said that there is nothing to support
the \aew that the condition depends on obstruction of the urinary passages,
though in the foetus as in advdts obstruction in the ureter leads to dilata-
tion of the kidney, but of the nature of hydronephrosis.
Symptoms. — The clinical history of this disease, according to Wilks
and Moxon, is much the same as that of Bright's disease, " of which,
notwithstanding their vastly diflferent appearance, these enormous-looking
tumours form only a variety. The cysts are, in short, an excessive pro-
duction of that minuter cj'stic condition of the kidney which we have
already described as occurring in granular kidneys." As with granular
kidneys, so with the large cystic kidney, hypertrophy of the heart is not
infrequently associated. In one of my cases the left ventricle Avas
much hypertrophied, the right kidney was converted into a congeries of
cysts, the secreting structure almost gone, and the pelvis enormously
dilated ; the left kidney was large and granular, had a wasted cortex, and
Avas puckei'cd in places on the surface.
The subjects of the large cystic kidney (not congenital) are more often
men than Avomen ; and are always adults, the majority being peisons at or
past middle age. In six cases the ages of the jiatients Avere thirty-nine,
fifty, sixty-five, two betAveen thii-ty and forty, and one tAventy-onc years
respectively. Out of 21 cases mentioned by Dickinson, the ages of 11
were betAveen forty and forty -nine. In this form of disease there is no
tendency to dropsical efiusions ; but jiain in the loins and hiematuria,
CYSTS OF THE KIDNEY 453
especially the latter, are frequent and pronounced symptoms, and are
useful in diagnosis.
When oedema occurs in a case of cystic kidney, it is the mechanical
effect of pressure of the tumour. The characters of the urine are like
those of the granular kidney. It is pale in colour, abundant in quantity,
of low specific gravity, and albuminous even when not admixed with blood.
Coagula and granular casts are occasionally found in the urine, and
more rarely pus in small amount.
However, the symptoms are not always very obvious.
In one case, the specimen of which is in the Hunterian Museum, the
patient at sixty -seven died of apoplexy ; his vessels were atheromatous,
and his heart weighed only 9i ounces. Both kidneys were enlarged and
cystic ; their state had not been recognised during life.
In another case, the patient, a sailor aged fifty, presented symptoms
of brain disease, became delirious, and died in a few days. Both kidneys
were almost entirely converted into congeries of cysts.
In a third case, a shoemaker had severe pain in the loins and along
the course of the ureters for five years ; his urine was scanty, and
always mixed with blood or pus. The other symptoms were numb-
ness of the right leg, frequent severe headache, and occasional oedema of
the lower limbs. Both kidneys were large and cystic, and the ureters
were dilated.
. Diagnosis. — When, with a sallow complexion, hypertrophy of the
heart, and increased arterial pressure, are found the above characters of
the urine and a tumour in each of the renal regions, or a tumour in one
and an increased fulness in the other, the diagnosis of " large cystic
kidney " is pretty clearly indicated.
The tumour will probably be yielding ; but it does not fluctuate, and
it presents the usual topographical characters of renal tumours in general.
In the late stages of the disease, obstinate vomiting, convulsions,
suppression of urine and coma supervene, and then follows death.
Death sometimes occurs from exhaustion brought on by haematuria ;
sometimes from bronchitis or pneumonia ; sometimes from oedema of the
lungs, and sometimes from some quite independent cause. Of the three
fatal cases in my list, one died of bronchitis, congestion of the lungs, and
morbus cordis ; one of epithelioma of the tonsil and soft palate ; and
the third of epithelioma of the penis.
AVhen death is caused immediately by the state of the kidneys, the
manner of death is most frequently by uraemia. The progress of the
disease is not usually very rapid, from two to five' years being a common
period.
Treatment. — This should be based upon the same principles as that of
interstitial nephritis. ]\Ioderate stimulation of the skin and bowels, with
the avoidance of excess of nitrogenous food or exposure to unnecessary
cold or exertion, so as to keep the production of nitrogenous waste down
to the lowest point while promoting elimination vicariously, constitute
the best general methods. As regards drugs, a laxative mixture containing
454 SYSTEM OF MEDICINE
iron is the most cflic.icious ; and if the heart show signs of feebleness,
strychnine and digitalis may be added "with advantage.
The surgeon's aid will not often avail, o\vnng to the frequency of the
bilatci-al incidence of the disease ; and when unilateral, unless the size be
very ineon^■enient, no surgical treatment is called for. However, in two
out of three cases in which I have removed such kidneys the patients
have recovei-ed.
Paranephric cysts are neither developed in the kidneys nor are they
due to a dilatation of the renal cavity or jielvis. They encroach upon
the surface of the kidney from Avithout, and if they have any com-
munication with the interior of the organ, it is only secondary and due to
a fistulous passage formed between the cyst and the kidney.
Such cases must be treated like hydatid, simple cysts, and hydro-
nephrosis ; namely, they should be opened and drained, the edges of the
C3'st being stitched to those of the wound in the abdominal parietes : or
they should be entirely excised.
Hydatids of the Kidney
Hydatid cysts form tumours in connection with the kidney. The
kidney stands third in order amongst the viscera favoured by this para:-ite,
being thus more frequently affected than any other organ or tissue of the
body except the liver and lungs.
The left kidney seems to be affected nearly twice as frequently as the
right; owing perhaps to the shortness and directness of its arterial branch.
The cyst may be immediately beneath the capsule, or lodged deeply in
the substance of the kidney. In either case, as it grows it forms an
elastic, rounded, and sometimes fluctuating tumour projecting frona the
surface of the organ. The whole kidney maj'' ultimately be destroyed
by the cyst, which may come to fill a large part of the abdominal cavity ;
but in the majority of cases it remains quite small, and does not exceed
the size of an egg or an orange, because the contents of the cysts find an
escape by the ureter.
A renal hydatid cyst may burst into the pelvis of the kidney or
into the intestine or lung. Sir AVilliam lloberts tells us that it has a
natural tendency to discharge its contents by the ureter ; and out of 63
cases collected by him, hydatids were discharged by the ureter in 52 :
in 47 the cysts opened into the pelvis of the kidney only ; in 1 into the
pelvis of the kidney and the lung ; in 3 into the intestine ; and in 1
into the stomach, as well as into the renal pelvis. In 1 case the
opening was into the lung only ; in 2 the cyst was opened artificially,
and in 8 cases it did not open at all. Roberts states that there is no
authenticated case of a h^-datid cyst of the kidney opening in the loin,
and that Eayer's two cases which so opened were hydatids in the muscular
tissue of the lumbar region. In a third case there was post-mortem
proof that the cyst was unconnected with the kidney.
HYDATIDS OF THE KIDNEY 455
Symptoms. — In some instances tlierc are no symptoms, and the cyst is
met with as a post-mortem surprise. In others there are no symptoms
until the cyst bursts, after the common manner of the disease, into the
renal pelvis, when attacks of renal colic begin and recur from the
passage of the daughter cysts and portions of the hj^datid membrane
along the ureter. In a third class of cases there is an abdominal tumour,
with or without the symptoms excited by the escape of the contents of
the cyst along the urinary passages.
In 18 out of 63 cases, according to Roberts, a tumour in the side
was discernible during life, and varied in size from an orange to an adult
head. Fluctuation is not always to be detected, either because of the
extreme tension of the cyst walls, or because of the small proportion of fluid
to daughter and grand-daughter cysts. The hydatid thrill or fremitus has
been seldom observed. The hydatids discharged by the urethra are in
various states ; broken or entire, as fragments, or as vesicles simply col-
lapsed. There may be one or two only, or scores of vesicles. Some con-
tain only water, others have minute cysts within. Crystals of uric acid
have been found adhering to them ; crystals of triple phosphates, uric acid,
and oxalate of lime have been found within. When the parent cyst has
suppurated before bursting, pus is discharged as well as hydatids. Blood
is sometimes dischai'ged in the urine. In a case of which I have notes,
the cysts were mixed with large quantities of pus in the urine ; but some
of the smaller and unruptured cysts contained the ordinary clear saline
and non-albuminous fluid characteristic of hydatids. In some cases,
booklets, shreds of hydatid membrane, and oil particles, but no vesicles,
are found in the urine.
In relation to the discharge of hydatids by the urethra, it must not
be forgotten that hydatid cysts of the liver have sometimes discharged
into the renal pelvis ; and hydatids in the cellular tissue of the pelvis,
or in the track of the ureter, have broken into the bladder or ureter,
and thus escaped by the urethra.
Such cases are infinitely rare. Mr. Birkett knew of one case in
which hydatids were withdrawn by a catheter from the bladder, the cysts
having escaped into the bladder from a hydatid tumour between it and
the rectum. Other similar cases of hydatid tumours in this situation
opening into the bladder are on record ; but they are to be distinguished
from hydatids in the kidney by the formation of a pelvic tumour, and
by the prolonged and increasing pressure-effects upon the bladder and
rectum.
The escape of the vesicles may or may not excite nephritic colic.
There may be one or several dischai-ges at longer or shorter intervals of
a fcAV months or several years. Sometimes at the first escape the cyst
empties itself and dries up ; in other cases there have been numerous
periods of escape over many years, and at uncertain and very variable
intervals.
Pain in the lumbar region and along the course of the ureter of the
affected organ, with a sensation of something giving way, usually precedes
456 SYSTEM OF MEDICINE
the discharge. Kigors, A-oniitiiig, spasmodic colicky ])ains, and sometimes
suppression of urine and retraction of the testicle, accompany the passage
of the vesicles along the ureter, which takes from a few hours to several
days to be accomplished ; then comes a period of relief during their stay
in the liladder, and this is followed l)y the distress, retention, and ])ainful
cflbrts to micturate which intlicate their journey through the urethra.
An accident, such as a blow, kick, or fall, or the jolting of horseback or
carriage exercise, may lead to the rupture of the tumour, and to the first
or to any sul)sequent escape of the vesicles.
When a tumour exists, and is very large, it may fill the loin, and to
a greater or less degree the corresponding side of the al)domen. It may
be quite round and regular in outline, or present a somewhat nodulated
surface. Its relations to the bowel and to the ribs and surface are
the same, and are subjected to the same exceptions as renal tumours
genei'ally.
In a case shown by Dr. Fotheringham to the Glasgow Pathological
Society (11«) the patient had a nodulated tumour, Avhich filled the right
lumbar region, and caused pain and tenderness ; the ordinary symptoms
of Bright's disease were also present. Within a fortnight, after sup-
purating and discharging pus and cysts by the urethra, the symptoms of
Bright's disease disappeared.
Suppuration may occur as the result of violence or of puncture ;
whether for the purpose of diagnosis or treatment, or independently of
either. If it occur, then rigors, fever, and increased pain and tension
about the tumour set in.
Pro(jnods. — The prognosis of renal hydatids is not always unfavoiu'-
able. Sir W. Roberts' list of 63 cases yields 20 in Avhich recovery was
believed to have been permanent, and 19 of which were fatal; in the re-
mainder (24) the results Avere not known. In 10 of the fatal cases the
cause of death Avas directly due to the hydatids bursting into bronchi, to
pleurisy, to the effects of pressure of the tumour, or to su]ipuration of the
contents. In one case a large renal calculus was found with the hydatids
in a solitary kidney, and the hydatid tumour opened into the renal pelvis,
and thus obstructed the outfloAv of urine. In 9 cases the causes of death
were unconnected with the hydatids.
The duration of the disease is uncertain, but often very much prolonged.
Patients have gone on passing vesicles at intervals for twenty and even
thirty years. There are no means, except by waiting, of telling whether
more remain behind after some have escaped by the passages. If, when
the cases are left untreated, the prognosis of hydatid tumours of the
kidney is more favourable than that of similar tumours of other internal
organs, it is because of the tendency to rupture into the renal pelvis.
"When the tumour is small, and situated in the central parts of the kidney,
the evacuation is easy and safe. There is no fatal case on record when
the vesicles have escaped Ijy the urethra from a renal hydatid cyst which
had not given rise to an abdominal tumour. The discharge of pus with
the vesicles is not necessarily unfavourable ; patients have recovered when
DIAGNOSIS OF RENAL FROM OTHER TUMOURS 457
the quantities of pus discharged have been very great. AVhen the cyst
breaks into the pleura or bronchi the probability of recovery is not good ;
when into the bowel or stomach it is much more favourable. When the
cyst grows continually, and does not burst in any direction, the dangers
of a large tumour and of its pressure-effects have to be met.
Diarjiiosis is made certain when, with a tumour in the renal region,
there is a discharge by the urethra of hydatid vesicles or of the other
products of hydatid tumour. If the cyst do not rupture into the
renal pelvis the urine Avill present no evidence of the nature of the
disease ; and if a tumour exists Avithout discharging its contents by the
ureter there is nothing to point out the precise nature of the enlargement
except the use of the aspiratory trochar. The renal origin of the
swelling must be diagnosed by the same means as other renal tumours.
When vesicles are voided but no tumour exists, nephritic colic generally
indicates the locality of the hydatids.
Treatment. — When a tumour increases without discharging by the
urethra the only proper treatment is to cut down upon the tumour, and
having tapped and emptied it of its fluid contents, to incise it and stitch
the edges of the cyst to the margins of the parietal wound. The cyst
should be opened from the loin if possible ; if not, then at its most
prominent or projecting point. When the kidney is very extensively
affected, nephrectomy will lie necessary. When there is no tumour, and
hydatids are discharged by the urethra, no surgical treatment is absolutely
needed unless renal colic is frequent and severe ; but in my opinion it is
distinctly better to explore the kidney and excise the cyst. [Cf. vol. ii.
p. 1140.]
Diagnosis of Eenal from other Tumours
Renal tumours are among the most difficult of abdominal enlargements
to diagnose correctly. The chief distinctive points about them are the
following : —
1. The large intestine is in front of the tumour. Normally the right
kidney, unless enlarged, lies a little way from the lateral wall of the
abdomen, behind and to the inner side of the ascending colon ; not in
close contact with the abdominal wall, and outside the ascending colon,
as the liver does. When enlarged, the ascending colon is usually placed
in front of the tumour and towards the inner side of it. On the
left side the descending colon is in front of the kidney, and inclines
towards its outer side below ; in some cases coils of small intestine
may overlie either right or left tumour, if the enlargement be not
sufficient to bring the kidney into direct contact with the front
abdominal wall. When the colon is empty or non-resonant, it can be
felt as a roll on the front surface of the tumour, and the anterior
Avails can be felt to travel over the posterior as oblique pressure is made
upon the gut.
458 SYSTEM OF MEDICINE
BoM'cl is never thus placed in front of a splenic tumour, and but
rarely in front of one of hepatic origin. Karcly, if ascites is present,
and the liver is enlarged in an irregular and misshapen manner, the small
intestines may float between the liver and the abdominal parietes.
As an exception, a right renal tumour may push the ascending colon
down instead of bearing the gut forwards in front of itself. A tumour
of cither kidney may push the bowel to its inner side towards or even
beyond the median line, in which case there is no resonance in front of
the tumour (15a).
2. There is no line of resonance between the kidney dulncss and the
vertebral spines, and no space between the kidney and the spinal groove
into which the fingers can be dipped Avith but little resistance, as there
is between the spleen and the spine.
3. Eenal tumours do not project or protrude backwards to any
marked extent. They fill up the hollow of the loin, and may even cause
some actual fulness there ; but often there is nothing more than the
effacement of the natural hollow of the loin. When the tumour attains
a large size the parietes may be projected laterally to a degree sufficient
to be observed by a superficial glance. Sir William Jcnner says : " Renal
tumours never cause enlargement behind. A renal tumour is not visil)le
in the back, it expands in front. A little greater fulness of the loin
there maj- be, but nothing like tumour. . . . Tumours due to disease of
the kidney enlarge in front ; whilst abscesses and other lesions which
may simulate renal tumours often cause considerable posterior projection."
A renal tumour may, however, as quite an exceptional thing, cause
pointing on the posterior aspect of the body. ]\Ir. Holmes reports a case
of pulsating cancer of the left kidney presenting a swelling over the
sacrum, and causing a?dema of the back as high as the neck.
4. " The kidney has no sharp edges. It is rounded on every side,
and in disease never loses this peculiarity " (Jenner). Whether solid or
cystic, and of whatever size, a kidney tumour is prone to retain some,
often much, of its natural outline.
AVhen the tumour involves only a part of the organ, and not the
whole, and therefore does not expand the entire capsule as it grows, it is
unusual for it to have the renal outline.
5. Renal less frequently and less mai'kedly than hepatic, splenic, and
suprarenal capsular swellings descend in inspiration. Hepatic and splenic
enlargements, and more especially the latter, are depressed by the con-
traction of the diaphragm ; whereas kidney swellings are often quite
fixed in their position. If the kidney and circumrenal tissues have liecn
inflamed, the kidney will be bound down in its natural situation, and
there fixed ; but in cases of new growth, where the organ and parts
around have not been the seats of inflammation, there may be a consider-
aT)le degree of movement. I have seen a renal tumour descend as much
as an inch by a deep inspiration, and fall foiwards or Ijackwards by its
own weight with the movements of the body.
^lobility of the tumour in respiration and by jialpation is so far from
DIAGNOSIS OF RENAL FROM OTHER TUMOURS 459
Iteing rare that it ought hardly to be enumerated amongst the exceptional
symptoms.
6. As a rule, renal enlargements never invade the pelvis, rarely reach
the median line, and frequently are separated from the hepatic dulness
by a resonant area.
Either a cystic or solid renal tumour may ultimately attain such a
size as to occupy the greater part of the abdomen. Numerous instances
of this kind are recorded ; but they attract attention long before this stage
is reached, and while they are still limited to one side of the abdomen.
7. When the tumour is large enough to reach the front wall of the
abdomen, the most anterior point at which it comes in contact with the
parietes is commonly about the level of the umljilicus, or a little higher ;
the lateral wall between the costal margin and the crest of the ilium is
then also bulged outwards.
When malignant growth or abscess affects only part of the kidney,
the abdominal tumour may appear to be somewhat removed from the
strict limits of the renal region. Thus, when the upper part of the
kidney is alone involved, there is much upward bulging, and the tumour
may be felt in the part usually occupied by liver or spleen. In malignant
disease of the right kidney I have seen the tumour occupy a great part
of the right hypochondriac region, and simulate a hepatic tumour.
8. There is a symptom which occurs in large tumours of the left
kidney, and not in splenic enlargements, namely, varicocele of the left
side, which gradually increases with the growth of the tumour. In one
case I operated upon, the varicocele was very large, and the spermatic vein
with the inferior mesenteric vein curved over the front and inner side of
the tumour, and was enlarged to the size of the ring-finger.
Little or no reliance can be placed on the absence of changes in the
urine. Solid tumours do not always cause ha?maturia, nor do accumula-
tions of pus in the kidney always cause a discharge of purulent urine.
The tumour may not involve the cavity of the kidney, or the ureter may
be temporarily or permanently plugged. Thus the urine which is
passed may all come from the other kidney and be quite normal. On the
other hand, however, hccmaturia and pyuria associated with the physical
signs of renal tumour are valuable adjuncts in forming a diagnosis.
To estimate the size of a renal swelling. As the patient lies on his
back, place the fingers of one hand flat upon the ilio-costal space just
outside the erector spinte muscles, and those of the other hand flat on
the front of the abdomen just over the hand which is behind. Then,
during expiration, and whilst the patient's attention is diverted, a very
fair idea will be obtained of the size and weight of the organ by depress-
ing the fingers in front as much as possible, and tilting forwards those
of the hand behind. In thin persons, and with the aid of an anaesthetic,
this mode of examination is very effective. By its adoption a renal swelling
too small to give rise to dulness on percussion M'ill often be detected.
Excepting in children and in persons much emaciated, a kidney which can
be brought entirely within reach of the touch is either movable, misplaced,
46o SYSTEM OF MEDICINE
or diseased. Sir Willi;ira .Tenner points out th;it, when the lower dorsal
and hinibar parts of the spine are curved well forwards, the kidney, even
though oidy of natural size, may bo sufficiently prominent to be seen
through the alxlominal jiarietes.
Diiir/nods. — From enlargements of the liver. — Renal tumours often
dip down or fade oil' so as to allow the fingers to be depressed between
the edge of the costal cartilages and the upper border of the tumour.
Hepatic tumours pass downAvards from beneath the ribs, and so rarely
do they have any intestine in front of them, the presence of bowel
in front of a tiunour may be regardetl as a strong indication that it has
not its origin in the liver. The presence of jaundice is an important
indication.
A tumour developed in the concave part of the liver is very likely to
cause error in diagnosis ; es})ecially hydatids in the left lobe of the organ,
iinless accompanied by jaundice.
On the clinical confusion between movable kidney, enlarged kidney,
and tumours of the gall-bladder the reader is referred to a paper by the
author in the British Mediail Journal for 1895 (vol. i.)
From enlargements of the spleen. — The enlarged spleen has not bowel
in front of it ; it generally presents a sharp or well-defined edge, beneath
which the fingers can be depressed ; this edge is in some cases notched.
There is resonance between the posterior edge of an enlarged spleen and
the spinal column, and the tumour is traceable upwards beneath the rijjs.
A splenic tumour is movable ; a renal tumour may be so, but often it is
fixed in the loin. Splenic tumour will not cause varicocele, a renal tumour
may do so.
Tumours of the suprarenal capsule cannot be distinguished clinically
from those of the kidney ; the absence of hsematuria is an insufficient
guide. The distinction, however, is not clinically of importance, since
new growths of the suprarenal capsule, when of any consequence from
their dimensions, involve the kidney, and sometimes completely effiice it.
From ovarian tumours. — With an ovarian tumour the intestines lie
behind ; l)Oth loins are resonant ; the tumour grows from b^low upwards,
is generally more central, and either drags up the uterus, or can be felt
as a swelling in the pelvis by vaginal or rectal examination. An ovarian
tumour exceptionally has intestine in front of it : (i.) if of small size, the
bowel may not be displaced backwards by it ; (ii.) adhesions ma}" be
formed between a coil of intestine and the front surface of the tumour,
so that the bowel retains an anterior position, as in a case of ovarian
dermoid with twisted pedicle which I removed.
Enlargement of the lymphatic glands, in the near neighbourhood of
the kidney, gives rise to a swelling very similar to a renal tumour. The
diagnosis may be made sometimes by the independent enlargement of one
or more lumbar glands not forming pait of the tumour ; l>y the abrupt-
ness of the outline of the swelling, and possibly even by a protrusion
from the growth along the spermatic cord into the scrotum.
From carcinoma of the large bowel, from flatulent or faecal accumula-
DIAGNOSIS OF RENAL FROM OTHER TUMOURS 461
tions in the caecum, sigmoid flexure, or colon, renal tumours may be
diagnosed by the absence of intestinal disturbance, of general abdominal
pain and colic, of flatulent distension and intestinal obstruction.
The proximity of the colon to the kidney renders the diagnosis
between nephritic colic and intestinal colic sometimes difficult. Sir
William Jenner wrote : " Nephritic colic will cause loss of power in the
colon, and so induce constipation, thus favouring the idea that the patient
has intestinal colic. Again, collections of stools in the colon may be
mistaken for an enlarged kidney ; a large enema will solve all doubt on
this point."
Fsecal abscess or perityphlitis will be distinguished by the marked
febrile disturbance, the associated intestinal symptoms, the tenderness
over the front surface of the part aff"ected, and the lower position of the
swelling, which will be in the iliac rather than in the renal region of the
belly.
Henry Morris.
REFERENCES
1. Baekek, T. H. On Cystic Entozoa in the Human Kidney. 1856. — la. Bikkett.
Med. Times and Gazette, vol. i. p. 161, 1855. — 2. Boeckel, Jules. Studies on Hydatid
Cysts of the Kidney. Paris, 1887. — 3. Bowditch. Perinephric Abscess. 1870. — 4.
Brodeur, Azarie. Surgical Interference in Kidney Affections. 1886. — 5. Clarke,
W. Bruce. Diagnosis and Treatment of Diseases of the Kidney amenable to direct
Surgical Interference. 1886. — 6. CouRBis, E. Cysts of the Liver aiid Kidney. Paris,
1877. — 7. Delafield, F. "Carcinoma," Pepper's Medicine, vol. iv. — 8. Dickinson,
W. H. Urinary and Renal Diseases. 1885. — 9. Duhlay and Reclus. Traitd de
Ghirurgie, vol. vii. 1892. — 10. Feron. Perinephritis. 1860. — 11. Fi.scher, H. Para-
nephric Abscess. 1885. — 11«. FoTHERiXGHAM. Brit. Med. Joum. Dec. 6, 1884. — 12.
Harrison, R. Twentieth Century Practice of Medicine, vol. i. 1895. Bililiography. —
12«. Holmes. Path. Soc. Trans, vol. xxiv. p. 149. — 13. Israel, James. Operations
on the Kidney. Berlin, 1894. — -14. Kraetschmar. Des absces perinephriques. Paris,
1872.— 15. Lancereaux. Encyclop. des Sciences medicales, 1876. Art. "Reins." —
15«. Lancet, Aug. 29, ]885. — 15&. Le Dentu. Affections chirurgicalcs des reins. —
15c. Legueu, Felix. Calculs du rein et de Vurctere. — 15fZ. Lejars, Felix. Gros
rein polykystiquc. — 16. Liaudet, Jean. HUriterectomie. 1894. — 17. Morris,
Henry. Diseases of the Kidney, 1885 ; Poyal Med.-Chir. Trans, vol. 59 ; Brit. Med.
Joum. 1885 ; Clinical Soc. Trans. ; Lancet, vol. i. 1888 ; Brit. Med. Joum. 1895, vol. i.
— 18. Newman, David. Glasgow Medical Journal, August ISSS. — 19. Ibid. Lectures
to Practitioners on the Diseases of the Kidney amenable to Surgical Treatment. 1888.— 20.
Ralfe, C. H. a Practical Treatise on Diseases of the Kidneys and Urinary Derange-
ments. 1885. — 21. Rayer. Traits des 7naladi>'s des reins. 1841. — 22. Ritchie, James.
General Cystic Degeneration of the Adult Kidney. — 23. RoHRER, C. F. Das primdre
Nicrencarcinmn. 1895. — 24. Roberts, W. Urinary and Menal Diseases. 1885.- — 25.
TuFFiER. Etudes experimental es sur la chirurgie du rein. — 26. Thornton, J.
Knowsley. Surgery of the Kidney. Harveian Lectures, 1889. — 27. Trousseau.
Clinical Medicine. — 28. "VVynter and Wethered. Clinical Pathology. 1890. — 29.
ZiEMssEN, Von. Encyclop.
H. M.
DISEASES OF LYMPHATIC AND
DUCTLESS GLANDS
DISEASES OF THE THYROID GLAND
Introductory Remarks
Physiology. — The structure of the thyroid gland is well known from
the descriptions given in the ordinary text-books. It consists of closed
vesicles held together in groups or imperfect lobules by areolar tissue.
The vesicles vaiy in size from about 0*0 3 mm. to 2 mm. ; their walls
consist of simple layers of cubical or columnar epithelium cells without
any basement membrane ; their interior is filled with a yellow glairy fluid,
the so-called colloid material, and detached epithelium cells. In the
periphery of the colloid, vacuoles are to be seen in the vicinity of the more
active cells. In the interstitial connective tissue there are plasma cells,
and its spaces may be filled, like the vesicles, with colloid material. The
blood-vessels and lymphatics reach the vesicles by means of the interstitial
tissue. The capillaries are in close contact with the epithelium, and may
even project between the cells.
Occasionally incompletely developed portions may here and there be
found in Avhich anastomosing cylinders of columnar cells occur.
Special attention has been drawn of recent years to certain bodies,
either embedded in the thyroids or external to them, which, Avhile
resembling thyroid tissue to the naked eye, are found to present important
structural differences from it. These bodies have been called parathyroids,
and were originally described by Sandstrom in 1880. They are found in
the lower animals as well as in man. In the dog, cat, and rabbit there
are usually four of these bodies — two internal lying close to the thyroid,
and two external. In man there are usually four external parathyroids,
but the number may be larger or smaller. These bodies were originally
supposed to consist of embryonic thyroid tissue, which in structure they
resemble. They consist mainly of secreting cells arranged more or less in
columns separated by capillaries. They, however, contain neither vesicles
nor colloid. Here and there may be seen drops of secretion which do not
stain darkly as does the colloid in thyroid vesicles. The parathyroids
develop in advance of the thyroid itself. This fact, in connection with
their resemblance to adult structures, such as the suprarenals and the
carotid gland, points to their being adult and not embryonic tissues.
The knowledge we possess of the function of the thyroid gland is of
comparatively recent date. That the gland had any important function
to perform was not considered likely. Some supposed it was simply a
VOL. IV 2 H
466 SVSTEJ/ OF MEDICINE
pad to protect the trachea, and till up the contour of the neck. Others
imagined that it acted as a kind of safety-valve to the vessels feeding the
brain. Sir John Simon suggested that each lol)e had a special nutritive
relation to the corresponding cerebral hemisphere. The importance of
the organ to life and health was first clearly demonstrated by Schiflf, in
] 884, who found that the removal of the thyroid gland in dogs is almost
inA'arial:)ly followed l)v profound illness and death.
It was next observed that some animals, such as rabbits, bore the
removal of the thyroid well ; and that sheep and monkeys, although
profoundly afiected at first, might survive the operation for a considerable
time. In some of the animals which survived the operation of removal of
the thyroid it was found that accessory thyroids or parathyroids had been
left. In the rabbit the external parathyroids are situated on each side of
the trachea below and quite apart from the thyroid proper. Hence when
the thyroids are removed in these animals, these parathyroids are almost
invariably left behind. In the dog, on the other hand, the parathyroids
are closely connected Avith the thyroid, and, as a rule, are removed along
with it. These observations suggest that the parathyroids are of great
importance, and that their removal is probably the cause of the rapidly
fatal result observed constantly in dogs, and sometimes in other animals.
It was therefore important to observe separately the eflects of removing
first the thyroid, and secondly the parathyroids.
The first experiments on the parathyroids were fallacious, because it
was not then recognised that there are internal as well as external para-
thyroids. Vassale and Generali have recently extirpated the four paia-
thyroid glands in ten cats and nine dogs. Nine of the cats and all the
dogs succumbed within ten days, the dogs dying more quickly than the
cats. One cat survived six weeks, but was then in a state of cachexia.
The removal of two parathyroids, or even of three, appeared to produce
only transitory symptoms; but the subsequent removal of the remaining
one or two resulted in acute symptoms and death. Apparently tlio
internal and external parathyroids are of equal importance, for it made
no difference which were removed first. The experiments of these
observers are both numerous and conclusive ; but like all investigations
of this kind they require confirmation.
The experiments carried out by Edmunds, previous to Vassale and
Generali's work, are thoroughly in accordance with their results. He.
found that if the A\hole of one lobe of the thyroid of the dog, including
the parathyroids, and also the greater part (two-thirds or more) of the
other lobe be removed, the animal will live or die according as the para-
thyroid is or is not left. In the animals which survived, the removal of
the remaining ])arathyroid at a later period, in some cases at an interAal
of six months after the first operation, was quickly followed by acute
illness and death.
The acute symptoms supervening on removal of all the piuathyroids
in cats and dogs are as follows : — The animal l)ecomcs dull and apathetic.
It suffers from general muscular weakness. Its gait becomes unsteady.
FUNCTIONS OF THE THYROID GIAND 467
Tremors and fibrillar twitchings come on. Trismus and rigidity of the
posterior limbs show themselves. Attacks of dyspnoea appear. The
appetite may be increased at first, but is soon lost. Vomiting, palpitation,
scantiness of urine, and sometimes albuminuria are also observed. Slight
convulsions appear just before death.
The symptoms observed in the dog on complete removal of the thyroid
gland agree with these in every respect ; except that convulsions come on
earlier and are more severe than when the parathyroids alone are removed.
In many instances conjunctivitis and keratitis have been observed to
follow the total extirpation of the thyroid gland.
Two other important symptoms observed after the latter operation
remain to be mentioned ; namely, a fall of the body temperature and
aiuemia. After a preliminary rise, the temperature gradually falls and
becomes subnormal before death. Leucocytosis and diminution in the
number of corpuscles are also observed.
When the thyroid gland is totally excised, and the animal survives
the operation, it is extremely probable that one or more parathyroids
have been left behind ; but this cannot yet be asserted dogmatically. The
eft'ects of removal of the thyroid gland, leaving behind the parathyroids,
have been studied in dogs. When the animal has recovered from the
immediate efi:ects of the operation it exhibits no signs of illness. In
these cases a small portion of the thyroid has generally been left in
addition to one or more parathyroids. Similar experiments have not yet
been carried out in monkeys ; but the effects of total extirpation of the
thyroid gland in these animals have been carefully studied by Horsley,
Munk, Edmunds, and others. Two classes of symptoms have been
observed in them, the acute and the chronic. The acute symptoms
closely resemble those observed in the dog. They appear within a few
days after the operation. These symptoms have been summarised by
Mr. Horsley as follows : " Motion, tremor, clonic spasm (paroxysmal), con-
tracture, paresis, paralysis. Sensation, pariesthesia, then anaesthesia.
Jieflexes gradually diminished. Mental operations normal at first, are soon
diminished in activity, and then follow apathy, lethargy, coma."
With these symptoms are associated subnormal temperature after an
initial elevation, gradual anorexia after voracity, anaemia, leucocytosis, fall
of blood-pressure, failure of nutrition with mucinous degeneration of the
connective tissues, and usually atrophy and falling out of the hair. It is par-
ticularly interesting that " the eyelids become pviffy with elastic oedema,
the features grow heavy and coarse, the skin being rough in some cases,
and the hair falling out." The duration of life averaged about twenty-four
days. The chronic symptoms closely resembled those of myxoedema.
They were observed in monkeys kept in a comparatively Avarm temperature.
The first few weeks after the operation were characterised by slight
attacks of tremor and malaise. Then followed dulness of intellect,
diminution of energy, and apathy alternating Avith idiotic activity.
Persistent paresis and an attitude exactly i'eseml)ling that of a human
idiot or cretin were very interesting features. Although the animal fed
468 SYSTEM OF MEDICINE
voraciously it steadily emaciated. The hair fell out in quantity. The
voice gradually altered until it became a hoarse croak. The scene was
finally closed by coma.
In man the functions of the thyroid can be studied in the condition
known as cachexia struniipri\'a, following on extirpation of the thyroid
gland, and in myxcedoma. The symptoms of cachexia strumipriva and
those of myxoedema are identical and have elsewhere been fully described.
It is not necessary to repeat what has been there said as to the removal
of these symptoms by the internal administration of the thyroid gland, or
of some preparation made from it. The logical conclusion is that the
thyroid gland secretes some substance which is of great importance in the
economy. The arrest of this internal secretion is followed by the changes
in mind and body characteristic of myxcedema.
The statement has been made that in the foetus, and during early
infancy, the thyroid gland is relatively larger than in after-life ; that its
I^roportion to the weight of the body in the new-born infant is 1 to 240
or 400, at the end of three Aveeks it has become only 1 to 11 GO, and in
the adult 1 to 1800. This statement was originally made by Huschke in
1844, but by a printer's error has been attributed to Krause in the
various editions of Quain's Anatomy, including the last published in 1896.
It is on the face of it extremely improbable that within three weeks of birth
the thyroid should shrink to a third or even a fifth of its original weight.
We have found the thyroid gland of infants a few days old to vary be-
tween fifteen and thirty grains, giving a proportion to body weight of 1
to 3000 or 1500. Dr. Stephen Mackenzie has published a series of
observations on the Aveight of the thyroid body in persons dying from
various causes. From these it Avould appear that there is no definite
variation in the proportion between the weight of the thyroid gland and
the body-weight in regard to age. Our own observations are perfectly in
accordance with those of Mackenzie.
Attempts have been made to find the active principle of the thyroid
gland. The sul)stance which removes the symptoms of myxuidema ia
not destroyed hj boiling nor liy desiccation. Gland desiccated appa-
rently preserves its properties unaltered for a long time if kept dry and
not exposed to the air.
Mr. E. White has prepared a powder in the manner usually employed
for the separation of ferments, and this has been found very efficacious
in treatment. In the method employed the colloid substance is precipi-
tated with calcium phosphate, and it is probably to the presence of this
colloid that the properties of the powder are due.
Roos has shown that the active principle is not destroyed by boiling
the gland in a 10 per cent solution of sulphuric acid. Baumann has
endeavoured to obtain the principle from the ])recipitate which falls in this
fluid on cooling. This precipitate is i-emoved by filtration and treated with
alcohol and petroleum-ether, to remove fat and fatty acids ; it is then
dissolved in a 1 per cent solution of caustic soda. This solution is
filtered. The precipitate formed on adding dilute sid])hniic acid is
I
MYXCEDEMA 469
carefully washed and dried. A brown amorphous substance is obtained
in this way which has been named " thyro-iodine," as it contains iodine
in intimate chemical combination. It is almost insoluble in water, and
is only slightly soluble in alcohol, although easily so in dilute alkalies.
The quantity of thyro-iodine present in the thyroid has been found
to vary considerably. Ordy a slight trace of iodine has been found in
abnormally large thyroids. There is less iodine in the glands of children
than in those of adults.
The sheep's thyroid is relatively rich in thyro-iodine.
Thyro-iodine has been found experimentally to be as efficient as the
thyroid gland itself in the treatment of myxoedema. This shows that it is
a substance actually manufactured in the thyroid. In animals it is found
that the amount of iodine present in the thyroid increases on administra-
tion of potassium iodide and other iodide-containing compounds ; but
the increase is most marked after the use of thyroid gland or thyro-iodine.
R. Hutchison has obtained the colloid matter of the thyroid sepa-
rately, and has shown that it is therapeutically effective. He has found
that the proteids of the gland are two in number. There is a nucleo-
albumin present in small amount which is probably derived from the
cells lining the vesicles. The other proteid is the colloid matter.
This in addition to phosphorus contains a considerable amount of iodine.
By gastric digestion the colloid can be split into two parts — a proteid
part yielding albumoses and peptones, and an insoluble non-proteid resi-
due which contains most of the iodine and all the phosphorus of the
original colloid.
Besides the proteids there are also extractives, creatin, xanthin, as in
other organs.
Neither the extractives nor nucleo-albumin have been found to pro-
duce any of the efiects of thyroid substance when administered internally.
The colloid substance, as has been said, is therapeutically active.
It is precipitated by adding acetic acid to a dilute alkaline extract of
the fresh glands. It is purified by reprecipitation and by washing with
alcohol and ether.
The proteid part of the colloid is much less active therapeutically
than the non-proteid. This bears out Baumann's observation as to the im-
portance of the iodine-containing compound, the so-called thyro-iodine.
W. M. Ord.
Hector Mackenzie.
Myxedema
Definition. — A disease, closely related to cretinism, endemic and
sporadic, if not identical with it ; determined by the loss of function of the
thyroid gland. The symptoms of myxoedema are also produced by
complete operative removal of the thyroid gland.
470 SVS7EM OF MEDICINE
The picture of the disease. — Thirty years ago the -writer of this
article had occasion to investigate the case of a lady suttering from
mvxa'denia in a most definite form, and therefore offering complete
opportnnity of studying the symptoms and the relations of the disease.
The patient, a lady of thirty-five, who had had several children, presented
an appearance suggestive of Briglit's disease ; yet, although she was
greatly swollen on the Avhole of her body, on careful examination the
swelling did not appear to be due to an ordinar}' dropsy. There was
nowhere any pitting on pressure, and there was no albuminuria in the
slightest amount. The diagnosis of chronic Bright's disease without
albuminuria at first suggested itself, l)ut on further examination many
symptoms not known to be related Avith Bright's disease came under the
eye. The face, very much swollen in all parts, was particularly swollen
in the eyelids, upper and lower, in the lips, and in the alje nasi. There
was a flush, ver}'^ limited, over the malar bones, contrasting with a com-
plete pallor over the orbital regions. The eyelirows were greatly raised
by the etl'urt to keep the lids apart. The skin of the face, and indeed of
the whole body, was completely dry, rough and harsh to the touch ; not
exactly doughy, but giving a sensation of the loss of all elasticity or
resilience. The hair was scanty, had no proper gloss, and was much
broken. In the absence of all signs of visceral disease the condition of
the nervous system Avas such as to attract much attention. The
physiognomy was singularly placid at most times, less frequently heavy,
with signs of somnolence ; very rarely alert. In interviews the patient
Avas imperturbably garrulous to a degree that could not fail to attract
attention. For many minutes she Avould talk Avithout cessation until
obliged to stop and take a good breath. What she said Avas not altogether
relevant, but it had to be said. All interrupting questions Avere dis-
regarded. If, at the end of a small pause, she Avas asked to ])ut out her
tongue, she ignored the request, but at the end of a varying time, Avhen
her breath became short, she Avould ])ut out hei- tongue for a long time.
She dealt in the same Av^iy Avith questions put to her in respect of the
points raised by her statements. Her letters Avere frequent, voluminous,
and, as regarded handwriting, A'cry good. Her speech AVas slow and
laboured. There Avas some difficulty in it, evidently due to the swelling
of the lips, ])ut there Avas more than this : the Avords hung in a Avay that
indicated nervous as Avell as physical difficulty, and iiifiexions of the voice
Avere Avanting. The tones of the voice Avere leathery, and suggested
rather those of an automaton. The pi-oper timbre Ava's quite lost.
Doubtless this Avas in part, again, (hu; to obvious thickenings in the fauces
and the larynx ; ])ut it did not in any way resemble the character of voice
ob.served in ordinary swellings of those parts. Her temper Avas singularly
equable, she was the most tender and solicitous of mothers, and in a long
course of years during Avhich she Avas under the Avriter's observation no
word of unkiiidness or suspicion fell from her lips. Lethargy Avas an
impressive part of her mental condition. Memory Avas slow, but correct.
She thought slowly, ])erf()rmed all movements slowly, and Avas slow in
MYXCEDEMA 471
receiving impressions. Her toilet, and she was no fashionable person,
occupied hours. Her household duties could never be overtaken, and
she had to seek assistance. Her gait presented a distinct ataxic quality.
As her bulky body moved across a room there occurred at each step
forward a quiver running from the legs upwards, such as may be seen in
people under the influence of great emotion, as in a Lady Macbeth.
This appeared to be due to a want of complete concert in the action of the
flexors and extensors of the body, the flexors acting for the most jiart in
advance. The interval between the action of the two sets of muscles was
at some times extreme enough to determine falls, not in any way
produced by obstacles. She fell forwards on her knees, and, as a result,
she sustained fracture of the patella on one side, and of the patellar
tendon on the other. Similar conditions existing in the head and neck
produced excessive distress. From time to time the head wovdd fall
forward in spite of all voluntary effort to prevent it. The chin would
then rest on the upper part of the sternum, as is seen in cretins. Some-
times by prolonged exertion of the will, sometimes with the assistance of
the hands, the head would be raised, not always to good eff"ect ; for unless
great care were exercised the head would fall backwards with a sudden-
ness that was alarming. There was no obvious defect of the sense of
tovTch, but it must be admitted that the speed of the reception of tactile
sensations was not noted. After the establishment of the disease she
bore two children ; on both occasions severe post-partum haemorrhage
occurred. She had no other haemorrhages. The first impression was, as
I said above, that the case was one of Bright's disease without albumin-
uria. The urine was examined regularly for years without detection of
albumin, and there Avere no such changes in the heart and arteries as
belong to Bright's disease. After ten years, however, albumin appeared
in the urine, and the patient died ultimately with symptoms of contracting
granular kidney. A post-mortem examination could not be obtained, and
therefore the condition of the thyroid gland and of the kidneys cannot be
recorded.
Symptoms. — I will now proceed to state in detail the development
of our knowledge of this disease. In 1875 Sir "William Gull contributed
to the Clinical Society a paper on " A Cretinoid State supervening in
Adult Life in Women," in which he graphically described the symptoms,
but did not discuss the pathology. In 1878 the writer read before the
same Society a paper in which he ventured to give the name myxoedema
to the disease, after describing the symptoms and discussing the pathology
so far as it could be determined by autopsies of patients for some years
under his care, and by examination, chemical and microscopical, of the
various tissues. To these early observations many have been subsequently
added. The general results of the whole series of observations may now
be stated. In the first place, it appears that myxoedema affects men also,
though in a much smaller proportion than women ; men apparently
contribute al)out 1 0 per cent of all the cases. Botli in women and in men
there is a remarkable agreement in the main symptoms, when the disease
472 SYSTEM OF MEDICINE
is complete. The whole bod}- is swollen and unwieldy, the swelling being
partly produced by an enormous thickening of the skin, partly by the
presence of a soft fat. The skin, besides being swollen, is excessively dry,
perspiration being very rarely observed. On the trunk and limbs in
particular the .skin becomes rough and scaly, almost as if it were sanded.
The swelling is not quite equally distributed, but is modified by the
relations of the skin in the various parts of the body. Thus, large soft
swellings are observed in the supraclavicular region, and the hands and
feet become greatly enlarged and Hatteued ; the condition of the hands
has been aptly described as spade-like by Sir Wm. Gull. They are usually
very broad, the fingers are much flattened, and the hand loses most of
the expression related with the actions of life. The most noteworthy
external changes are those which are seen in the face. With a great
general swelling it is to be noted that certain of the features are par-
ticularly altered. The eyelids, upper and lower, are excessively thickened
and hang in translucent folds. So also both lips are usually greatly
swollen, and the ala? nasi are gi-eatly broadened. The skin of the face is
pallid, excepting over the malar bones, where a pink flush, al)niptly
limited by the lower margin of the orbit, is usually present. There is no
pitting of the skin on the face or elsewhere ; it presents everywhere the
same sort of doughy consistence described on a previous page. As in
cases of ordinary dropsy, involving the face, the victims come to resemble
one another very much, so it is in myxcedema ; but not quite in the same
way, for the lines of expression, while altered, are not obliterated as iii
simple oedema. The general expression is one of heaviness and dulness.
The eyebrows are generally very much raised and arched by the eflbrt
necessary to keep the lids apart. There is great diminution in the
mobility of the features, particularly of the mouth ; the eyelids often take
an obli(jue direction, such as is seen in Mongolian tribes. The general
alteration of physiognomy is intensified by the state of the hair, which
first loses its natiual gloss, becomes fragile, rough, and scanty, often
almost to baldness. The swollen ears then stand out with marked
prominence. Moles are often developed, esi)ecially on the trunk.
The same swelling which is seen in the skin affects the mucous mem-
branes. The inside of the lips and cheeks is tumid, and is very apt to l)e
bitten during mastication. The soft palate is generally found swollen to
tran.slucency and with gi^eat decrease of mol)ility. The teeth, like the
hair, undergo degeneration, become loose in their sockets, or fall out. The
speech is altered in so uniform a way that a diagnosis may almost be
made when a patient, unseen, is heard talking. The words come very
slowly and delilierately, the voice is monotonous and of a leathery timbre,
no donl)t much detei'mined by the swelling of the throat, and is evidently
produced with consideral)le eff'ort owing to the swelling of the lips. This
can be well recognised if the patient be watched as he speaks, the words
.seeming to be scpxeezed out of the lips M'ith much difficulty. As already
mentioned, there is probably a nervous as well as a mechanical cause for
this change in speech. The gait already described is typical of myx-
MYXCEDEMA
473
oedema, and the tendency to fall, as mentioned in the first case, usually
exists, to the production of many accidents. The movements of the hands
are also limited and awkward, partly by reasoji of the swelling, partly by
the slow sensation. "All the fingers are thumbs," as a patient once
remarked. Thought and movement are slow, and there is a slowness in
the reception of tactile sensations, constituting a marked brada^sthesia.
There is considerable variation in the mental condition ; most of the
patients are persistently and obstinately garrulous, but all have not the
placid temper noted in the first case.
Fig. 7. — Belore iiiyxoedema.
There is generally a tendency to a mixture of irritability with the
torpor, and a proneness to unfounded suspicions of many kinds. If not
suspicious of others, patients Avill come to be suspicious of themselves.
This condition may be developed to the point of insanity, and Avill often
survive other symptoms of the disease when the general illness appears to
have yielded to treatment. Such patients have to be watched very care-
fully, as at times they are tempted to suicide ; many of them are to be
found in the wards of asylums. The temperature of the body is gener-
ally below the normal, 97° or 96° Fahrenheit being a common record ;
and the patients are extremely sensitive to cold. Where the temperature
ranges at all above the normal it mtist be recognised at once as pyrexial.
The urine is generally reduced in quantity without much change in its
474 SYSTEM OF MEDICINE
specific gravity. As a rule it contains no albumin or sugar, but the
daily excretion of urea is diminished, even under ordinary diet. The
catamenia are usually regular, but apt to be excessive. Pregnancy may
occur after the full establishment of the disease, and, as already noted,
ha'morrhagc is to l)e dreaded. In connection "with pregnancy fluctuations
in the swelling of the body often occur. There is sometimes an increase,
more commonly a decrease, so that in early stages the patient may
resume almost a natural appearance during pregnancy. Independent of
pregnancy, moreover, the amount of swelling is ajjt to vary. There is
usually a first period in Avhich the swelling affects some parts more than
others, and disappears and recurs in one part or another somewhat
rapidly. Then comes the estaljlishment of the definite disease. Finally,
in later stages, particularly where some additional ailment is intruded,
the skin becomes flaccid and dull, though without resumption of its
natural function. In addition to the tendency to uterine haemorrhage
bleeding is very common in myxcedema. It will often follow the extrac-
tion of a tooth so loose as to seem ready to drop away from the gum,
and may be very intractable for hours or days. Bleeding from the nose
is also common, and small wounds give much trouble in this respect.
Patholog"y. — There can be no doubt that Sir William Gull struck the
kev-note of the etiology of this disease when he used the Avord " cretinoid."
It is now generally recognised that absence of the function of the thyroid
gland is the essential cause of myxoedema. In a great majority of cases
the gland is atrophied and its proper structure lost. In such cases the
Avasting of the gland can mostly be recognised during life, very often it
may not be felt at all. But in certain cases the gland may be actually
enlarged, either by destructive infiltration, by new growth, or by the
presence of excess of fibrous tissue. The fact that myxoedema is chiefly
a disease of Avonien su2;2;ests a relation of the destruction of the thyroid
Avith changes in the structure of the gland related with menstruation or
pregnancy. It is to be noted that the disease occurs more often in
married than in single women ; and it must be remembered that it is
chiefly in Avomen an affection of adult and middle life, in marked contrast
to the appearance in earlier life of exophthalmic goitre. There can be
no doubt of the frequent existence of an active congestion, bordering on
an inflammatory condition, occurring in the thyroid gland at the time of
menstruation. Such changes are distinctly marked in exophthalmic
goitre. It apjicars to mc that probably the atrophy of the gland, pro-
ductive of myxoedema, is frequently due to inflammatory destruction of
the gland tissue. Several cases have now been recorded in which the
symptoms of exophthalmic goitre have been followed and replaced by
those of myxd'dema, the once greatly enlarged thyroid lining liecome
much diminished, or been reduced to a very small size. Here the sequence
of atrophy upon a destructive inflammatory cidargement is strongly
indicated. It has occurred to me to Avatch several such cases undergoing
this transition, and to note that myxo'doniatous sweHing has appeared
before the general symptoms of exoj)hthalmic goitre have passed away.
MVXCEDEMA
475
Origiiiallv the idea that the thyroid played a part in myxoedema was
partly based on the observations of Curling and others in regard to
sporadic cretinism, in ■which the great diminution or absence of the
thyroid had been "svell cstal)Iished. It is now well known, originally
through the observations of Kocher and Reverdin, that complete removal
of the thyroid body in cases of goitre is followed by symptoms indis-
tinguishal)le from those of myxoxlema. Opex'ations consisting in the
removal of the thyroid of animals, particularlv of monkeys, and more
especially the experiments of Horsley, have shown that symptoms re-
sembling those of myxoedema can l)e so produced.
Ni
^ ^J^S^K^Kk^r
iSHHH^^BH^^MlK^'^^^^l^^ '^^^^■^
■^M
^B^ "' ^m
Hj
^^^^^^^^^^^Ih ''^^^ fl^^^l
^M
1
'• . 1
^
X
Fir,. 8. — PronoTUiciNl myxniliMjia
Morbid anatomy. — Apart from the change in the thyroid, the tissues
in the l>ody, when obser\'ed in cases of full development of the disease,
present some remarkable appearances. Throughout the body the con-
nective tissue is swollen in some such way as is suggested by the state of
the skin. "When the skin is ci;t into, there is no escape of serous fluid from
it, and it remains unshrunken as though soaked in jelly. In microscojiic
sections it can be recognised that the connective tissue is interpene-
trated by an almost transparent or faintly granular material, separating
the fibrils, increasins; orreatlv the bulk of the connective tissue in all
parts, and determining compression of glandular structures. In the skin,
for example, the hair-bulbs and sweat-glands undergo great comjjression.
476 SYSTEM OF MEDICINE
M-hich is no doubt the explanation of the impaired nutrition and falling
out of the haii's. Similar chan<ijes can be observed in the viscera : in the
liver, for instance, the cells can l)e seen separated from one another, and
evidently compressed. In some cases the kidneys have been found much
enlarged and nuich toughened, showing, microscopically, the presence of
large quantities of this intrusive substance strangling the secreting
structures. In my first investigations it appeared to me that this
substance was a mucin -^yielding modification or infiltration of the
connective tissue. This view has not altogether been accepted, although
in Mr. Horsley's experiments mucin was found in the skin of monkeys
previously operated upon. Seeing that a large number of the victims of
m3'^xcederaa undergo great shrinking or emaciation before death, it is very
probable that the infiltrating material will, in such cases, have undergone
considerable absorption ; and the fact that mucin has not been found in
such cases is hardly an argument against its pi'esence during the full
development of the disease.
Prognosis. — Untreated ni3'xoedema is usually progressive in its char-
acter, though it may last for many years, the patients either becoming
wasted, and dying of inanition, passing into coma, or dying with signs of
bulbar afiection. In a few cases death has been the result of cerebral
hemorrhage. In a certain proportion, intercurrent disease, either of an
acute kind, or notably tubercular affections, may lead to death. It has
been seen that symptoms like those of contracting granular kidney may
be observed and may prove fatal.
The prognosis in cases of unti-eated myxoedema, particidarly in the
poor and ill-clad, is most unfavourable. In cases of fairly early or fully-
developed myxoedema the results of treatment by thyroid justify a strong
expectation of cure ; but in cases of long duration, where the age is for
the most ])art advanced and shrinking has set in, less confidence can
be entertained. In such cases, although the swelling may be further
diminished, the patient will often sink into fatal weakness, in spite of the
use of the thyroid backed up by tonics. More has yet to be learned of
cases in which much mental disorder exists. It is to be feared that the
prognosis here also is unfavourable.
Treatment. — The early treatment of myxoedema consisted in giving
tonics, such as iron, arsenic, and the hypophosphites ; in giA'ing diapho-
I'etic drugs, s\ich as jaborandi ; and in applying baths. Great care was
found to be necessary in the protection of patients from cold. Suflereis
from myxoedema have all their symptoms aggravated and sufi'er from
great weakness and depression when exposed to cold ; though it is a
singular fact that they are often not conscious of any discomfort from
impact of cold aii-, this being doubtless due to the thickened and insen-
sitive condition of the skin. Wliere patients wei'e able to atlord it they
were sent away during the winter and spring to warmer climates than
our own. Of late years a most complete and successful revolution has
occurred in the treatment of myxredenia. The evolution of this tieatment
has been gradual. At hrst an endea\ovu' was made to replace the lost
MYXCEDEMA 477
thyroid by the introduction of the thyroid glands of anirauls, or portions
of bronchoceles within the tissues or cavities of the human body. It was
found that while some temporary relief was afforded, these introduced
substitutes in a short time underwent absorption, and ceased to be effec-
tive. Later it occurred to Dr. George Murray of Newcastle to practise
regular hypodermic injections of a carefully-prepared glycerine extract
of the thyroid gland of the sheep. The injections used represented
individually only a fraction of a thyroid gland, but, being repeated at
regular intervals, were found to bring about a rapid melting away of the
Fig. 0. — The same patient as in Fiss. 7 and 8 after two years of treatment by administration of
prt'paiatiou of thyroid gland.
swelling and removal of the attendant symptoms. Dr. Hector Mackenzie
subsequently tried with great success the internal administration of the
thyroid gland of the sheep. It appears that, taken internally, either in
a raw state or in the form of various extracts and dry preparations, the
drug is one of great curative power. In fact it is quite possible to give
too large doses of it with very unpleasant and injurious eflfects. The
immediate effect of the administration of the extract of the thyroid gland
to a patient suffering from the characteristic symptoms of myxoedema is to
raise the temperature of the body rather quickly to the normal. In fact,
too large and too frequent doses will produce violent pains and some
pyrexia. Then follows a diminution, generally gradual, sometimes very
478 SYSTEM OF MEDICINE
speedy, of the Inilk of the body, with restoration of the functions of the
skin, and, for the most part, a restoration also of the natural conditions
of the nervous system. Sometimes, however, where marked symptoms of
mental disorder have 1)cen present, they are abated only after long treat-
ment; and it must he admitted that in a few cases they seem actually
to be aggravated. In the earlier days of the administration of thyroid,
the qi;antity of the urine, and the total excretion of nitrogen, particularly
in the form of urea, arc increased. As time goes on, the frequency of
administration or the dose may be diminished, but discontiiuiance of
administration for any long period is followed by return of symptoms.
Apparently it is necessary to maintain the treatment throughout life or
at least for many years. Experience shows that, even while reaping so
great a benefit from the use of the thyroid, we arc still bound to shield
our patients as far as possible from exDOSure to cold
W. :M. Ord.
REFERENCES
1. Abercrombie, J. " A Case of My.vredenia in a Young Subject," Tr. Clin. Soc.
Load. 1890, xxiii. 240. — 2. Aimiahams, R. "Myxtt'denia treated with Tliyioid
Extract; Report and Presentation of a ease," J/c^/. Record, N.Y. 1895, xlvii. 429--13].
— 3. Adams, J. "Two Cases of Myxcedema treated by Thyroid Feeding," Glasgow Med.
Jouni. 1893, xL 19(3-198. — 4. Alexander, J. W. "Note on a Case of Myxcedema
occurring in an Insane Patient," Med. Chron. ISIanchester, 1893, xs'iii. ] 75-1 78. — 5.
AxDEiisox, J. A. " Ett fall af myxodeni behandladt mid tliyreoideatabletter [Case of
. . . treated with thyroid tablets]," Hijgu'a, Stockholm, 1896, Iviii. 303-326.— 6.
Axdersox, T. McC. "The Treatment of ^lyxotA^ma.,' Pruditioncr, Lond. 1893, 1.
C6-44. — 7. Anderson, W. " Patient with Congenital Myxoedema shown after Treat-
ment with Thyroid Extract," Glasgow Med. Journ. 1895, xliii. 291-293. — 8. Ander.son,
W. M. A. "A Case of Myxcedema in the Adult, following Bronchocele in the Child ;
successfully treated by Hypodermic Injections of Thyroid Juice and by Feeding with
Thyroid Glands of the Calf; with Notes on the Treatment of Obesity and Chlorosis,"
Journ. Laryivjol. Lond. 1893, vii. 68-70. — 9. Anson, G. E. "Treatment of Myxo-dema
by Thyroid Juice," A'. Zealand Mi d . Journ. Dunedin, 1893, vi. 169-176. — 10. Arnoz.an, X.
' ' Un cas de m^'xcx-deme guc-ri par la medication thyroidienne, " Journ. de med. de Bordca u.r,
1894, xxiv. 397. — 11. Idem. " Un cas de myxcedeme," Mem.. el hull. soc. dc mtd. et dc chir.
de Bordeaux {\?)^V), 1895, 466-472.-12. Ayres, S. "A Case of Myxcedema treated by
Sheep's Thyroid," Journ. Ncrv. and Mental Dis. N.Y. 1894, xxi. 481-85. — 13. Barer,
E. C. " Feeding with fresh Thyroid Glands in Myxci'dema," Brit. Med. Journ. 1893. i.
10. — 14. Idem. " Traitement du myxndi'me par alimentation avec la glande thyroide
fraiche," Revue interned, de rhinol. otol. et leiri/ngol. 1894, iv. 25. — i5. Bai.zer, F.
" ilyxcedeme ; traitement par I'injection du corps thyroide frais, " Ann. de dcrmnt. et
syph. Paris, 1895, 3 sc'r. vi. 378 ; Bull. soc. franc, dc dermal, et si/pli. Paris, 1895. vi.
169. — 16. Barton, J. H. " Case of Myxcedema treated by Injection of Sheep's Thyroid
at Jlentone," Z>«Wm Journ. Med. Sci. 1893, xcv. 431-433.-17. Barron, A. "Two
Cases of Myxadema treated bv Thyroid Injections," Brit. Med. Journ. Lond. 1892, ii.
1384.— 18. Barrow, A. " On My\a-i\cma.'" Lirerjwol M.-Chir. J. 1893, xiii. 135-149.
— 19. Beadles, C. F. "A Case of Jlyxcedema with Insanity treated by the Sub-
cutaneous Injection of Thyroid Extract," Brit. Jfed. Journ. 1892, ii. 1386.— 20. Idenh
"The Thyroid Treatment of Myxcedema a.ssociated with Insanity," Lancet, 1894, i. 400.
—21. Beatty, W. "A Case of Myxcedema successfully treated by Massage and
Hyi)odermic Injections of the Thyroid Gland o' a Sheep," Brit. Med. Journ. London. 1892,
i. 541. — 22. Idem. " A Ca.sc of Myxo'dema successfully treated bv Injections of Extract
of Sheep's Thyroid," Trfius. Rin/al .lead. M<d. Iretand, lS92-93,\xi. 87-92.-23. Idem.
" A Case of Myxcedema successfully treateil by Injection of Extract of Sheei)'s Thyroid."
iJiihl ill Journ. Med. Sci. 1893, xcv. .•'.75-379.— 24. Beccaria, F. " Osserva/icnii oftal-
MYXCEDEMA 479
mometiiche in una nialata atletta da mixoedeina, per ettetto di compressione diietta sul
cervello," Gior. d. r. Accad. di mcd. di Torino, 1891, 3 s. xxxix. 89-96. — 25. Idem.
" Osservazione oftalmometriclie in una nialata atletta da mixoedema, per effetto di eoni-
pressione diretta sul cervello," Ann. di ottal. Pavia, 1891-2, xx. 90-103. — 26. De Eeck?:i;.
" Traitement d'un cas grave de niyxoideme par ingestion de glandes thyroides du mouton ;
guerison," Prcsse med. Bdg. Brux. 1894, xlvi. 225.-27. Bell, R. E. "A Ca.e of
Myxoedema," Boston Mcd. and Surg. Joiirn. 1894, cxxx. 364. — 28. Ben.son, J. H.
"Case of Myxoedema of long standing treated by Administration of Thyroid Extract Ly
Vlq\\X\\" Brit. Mcd. Journ. 1893, i. 795. — 29. De Boeck. "Un cas de myxoedeme
avec troubles psychiques traite par les injections de sue thyroidien," Journ. de med.-chir.
et -pliariivxcol. Brux. 1892, xciv. 484-488. — 30. Bohxcke, Cakl A. B. Zur MyxKlem-
frarje, Berl. 1890; 0. Friincke. — 31. Bouchard. "Deux cas de myxcedeme traites
par les injections de sue thyroidien," Bull. med. Par. 1892, vi. 1263. — 32. Bourxeyille.
"Nouveaucas d"idiotie avec cachexie pachydermique (myxoedeme infantile), avant le
traitement par I'injection stomacale de glande thyroide," Compt. rend. soc. de biol. Par.
1896, 10 s. iii. 467. — 33. Idem. "Nouveau cas d'idiotie avec cachexia pachydeiinique
(myxredeme infantile) ; apres le traitement," ComjJt. rend. soc. de biol. Par. 1896, 10 s. iii.
698-701. — 34. Idem. "Trois cas d'idiotie myxoedemateuse traites par I'ingestion thy-
roidienne," Archives de neurol. Paris, 1896, 2 ser. 1-28. — 35. Idem. " Cinq cas d'idiotip
myxoedemateuse traitement par I'ingestion de glande ihyyoiAe," Bull, et mem., soc. mu*.
des hop. de Paris, 3 .ser. xiii. 1895, 32-39. — 36. Idem. "Cas de myxcedeme
congenital," Progres med. Paris, 1895, 3 ser. ii. 33, 49. — 37. Botce, R., and C. F.
Beadles. "Enlargement of tlie Hypophysis Cerebri in Myxedema ; with Remarks upon
the Hypertrophy of the Hypophysis ; associated with Changes in the Thyroid Body," Jour.
Path." ami Bacteriol. Edinb. and Lond. 1892, i. 223-239, 2 pi.— 38. Bradley, 0. C.
"Myxcedema in the Horse," Vet. Jour, and Ann. Comp. Path. Lond. 1893, xxxvi. 309-
311.— 39. Bramwell, B. "Myxedema," Atlas of Clin. Mcd. Edinb. 1891, ii. pt. 1.
1-16, 3 pi.— 40. Idem. "The Clinical Features of Myxo-dema," ^f/«i6. 3Ied. Journ.
1892-3, xxxviii. 985-995. —41. Idem. "The Thyroid Treatment of JMyxcedema and
Sporadic Cretinism, with Notes of Twenty-three Cases of ilyxa-dema and Five Cases of
Sporadic Cretinism treated by Thjroid Extract," Edinb. Hosp. Pep. 1895, iii. 116-249. —
42. Brissaud and SouQUES. " Un cas de myxoedeme operatoire traite par I'ingestion
de glande thyroide de moiiton," Cong, de med. alienistes et nenrol. de France . . . [Proc.
verb, etc.], 1894, Paris, 1895, v. 518. — 43. Idein. "Un cas de myxademe congenital
traite et gueri par I'ingestion de corps thyroide de mouton," Bull, et mim. soc. mid.
des hop. de Paris, 1894, 3 ser. xi. 236-41, 1 plate. — 44. Browx, Ethel D. "Case of
Myxoedema, three and a half Months' Treatment with Thj-roid Glands," Mcd. Rcc. Is.Y.
1893, xliv. 142. — 45. Buchanan, R. M. "A Case of Myxoedema with Microscopic Ex-
amination of the Thyroid Gland," Glasgoiu Med. Journ. 1892, xxxviii. 329-333. — 46.
Idem. " Case of Myxoedema in an Early Stage," Glasgotv Med. Journ. 1893, xxxix. 440-
442. — 47. Idem. "Case of Myxa2dema, with Microscopic Examination of Thyroid Gland,"
Jour. Glasg. Path, and Clin. Soc. 1891-3, iv. 150-155. — 48. Burckhaedt, 0. "Cas de
myxcedeme gueri par le thyroidine ; mort par broncho-pneumonie ; absence totale de
corps thyroide," Bevue mid. de la Suisse romamle, Geneve, 1895, xv. 341-346. — 49. ZvM
BuscH, J. P. "Die Schilddrlisenbeliandlung bei Myxodeme und verschiedenen,"
nautkrankheiten dcrmat. Zeitschr. Berl. 1894-95, ii. 433-459.— 50. BuY.s, E. "Con-
tribution a I'etude du principe anti-myxcedemateux de la glande thyroide," Pevue
Iiiternat. de rhinol. otol. ct laryngol. Paris, 1895, v. 85. — 51. Buzdy'gan, M. "■Myx-
oedema Pryegl. lek. Krakow, 1891, xxx. 52, 65, 82, 95. — 52. Idem. "Zwei Falle von
Myxijdem," IVien. klin. Wochenschr. 1891, iv. 570-573.-53. Calvert, J. "A Case of
Myxoedema treated by the fried Thyroids of Sheep," Trans. Clin. Soc. Lond. 1892-3
xxvi. 237. — 54. Campbell, W. M. "Case of Myxedema with Gtycosuria treated witli
Thyroid Extract," Liverpool Mcd.-Chir. Journ. 1894, xiv. 452-454. — 55. Cauter, C.
"Myxcedeme et goitre exophtalmique," Ann. soc. med.-chir. de Liege, 1894, xxxiii. 12-
25. — 56. Chopixet. " Myxcedeme ou cachexie pachydermique observee chez une jeune
fille de vingt-trois ans ; guerison presque complete an moyen des injections sous-cutanees
d'extrait liquide du corps thyroide de mouton," Compt. rend. soc. de biol. Par. 1892, 9
s. iv. 602-607. — 57. Clakk, A. C. "Case of Myxoedema with Tumours of the Brain,"
Edinb. Med. Journ. 1890-1, xxxvi. 1012-1016.-58. Clouston, T. S. "The Mental
SjTuptoms of Myxc»dema and the Effect on them of the Thyroid Tveatmewt," Journ. Mental
Science, xl. 1894. 1-11. — 59. Cocking, W. T. "Notes of a Case of Myxcedema treated
by Thyi-oid Feeding," Sheffield Med. Journ. 1892-3, i. 312-314, 1 pi.— 60. Comby, J. " M yx-
4So SyS7'£A/ OF MEDICINE
cedenie chez une tillettc de deux ans et demi ; traitement par de n'gime thyroi'dien ; ameliora-
tion," J/tW. inf. Paris, lt>94, i. 578-80. — 61. CoNsur. " Idiotie avec cachexie jiacliyder-
mique (idiotie inyxiedemateuse)," Bull. soc. de mtd. vient. dc Bthf. Gaud et Leipzig, 1891,
421-427, 2 phot.— 62. CoiiKiiiLi,, J. G. G. "Myxoedema, with enlarged Tliyroid, treated by
Subcutaneous Injections of Thyroid Extract; recovery," Br it. Med. Jonrn. 189-"5, i. 8. — C3.
CowLEs. W. N. "A Case of Jlyxiedeina treated by Thyroid Extract," VAasYcoi Med. and Surij.
Journ. 1894, cxxx. 167. — 64. CliAliY, G. W. " Myxadenia, acquired and congenital, and
the U.se of the 'i'hyroid Extract," Amcr. Journ. Med. Science, 1894, n.s. cvii. 515-531. — 65.
Idem. "A Case of Myxiedema, treated with Thyroid Extract by the Stomacli, and a Dcscriji-
tion of the Method of i)rcparing the Extract," Med. Itcc. N.Y. 1893, xliii. 739-743. —
66. Curtis, H. H. "The Throat Appearances in Myxu'denia," Journ. Amcr. Mrd.
Jsso. Chicago, 1894, xxiii. 486.-67. Daxduis. " Un cas de myxa'deme infantile,"
Beviie mid. Louvain, 1894-95, xiii. 49-55.-68. Davies, A. T. "A Case of Myx-
edema," Trans. Clin. Soc. Lmul. 1891-92, xxv. 285.-69. Idem. "A Case of Myxa-denia
iu a Male successfully treated by Injections of Sheep's Tliyroid Juice," ibid. 306, 1 b.
1 pi.— 70. Idem. "A Case of Myxcedema," ibid. 306.— 71. Idem. "A Case of Myx-
iTcdenia in a Male treated by dried Thyroid Extract given by tiie Mouth," Ir. Clin. Soc
Bond. 1891-93, xxvi. 234-236. — 72. Idem. " Myxcedema and its recent Advances in
its Therapeutic Treatment," Internal. Clin. Phila. 1893, 3rd s. ii. 74-83. — 73. Idem.
" A Clinical Review of the Treatment of Jlyxoedenia and its bearing on certain other
Diseases," Ink mat. Clinics, 1893, 3rd ser. iii. 12-21. — 74. Debovk. "Myxa-denie,"
Ann. de mM. scient. et prat. Par. 1894, iv. 201. — 75. Dessau, S. H. "Lipomatosis
Universalis, with Symptoms of obscure Nerve Lesions, versus Myxa-dema," Cliru Be-
corder, N.Y. 1896, i. 15. — 76. Duckworth, Sir D. "Sequel to a Case of Myxedema
reported to the Society, November 1880," Tr. Clin. Soc. Bond. 1891-92, xxv. 224-226.
— 77. Duke, E. " Myxa-dema," i?jr»H«(jr. M. Ber. 1893, xxxiv. 86-89.-78. Dunlop,
G. H. M. "Six Cases of Myxedema treated by Thyroid Feeding," Edinb. M. J.
1892-93, xxxviii. 1005-1014. —79. Dryson, W. "A Case of Myxuedema," Sheffield
M. J. 1892-93, i. 30-35, 1 pi— 80. Elam, G. "A Case of Myxredema treated with
Thyroid Extract," Ban-cet, 1893, ii. 631.— 81. Elder, N. "A Case of Myxcedema
treated with Thyroid Extract," Brit. Med. Jouni. 1895, i. 697.-82. Embley, E. U.
"A Case of Myxcedema with Svmptoras .simulating Ovarian Tnmour," Austral. Med.
Journ. Melbourne, 1895, New Ser. xvi. 277-280. — 83. D'Evelyn, F. W. "Myx-
cedema," Bacific M. J. San Fran. 1893, xxxvi. 469-476.-84. Ewald, C. A. Die Erkran-
kungen dcr Schilddriisc, My.cddem und Crctinismus, Wien, 1896, A. Holder, 253 j)p., 1
map. — 85. Idem. " Ueber einen durch die Scliilddriisen Therapie gehalten Fall
von My.xiJdem nebst Erfahrungen iiber onderweitige Anwendung von Thyreoidea-
priipara'ten," Verlwndl. d. Ber. vied. Gesellsch. (1894), 1895, xxv. pt. 2, 284-306 [Dis-
cus.sion], pt. 1, 179.— 86. Fenwick, H. "Myxcedema treated by Injections of fresh
Thyroid Juice," Ba.ncet, Lond. 1892, 11, 941.-87. Feiuuek, D. "Notes of a Case of
Myxcedema treated by Thyroid Extract (complete recovery)," Clin. Sketches, 1895, i.
36-38, illustrations. — 88. Feulard, H. "Cas de myxredeme congenital chez un
sujet feminin age de 19 ans et demi," Bull. soc. fran(;. de dermal, et syph. Par. 1890,
i. 232-237.-89. Fini,.\y, D. W. "On a Case of 'Myxcedema," Internal. Clin. Philad.
1892, 2nd s. ii. 1-7, 1 pi. 1 diagram.— 90. Fox, E. L. " A Case of Myxcedema treated
by taking Extract of the Thyroid by the Mouth," Brit. Med. Journ. 1892, 11, 941.-91.
Eraser, C. " The Treatment of Myxcedema with Thyroid Gland," Atti d. xi. Congr.
Med. Intcrnaz. Roma,, 1894, iii. Farmacol. 117. — 92. Godart-Danhieux. "Un cas de
myxcedeme avec ascite traite par I'extrait thyroi'dien," Journ. de mM.-chir. etpharmacol.
Brux. 1895, 433-441.-93. Idem. " Un cas de myxaHh'me," ibid. 643-645.-94. GoR-
DIN'IER, H. C. " Report of Two Cases of Myxcedema, with One Autopsy," N. York Med.
Journ. 1892, Ivi. 169-172. — 95. Govvan, B. C. " Myxirdema and its Relation to Graves'
Disease," Bancet, 1895, i. 478-580.— 96. Haig, A. "The Effect of Thyroid Extract in
Myxredema comi)licated by Angina Pectoris, "ifl;icc<, 1895, ii. 873. — 97. Hai.bert, H. V.
" Myxcedema illustrated by a Case : Clinique," Chicago, 1895, xvi. 385-394.-98. Hale,
G. E. "Four Cases of Myxiedema treated by Injections of Thyroid Extract," /.ViV.
Med. Journ. 1892, ii. 1428.-99. Harold, J. "Cases of Myxcedema treated by Thy-
roid Gland," Practitioner, Lond. 1894, liii. 100-105.— TOO. Idem. "A Case of Myx-
redema treated by Tliyroid Gland," Zrt«cc<, 1894, ii. 434-136.-101. IIaiivls, T.. and
G. A. Wrkjiit. "Myxiedema treated by Tlivroi.l Grarting," Bancet, 1892, i. 81-84.—
102. Hayes, "W. A. "Case of Myx(x-dema," V.ViVy; Med.-Chir. Journ. 1894, xii. 230-
232.-103. He.mrv, J. P. "A Case of Myxcedema cured by Thyroid Extract," Brit.
MY X (ED EM A 481
Med. Journ. 1893, i. 737.— 104. Hodge, G. "llyxoidntTaa,," Am. Med.-Surg. Bull. N.Y.
1896, ix. 724.— 105. Holmax, C. "A Case of Myxojdema treated by Thyroid Feeding,"
Brit. Med. Journ. 1893, i. 114. — 106. Hopmax. "Operatives Myxiideni schwerer Art
von ungewohnlich langer Dauer," Deutsche med. Woclieiischr. 1893, xi.x. 1357. — 107.
HouEL, E. "Notesur une malade presentaut un etat general cachectiqiie particulier
(myx(jedeine), anielioree par des injections d'extrait de corps tliyroide," N. Montpel.
mM. 1895, iv. 271-282.— 108. HuN, H. "The Treatment of Myxcedema by Feeding
with the Thyroid Gland," A/hany M. Ann. 1894, xv. 1-17.-109. Immerwol, V. "Du
myx(edeme infantile," J/e'rf. inf. Paris, 1894, i. 558-66. — 110. Immkrwolt. "Mittheilung
liber einen Fall von kindlichem Myxoedem (sporadic cretinism) init abweichenden hysto-
logischein Befund der Haut," Atti d. xi. Congr. Med. Internaz. lio^na, 1894, iii. Pediat.
141-143. — 111. Janicke, 0. "Ueber JMyxoedeni niit Demonstration eines einschliigigen
Falles," Jahresb. d. schles. Gesellseh. f. vaterl. Kult. 1890, Bresl. 1891, Ixviii. med. Abth.
19. — 112. Jaunin, p. "Observation d'un nain myxoedematcux traite par les pre-
l)arations thyroidiennes," Revue iMd. de la Suisse romande, Geneve, 1896, xvi. 34-38. — -
113. Ka.sche, Heinriuh. Kachexia thyreo2)riva und Myxiideni, Berl. 1893, G. Schade.
44 pp. — 114. Kenny, F. H. "A Case of My.xcedema," Australian Med. Journ.
1893, n.s. XV. 634-641. — 115. Kimball, R. B. "A Case of Myxoedema with unusual
Features and rapid Recovery, " J/a^. Record, N.Y. 1893, xliv. 814. — 116. Kinnicutt, F.
P. "Myxoedema; the Functions of the Thyroid Gland and the present Method of
Treatment of Myxoedema," Tr. Assoc. Amcr. Physicians, Piiilad. 1893, viii. 309-332. —
117. hlem. "Myxcedema; the Functions of the Thyroid Gland, and the present Method
of Treatment of Myxedema," Med. Rec. N.Y. 1893, xliv. 449-455.— 118. Kirk, K.
"Notes on Cas'es of Myxcedema, " ZaMtr^, Lond. 1893, ii. 743-745. — 119. Klee, F. E.
" Et. Tilfaelde af Myxoedem ; Restitution rea sniaa doser Thyreoidin i et laengere Tids-
rum " Ucjesk. f. Larger, Kjiibenh. 1896, 5 R. iii. 145-151. — 120. Kohler, R. "Myx-
odem, auf Syphilis berahend," Berl. klin. Wochnschr. 1892, xxix. 743. — 121. Idein.
"Myxodem auf seltener 'Qa&\<&," Berliner klinische JFochenschr. 1894, xxxi. 927. — 122.
Kkaepelin, E. "Ueber Myxodem," Deutsches Arch. f. klin. Med. Leipz. 1891-92,
xlix. 587-603. — 123. Kiiauss, W. C. " Observations on a Case of Myxo'dema," Johtw.
Nerv. andMent.Dis. NY. 1893, xx. 685-688.— 124. Krowczyu.ski, Z. "Myxoedema,"
Medycyna, Warszawa, 1892, xx. 129-132. — 125. Laache, S. " Ueber Myxodem und
dessen Behandlung mit innerlich dargereichter Glandula thyreoidea," Deutsche med.
Wochenschr. Leipz. u. Berl. 1893, xix. 257-259. — 126. Leichtenstern, 0. " Ein
mittels Schilddriiseninjection und FUtterung erl'olgreich behandelter Fall von Myxoe-
dema operativum," Deutsche med. Wochenschr. 1893, xix. 1297, 1333, 1354. — 127. Idem.
" Zur Geschichte der Myxciderafrage," Dct^^sc/;*; med. fFochcnschr. 1894, xx. 251. — 128.
Le.szynsky, W. M. "A Case of Sporadic Myxcedematous Cretinism," Post-Gradunte,
New York, 1894, ix. 413-415.-129. Little, J. "Sequel of a Case of Myxcedema
treated by Thyroid Juice," Duhlin Journ. Med. Sci. 1894, xevii. 293-295. — 130.
Loewy, a. "Ein Fall von Myxodem bei cretinartigem Zwergwuchs," Berl. klin.
Wochenschr. 1891, x.wiii. 1130-1132.— 131. Lundie, R. A. " The Treatment of Myx-
oedema," Edinb. M. J. 1892-93, xxxviii. 996-1005, 1 tab.— 132. Idem. "A Case of
Myxcedema treated by Thyroid Extract and Thyroid Feeding," Brit. Med. Journ. 1893,
i. 64. — 133. LuNN, J. R. " A Larynx from a Myxedema Female Patient," Tr. Path. S'oc.
Lond. 1888-90, xli. 32.— 134. M'Gregor, G. W. "Myxcedema," Columbus M. J. 1896,
xvii. 151-156. — 135. Mackenzie, H. W. G. "A Case of Myxoedema treated with
great Benefit by Feeding with fresh Thyroid Glands," Brit. Med. Journ. 1892,
ii. 940.-136. Idem. "The Treatment of Myxcedema," Lancet, 1892, ii. 999.—
137. Idem. "Clinical Lecture on Myxoedema and the recent Advances in its Treatment,"
Lancet, 1893, i. 123-25. — 138. Idem. " A Case of Myxcedema associated with Tubercular
Disease of the Lungs and Larynx," Trans. Path. Soc. Lond. 1891-92, xliii. 184. — 139.
Macpherson, J. ["Treatment in Myxcedema"] Trans. Med.-Chir. Soc. Edinb. 1891-92,
n.s. X. 99-103. — 140. Idem. " Notes on a Case of Myxoedema treated by Thyroicl
GTSLhing," Edinb. Med. Journ. 1891-92, xxxvii. 1021-24.-141. Marie, P., 'and Guer-
LAiN, L. "Sur un cas de guerison de myxcedeme par I'ingestiou du glande thyroide du
mouton, et sur les accidents qui peuvent survenir au cours de traitement thyroidien,"
Bxdl. et mem. de soc. mM. des hop. de Paris, 1894, 3 s. xi. 83-87.-142. Marie, P. "Pre-
sentation d'une myxoedemateuse guerie par I'ingestion des glandes thyroides de mouton,"
Ball, et mem. soc. m^d. des hdp. de Paris, 1894, 3 s. xi. 334-336. — 143. Idem. "Recti-
fication au sujet du cas de myxoedeme traite par le Dr. Canter et presente a la societe
des hopitaux dans la seance du 18 mai 1894," Bull, et mem. soc. m6d. des hop. de Paris,
VOL. IV 2 I
482 SYSTEM OF MEDICINE
1894, 3 s. xi. 371.— 144. JIarxer, G. P. " Myxoedema, " Proc. Kansas Med. Soc.
Topt'k.i, 1S94, xxviii. 113-l.'4.— 145. Marr, H. C. " A Case of Myxa-denia treated with
Thyroid Feeding aud Tiiyroid Extract," Glasi/ow Med. Jour. 1893, xl. 125-28. — 146.
Meltzi:k, S. J. "Ueber Myxodem," N. Yorker vted. Motuitschr. 1894, vi. 135-54. —
147. Idea. "Myxuideiua," Med. Age, Detroit, 1896, xiv. 129-32. — 148. Mendei,,
E. " Eiu Fall von Myxodem," DeutscJie wed. IFochcnschr. Leipz. u. Berl. 1893, xix. 25.
— 149. Idem. " Drei Falle von geheilteni Myxodem," Deutsche mrd. JFochenschi:
Leipz. xmd Berl. 1895, xxi. 101-3. — 150. Merklen, P., and C. Waltuer. " Snr un
cas de myxcedeine ameliore ))ar la grelie thyroidienne," Hull, et mem. soc. med. des h6p.
de Par. 1890, 3 s. vii. 859-70.— 151. Miuanicii, P. ["Case of Myxedema "J Med.
(Hnnr. Mask. 1890, xxxiv. 493-95. — 152. Miller, A. C. " Case of Jlyxcjedema cured by
Thyroid Feeding," Edinb. Med. Journ. 1893-94, xxxix. 215-19, 2 ])1.— 153. Miller, H.
T. " Failm-e of Thyroid Extract in a Case of Myxccdema," Med. lice. N.Y. 1895, xlviii.
24. — 154. Mo-SLKR. "Ueber Myxodem," Thcrap. Moiiatsh. Berl. 1891, v. 461.-155.
Idem. " Ueber das Myxoedem," Verhaiull. d. x. Internat. Med. Cong. 1890, Berl. 1891,.
ii. 5, Abtli. 134-38. — 156. iluRRAY, G. R. " Remarks on tlie Treatment of Jilyxcedema
with Thyroid Juice," Brit. Med. Journ. 1892, ii. 449-51. — 157. Idem. "The Treatment
of Myxcedema aud Cretinism," Lancet, 1893, i. 1130-32. — 158. Idem. "After-history
of the First Case of Myxa'dema cured by Thyroid Extract," Brit. Med. Journ. 1895, i. 334.
— 159. Napier, A. " Notes of a Case of Myxtedema treated l)y Cleans of Subcutaneous
Injections of an Extractof Sheep's Thyroid," ^//(ts;/o(« J/. J. 1892, xxxviii. 161-65, 1 chart,
1 pi. — 160. Idem. " Diuresis an increased Excretion of Urea in the Tiiyroid Treatment
of Myxcedema," Lan<:et, 1893, ii. 805. — 161. Idem. "Patient who had recovered from
Myxoedema under Thyroid Treatment ; Reference to six other Cases similarly treated suc-
cessfully," Trails. Glasgow Patli. awl Clin. Soc. 1893-95, v. 104-122. — 162. Idein.
"Seven Cases of Myxoedema treated by Thyroid Feeding," Glasgoiv Med. Journ. 1894,
xlii. 81-99. — 163. NiELsox, L. " Ein Fall von Myxodem durch Futterung mit glan-
dulae thyreoidea (von Kalbern) geheilt, nebst einer Hypothese uber die pliysiologische
Funktion dieser Driise, " Monatsh. f. prakt. Dermat. Hamb. 1893, xvi. 403-15. — 164.
Idem. "Behandlung af Myxodem med. Pil. glandulae thyreoideae siccatae," IIosp.-Tid.
Kjobenh. 1893, 4 R. i. 1189-98; transl. Monatshcfte f. jn-akt. Dermat. 1894, xviii. 115-
25. — 165. North RUP, W. P. " Infantile Myxcedema (two cases)," Archives of Pediatrics,
New York, 1894, xi. 793-801, 1 plate.— 166. Oddo, C. "Un nouveau cas d'idiotie
inyxiedemateuse traite avec succes par la methode thyroidienne," Marseille vikl. 1895,
xxxi. 193-210.— 167. Oliver, T. "Myxcedema," Internat. Clin. Phila. 1892, 2nd s. ii.
8-20, 2 pi. 1 diagram. — 16S. Oppenheimer, A. R. "Myxredenia and Exophthalmic
Goitre in Sisters, with Remarks on the Symptoinatologyof the latter Disease," Journ. Nerv.
andMent. Dis. N.Y. 1895, xxii. 213-22; Johns Hopkins Bosp. Bull. Bait. 1895, vi. 33-35.
—169. Ord, W. M. "Recent Cases of Myxcedema," St. Thomas's IIosp. Pep. 1889-90,
Lond. 1891, n.s. xix, 125-135, 1 pL— 170. Idem. "Ueber das Myxoedem," Ver-
handl. d. x. Internat. Med. Cong. 1890, Berl. 1891, ii. 5 Abth. 132-134. — 171. Ord,
W. M., and E. "White. " Clinical Remarks on certain Changes observed in the Urine in
Myxoedema after the Administration of Glycerine Extract of Thj-roid Gland," Brit. Med.
Journ. Lond. 1893, ii. 217. — 172. Osler, W. "An Acute Myxoedematous Condition
occuriing in Goitre," Johns Hopkins Hosp. Bull. Bait. 1892, iii. 42. — 173. Owex, J. L.
"A Case of Myxcedema, treated by Tiiyroid Extract," She/field Afed. Journ. 1892-3, i.
315. — 174. Pa(;et, Sir J. "Swellings al)ove the Clavicle," in his Stiul. Old Case-books,
Lond. 1891, 136-138.-175. Pa.steir, W. "A Case of Myxoidcma treated by Raw
Thyroid Glands and Fresh Thyroid Extract, in which severe Constitutional Symptoms
developed under Treatment," Trans. Clin. Soe. Lond. 1S92-3, xxvi. 230-234. — 176.
Idem. "Da traitement du myxoedeme par les preparations thyroidiennes, " Pevue
inkL de la Suisse romandc, 1894, xiv. 35-50. — 177. Idem. " M vxcedi^ma," Middlesex
Hosp. Penorts (1892), 1894, 72-74.— 178. Pel, P. K. "Myxiiilema," Samvil. klin.
Vortr. N.F. Leii)Z. 1895, No. 123. {Innere Med. No. 36, 255-288, 2 pi.)— 179.
Peli, G. " L' iiliotismo mixedeniatoso," Boll. d. se. med. di Bologna, 1891, 7 s. ii.
163-174. — 180. PuN('ET, A. " Thyroido-en'thisnie chirurgical pour myxcedeine et per-
version mentale," jl/crtT«i?t «i^(^. I'ar. 1893, iv. 465. — 181. Porieou.s, J. L. " Myx-
ledenia. its History, Etiology, Pathology, and Treatment, with Particulars of a Case
successfully treated," Amer. Therap. N.Y. 1893-4, ii. 1-9.-182. Putxam, J. J.
" Ca-ses of Myxoedema and Acromegalia treated with Benefit by Shee]i's Tliyroids. Recent
Observations respecting the Pathology of the Cacln-xias following Di.sease of the Thyroid ;
Relationship of Myxoedema, Graves' Disease, aud Acromegalia," 2'rans. Assoc. Amer.
MVXCEDEMA 483
Physicians, Phila. 1893, viii. 333-360.-183. Pye-Smith, R. J. "A Case of Myx-
tedeiua ; with Microscopical Examinatioii of Tliyroid Body by A. J. Hall," Sheffield Med.
Jonrn. 1892-3, i. 35-41, 1 pi.— 184. Ravek, T. F. " Myxedema treated with Thyroid
Tablets," Brit. Med. Jonrn. 1894, i. 12. — 185. Regis, E. "Uii cas type de niyxcedemo
congenital (cretinisme sporadique) au debut de traitement tliyroiJien, " Mem. et hull.
S(K. de iiiM. et chir. dc JJardccdu: (IS^i), 1895, 763-70. — 18t). Idem. " Nouveau cas de
myxoedeme infantile iiotablement ameliore par le traitement thyroidien," Journ. de
ineel. de Bordeaux, 1895, xxv. 254 ; Oaz. d. hop. de Toulouse, 1895, ix. 148. — 187. Idem.
" Un cas type de myxcc'deme congenital ameliore par le traitement thyroidien," M^m.
et bull. soc. de vied, et chir. de Bordeaux (1S95), 1896, 90-93. — 188. Idem. " Nouveaii
cas de myxoedeme infantile notablement ameliore par le traitement thyroidien," ibid.
263-267. — 189. Rehn, H. " Ueber die Myxiidemform des Kindesalters und die Erfolge
ihrer Behandlung mit Schilddriisenextract, " Verhamll. d. Cong. f. innere Med. Wiesb.
1893, xii. 224-229. — 190. Mem. "Ueber cachessia thyreopriva congenita und deren
Behandlung mit Schilddriisenextract nach einjahiige Beobachtung an zwei Kindern,"
Atti d. xi. Coiujr. Med. Internaz. Iloma, 1894, iii. Pediat. 54.^191. Rennie, G. E.
"Myxojderaa," Australasian Med. Gazette, 1894, xiii. 2-6. — 192. Robin, A., and E.
Serkdde. "Observation d'un cas de myxoideme," Ann. de dermat. et syph. Par.
1892, 3 s. iii. 701-704. — 193. Idem. "Observation d'un cas de myxcedeme," Bull. soc.
frani;. de dermcd. et syph. Par. 1892, iii. 303-306. — 194. Robin, V. " Myxcedeme con-
genital traite par des injections hypoilermiques de sue thyroidien et par la grefi'e des
corps thyroides," Gaz. hebd. mid. Par. 1892, 2 s. xxix. 451-453. — 195. RoGEHS,
J. K. P. "Myxcedema successfully treated by desiccated Thyroids," Trans. Maine
Med. Assoc. Portland, 1895, xii. 166-72. — 196. Roque. "Myxcedeme chez une jeune
mie," Lyo)i inM. 1893, Ixxii. 615-618. — 197. Sacchi, E. "Di un case di mixedema
operativo curato con successo col trattaniento tiroides," Biv. sper. di freniat. Reggio-
Emilia, 1894, xx. parte ii. 182-92, 1 plate. — 198. Saundby, R. "Case of Myxcedema
treated by Thyroid Gland," Birming. Med. Ilev. 1893, xxxiii. 278-283. — 199.
Schmidt, J. J. "Ueber Myxudembehandhrng ; Vorstellung von spontanem Myx-
odem mit Zwergwuchs," Deutsche mcd. IVochen. Leipz. u. Berlin, 1894, xx. 806-809. — -
200. ScHNEiDEK, Alfkkd. Die Zusammensetzung des Blutcs der Frauen vcrglichen
mit derjenigen der Manner, nebst einer Analyse des Blutcs drcier an Myxoedem erkravk-
tcn Frauen, Dorpat, 1891, C. Mathiesen, 35. pp. — 201. Schotten, E. "Ueber
Myxbdem und seine Behandlung mit innerlicher Darreichung von Schilddriisensub-
stanz," Miinchen. med. Wochenschr. 1893, xl. 981, 1002.-202. Shapland, J. D.
"The Treatment of Myxcedema by Feeding with the Thyroid Gland of the Sheep," Brit.
Med. Journ. 1893, i. 738. — 203. Sinkler, W. "Myxcedema and its Treatment by
Thyroid Extract," Pkilad. Policlinic, 1894, iii. 141-143.— 204. Smith, T. F. H. "En-
larged Thyroid ; Disappearance of Gland followed bv Myxcedema," Brit. Med. Journ.
1896, i. 14.-205. Smith, J. L. "Myxcedema and" the Thyroid Gland," i/rr/. Mag.
Lond. 1893-4, ii. 124-134.— 206. Snowball, W. "Sequel of a Case of Congenital
Myxcedema," Intercolon. Quart. Journ. Mcd. and Sui-g. Melbourne, 1894, i. 269. — 207.
SoxNENBURG. " Acutes Operatives Myxoedem behandelt mit Schilddriisenfiitterung,"
Verhandl. d. deutsch. Gcsellsch. f. Chi?: Berl. 1894, xxiii. 497-503 ; [Discussion] pt. i.
169 ; Archiv fur klin. Chiritrgie, Berl. 1894, xlviii. 857-63. — 207«. Stalkei:, A. M.
" Case of Myxcedema," Lancet, 1891, i. 82. — 208. Stansj'ield. "A Case of Myxa-dema
with restless Melancholia treated by Injections of Thyroid Juice ; recovery," Brit. Med.
Journ. Lond. 1892, ii. 451. — 209. Starr, M. A. "A Contribution to the Subject of
Myxcedema, with the Report of Three Cases treated successfullv by Thyroid Extract."
Mcd. liec. N.Y. 1893, Ixiii. 705-708.-210. Idem. "A Contribution to the Subject
of Myxcedema with the Report of Three Cases treated successfully by Thyroid Extract,"
Tr. Assoc. Amcr. Physicians, Philad. 1893, viii. 361-371. — 211. Steiner. "Ueber
Myxodem," Devtsch. med. Wochnschr. Leipz. 1891, xvii. 1070-1072. — 212. Stewart,
G. "The Treatment of Myxcedema by Thyroid Feeding, its Advantages and Risks,"
Praclilioncr, Lond. 1893, Ii. 1-8. — 213. Thomson, J. "On a case of Myxcedematoid
Swelling of One-half of the Body in a Sporadic Cretin," ^rfiwfe. Med. Journ. 1891-2,
xxxvii. 249-253, 1 pi. — 214. lelem. "Note on a Case of Myxcedema which ended
fatally shortlv after the Commencement of Thyroid Treatment," Edinb. Med. Journ.
1892-3. xxxvi'ii. 1014-1018.— 215. Thomp.son, W. G. "Report of a Case of Myxcedema,"
Med. Rec. N.Y. 1893, xliv. 174.— 216. Idem. "Report of a Case of Myxcedema,"
Trans. Assoc. Amcr. Physicians, Philad. 1893, viii. 372-379. — 217. Thibierge, G.
" De la cachexie pachydermi<iue, ou myxcedeme," Gaz. d. hop. Par. 1891, Ixvi. 117-126.
484 SYSTEM OF MEDICINE
— 218. Idem. "De la cachexie pachyderniique, on mj'xcudeme," Gaz. d. h6p. dc Tou-
louse, 1891, V. 42, 51, 59, 67, 76, 84.— 219. Thksiman, V. "A Fatal Case of Myx-
oedema," Med. Press and Circ. Lond. 1895, n.s. lix. 270.— 220. V.vLLix, E. " Le
traitenient culinaire du niyxd-doiiip," Hev. d'lnjg. Par. LS93, xv. 478-486. — 221.
Ykhmkhiikn, F. " Stothveclisehveitersucluingen nacli Ikdiaiidluiig init Glaiulula thy-
reoidea an Iiidividuen mit und ohne Myxodeni," Ueutsclie vied. IVochnschr. Leipz. u.
Berl. 1893, xix. 1037. — 222. Idem. " Sul trattamento del niixoedema," Gazz. d. asp.
Milano, 1893, xiv. 275. — 223. Idem. " Ueber die Heluuidliiiig des Myxodeius,"
Dmlscke mrd. JForlmsc/n: Leipz. u. Berl. 1893, xix. 255-257.-224. Idein. " Ora
Myxoedemheliandliiig," Hoxp.-Tid. Kjobenli. 1893, 4 R. i. 125-132.-225. Idem.
" Nogle Heinaerkiiiii'.,'er 0111 Beliandlingen af Mvxoedeni," Hosp.-Tid. Kjiihenh. 1893,
4 R. i. 389-391.— 226. Vinton, Maria M. " A Ca.se of iMyxa'denia," Med. lice. N.Y.
1892, xli. 250. — 227. Voisix, J. " Idiotic myxddemateuse amelioree par la greHe thy-
roidienne et par I'alinientation thyroidienne," HulL et mdni. sac. vied. d. Ji6p. de Paris,
1894, 3 s. xi. 187-89.— 228. Wk.ssincek, J. A. '• My.vcudema, with Photograpliic
Illustrations," Trans. Mic/iii/an Med. Jssoc. Detroit, 1894, xviii. 232-36, 1 plate. — 229.
^V^lT\VF,LI,, J. R. "The Nervous Element in Myxu'denia," Brif. Med. Jonrn. 1892, i.
430-432.-230. Wichmanx, R. " Ein Fall von Myxtideni, gebessert durch Injectionen
mit Schilddriisensaft," Dcutsrhc vierL IFochnschr. Leijiz. u. Berl. 1893, xix. 26-28.
— 231. Idem. " Weitere Mittheilungen liber Myxiidem," Deutsche iTied. Wochenschr.
Leipz. u. Berl. 1893, xix. 259.-232. Wiusox, A. Martu.s. Myxo&dcma aiid the Effects
0/ Climate on the Disease. Lond. 1894, Scientific Press, 36 pp.
The Functions of the Thyroid Gland: — 1. Babek, C. Philosophical Transactions,
1S76 and 18S1. — 2. Baumann, E. Hoppe-Seyler's Zeit. f. phi/s. Chcmie, vol. xxi. p.
319. — 3. HoKSLFA', Victor. "Report on Mj'xuidema," Trans. Clin. Soc. Loud. 1888;
" Physiology and Pathology of Thyroid Gland," Brit. Mai. Journ. vol. ii. 1896, i)p. 16-
23. — 4. HuTCHi.soN, R. •' On the Active Constituent of the Thyroid Gland," Brit. Med.
Jowni. vol. i. 1897, p. 194.— 5. White, E. "The Pharmacy of the Thyroid Gland,"
P/iarmaceut. Journ. 2nd Sept. 1893.
The Parathyroid Glands :— 1. Edmunds. Trans. Path. Soc. Lond. 1895, 1896 ; and
Journ,. I'litli. and Barter. Jan. 1896. — 2. Gley. Arch, dc jihi/siol. norm, et path. 1892
and 1893.-3. Hor.sley. Brit. Med. Journ. Dec. 1896.-4. Kohn. Arch.f. viikrosk.
Anat. Bd. 44, H. 3, 1895. — 5. Saniwtr()M. "Ueber eine neue Drilse beim Alenschennnd
bei ver.schiedenen Saugethieren," Schvxidt's Jahrb. 1880. — 6. Vassale and Gknehali.
Biv. di Patol. nerv. e vicnt. March and .hily 1896.
W. 0.
Sporadic Cretinism
(congenital myxcedema, or myxcedema of childhood)
Definition. — A state allied to endemic cretinism and to myxcedema;
occurring in countries and districts where the malady is not endemic ;
associated Avith imperfect development both of the intellect and of the
l)ody, and due to congenital absence of the thyroid gland, or to want of
function in this organ.
Causation. — The conditions of the origin of sporadic cretinism
are unknown. Some cases have been ascribed to consanguinity between
the parents ; others to a family history of alcoholism, or of tubercular or
syphilitic disease. Other.s, again, have been attributed to mental shock
or worry on the part of the mother during pregnancy. There is some-
times a family history of " deformities." But in the large majority of
the cases recorded the mode of causation is obscure, the subjects of this
disease Itoiiis' members of lart'c and otherwise healthy families.
Description. — The condition is rarely observed before the completion
SPORADIC CRETINISM 485
of the second year, as no sei'ious symptoms are noticeable before that
time ; and, if any difference from the normal be noted, it is usually
regarded merely as "backwardness." The disease is, however, quite
recognisable, at all events, as early as the tenth month, when the main
features may be as follows : — -The child is stunted in growth, there is a
great want of due proportion between the various parts of the body, the
growth of the trunk and limbs not keeping pace with that of the head,
hands, and feet. The face is broad and expiessionless ; the eyes dull,
and situated far apart at the ends of a furrow running across the root of
the nose. The nose is broad, with flattened extremity, like that of a
negro ; the lips coarse, protruding, and gaping, give a glimpse of a swollen
tongue appearing between two rows of carious teeth. There is usually
well-marked salivation. The head hangs forward on the chest, the erector
muscles being too weak to support its weight. In this way an antero-
posterior curvature of the cervical and upper dorsal vertebrae is often
established, the convexity being directed backwards so as to give rise in
some cases to suspicion of spinal disease. In well-marked cases there is
usually a complementary cvuvature of the lumbar spine, increasing the
projection of the abdomen ; a characteristic feature which is one of the
last to disappear under treatment. The limbs are short, the legs are
often bowed in a manner suggestive of rickety deformity, and occasion-
ally require operative treatment ; there may be some epijihyseal enlarge-
ments also. The skin is yellow and leathery, and is rough to the
touch ; it is loose, and often hangs in folds over the abdomen. In some
cases there is a total absence of perspiration ; but this symptom is not
constant, as in myxoedema. The hair is scanty and stunted, owing to its
extreme brittleness : its appearance resembles a poor crop of wheat after
a storm ; and to the touch it is harsh, with a dry quality of harshness
which almost suggests heat. The scalp is dry and scurfy. Usually there
is nothing to be felt in the region of the thyroid gland, but the gland may
be present, even indeed in an enlarged form. In many cases there are
large lobulated fatty masses situated between the sterno-mastoids, above
the clavicles, and in the armpits ; they are not, as a rule, symmeti'ical.
The temperature is sul^normal, and the patients are extremely sensitive
to cold. The urine usually is passed in large quantity, contains no
albumin, and presents a marked diminution of urea ; but in a certain
number of cases the urea has been found decidedly increased. The blood
exhibits little change in its corpuscular elements ; there is no leuco-
cytosis, but there is a marked diminution in the quantity of haemoglobin,
the defect amounting to 50 and even 60 per cent.
There is a great variety in the mental condition of patients suffering
from this disease. In the most favourable cases, although the patient
remains dwarfed as he grows up, he is capable of attending to housework
and of following some light employment. On the other hand, he may
remain absolutely imbecile, a mere log. In the majority of cases a
medium state exists. The patient is dull, and is roused with difficulty, but
can be made to recognise external oljjects to a certain extent ; he especi-
486 SYSTEM OF MEDICINE
ally enjoys dainties ; sensation is retarded, and all movements are begun
with difficult}', and are slow and deliberate — the gait especially so. The
temper, as a ruU', is placid ; but it may be varied by fits of passion and
of despondency. A certain numl)er of patients are spiteful and vicious.
Tlie habits are usually dirty, and even at the age of six or eight years the
patient is often unable to feed himself. The difference between the real
and the apparent age becomes more noticeable as time goes on, patients
of twenty years of age or over having the size and general appearance of
young cliildren.
Pathology and morbid anatomy. — The thyroid gland is absent in
the majority of cases, being represented merely by a few fatty granules.
In other cases it has undergone cystic or fibro-cystic degeneration.
The cranial liones are thickened and the diploe diminished. Pre-
mature .synostosis of the spheno- basilic suture has been described ])y
Virchow. The brain is small, and there is an increase of intraventricu-
lar and subarachnoid fluid. The long bones, with the exception of the
clavicle, are shortened, and often })rosent a curious cupping at the
extremities which, embracing the epiphyses, gives rise to an appearance
of epiphyseal enlargement. There are no peculiar visceral lesions.
Diagnosis. — The various forms of idiocy unassociated Avith thyroid
affection, and rickets must be distinguished from this disease. The con-
dition of the hair, skin, and teeth and the j^resence of the thyroid will
mark the former class, the absence of mental symptoms the latter.
Prognosis. — Under the thyroid treatment this is eminently favourable.
•Suitably conducted, it will certainly ensure rapid and complete bodily
improvement, and though, as we shall see presently, mental improvement is
not invarial)le, it is even more remarkable when it occurs. The earlier
in life the treatment is begun the more complete and lasting appear
to be the results. In all probability, however, the treatment in some
form will ha\-e to be persisted in throughout the life of the patient.
Treatment. — Pre\ious to the experiments of IMurray and Mackenzie
little could be done to alle^date this disease. Several German siu'geons,
notably Boccher, and in this coimtry Victor Horsley, Glutton, and others
had tried the ini|)lantation, either in the abdominal cavity or beneath the
skin, of portions of thyroid glands of sheep, or of parenchymatous
bronchoceles from human subjects. The effect, though favoui-able, M'as
transitory, and disappeared with the absorption of the implanted tissue.
In 1892, Dr. Murray showed that subcutaneous injection of an extract of
the thyroid gland caused alleviation of symptoms, and, later, Dr. Mac-
kenzie showed that feeding by the mouth was et[ually efficacious. The
gland is Itcst administered in the form of a diied extract, either as a
powder, or in the form of a tablet. The dose .should be small at first,
begiiHiing with three grains a day, and should 1)e carefully increased in
amount until the full effect is ol)tained. Tlien large doses must be kept
up until what may be called a cure is obtained. Then only a sufficient
dose, which varies according to the individual, should be given to main-
tain the proper condition of health. The effect of the treatment in cases
SPORADIC CRETINISM 487
of sporadic cretinism resembles closely that which obtains in myxoedema ;
but there are some considerable differences. In the first place, there is as
a rule a complete absence of the symptoms of discomfort due to the treat-
ment which are so often noted in the adult disease. On the other hand,
symptoms of improvement do not occur so soon as in cases of myxoedema,
no change of any importance being noted in the first week. First, there
appears a maiked decrease in the body-weight, accompanied by a decided
decrease in bulk. This is accompanied by increased diaphoresis, an im-
provement in the condition of the skin and hands, an increased activity
of movement, and Pv brightening of expression. Where diminished before,
the Cjuantity of urea excreted approaches the normal. The cjuantity of
haemoglobin rapidly increases, with a corresponding diminution of pallor.
After a period of loss the body-weight begins to ascend, and this is the
most trustworthy sign of the approach to a "cure." When the body-
weight corresponds fairly well to the height of the child, the quantity of
thyroid extract given may be gradually diminished, until the smallest
dose compatible -with health is reached. This in each case must be a
matter of experience. Overdose, or a prolonged course of large doses,
may induce symptoms of irritability and other troubles suggesting Graves'
disease. It is interesting to note that where treatment is begun before
the period of second dentition, however badly decayed the first set may
have been, the second set of teeth are large and strong. Bodily growth
is in some cases remarkably rapid, as much as 5| inches in one year
having been recorded. Mental improvement varies considerably in
degree. In some cases, even Avhere there has been a marked degree of
hebetude at first, the children after a time become equal in intelligence
to their contemporaries, and are able to rival them at their studies. In
other cases, although the bodily improvement is remarkable, the mental
condition remains absolutely unimproved. There are various stages
between these two extremes.
W. M. Ord.
W. Wallis Ord.
REFERENCES
1. Allara, Vixcenzo. Sulla causa del cretinesimo ; shuUo. Milano, 1S92, C.
Chiesa and F. Guindani, 419 pp. 2 tab. — 2. Idem. Der Kretinismus, seine
Ursuchen jmd. seine Heilung, Studic .- autorisierte Uebersetzung aus dem Italienischen von
Hans Merian. Leipzig, 1894, W. Friedrich, 396 pp. 2 tab. —3. Allen, H.
"Demonstration of Skulls showing the Eflects of Cretinism on the Shape of the Nasal
Chambers," Trans. Amcr. Lanjnyol. Assoc. 1894, New York, 1895, xvi. 142-68.— 4.
Anson, G. E. " Result of a Year's Treatment of a Case of Sporadic Cretinism by Thyroid
Juice," Lancet, 1094, i. 1863.— 5. Beadles, C. F. "The Treatment of Myxudenia and
Cretinism, being a Review of the Treatment of those Diseases bv Thyroid Gland, with a
Table of 100 published Cases." Jo^irn. Ment. Sc. London, 1893, xxxix. 343, 509, 622,
1 pi. — 6. Blakr, E. T. Myxoedcmn, Cretinism ami the Guitrc, with some of their
Relations. Bristol, 1894, 89 pages, 5 plates. — 7. Beamwrll, B. "Sporadic
Cretinism," Atlas of Clin. Med. fol. Edinb. 1891, ii. pt. 1, 17-27, 2 ph— 8. Idem.
" Clinical Remarks on a Case of Sporadic Cretinism," Brit. Med. Journ. 1894, i. 6-11.-9.
Idem. "Clinical Remarks on a Case of Sporadic Cretinism," Trans. Med.-Chir. Sac.
Edinb. 1894, n.s. xiii. 34-45. —10. Carmichael. E. "Cretinism treated by the
Hypodermic Injection of Thyroid Extract and by Feeding," Lancet, 1893, i. 580.— 11.
488 SYSTEM OF MEDICINE
"Congenital Cretinism," Clinical Sketches, London, lS9o, ii. 33-35. — 12. Derci'M,
F. X. "A Case of Sporadic Cretinism," Philad. Jfosp. J!ej). 1893, ii. 157, 1 plate. — 13.
DoLEGA. " Ein Fall von Cretinismns beruhend auf einer priniaren Hemmung des Kiioolien-
wachstlmms," Ucitr. z. path. Anat. u. z. ally. Path. Jena, 1890, i.\. 488-514. — 14.
FiNLAY-sox. "Ca,se of a Cretin Child under Thyroid Treatment," Gla.ir/ow M. J. 1896,
xlv. 378-382.— 15. GAKiton, A. G. "Ca.se of a Cretin under Thyroid Treatment,"
Trans. Med. Soc. Lond. 1894-95, xviii. 308.— 16. Hagan, H. "A Case of Cretinism,"
Atlanta M. and S. J. 1892-3, n.s. ix. 705-707.— 17. Haskovec, L. "Ein Fall von
sporadischen Cretinismns behandelt mit einem Scliilddrii.senpraparat," Jfiener med.
n'ochcnschr. 1895, xlv. 1805, 1857.-18. Hellier, J. B. "A Case of Sporadic
Cretinism treated by Feeding with Thyroid Extract," Lancet, 1893, iii. 1117. — 19.
Ireland, W. W. "On Sporadic Cretinism," Edinh. Med. Journ. 1892-3, xxxviii.
1018-1022.— 20. Kirk, R. "Death of a Cretin aged Twenty Years," Lancet, 1893, i.
524. — 21. KociiEi!, T. " Zur Yerhutung des Cretinismns und cretinoider Zustiinde
nach neueu Forscliungen," y-'r^/sr/ic Zci7.sf/(r./. C7m>. xxxiv. Festsehr. . . C. Thiersch,
etc. Leipzig, 1892, 556-626, 1 plate. — 22. Leech, P. " A Case of Sporadic Cretinism
treated by Tabloids of Thyroid Gland," Quartcrhj Med. Journ. Slieffield, 1893-94, ii.
320-22, 1 plate. —23. Lloyd, J. H, "Sporadic Cretinism," Intcrnat. Clin. Pliila.
1892, 2nd s. ii. 113-117, 1 pi.— 24. Lunx, J. R. " A Case of Female Cretin treated by
the Administration of Sheeji's Thyroid," Trans. Med. Soc. Loml. xvii. 1894, p. 330. — 25.
MiDDLiTiix. "A Ca.se of Sporadic Cretinism," G'lastjow Med. Journ. 1896, xlv. 127-30.
— 26. MuuRELL, G. F. " A Case of Sporadic Cretinism treated by Thyroid Juice," St.
Barthol. IIosp. Rep. 1893, xxix. 101-103.— 27. Ne.s.s, B. "Case of Sporadic Cretinism,"
Gla.srjo}o Med. Journ. 1896, xlv. 125-27.— 28. Noyes, \V. B. "A Study of Sporadic
Cretinism," .Y. York M. J. 1896, Ixiii. 334-341 ; Nerve and Ment. Dis. N.Y. 1896,
xxiii. 312-315. — 29. Osler, W. "On Sporadic Cretini.sm in America," Amer. Jouni.
Med. Sci. 1893, n.s. cvi. 503-518. — 30. Idem. "On Sporadic Cretinism in America,"
Trans. Assoc. Amer. Physicians, Phila. 1893, viii. 380-398.-31. Idem. "Case of
Sporadic Cretinism (Infantile Myxcedema) treated successfully with Thyroid Extract,"
Archives of Pediatrics, 1895, xii. 105-108. — 32. Ottolexghi, S. "II campo visivo nei
cretini," Arch, di psichiat. etc. Torino, 1893, xiv. 256-263, 1 pi. —33. Parker, W. R.
"A Goitrous Cretin under Thyroid Extract," Prit. M. J. Lond. 1896, i. 1550-1552.—
34. Idem. "A Cretin treated by Thyroid Extract," Brit. Med. Jovrn. 1896, i. 333.—
35. Patersox, G. a. "A Case of Sjioradic Cretinism in an Infant ; Treatment by
Thyroid Extract," Lancet, 1893, ii. 1116.-36. Railtox, T. C. " Sporadic Cretinism,"
Brit. Med. Journ. Lond. 1891, i. 694. — 37. Idem. "Sporadic Cretinism treated by
Administration of the Thyroid Gland," Brit. Med. Journ. 1894, i. 1180.-38. Sixkler,
W. " Sjioradic Cretinism and its Treatment by Thyroid Extract," Internat. Med. Mag.
Philad. 1894-95, iii. 785-93,1 plate.— 39. Smith, T. "Case of Sporadic Cretinism
treated with Thyroid Gland," iVil Med. Journ. 1894, i. 1178-80.— 40. Smith, T. T.
"Cases of Sjioradic Cretinism treated by Thyroid Extract," Journ. Mental Science,
Lond. 1895, xli. 280-89, 4 ])lates.— 41. Svmixgtox, J., and H. A. Tikimsox. "A
Case of Defective Endochondral Ossification in a Human Fu'tns (so-called Cretinoid), ~
[From Proc. Pay. Soc. Edinh. xviii.] Pep. Lab. Poy. Coll. Physic. Edinb. Edinb. and
Lond. 1892, iv. 237-254.-42. Thomsox, J. "Further Notes of a Case of Sporadic
Cretinism treated by Thyroid Feeding," J^rfiM 6. Med. Journ. 1893-94, xxxix. 720-23, 1
plate. — 43. Idem. " Further Notes of a Case of Sporadic Cretinism treated by Tliyroid
Feeding," Trans. Med.-Chir. Soc. Edinb. 1894, n.s. xiii. 65-68, 4 plates. — 44. Hern.
" On a Milil Case of Cretinism and its Progress under Thyroid Treatment," Edinb. IIosp.
Reports, 1894, ii. 252-57, 1 plate. — 45. Idem. "A Case of Sporadic Cretinism (Cretinoid
Idiocy) with an Gidematous or (?) Myxredematoid Condition of tlie Right Side of tlie
Body," Tr. Med.-Chir. Soc. Edinb. 1889-90, n.s. ix. 145. —46. Towxsexd, C. W.
"A Case of Sporadic Congenital Cretinism," ^/ re//. Pediatrics, N.Y. 1892, ix. 825-829.
— 47. Yariot, G. " Un cas dc crotinisme sporadi([ue," Jew?-?!, de din. ct dc thi'rap.
infantile, Paris, 1895, iii. 741-744. — 48. Yinke, H. H. "Sporadic Cretinism, with
IJeport of a Case treated with Thyroid Gland," Meil. Xcus, New York, 1896, Ixviii.
309-13.-49. Vouotyxski, B. T. ["Ca.se of Sporadic Cretinism"] Vestnik. Klin, i
swlebnoi jjsichiat. i nerropatol. St. Petersb. 1892, ii. 40-51. — 50. Wagxer. " Unter-
.suchungen iiber den Cretinismns," Jahrb. fiir Psychiatrie, Leipzig u. Wien, 1893, xii.
102-137 ; 1894,xiv. 17-36.— 51. Idem. "Ueber den Cretinismns," J/cy/.-C/z/r. Centrnlhl.
AVien, 1893, xxviii. 245-252.-52. Idem. " Ueber den Cretinisnnis," .!/////(. d. Vrr. d.
Aerzie in Steicnnark, Graz, 1893, xxx. 87-101. — 53. West, J. P. "A Case of Con-
GRAVES' DISEASE 489
genital Cretinism," A7-chives of Pediatrics, New York, 1895, xii. 348-52, 2 plates. — 54.
Wood, A. J. "Three Cases of Sporadic Cretinism," Austral. Med. Jouj-ii. Melbourne,
1893, n.s. XV. 165-175. — 55. Bibliograjihy of Myxcedema.
W. M. 0.
W. W. 0.
Graves' Disease
Definition. — A disease characterised by enlargement of the thyroid
gland, protrusion of the eyeballs, tachycardia and palpitation, and tremors
of the extremities. With these may be associated a more or less profound
disturbance of mental equilibrium, emaciation, sweating, anaemia, loose-
ness of the bo\yels, and derangement of the catamenial function.
Etiology. — This disease mainly affects women between the ages of
sixteen and forty years. Its incidence according to age is shown by the
figures compiled by Euschan. Of 495 patients, 15 were under ten years
of age, 352 were between sixteen and forty, 163 occurring between
twenty and thirty, 69 were between forty and fifty, and 31 were over
fifty. The disease is thus rare at the two extremes of life. Only about
30 cases altogether have been reported in children. The age of the
youngest was two and a half years, a case which is recorded by Divel.
Dr. Dreschfeld has observed a definite example in a child aged three.
The disease, though rare in men, may occur in them in a well-marked
form. Its relative frequency in men and women has been very variously
estimated. Buschan, who has collected 980 cases from the records, found
805 females to 175 males, a proportion of about nine to two. It is
probable that cases in men are recorded more frequently than those in
women on account of their comparative rarity ; and thus the proportion
of men to women, given by Buschan, may be too high. It is possible,
too, that the proportion varies in diflierent countries. Charcot speaks of
the disease as being only a little less frequent in men than in women,
and Eulenburg gives the proportion as one male to two females. Out of
nearly a hundred cases of the malady personally observed by us, there
have been only five cases in males. As with adults, the children attacked
have been usually females — a contrast to our experience in cretinism.
The disease may occur in several members of the same family. It
has been observed in three successive generations. Thus it has Iteen
recorded that two sisters, their father, and two of his sisters, and his
mother were subjects of the malady. There is also Oesterreicher's well-
known case where a hysterical woman had ten children, of whom eight
suffered from exophthalmic goitre ; and one of the latter had three
children thus affected.
The malady is often consequent upon acute disease, fright or other
severe mental shock, worry, prolonged mental strain, and over - fatigue.
A good many cases appear to have dated from an attack of influenza.
Quinsy, rheumatism, and a tendency to bleeding, especially in the
form of epistaxis, have been observed as antecedents in a significant
number of cases.
490 SYSTEM OF MEDICINE
Fright, intense grief, and other profound emotional disturbances have
long been recognised as immediate causes of the disease. It is interest-
ing to note the close connection between the acute or chronic symptoms
of exophthalmic goitre and the more immediate eflects of terror. The
descriptions given by Darwin and Sir Charles Bell of the condition j)re-
sented by persons under the influence of intense fear at once suggest the
symptoms of exophthalmic goitre. The heart beats quickly and violently,
so that it ])alpitates or knocks against the ribs. There is trembling of
all the muscles of the body. The eyes start forward and the uncovered
and protruding eyeballs are fixed on the object of terror ; the skin breaks
out into a cold and clammy sweat, and the face and neck are flushed or
pallid. The intestines are aft'ected.
Of all the emotions, fear is notoriously the most apt to induce
trembling.
Protrusion of the eyes, as well as trembling, is mentioned by nearly
all writers who describe the eflects of horror or fear.
We have no knowledge that the thyroid gland ordinarily becomes
enlarged under the influence of fear, but it is evident that the other
chief features of exophthalmic goitre temporarily result from such
emotion. That, occasionally. Graves' disease, in a well-marked form,
rapidly follows a sudden shock to the nervous system, indicates that all
the symptoms may be produced in such a way.
We think that these facts suggest that the thyroid condition is, at
any rate, not the primary cause of the disease. AVe conclude that the
disease depends on a derangement of the emotional nervous system,
together Avith an altered perverted condition of the thyroid gland, which
serves to keep up many of the characteristic symptoms.
We are bound to recognise that, as in the case of myxoedema, the
large majority of the patients are of the female sex. It is well known
that changes of a quasi-inflammatory nature occur in the body during
disordered menstruation and during pregnancy.
The association of the disease with other nervous disorders in the
patient, or in other members of the same family, has often been pointed
out. Chorea, hysteria, epilepsy, diabetes, and insanity are some of the
diseases xnth. which it thus appears to have relations.
The connection of the malady with chlorosis is uncertain, but un-
doubtedly the latter frequently accompanies it in young women. Occii-
sionally the disorder shows itself for the first time during pregnancy or
after parturition. On the other hand, its symptoms may undergo
amelioration during pregnancy. Disorders of menstruation sometimes
precede the disease, and probably have some causal relation with it.
Some have looked on Graves' disease as an auto-intoxication ; others
regard it as reflexly excited by some local morbid condition in the nose
or elsewhere.
The disease aff'ccts per.'^ons of all classes of society. It appears to be
on the whole as prevalent in one country as another ; but some localities
furnish more cases than others. Thus certain parts of Kent, Surrey,
G A' A FES' DISEASE
491
Wiltshire, and the Thames valley have produced a relatively large pro
Fie. 10. — Case of acromej^aly, exophtlialmic goitre, phthisis, and glycosuria. (Dr. George Murray.)
Reprinted by permission of the Editor of the Edinburgh Medical Journal, New Series, vol. i. 1897,
p. 170.
portion of the cases under our observation. In districts where ordinary
goitre prevails, the exophthalmic form is also met with.
Symptoms. — The symptoms mentioned in the definition as character-
492 SYSTEM OF MEDICINE
istic of the disease may come on simultaneously or may gradually appear
one after the other. The thyroid enlargement, together with the pro-
trusion of the eA'es, renders the disoi'der easy to recognise. Sometimes
the first sign of anything amiss is an alteration in temper, the patient
being easily worried and extremely irritable. With this is soon asso-
ciated functional disturbance of the heart. The thyroid enlargement has
proljably ])een present from the first, l)ut may not be observed till a later
period. The palpitation now increases and the eyes become prominent ;
the patient becomes more irritable and excitable, and is apt to have
attacks of trembling.
We shall fii'st proceed to consider the various symptoms in detail,
and then discuss the varieties of the disease, its course and its duration.
The fhi/roid enlargement is usually moderate. In many cases the en-
largement is uniform, btit ap])ears to be unsymmetrical, the right side
being larger than the left. The reason of this apjjarent ditl'erence on
the two sides is that, as a rule, the normal gland is not reall\' sym-
metrical, the right lobe being larger than the left; and hypertrophy
magnifies the disparity. In some cases the enlargement is iri-egular and
the tumour may present local nodular swellings. The swelling is gener-
ally soft, but sometimes, especially when irregular, it is firm and hard.
The latter is especially likely to be the case where a goitre has preceded
the onset of the other symptoms of the disease.
The gland appears to pulsate in common with the vessels in the neck.
On placing the hand over the goitre a thrill is often perceptil)le, and
on applying the stethoscope a loud murmur is audible, like the venous
hum in the neck in a case of antemia.
During the course of the disease the goitre fluctuates in size. After
slowly increasing for a time it may gradually diminish. In other cases
it may repeatedly increase and diminish.
Often the patient has not noticed any enlargement of the thyroid
until it is pointed out by the physician. In men, attention is sometimes
first drawn to it by their collars becoming too tight.
The ei/e.<. — The exophthalmos, like 'the thyroid enlargement, varies in
amount in different cases. Occasionally the protrusion is so great that
the eyelids cannot voluntarily be closed, nor do they meet in sleep. On
the other hand, it may be so slight as to be hardly perceptilile. In
marked cases the eyeballs appear as if starting out of the head. In some
cases nothing more than a slightly staring look may be noticed. The
exophthalmos is often not (piite equal on the two sides, and several
purely ujiilateral cases have been reported. Two important signs have
been described in connection with exophthalmos ; these are known as
Von Griife's sign and Stelhvag's sign.
Von Griife's sign consists in the lagging of the upper eyelid in down-
ward movement of the eyes. To obtain it the finger or a pencil should
be held horizontally in front of the patient's eyes, and she should be
directed to follow it while it is gradually loweied. If the sign is present
the upi)er eyelids lag, not closely following the movements of the eye-
GRAVES' DISEASE 493
balls, so that the sclerotics may become visible between the lids and the
cornea^. Von Griife's sign is generally present in the disease, but it is
sometimes observed in other conditions.
Stellwag's sign consists in an increase of the palpebral fissure due to
retraction of the upper lid and diminished frequency and incompleteness
of winking under reflex stimulation. In consequence of the retraction
of the lids, the sclerotic may show all round the iris. The widening of
the palpebral fissure is not a mechanical result of the exophthalmos, and
is not directly in proportion to it. The diminished reflex excitability
contributes to give the eyes their staring look. Stellwag's sign is usually
present.
Mobius has drawn attention to another eye symptom, namely, in-
sufficient power of convergence for near objects. On convergence the
patients experience a sense of strain, but have no double vision. This is
by no means a constant feature of the malady. A glistening, slightly
oedematous condition of the conjunctivse may frequently be noticed.
Occasionally some weakness of the external ocular muscles exists.
Slight drooping of both upper eyelids has been observed. At times
there is some weakness of the external recti, producing double vision on
looking to the extreme right or left. In rare cases complete ophthalmo
plegia externa has been recorded.
No defect of vision, as a rule, accompanies the exophthalmos. Be
sides the straining which sometimes accompanies convergence, patients
often complain of various subjective symptoms, such as flashes of light
before the eyes, and feelings as if the eyes were being pushed for-
wards.
Sometimes there is painful spasm of the orbicularis palpebrarum.
Sometimes accompanying the spasm there is dislocation of the eyeball ;
but this, fortunately, is a rare event. Watering of the eyes is often a
source of annoyance, but, on the other hand, there may be an abnormal
dryness.
Ulceration of the cornea occasionally occurs, though rarely, and
this may go on to perforation and destruction of the eye. In a case
recently under the care of one of us, the perforation had occurred quite
painlessly, and the eye was lost before the patient made any complaint
about it.
Accompanying the protrusion of the eyeballs and the aflfections of
the lids already mentioned, an oedematous swelling of the upper and
sometimes also of the lower eyelids is not infrequently found. Some-
times the swelling is not a true oedema, as it can be dissipated by caus-
ing contraction of the orbiculares by electric stimulation. Sometimes
the swelling remains for a long period, even after many of the other
symptoms of the disease have disappeared.
Arching of the eyebrows is generally to be observed whenever
exophthalmos is well marked.
The disturbances of the circulation form the most marked and constant
features of the disease.
494 SYSTEM OF MEDICINE
The heart's action is always increased in rapidity. The rate varies
in the slii^htcr cases between 90 and 100 beats in the minnte, and in
cases of ordinary severity between 100 and 130. In severe cases the
heart may beat at the rate of 160 pulsations or even more in the
miimte.
The action is not merely persistently rapid, bnt it is apt to be
increased on slight exciting causes.
The patients, as a rule, are painfully conscious of palpitation, and it is
the chief trouble of v/hich they complain. In some cases they have a
feeling as if the heart were beating all over the body. Occasionally,
however, there is a Aery ra])id cardiac action without the patient being
uncomfortably conscious of it.
The pulsation of the carotids in the neck is generally a very con-
spicuous feature of the disease. On inspection, they can be seen beating
forcibly and rapidly.
As a rule the action of the heart is regular ; but it may become
irregular, and this is most likely to be the case when the disease is pro-
gressing unfavourably.
Often the increased cardiac action is accompanied by cardiac hyper-
trophy or dilatation. Systolic murmurs at the base of the heart are
not uncommon, while sometimes there is evidence of organic valvular
disease.
As regards the radial pulse there is nothing constant in its character
except its frequency. In different cases it is hard or soft, strong or
weak.
Tremw is noAv recognised as one of the cardinal symptoms of the
disease. It vai'ies very much in degree. In one case it may be the chief
trouble of which the patient complains, while in others its presence will
only be recognised by the physician on careful examination. If a
patient, the subject of this disease, be asked to stretch out her extended
hands, a characteristic tremor will be observed, consisting of viliratory
movements of small amplitude, Avith a period of about one-eighth or one-
ninth of a second. The tremor is of the same nature as that Avhich may
be observed in over-fatigued muscles in healthy persons. The tremor is
a comnuinicated one, and affects the Avhole extremity, not the fingers
only. It may be observed in the leg as Avell as in the arm. It usually
affects both sides of the body, but in some cases it is limited to, or is
very much more marked in one limb.
The tremor is generally more obvious Avhen the patient is flni-ried,
and sometimes may only be noticeable under such circumstances. It is
more conspicuous when the patients are examined standing up than Avhen
they are lying down.
Besides the tremor Avhich the physician observes on examination, the
patients frequently themselves experience attacks of trembling Avhich may
affect the Avhole of the body, such attacks bearing the same relation to
the tremor that palpitation does to the rapid cardiac action. It is, as a
rule, only when the tremor is aggravated that it interferes Avith the
GRAVES' DISEASE 495
movements of the hands, and then only the more delicate actions are
affected, such as writing, sewing, or buttoning a glove or dress. The
patient will probably use the spoon or fork or carry a cup to the lips
with perfect steadiness. Trousseau remarked of one of his patients, that
on account of trembling she was unable to sign her daughter's marriage
contract.
We shall proceed now to describe the symptoms which are usually
a5sociated with those of more special diagnostic importance already
described.
Emaciation is a very characteristic feature of all acute cases, or of
those in which the disease is active. Sometimes the degree of emaciation
is extreme, and when this is the case the prognosis is most unfavourable.
A loss of two or three stones is not uncommonly seen. As the disease
subsides the patient regains flesh. Mild cases are sometimes met with
where the patients remain well nourished throughout.
Loss of strength is generally in proportion to the severity of the disease.
Usually the patients are easily tired, but sometimes excitement will carry
them through a great deal of exertion.
The temperature of the body, as a rule, is little elevated if at all. We
have observed the temperature with great care in a large number of
cases and find that a rise of temperature is quite exceptional. Some
ob5ervers, however, have recorded febrile cases. Our belief is that,
generally speaking, if fever is present it is due to some complication.
Although the temperature may not be raised, a subjedire feeling of heat is
the rule. It is most troublesome at night when the patient is in bed,
and even when the weather is cold she will feel warm with an amount
of covering which a healthy person would consider quite insufficient.
She likes cold weather and is very intolerant of heat.
Affections of the skin are of considerable interest and are not in-
frequent.
In the first place the patients often suffer from flushing of the head
and neck, especially when under observation. At the same time they
feel as if the blood were rushing to the head, and their face and neck
become uncomfortably hot. These attacks, although worse under observa-
tion, often come on without apparent cause. The sweat-glands are
generally over-active, and sweating may be much in excess. Sweating
of the hands and feet may be a source of great annoyance to the patient.
The increased moisture on the skin is no doubt the cause of the great
diminution of the electrical resistance of the body observed by Vigouroux
and Charcot.
Pigmentary changes in the skin are not uncommon. The complexioii
almost invariably suffers. The skin of the face and of other parts of the
body becomes dark and muddy-looking. Sometimes a general bronzing
of the skin takes place. At other times irregular patches of pigmentation
appear on various parts of the body. The parts generally aftected are
the face, neck, the sides of the chest, the nipples, the abdomen, the
lumbar region, the axillae, and the flexures of the arms and thighs. The
496 SYSTEM OF MEDICINE
colour of these parts is a more or less dark brown in marked contrast
■with the normal colour of the skin on the front of the chest. Sometimes
the pigmentation is limited to the eyelids.
Patches of leucoderma have also been noticed occasionally.
The association of scleroderma with Graves' disease has been recorded
by several observers.
Mention must also be made here of the occurrence of a fleeting
oedema which appears and disappears quickly in various parts of the body.
Factitious urticaria has also been observed.
The nutrition of the hair also is generally affected. Many patients
complain of the thinness and falling out of the hair, which is abnormally
dry as well as scanty. The hair of the eyebrows and eyelids may also
fall out. The axillary and pubic hair may similarly be affected. Almost
universal alopecia has been recorded.
In connection with the change in the hail', it may be pointed out
that the teeth also frequently become carious during the course of the
disease.
Ancemia is often present to a certain degree among the younger
patients, but is not a constant symptom. That it may be a marked
feature of the disease is shown by the fact that Begbie considered it to be
the primary factor in the malady, while Wilks has cautioned the in-
experienced to beware of mistaking cases of Graves' disease for ordinary
anaemia.
Epidao-AS is not infrequent in the course of the disease as well as before
it ; of this we have had a number of examples. Trousseau recorded
the occurrence of pulmonary, intestinal, meningeal, and cerebral haemor-
rhages.
Dr. Dreschfeld has lately called attention to the occurrence of
acetonicmia in connection with attacks of persistent vomiting, to which
reference will be made farther on.
In the respiratory system the chief troubles are nervous cough and
attacks of dyspncea. The cough is generally dry, like that observed in
cases of ordinary goitre. The attacks of dyspncea are attended with
aggravation of all the symptoms, swelling of the vessels of the neck,
blueness of the face, and impending asphyxia. Such attacks have at
times proved fatal. It has been supposed that they arise from a sudden
increase of direct pressure of the goitre on the trachea ; and this is
supported by the resemblance they bear to the similar attacks which
arise in cases of aneurysms pressing on the trachea or main bronchi, and
by the fact that the trachea bears evidence of ha\-ing been compressed
laterally. Attacks of dyspnoea of a similar kind are ()l)scrved in the con-
dition known as athyroidea, and it is therefore improliable that they
depend merely on mechanical causes. A symptom recorded by American
authors as Bryson's symptom is by no means characteristic, and is only
exceptionally met with. This consists of greatly diminished expansion
of the chest in inspiratitjn.
Little has to be added to what has already been said in regard to
GRAVES' DISEASE 497
circulatory disturbances. (Edema of the lower extremities is not infrequent
as a result of cardiac weakness. General oudema may occasionally be one
of the main features of the disease at an early stage, and there may be
effusions into the serous cavities as Avell as anasarca. Sometimes local
cedema has been observed, such as that already referred to as affecting
the eyelids. (lEdema has been observed to be more marked on one side
than on the other ; this is indej^endent of position, and is associated with
vaso-motor 'disturbances. A very interesting form of swelling has been
observed by us in Avhich the lower extremities become greatly enlarged
without any pitting. Such non-pitting swelling was first descrilx'd by
Basedow, and is j)robably of the same nature as the swelling which is
observed in myxoedema.
The digestive sijstem is commonly disturbed. The appetite is often
capricious, and the patient, like a pregnant woman, has longings for unusual
kinds of food. Sometimes the appetite is ravenous, and the patient can
hardly "wait for the conveyance of the food to the mouth. On the other
hand, especially Avhen the disease is progressing unfavourably, thei'emay
be more or less complete anorexia. Excessive thirst is also a frequent
symptom, and the patient will sometimes gulp down Avater Avith the
greatest eagerness and impatience. Vomiting, apparently unrelated to
the ingestion of food, is not uncommon. Looseness of the boAvels is a
very frequent symptom. It is apt to come on Avithout apparent cause,
and as a rule is attended Avith no griping. The patient may have four
or five loose motions in the course of the day, and this may continue for
a Aveek or a fortnight at a time. Sometimes acute attacks of diarrhoea
may supervene, Avhich completely prostrate the patient and occasionally
prove fatal.
Vomiting sometimes becomes a \-ery grave symptom. The patient
complains of epigastric pain, and can retain nothing on the stomach. Dr.
Dreschfcld states that in seA'en cases Avhere such attacks have occurred,
he ol)served that the breath had a peculiar SAveet odour, and that the
urine not only smelt of acetone, but gave the characteristic reaction of
diacetic acid. With the A'omiting there is intense piostration, restlessness,
and the dyspnoea or air hunger observed in diabetic coma. Fortunately
these symptoms not infrequently pass off, but they occasionally end in
death. Sometimes vomiting and diarrhoea occur together.
Intermittent alhiiminnyia, generally considerable and sometimes ex-
cessive, has been recorded by Warburton Eegbie and others, but cannot
be considered as a common feature of the disease. Sometimes poly-
uria and sometimes glycosuria haA^e been observed. In most cases,
hoAA^ever, the urine is normal in amount, and free from albumin and
sugar.
The catamenial function is generally deranged during the course of the
malady. Irregularity of menstruation, amenorrhcea, and menorrhagia are
common, lint in some cases the function is normal. Female patients
frequently suffer from leucorrhoea.
The existence of the disease does not appear to offer any obstacle
VOL. IV 2 k
498 SVSr£J/ OF MEDICINE
to the occurrence of pregnancy. As lias been pointed out, patients
frequently improve during pregnane-}', and geneially go to full time. In
some of the cases under our care severe flooding occurred after delivery.
As a rule, in them also the influence of pregnancy was favourable ; although
we have observed cases where the symptoms of the disease have appeared
for the first time during gestation.
We now come to what arc the most interesting of the symptoms of
this complex disease, those, namely, att'ccting the
Nervous system. — A change in the mental condition of the patient is
often one of the earliest symptoms. She becomes abnormally irritable,
excitable, fidgety, and restless. She longs for continual change, and
feels she must constantly be seeing or doing something new. Often she
is quite uncomfortably conscious of this alteration, and will tell the
physician all about it ; at other times he only hears of it through the
patient's friends. At one time she is low-spirited and lachrymose, at
another she is buoyant and smiling. The moral nature is often j3er-
verted, so that the patient becomes spiteful, untruthful, suspicious, and
generally discontented. She is wayward and Avilful, and cannot bear to
be th waited or contradicted. She is readily upset hy any unusual
occurrence. A sudden loud knock at the door, or the arrival of a tele-
gram, may throw her into a state of great agitation, perhaps lasting for
hours. She is profoundly affected by the receipt of good or bad news.
Such patients are very trying to relations and friends with whom they
live, or to the nurses who attend upon them. The sleep is often dis-
turbed ; the restless patient tosses about in bed, is troubled with dis-
agreeable dreams, and is apt to wake up in a fright. Sometimes she
walks in her sleep or jumps out of bed, and wakes to find herself on the
floor.
Although mental changes are common, cases are met with now and
then in which the patient remains placid, good-tempered, and generally
amiable. In other cases, again, more serious mental changes occur, and
the patient Ijecomcs quite insane. Melancholia and mania ai-e the usual
forms which the insanity assumes. Such eases are usually fatal.
Headache is frequently complained of, but presents- no peculiar
features. Those afiected with the disease are also liable to neuralgias of
various kinds.
The tremor or trembling, already mentioned as one of the cardinal
symptoms, belongs, of course, to disorders of the nervous system. Among
the other nervous symptoms are painful cramps. These often occur in
the extremities, especially in the hands and feet ; they commonly come
on in the feet and legs at night-time. As a rule, these cramps do not
last long ; Ijut occasionally we have observed more persistent spasm in
which the hands assume the characteristic form seen in tetany.
Another trouble which patients experience is giving way of the legs
when walking or standing. They feel their knees suddenly giving way,
and they cither fall or .save themselves with dilficulty. It is interesting
to notice that the same symptom is common in myxoedema.
GRAVES' DISEASE 499
A decided feebleness in the lower extremities, almost amounting
to paraplegia, has been observed in some aggravated cases of the dis-
ease. Hemiplegia and monoplegia have also been observed, but these
are decidedly rare. The tendon reflexes are present and are generally
brisk.
Varieties of the disease ; course and duration. — A well-marked
case of Clraves' disease is Aery readily recognised at first sight. The
malady is typical when all the four cardinal .symptoms— goitre, exoph-
thalmos, rapid cardiac action, and trembling— are present. \Mien the
chief symptoms are present, many of the others Avill be found also. Of
these chief signs, exophthalmos is that by means of which the nature
of the case is usually recognised.
It must be borne in mind, however, that the disease is often incom-
plete, and in its slighter forms may easily be overlooked. The most
important and most essential symptom is the rapid cardiac action. The
goitre and the exophthalmos may ])e present '\\\ very varying degree.
The enlargement of the thyroid may be so slight that the patient may
never have been conscious of it, and at the time she comes under the
observation of the physician none may be perceptible. The exoph-
thalmos may exist to such a small extent as to escape notice.
We hesitate to go so far as Trousseau, who said : " I believe that the
disease may be foreseen, and does really exist in a great number of
instances without there being exophthalmos, bronchocele or extreme fre-
quency of the pulse." "Without at least one of these features with some
of the associated symptoms we do not consider the diagnosis of the disease
can be made. AVe are, however, satisfied that incomplete forms of the
disease {formes frustes) are not at all uncommon. Charcot and Marie
have specially called attention to the incomplete forms. Two A-arieties
of the disease may thus be described — the complete and the incomplete. The
manifestation of the complete form of the disease throws light on the
incomplete form. In some cases all the four main symptoms appear
more or less simultaneously. More commonly, hoAvever, one or two
symptoms shoAV themselves first. Thus rapid cardiac action A.ith tremor
and palpitation and some of the secondary symptoms mny first appear,
while exophthalmos or goitre, or both, folloAv later. Indeed the malady
may suljside Avithout the appeai'ance of the latter, and the case is then an
incomplete one. Sometimes exophthalmos is the first symptom to appear,
sometimes it is the last. INIost commonly the goitre is the first sign of
the disease. The incomplete form is characterised by rapid action of the
heart, tremor, nervous irritability, together Avith probably slight SAvelling
of the thyroid and slight ocular symptoms.
Again, the disease may be divided into the acute and the chronic forms ;
the latter of common occurrence, the former more rare. In the acute
cases the symptoms may disappear Avithin a fcAv days. A number of the
reported cases have been in quite A'oung children. In a case reported by
Moore the symptoms, Avhich appeared in a young girl on reading a letter
telling of her brother's death, lasted only two days. Soll)rig has reported
500 SYSTEM OF MEDICINE
a case of a boy aged eight, who, after suffering from palpitation, enlarge-
ment of the thyroid, and i)ronunencc of the eyes, entirely recovered after
twelve days. A case in a gii-1 of ten years, where the duration Avas six
weeks, was reported hy Miiller ; the symptoms were extreme awkward-
ness in the movements of the hands, frequent vomiting, lassitude, and
pains all over the body followed by exophthalmos and swelling of the
thyroid.
Numerous cases have lieen related where the duration has been no
more than three or four months.
Besides these cases of short duration followed by recovery, there are
others where the illness has ended fatally within six weeks of the onset.
The acute cases arc, on the Avhole, extremely rare ; and it is evident
from those which have been recorded that in them recovery is commoner
than death.
A considerable number of the chronic cases begin more or less acutely;
and in the course of a chronic case acute symptoms may appear, so that
no hard and fast distinction can be drawn between the two forms.
Another division may be made into primary and secondary cases. The
secondary cases are those where the disease occurs in a patient who has
previously suffered from ordinary goitre ; these cases are not very common.
While the duration of the acute cases varies from a few days to a
few months, that of the chronic cases is, as a rule, to be measured by
years. AYe have had cases under our care where the duration of the
disease has been over twenty years.
Relapses are not at all uncommon. Sir R. Gowers speaks of a patient
who had three attacks at intervals of several years. Trousseau relates the
case of a lady wTio, for the sixth time during six years, presented all the
symptoms of the disease, and each time was much benefited by hydi'o-
pathic treatment. Dr. Huggard of Davos Platz has shown us the case of
a lady who relapsed repeatedly on leaving the high altitude-s, and finally
presented some of the symptoms of myxoedema. Mobius speaks f>f re-
lapses as the rule. They may occur after years of apparent recovery.
Our opinion is that in these cases the disease has really never subsided ;
that the recovery has been apparent only, and that the relapses may
more pi-operly be considered as exacerbations or recrudescences of the
malady. The possibility of relapse must be taken into consideration in
making a prognosis.
A sequel to exophthalmic goitre which has now l)een observed in a sig-
nificant number of cases is myxcedcma. Occasionally the two conditions
seem to be coml)ined ; the symptoms of myxoedema supervening, while
those of exophthalmic goitre are still present. Sometimes mvx(vdema
follows closely on exophthalmic goitre, but there may be a long interval
between the time of onset of the two diseases.
Death may occur directly from the malady itself or as the result of
intercurrent diseases. The end may be sudden and due to syr.copc.
Syncope may occur in patients who are apparently going on well. Thus
Dr. Hale White mentions the case of a young woman, an in-patient in the
GRAVES' DISEASE 501
Hospital, but not ill enough to be confined to bed, who, seeing the electric
current applied to another patient, asked that it might be tried on herself.
On the application of the current she fell back dead, having been laugh-
ing and talking only an instant before she died. It is, however, more
usual to have some previous evidence that the case is not progressing
satisfactorily. A form of marasmus occasionally ensues and the patient
becomes greatly emaciated and prostrated. Persistent vomiting, diar-
rhoea, and dyspnoea may usher in death. In this condition also death
may occur from cardiac failure. Sometimes mania occurs and precedes
death.
In about half of the fatal cases the end comes from intercurrent dis-
eases. Of the latter the commonest are pneumonia, bronchitis, and
cardiac disease. The disease may prove fatal at almost any stage. We
have mentioned that death may occur within six weeks of the onset.
We have observed a fatal termination in a case of fifteen years' standing.
Diagnosis. — There is no difficulty about the diagnosis when the
symptoms of the disease are well marked. Slightly marked cases are
frequently overlooked on too cursory an examination. The combination
of symptoms which have been described cannot, however, be mistaken for
any other disease.
Prognosis. — It Avill be gathered from the account we have given of the
course of the disease that a guarded prognosis must always be given.
The duration, the course, and the end of the disease in any individual case
must be uncertain. Relapse, as we have seen, occurs even after the
apparent subsidence of the disease. The more severe the symptoms the
greater will be the anxiety as to the issue. Progressive emaciation, loss
of strength, great rapidity of the heart's action, anorexia, continued vomit-
ing, diarrhcea, dyspnoea, muscular tremors, must all be looked on as
symptoms of grave omen ; on the other hand, many cases present a mild
course throughout, and in these a hopeful prognosis may be given with
some confidence.
The disease is, as a rule, so long drawn out that many cases get lost
sight of, especially in hospital practice ; and a good deal of uncertainty
thus prevails as to the issue of them.
We have summarised the result in thirty-three patients observed by
us in which the disease either lasted over five years or ended fatally. Dr.
R. T. Williamson has similarly tabulated the result in twenty-four cases
observed at the Manchester Infirmary.
Result in Fifty-seven Cases.
Fatal termination .
Recovery complete .
Recovery almost complete
Improvement considerable
Improvement slight
In statu quo
Alive, but exact condition not known
Our own
Dr. Williamson's
T/-.f a
Series.
Series.
iota
8
6
14
5
6
10
9
2
11
9
4
13
1
3
4
1
3
4
0
1
1
502 SYSTEM OF MEDICINE
Buschan, out of 900 cases collected by him from records, found a fatal
result recoi-(lcd in 105. We think avc shall not be far wronc; in savin"
that in about 25 per cent of the well-marked cases death Avill result from
the disease. In about 50 per cent more or less complete recovery will
eventually take place.
There does not seem to be any guide to the duration of the malady.
Before they disappear the symptoms may last from a few months to
many years.
Even when recovery takes place, the disease as a rule docs not
leave the patient as she was before the attack. Trousseau remarked
Avhen recovery took place that swelling and induration of the thyi-oid with
prominence of the eyeballs always remained. In the generality of cases,
no doubt, this is true ; l>ut sometimes the exophthalmos quite disappears
and the goitre may vanish. The latter is more likely to be the result if
the exophthalmos be moderate and the goitre small. The longer
exophthalmos lasts, and the more extreme it is, the more probable is it
that it will be permanent.
It is interesting to note that, according to Dreschfeld, the prognosis of
exophthalmic goitre m children is not unfavourable. Some of the little
patients recover completely ; in others, as in adults, a certain degree of
goitre and exophthalmos may remain Avithout other troul)les. In the
few cases in children Avhich have ended fatally, death has resulted from
intermittent affections, and not from the disease itself.
Morbid anatomy. — General emaciation is usually first to be noted.
The prominence of the eyes is not so marked after death as during life.
An excess of fat in the orbits, or rather an excess as compared with the
general amount of fat in the body, has been observed. The thyroid
gland shows general and uniform enlargement. The thymus gland is
often not only persistent, but large. An increased amount of coimective
tissue in the neck, enlarged cervical and bronchial glands, and enlargement
of the lymphatic structures of the intestines, have sometimes been
recorded. The spleen is occasionally enlarged. There are usually no
naked-eye changes in the nervous system.
The heart may be normal, dilated, or the seat of vah-ulni- disease.
The lungs are unaffected save for accidental complications, of which
pneumonia is the most common.
The condition of the thyroid and thymus glands must be more
particularly considered. It has been alleged that the thyroid gland in
this disease is extremely vascular. The vascularity is, however, princi-
pally superficial. The veins over the capside are dilated and numerous.
The nutrient arteries are also cnlai-gcd, tortuous, and dilated. Dr. Green-
li'dd oljserves that in cases examined by him there has been no increase
in vascularity of the gland itself, but lathcr a diminution. Mr. Edmunds,
however, states that a remarkable h^^pertrophy of the blood-vessels is
sometimes found, and F. T. Paul is of opinion tliat the vascularity of the
gland in (Ji-avcs' disease is decidedly greater than in other forms of
goitre. The vascularity of tlie gland seems to be simply the result and
GRAVES' DISEASE 503
the concomitant of increased activity, and will vary according to the
stage of the disease. For this reason it is more likely to he ol)served in
the specimens removed hy the surgeon than in those wliich arc obtained
in the i^ost-mortem rooms. The enlargement of the gland is a general
one. On section the tissue is firm but elastic, and of a brownish colour ;
its consistence is less than that of the ordinary gland. Sometimes there
are irregular swellings due to encapsuled masses of tissue in which are
numerous islands of colloid material.
On microscopic examination the striking feature is the great increase
of secreting structure. The secreting structure, moreover, is not merely
increased, but is much altered. The epithelium lining the vesicles is
changed in form from the cul>ical to the columnar .type ; there is in-
creased proliferation also, so that the lining membrane becomes convoluted,
and papillary projections into the spaces are commonly seen. The
seci'etion contained in the vesicles is more mucous than the ordinary
colloid, and stains much less deeply. Desijuamation of the epithelium is
not uncommon, so that the vesicles contain detached columnar cells. In
addition to the changes in the vesicles there is the production of a great
numl)er of newly-formed tubular spaces lined by a single layer of cubical
epithelium. These columns, as Dr. Greenfield points out, closely resemble
the tubules of a secretory gland.
At a later period the gland may become firmer from the growth of
fibrous tissue, and the proliferative changes may be ol)scured.
Ednuuids has shown the great similarity between the gland-tissue
in exophthalmic goitre and that in an, animal which has had a large
portion of the thyroid removed by operation. From this he infers that
the alteration in the thyroid gland in Graves' disease is of the nature of
compensatory hypertrophy.
Greenfield has pointed out the resemblance in appearance of the
goitre to a salivary gland. The goitre, according to him, bears the same
relation to a normal gland that the mammary gland during lactation bears
to the quiescent gland.
The persistence and enlargement of the thymus gland is certainly
a very frequent if not a constant feature of the disease. Isolated cases
were recorded by Markham and Goodhart many years ago. In all the
cases we have recently examined post-mortem at St. Thomas's Hospital
we have found this condition, and the experience of pathologists at other
hospitals is to the same effect. The thymus gland in these cases consists
of two flat triangular fleshy Iwdies lying behind the manubrium sterni,
and reaching down to the pericardium, over the upper part of which they are
spread out like an apron. Unless specially looked for, the thymus may
be easily missed.
The thymus tissue, under microscopical examination, presents no
features different from those of the gland under ordinary circumstances,
but shows the usual structure, including the corpuscles of Hassall.
Alterations in the sympathetic ha^e Ijeen described by some patholo-
gists, but it has not been sho^\n that the changes found are in any waj'
504 SYSTEM OF MEDICINE
peculiar to exophthalmic goitre. Dr. Greenfield describes swelling of the
ganL,dia with marked hyperamiia in the more superficial parts, active
invasion of the tissue by leucocytes, and degenerative changes in the
ganglion cells.
As regards the central nervous system, minute lia^morrhages have
been o))scrved by Greenfield and Hale White ; but beyond these there is
nothing of importance. Most careful and thorough examination of the
pons medulla and othci- parts in a case at 8t. Thomas's Hospital failed to
reveal any microscopical changes.
Pathology. — A great many hypotheses have been propounded to
explain the curious symptoms of this disease. It has been ascribed to
an idtoi'ed condition of the l)lood, to an affection of the sympathetic, to a
derangement of the emotional nervous system, to a disorder of the ganglia
about the fourth ventricle, and finally to the diseased condition of the
thyroid gland itself. We have seen that there are no characteristic
changes in the blood, and such as have been observed do not appear to
stand in any causative relation to the disease. The sympathetic ganglia,
it is true, in some cases, have been found diseased ; but this is not a
constant feature. Only some of the symptoms of exophthalmic goitre
can be explained bv affection of the symj)athetic, and it is impossil)le to
fornuilate a satisfactory theory of the malady on this basis. The de-
rangement of the emotional nervous system Avill explain a good deal, but
does not account foi' the eidargement and over-activity of the thyroid,
nor for the persistence and hypertroj)hy of the thymus.
The same may l)e said as regards a disorder of the ganglia in the
nei(ihl)Ourhood of the fourth ventricle. AVe think that too nuich im-
portance has been attached to a few, as yet unconfirmed, experiments by
Filehne on animals. He claimed in one case to have produced ex-
ophthalmos, enlargement of the thyroid, and increased cardiac action, by
dividing the anterior fourths of the restiform l)odies. Minute luemor-
rhages in the medulla are found in a variety of affections besides
exophthalmic goitre — in myxedema, for example — and are clearly the
result, not the cause of the disease. No mere limited lesi(»n of the bulbar
nuclei could explain the widely spread character of the sym])toms.
Since a knowledge has been gained of the great functional importance
of the thyroid gland, exophthalmic goitre has l)een attributed by many
Avriters to a disease of tliis organ. Mobius was one of the earliest of
those who supported this opinion.
AVe have seen that the gland has a nuich increased blood-supply, and
that the microscopical a])pearances show increased secretory activity with
hyperplasia of the epithelium. It ma\' with reason be inferred from this
that ail amount of th^'roid secretion greater than usual will be discharged
into the circulation. If the change in the thyroid be the cause of all the
symptoms of the disease we should expect to find in it the reverse of the
picture in myxredema. The contrast which the two diseases jM-esent has
been dwelt on by many writers, and especially by Miiliius. Comparing
the myxojdcma patient on the one side with the victim of exophlhalinic
GRAVES' DISEASE 505
goitre on the other, we see many points of contrast. One patient, the
myxoedematons, gets more and more bulky, while the other steadily
loses flesh. The one is intolerant of cold, the other of heat. The skin
of the one is dry and swollen, of the other moist and shrunken.
The temperature of the one rarely rises above the normal ; that of
the other rarely if ever falls below it. The one is slow, placid, and
delil)erate ; the other quick, irritaljle, and impulsive. The heart's action
in the one is cpiiet, in the other rapid.
We know that the secretion of the thyroid gland Avhen administered
to a patient in large doses, either by subcutaneous injection or by the
mouth, has the power of increasing the rate of the heart's action, of
causing loss of body-weight, and of stimulating the action of the skin. It
raises the subnormal temperature of the myxoedematous patient to the
normal or above it, and in over-doses produces vomiting, headache, and
violent pains in the limbs. If over-activity or over-secretion of a hyper-
trophied thyroid gland were the whole disease, it ought to be possible to
produce it by the administration of large quantities of thyroid gland.
No one has yet succeeded in causing exophthalmos in this way.
It is here that the hypothesis that the disease is due to over-action of
the thyroid gland fails. The supporters of this hypothesis have, therefore,
fallen back on another surmise ; namely, that not merely is the gland
over-active, but that its secretion, besides being increased, is also per-
verted. Of this we have at present no absolute proof.
Some have supposed that the primary disease may be in the para-
thyroids. The resemblance of many of the symptoms of exophthalmic
goitre to tlioso of athyroidea, which there is good reason to believe depends
on removal of the parathyroids, has been pointed out by Edmunds and
others. Exophthalmos, however, has not been observed to follow
removal of the parathyroids during the short time which the animals
survive this operition.
No explanali lu has yet been given of the relation of the persistent
thymus to the disease.
Treatment. — The natural course of the disease is so variable that
there is great difficulty in correctly interpreting the effects of treatment.
Under similar conditions as to treatment some cases improve rapidly,
some remain stationary for a long time ; others fluctuate, or steadily lose
ground, and end fatally. It is not surprising that a great many remedies
have been employed for such a disease, and that there should be much
difference of opinion as to their value. Hygienic measures are of great
importance. The diet should be carefully regulated. It will be found
that the patient has sometimes a craving for most iinsuitable articles of
food, such as nuts, pickles, shell-fish, pastry, and ices. Such things
should be strictly prohibited. Meals should be taken at regular intervals,
and should consist of plain, wholesome, well-cooked meat, with a proper
proportion of vegetables and fruit. In regard to the amount of the
latter we must be guided by the condition of the liowels. Tea and
colfee should be allowed Avith discretion, and in small quantity. The
5o6 SYSTEM OF MEDICINE
patient, as a rule, is better Avitliout alcohol. The disease being so
rare in men, it is almost superfluous to say that tobacco should be for-
bidden ir^ all its forms.
In the less severe forms of the disease a moderate amount of exercise
in the open air is beneficial. Dancing, sight-seeing, visiting theatres
and picture galleries, and shopping should be {)i-ohibited. If the patient
be sent away to some health resort, special injunctions in regajtl to this
matter should be laid down ; as the benefits of the change of air and
scene may be altogether counterbalanced by the excitement of social
entertainments.
In se\orc cases, where the heart's action is A'cry rapid and the patient
is losing ground, rest in the I'ecumbeut position should be oi'dered.
Change of air and change of scene often j^rove most beneficial. The
change should be as thorough and as restful as possible. Sometimes the
seaside suits the patient better, sometimes an inland health resort.
Mountain air, especialh' the high altitudes of Switzerland in winter, has
occasionally proved of great service. A sea-voyage also has been credited
with an occasional cure.
Baths of mail}' kinds have been found useful ; but it is difficult to see
how they act in the case. Tepid sea-water baths or effervescing mineral
baths have been found serviceable ; but open sea-baths, cold and hot Ijaths
should be avoided. Hydropathic treatment, douching, and massage are
held m much esteem in France for the relief of this malady.
Local cold applications to the thyroid have sometimes been found to
quiet the circulation. Leiter's tubes may be conveniently used for this
purpose.
The principal drugs which have been employed are those which have
an effect on the heart or circulation, on the nervous system, or on the
thyroid gland. Thus digitalis and strophanthus have been employed for
their action on the heart ; belladonna, bromide of potassium, and opium
for their effect on the ner\ ous system ; while the iodides have been used
on account of their influence on goitres in general. As regards digitalis
and strophanthus, we have found some patients very intolerant of them ;
others have derived benefit. A more generally useful drug is belladonna
in doses of ten to fifteen minims of the tincture three times a day.
Its principal effect appears to be on the nervous system, the patient
feeling better and less excitable and restless while taking it ; it has,
however, little effect on the cii'culation. Bromide of potassium we have
also found useful Avhere the nervoiis symptoms predominate. It may be
given either in combination Avith belladonna or in a single dose of twenty
or thirty grains at bedtime. Opiiun, which has been recommended by
Cheadle and others, is in our experience not well borne. Iodides, except
in combination, appear in many cases to aggravate the malady, although
in rare cases they may be of benefit. Iron is useful when the disease is
combined with chloi-osis or a marked degree of aiuemia, otherwise it is
not beneficial. Arsenic is sometimes of use, and two to five minims of
the liquor arsenicalis may be given after meals. A remedy which has
GRAVES' DISEASE 507
lately been much used is phosphate of soda, of Avhich fifteen to thirty
grains may be given three times a day. We have used it, but are not
convinced that it is beneficial. The glyeero-phosphate is said to be better
than the ordinary phosphate. Cod-liver oil, if the patient can take it, is
useful when there is malnutrition. Some recommend it in lai-ge doses,
and by the rectum as well as by the mouth. We have given pancreatic
emulsion, as recommended l:)y Dr. Dreschfeld, with apparent benefit.
It is unnecessary to add, as regards drugs, that cases must always be
treated on general })rinciples. If dyspepsia be pi'esent, or diarrhoea, or
constipation, the appropriate remedies must be employed. Complica-
tions must be treated as they arise. In the attacks of A'omiting the
imticnt must be fed by the rectum. Dreschfeld speaks of citrate of
potash in large doses as a most useful remedy in checking the
vomiting.
Galvanism has been employed for many years. It was first intro-
duced to influence the S3"mpathetic in the neck, one pole being placed at
the back of the neck and the other over the sympathetic, first on the one
side, then on the other. Weak currents should be used, and the direction
may be reversed. The poles may be applied also to the eyes, the thyroid,
and the region of the heait.
Vigouroux recommends faradisation in preference to galvanism. The
positive pole of a large electrode is applied to the neck, while the negative,
a small electrode, is applied in succession to the carotids, to the eyelids,
and to the goitre.
We have made a fair trial of both . methods, and are very doubtful
whether any benefit has followed their use apart from the mental im-
pression made upon the patient.
Of recent years thyroid, thymus, and other organic preparations have
been employed. Thyroid gland prepai-ations, theoretically speaking,
should always make the disease worse. Although usuall}^ we haAe found
the patient's symptoms distinctly aggravated even by small doses, yet
we have given large doses without affecting the patient in any Avay. We
have not ol>served any case where the patient was decidedly benefited.
A number of cases of reported benefit from thymus gland preparations
having been reported by various observers, Ave made an extensive trial of
them in tAventy cases of the disease. The conclusion Ave came to Avas
that no appreciable effect folloAved their administration, although in a fcAv
cases the patients felt better Avhile taking them.
Trousseau has recorded that great relief has been afforded during
attacks of dyspnoea by leeching or bleeding.
OperatiA'e treatment has recently been in vogue, principally in
Germany. Lister in 1877 removed the bulk of a goitre in a case of this
disease Avhere life Avas threatened by suffocation. In a fcAv Aveeks all the
symptoms Avere alleviated, and the patient, Avho AA'as still alive in 1887,
then presented fcAv signs of her former malady. Since that time larger
or smaller portions of the goitre have been surgically removed in many
cases. The most complete statistics on the subject have been published
5o8 SYSTEM OF MEDICINE
by Starr. Out of 190 cases operated on, 23 died as the immediate
result ol the operation ; 3 were in no way improved ; 45 were improved,
and 74 were reported as entirely cured: in 45 the results were douhtful.
If we com]iare these results with those of other metliods of treatment, Ave
find no striking difference except a death-rate of 12 per cent due to the
operation. We have seen that recovery takes place in about 40 per
cent, and operation does not give a lai-ger proportion. The risk of death
from the operation is much gieater in the acute cases than in the chronic,
and we consider that operative removal of a portion of the thyroid is
never justifiable in an acute case. In a chronic case we should only be
disposed to recommend it where the tumoiu* seriously interferes with the
breathiiin, or where other methods of treatment have failed. We have
had a portion of the thyroid removed by the surgeon in two chronic
cases ; in one, where the exophthalmos was extreme, there Avas no im-
provement, while in another, where the exophthalmos was slight,
decided improvement followed.
The methods of ojjcration have been various. The thyroid arteries
have been ligatured, with the object of causing the gland to atrophy.
The isthmus of the gland has been divided. One lobe, or a portion of
one lobe, has been removed. In cases of well-defined adenoma, or cyst,
the growth has been enucleated.
A method called exothyropexy, which consists in stripping the capsule
from the gland, and so fixing the latter in the superficial Avound as to
produce shrinkage fi'om exposure to the air and from thrombosis of the
A'cnous sinuses, has been introduced by Jaboulay, Avho has had fomleen
successful cases Avrth no death.
Another method of surgical treatment of the disease has recently
been carried out by Jabovday. This consists in section of tlie cervical
sympathetic. Mr. Walter Edmunds suggested the possible utiht}' of this
operation as the result of experiments on animals. He found that the
proptosis produced in monkeys by subcutaneous injection of cocaine
could be lessened by section of the sympathetic. He recommended
division of the sympathetic for cases Avhere the prominence of the eyes
was so great as to cause ulceration of the cornea. Jaboulay, hoAvever,
alleges that an actual and lasting ciu"e may be brought about by this
operation, AAdiich, he says, is easy, and free from ill-cftects, immediate or
remote He has operated in six cases, and in all Avith benefit.
"W. M. Ord.
Hector Mackenzie.
REFERENCES
1. AuiiAM, J. II. "Exophthalmic Goitre," Z«7«w<, ISOf), ii. 1221.— 2. A.MmiANO, A.
"Contril>uto clinico alia jiatogeuesi dc4 niorbo di Flajani," Arch, internaz. d. spec, mal.-
chir. Napoli, 189.5, xi. 376-81. — 3. Auui^uas. " tin cas de goitre exoijlitalnnqiie,"
Revue gen. d'ophl. I'aris, ISQ.'J, xiv. 97-99. — 4. Baldavin, W. W. " Some Cases ofCiravos'
Disease sncfeedi-d by Tliyroiil Atrophy," Lancet, 189.'), i. 14.'). — h. Bakki.i.a, Wii.iiklm.
Ucbcr cinscUiycn Exophlluilmus bci Morbus Jiaseduwii, BerL 1894, G. Schadc, 3- pp.
GRAVES' DISEASE 509
— 6. Basedow. WochnscJir. f. d. gcs. Ileillc. Nos. 13, 14, 1840, and C:is2)er's JJ'ochnschr.
No. 49, 1848. — 7. Bii;cLfeRE, A. " Uu iiouveau cas ile niyxcedenie rrueri par ralinientation
thyroidienne ; le thyroidisme dans ses rapports avec la maladie de Basedow et avec
riiysterie," Bull, et m6m. soc. vied, des hop. de Paris, 1894, 3 ser. xi. 631-46, 1 plate. —
8. Bkubie, J. EdAn. J/cfZ. Jbitni. Feb. 1849. — 9. Begbie, Warburton. Edin. Med.
Juurn. Sept. 1863. — 10. Bekger, E. " Du larmoiement dans le goitre exojilital-
rniquc," Bull. m&l. Par. 1893, vii. 241.— 11. Bershing, H. T. " A Case of Lxoph-
thalniic Go'itK," Denver Med. Times, 1891-92, xi. 429-36.— 12. BiENFAiT, A. " Etude sur
la pathogenie de la maladie de Basedow," Ann, soc. med.-chir. de Litge. 1895, xxxiv,
111-26 ; Gccz. mid. de Likge, 1894-5, vii. 328. — 13. BoETEAU, L. Des troubles ■psyddques
dans le goitre exofldalmiquc , Paris, 1892, G. Stiinheil, 114 pp. — 14. Bogroff, A. ["Con-
tribution a I'etude de la valeur physiologique de la glaiide tliyi'oide et de sou role dans la
pathologic et dans la theiapie de la maladie de Basedow "] Yuzhno-russk. i.iM. gaz. Odessa,
1894, iii. 93, 107, 125. — 15. BdiNET and Bourdillon. " Quelques pbenomenes psii
communs dans le goitre exophtalnn(jue," MarftriUe vied. 1891, xxviii. 60tj-60y. — 16.
BoiNEi", E., and Silbekt. "Des ptomaines uriuaires dans legoitre-exoplitidniique,"^ev.
m6d. Paris, 1892, xii. 33-47; Marseille viM. 1892, xxix. 348-67.— 17. Idem. "Des
ptomaines uriuaires dans le goitre exoj)litalmique,".^rm. c^e^'^coZc . . . demed. et2>harm.
de Marseille, 1892, Paris, 1893, 71-90. — 18. Bonne, C. " Examen par la metliode de
Golgi des nerfs intratliyroidieus dans un cas de goitre exophtalmiij^ue," Ilcvue neural.
Paris, 1895, iii. 521-24. — 19. Booth, J. A. " Exoi)htlialmic Goitre ; Thyroidectomy,"
i\'ew York Med. Journ. 1894, lix, 375 ; Boston Med. and Surg. Journ. 1894, cxxx. 391.
— 20. Idem. "A brief Review of the Thyroid Theory in Graves' Disease : Report of two
Cases treated by Thyroidectomy," Jowrw. Nervous and Mental Disease, K.Y. 1894, xxi.
486-93. — 21. Idem. " (Edema in Graves' Disease ; l.'eport of a Case of CEdema of the
Eyelids; Thyroidectomy," Med. Eec. N.Y. 1896, i. 45.-22. Bottini, M. " L'ester-
pazione del gozzo nel morbo di Basedow," Gaz. d. osp. Milauo, ]893, xiv. 97-104. — 23.
BoucHAun. "Goitre exo])htalrnique et ti'emblement hereditaire," Journ. de sci.
7nM. de Lille, 1895, ii. 569-80. — 24. Bradshaw, T. R. "Case of Graves' Disease com-
plicated by Hemiplegia and Unilateral Chorea," Brit. Mrd. Journ. Loud. 1891, i. 1384.
— 2'>. Bramwell, B. "Exophthalmic Goitre," Atlas 0/ Clinical Medicine, fol. Ediub.
1892-93 ; ii. 91-103, 2 plates.— 26. Brandenburg, G. Die Basedow' sche Krankheit.
Leipzig, 1894, B. Konegen, 136 pp. — 27. Le Breton and A'aquez. " Un cas
de myxQideme infantile ; traitement thyroidien ; modifications du sang," Bull, et mem.
soc. m&l. des h6p. de Paris, 1895, xii. 22-29. — 28. Briddon, C. K. "Exophthalmic
Goitre," Annals of Surgery, 1895, xxi. 66. — 29. Briner, 0. " Ueber die operative
Behaudlung des Basedow'schen Krankheit durch Strumektoiide," Bcitrdge zur klin.
Chirurgie, Tubingen, 1894, xii. 704-750. — 30. Brissaud, E. "Les lesions thy-
roidienne.s et la theorie nerveuse de la maladie de Basedow," Archives c/in. de Bordeaux,
1895, iv. 289-318. — 31. Idein. " Cuerpo tiroides y enfermedad de Basedow," Transl.
Semana rued. Buenos Aires, 1895, ii. 329, 335.^ — 32. Idem. " Sur un cas de niort par
exothyropexie pour un goitre exophtalmique," Mul. mod. Paris, 1S94, v. 243-45. — 33.
Idem. "Corps thyroide et maladie de Basedow [rapport]," Ann. de med. scient. et prat.
Paris, 1895, v. 281-87 ; Courier med. Paris, 1895, xlv. 2G6, 273 ; Semaine mid. Paiis,
1895, XV. 326-30 ; Archives de neurol. Paris, 1895, xxx. 225-42 ; Bull. mid. Paris,
1895, ix. 743-54 ; Journ. dc Conn. mid. prat. Paris, 1895, 294, 302, 309 ; Presse mid.
Beige, Brux. 1895, xlvii. 280-83. — 34. Bi;t'hl, L "Des rapports du goitre simple
avec la maladie de Basedow ; des faux goitres exophtalmi(jues," Gaz. d. hop. Paris,
1891, Ixiv. 683, 701.-35. Brxtns, L. "Ueber das Grafe'sche Symptom bei Morbus
Basedowii," Neurol. Centralhl. Leipz. 1892, xi. 6-13. — 36. Bryson, LfiUisE F.
" Exoj.hthalmic Goitre," Post-Gradnate, X.Y. 1891-2, vii. 269-274.-37. Burr, C. W.
"Exophthalmic Goitre," Philad. Polyclin. 1893, ii. 46-50.-38. Bitschan, G. Die
BascdouS sche Krankheit, 1894. — 39. Idem. Die Basedow sche Krankheit (doitre eroph-
tahnique. Graves' Disease, morbo di Flajani), eine Monoqrc(j)hie, Leijjz. u. "Wien, 1894,
F. Denticke, 184 pp. —40. Cardew, H. W. D. "The Electrical Treatment of
Graves' Disease," Abstr. Trans. Hunlcrinn Soc. Lond. 1892-93, 62-66. —41. Idem.
"The Value of diminished Electrical Resistance of the Human Body, as a Symptom in
Graves' Disease," Lancet, 1891, i. 483-485. — 42. Idem. "The Practical Electro-Thera-
peutics of Graves' Disease," Lancet, 1891, ii. 6, 64. — 43. Chamberlaix, Frederick.
Contribution d Titude de la maladie de Basedow et en particulier de sa^ pathoc/enie, Paris,
1894, 211 pp. No. 208.-44. Charcot, J. ,Iir. "Les formes frusLes,'" Gaz. des
hdp. 1885 and 1889. — 45. Ch^eon, P. " fetiologie, pathogenic et traitement du
5IO SYSTEM OF MEDICINE
goitre exophtalmhiue," Tribune m&l. Paris, 1S95, 2 ser. xxvii. 931-3G. — 46. Idem.
"Traitomeat du goitre oxoplitaliiiiciue," Union mid. Paris, 1S9(), 4 s. ii. 301-313. — 47.
Chihukt. " Le sal3-cilati3 dc sonde dans la goitre c.voplitalniiijuc," licvuc gen.
d'opldaliiwhnil,', Paris, 1895, xiv. 1-3. — 48. CirvosmK, F. " Ueber aliiiiPiitaro GJy-
kosurie bi-i Morbus Basedowii," IVien. klin. JFochcnscfir. 1892, v. 251, 207, 325.-49.
Coi.QruoLN, D. "Graves' Disease," New Zealand Med. Journ. Dunedin, 1894, vii.
144-5G.— 50. CouBiN, T. \V. "On Myxa'dema," AvMralas. M. Gaz. Sydney, 1894,
xiii. 155. — 51. Curdell, E. F. " Some Remarks on Exoi)litlialmic Goitre," i1/«.n//rt«<J
M''A. Journ. Bait. 1895-96, xiii. 2S7-90.— 52. Ck.uc, J. "An unusual Case of Kxo])li-
thalmio Goitre," Lancet, 1894, i. 1375. — 53. Idcui. "An unusual Case of Graves'
Disease," Dublin Journ. Med. Sci. 1894, xcvii. 50S-51(;.— 54. Ci;ooK, J. K. "A
Clinical Lecture on Exoplithahnic Goitre (Graves' or Basedow's Disease)," New York
Med. Journ. 1894, lix. 422-24.-55. CuuTis, B. F. "Thyroidectomy for Exoph-
thalmic Goitre," Internat. Clinics, Philad. 4th ser. ii. 213-16.— 56. Davikr, A. T. "A
caseofMyxa'dema after Thyroid Treatment," Trans. Clin. Soc. Lnnd. 1893-94, xxvii. 275.
— 57. Demmk, R. " Basedow'sche Kranklu-it nacli Scharlach," A'lin. Mitth. a. d. Gcb. d.
Kinderhcilk. d. Jciiner'sch Kindcrsp. in Bern, 1S19, 81-83. — 58. Ditisiieim, Max. Urb"r
Morbus Basedow' i, IJiscl, 1895, pj). 92, 3ch. — 59. Dock, G. "Goitre in I\Iichigan." J/er/.
News, Philad. 1S95, Ixvii. 60-63 ; Trans. Assoc. Amcr. Phys. Philad. 1895, x. 101-107.— 60.
Dol^ris, G. A. "Affections genitales de la iemme et la maladie de Basedow," Bull,
et mim. soc. obst. ctr/i/nec. de /'aris, 1895, 298-314 ; Journ. demed. dn Paris, 1895,2 ser. vii.
465, 491 ; N. archives d' obst. ctde fii/nec. Paris, x. 241-254.— 61. O'DoxovAX, C. "A Case
of Exo])htIialmit; Goitre treated dnriugtwo Years with Tincture of Stropjiantlius," J/rtrv-
landMrd,. Jour. Bait. 1894-95, xxxii. 208-210.— 62. Dauchkiitv, C. .A. " Exophthahnic
Goitre, witii a Report of Cases, " Trans. Indiami Med. Soc. Indiauop. 1895, xlvi. 168-78. —
63. DuiCKsMANX, H. "Die cliirurgische Behandlung des Morbus Bascdowii," Deutsche
med. Wochn^chr. Leipzig, 1892, xviii. 90-93. — 64. DuEscHFELr), J. "Notes on Graves'
Disease," Prcuiitioner, Lond. 1896, Ivii. 135-154. — -65. Diu'Mjioxd, D. Brit. Med.
Journ. May 1887.— 66. Durduff, G. N. " Pathogenesis of Basedow's Disease," Bolnitsch.
gaz. Bu/kina, St. Petersb. 1893, iv. 71, 101.-67. Edgewoiith, F. H. "Xotes on a
Case of Exophthalmic Goitre," Bristol Med. -Chir. J. 1896, xix. 41-47.— 68. Edmunds, W.
" Pathology of Graves' Disease," ./uii/'ji. Pcdh. and Bactcriol. Loud. Jan. 1896; Trans.
Path. Soc. Lond. vols. xlvi. and xl vii. — 69. Idem. " Observations and Exjieriments on
the Pathology of Graves' Disease," Journ. of Pathol, and Bacterial. Edinb. ami Lond.
1894-96, iii. 488-501, 11 plates. — 70. Ehrlich, Hans. Ueber Morbus Basedoicii im
kindlichen Alter, Berl. 1890, G. Schade, 31 pp.— 71. E.shner, A. A. "A Case of
Exophthalmic Goitre," I'hda/l. Polyclinic, 1895, iv. 285.-7-2. Eut.kniumu;, A.
Zicni'iscns Uandb. 1875. — 73. Idem. " Ueber Astasic-Abasic bei Basedow'scher Kraidv-
heit," Neurol. Ccntntlbl. Leipzig, 1890, ix. 706-710. — 74. Idem. "Basedow'sche
Krankheit und Schilddrtise," Deutsche med. Wochcnschr. Lciiwig u. Berl. 1894, xx. 769-
72. — 75. EwALD, C. A. "Ueber einen durch die Sehilddriiseutherapie gelieilter Fall
von Myxiidem nebst Erfahrungen iiber anderweitige Anwcndung von Thyrcoideii-
priiparaten," Berl. klin. JFochnischr. 1895, xxxii. 25, 55. — 76. Earner, E. "Beitriige
zur imthologischen Anatomic des ilorbus Bascdowii niit be.sonderer Berucksichtigung
der Strunui," Archiv filr path. Anal. Berl. 1896, cxliii. 509-74, 1' plite. — 77.
Fergu-son, E. D. "Recent Experience in the Treatment of Exophthalmic Goitre,"
rra)i«. New York Med. Ass. 1890. vii. 2-23-230.-78. Idem. "Recent Experience in
the Treatment of ExophthMlmic Goitre," Gail lard' s M. J. N.Y. 1890, Ii. 511-516.-79.
Idem. "An Adilitioual Note on the Use of Strnphanthus in the Treatment of
Exophthalmic Goitre," Journ. Amcr. Med. Assoc. Chicago, 1893, xxi. 187-189. — 80.
Ferri, L. " Dellc cause del sintomo di Gral'e nel moibo di Basedow," Gior. d. r.
accad. di mM. di Torino, 1892, 3 s. xl. 172-180. — 81. Flajani, G. Collez. d' osscrv. e
rifiess. di chirurq. Rome, 1802. — 82. Foot, A. W. "Graves' Disease," Internat. Clin.
I'hilad. 1892, 2nd s. i. 57-75.-83. Forstkr, R. " Ein Fall von Braunfiirbung der Haut
nach liingerem Arsengebrauch bei Basedow'scher Krauklieit," Berl. klin. JYochnschr.
1890, xxvii. n50-li52. — 84. Freibeiiu, A. IL "Tlie Surgical Treatment oi
Exoi.hthalmic Goitre," Med. News, Phila. 1893, Ixiii. 225-230.-85. FiiinENnERc,
P. "A Case of Exophthalmic Goitre, with Alonocular Svmptonis and Unilateral
Thyroid IIypertro].hy," .M-d.. B-rord, N.Y. 1895, xlviii. 46-49.-86. Idem. "Ueber
einen P'all von Graves'sdicr Kr,ud<heit mit Exophthalmus nionocuhiris und einseitiger
Schilddrti.scn Anschwellung," Archiv fiir Ophthalmol oijic, Tiei])zig. 1895, xli. 3 Ablh.
158-68, 1 plate. — 87. FCr.st, A. " Bemerkungen zum Morbus Basedowii," Deutsche
GRAVES' DISEASE 511
mcd. Il'ochenschr. Leipzig u. Beii. 1895, xxi. 338. — 88. Garampazzi, C. "Due cast
di mascliera uel morbi di Flajani," (Jazz. d. os]). Milaiio, 1890, xi. 530-533. — 89.
Gauthier, G. "Corps thyroide et nialadie de Basedow," Li/071 mid. 1895, Ixxx. 5-12.
— 90. Gekhardt, C. " Ueber krankhafte PulsatioDen Lei Schlussunfahigheit der
Aortenklappen uiid bei Basedowr'scher Kraidcbeit," Charif.d-Annalen, Berlin, 1893,
xviii. 243-J8. — ^\. Idem. " Ueber das Verhalten der Korperarterien bei Bascdow'scher
Kraukheit," Mitt. a. d. Grenzgcb. d. Mcd. u. Chir. Jena, 1896, i. 135-138.— 92. Von
Geknkt, R. " Ein Beitrag zur Behandliing des Myxiidenis," Bcutscha Zeitschr. f.
Chir. Leijizig, 1894, xxxix. 455-66. — 93. Giuvanklli, G. " Contributo alia siiito-
matologia e cura del morbo di Basedow," Gazz. mcd. di Pavia, 1893, ii. 289, 313, 337,
366. — 94. Glax. "Zur Klimatotberapie des Morbus Basedowii," Internat. kliv.
Rundschau, Wien, 1894, 1505-7; Wiener vied, tresse, 1894, xxxv. 1878. — 95. "Goitre
(le) exophtalniicjue d'apres les traveau.v recents ; patbogeiiie ct symptomes," Union nied.
Par. 1896, 4 s. ii. 229-234. — 96. "Graves' or Basedow's Disease in A\\\mvi\%" Lancet,
1892, ii. 427. — ^^97. Gkawitz, E. " Morbus Basedowii ; its Synijitoniatology," /;(for?irt<.
Cliidcs, Pliilad. 4th ser. iv. 85-93, 1 2)late. — 98. Geeekfjeld-, W. S. "On some
Diseases of the Tliyroid Gland," Brit. Med. Juurn. vol. ii. 1893. — 99. Gjieiden-
Bui'.G, B. S. "On Mental Alienation in Basedow's Disease," Vcstnik. Klin, i svdchnoi
psichiat. i nevropatol. St. Petersb. 1893, x. jit. 1, 183-194. — 100. Grohmann, Max.
Bcitrdge zur Aetiulogie und Symptomatologie des Morbus Basedovii, Berl. 1^94,
G. Schade, 31 pp. — 101. Gkube, K. " Zur Aetiologie der l^)asedow'scheu Krankheit,"
Neurol ogisches Centra/blatt, Leipzig, 1894, xiii. 179-83. — 102. Guttmann, P. "Das
arterielle Struinagei'auseh bei Bas' dow'sclier Krankheit und seine diagnostiche
Bedeutung," Deutsche mcd., Wochnschr. Leipzig u. Berl. 1893, xix. 254. — 103.
Halt,, A. G. "A Clinical Lecture on Exophthalmic Goitre," Clin. Journ. London,
1895-96, vii. 38-40.— 104. Hawthorn, C. 0. "A Cas<> of Graves' in a Patient tlie
Subject of Articular Rheumatism and Mitral Sti-nosis," Glasgow Mcd. Journ. 1895, xliii.
446. — 105. Hay, C. M. " Exophthalmic Goitre with ilental Disease ; Report of Tliree
Cases with Rare Complications," Med. Age, Detroit, 1891, ix. 327-334. — 106.
Hektoen, L. " Hy|ierplastic Persistent Thynuis in Exophthalmic Goitre," Internat.
Med. Mag. Philad. ]89.')-96, iv. 584, 594.-107. Heurick, J. B. "Exophthalmic
Goitre,'" Internat. Clin. Philad. 1894, 4th ser. ii. 32-36.-108. Herski.nd, E. "Om
den kirurgiske Behandling og Patogenesen af Mb. H&sedowii," Biblioth. f. Lacgcr, Kjobenh.
1894, 7 1!. V. 204-42.-109. Hezel, O. " Ein 'Beitrag zur pathologisrhen Anatomic
des Morbus Basedowii," Deutsche Ztschr. f. Ncrvenh. Leipzig, 1893-94, iv. 353-358. —
110. HiR.scHBKRG, L. "Ueber die Basedow'sche Krankheit; historisch-kritische
Studie," JViener KliniJc, 1894, xx. Heft 2-3, 15-90. — 111. Hitschmann, R. "Beitrag
zur Casuistik des Morbus Basedowii," Wiener klin. Wochc7ischr. 1894, vii. 923, 945. —
112. Van't HoFF, L. "Morbus Basedowii; een pathologische schrickrcactie," A'crfc?'^.
Tijdschr. v. Genecsk. Ani.st. 1895, 2 R. xxxi. pt. 1, 713-31. — 113. Homen, E. A. "Beitrage
zur Symptomatologie des Morbus Basedowii," Neurol. Centralbl. Leijiz. 1892, xl. 427-434.
— 114. HucHARD. "Les c ises d'amaigrissemput dans le goitre exophtalmique," I!ei\
prat. d. trav. d. mdd. Par. 1896, liii. 107. — 115. Lsaac, Rudolf. Beitrag zur
Bathologie der Basedow' schen Krankheit. Siegburg, 1891, W. Reckinger, 35 pp. — 116.
Jaboulay. "Le traitemeut du goitre exojihtalmique par I'exothyropexie," Jfe'c^. mod.
Paris, 1894, V. 275. — 117. Idem. " La regeneration du goitre extirpe dans la raaladie
de I5asedowet la section du sympathique cervical dans cette maladie," Lyon med. 1896,
Ixxxi. 389.— lis. Idem. Z;/oti ?«eV;. March and May 1896 and Feb. 1897.-119. JaccoI'Ij.
" Etiologie et traitement du go^itre exophtalmique," Gaz. d. hop. de Toulouse, 1890,
iv. 377. 385. — 120. Idem. " Etiologie, pmnostic et traitement du goitre exophtal-
mique," Gaz. d. h6p. Par. 1890, Ixiii. 1229.-121. Jeaffrkson, C. S. "Thyroid
Secretion as a factor in Exophthalmic Goitre," La^icet, 1893, ii. 12S1. — 122. Jeanselme,
E. "Sur la coexistence du goitre exophtalmique et de la sclerodermic," Mercredi
mM. Paris, 1895, vi. 1. — 123. Jessnei;. "Morbus Basedow; exitus Jetalis unter
Ersclieinungen von Erbrechen, Durchf'all, Storing der Hirnfuuktionen," Deutsche mcd.
Ztg. Berl. 1893, xiv. 804.— 124. Jessop. "Three Ca.ses of Exoiihthalmic Goitre with
Severe Ocular Lesions," Brit. Med. Journ. 1895, ii. 1296. — 125. Joffroy", A. "Traite-
ment du goitre exophtalmique," Union med. Par. 1892, 3 s. liii. 649, 673. — 126.
Idem. " Xature et traitement du goitre exo]ihtalmique," Progrhs m6d. Paris, 1893,
2 ser. xviii. 477-80; 1894, 2 ser. xix. 61, 165, 205, 217.-127. Joffroy% A., and C.
Achard. " Contribution a I'anatomie pathologique de la maladie de Basedow," Arch.
de m4d. eccper. ct d'anat. path. Paris, 1893. v. 807-825. — 123. Ide^n. "Maladie de
512 SYSTEM OF MEDICINE
Basedow et tabes ; observation avcc atitopsie," Arcli. dc mid. expir. et d'anat. path.
Par. 1893, v. 404-409.— 129. Johnson, F. S. " Exophthalmic Goitre," Trans. Illinois
Med. Soc. Chicago, 1893, xliii. 193-211.-130. Johnstox, G. F. "Clinical Remarks
on Fxophthalmic Goitre, with Special Uelerence to its possible Etiology," Lancet, 1893,
ii. 1121-ir_'3. — 131. Joui.N. " Palholo^'ie uterine et maladie de Hasedow," JJtdl. et
■meui. soc. obst. et gi/ndc. de Paris, 1895, 188-203. — 132. Jousskp, M. " Gorjis thj-roi'de
ct maladie de Basedow," Jrt. mal. Paris, 1895, Ixxxi. 183-93.-133. Kinnicutt, F.
" The Theory of the Origin of Graves' Disease ; with its Bearing on the Surgical Treat-
ment of the Disease," Med. Rec. X.Y. 1S9(;, xlix. 541-546. — 134. Kleixw.\chtei;, L.
"Das Yerhaltcn der Genitalien bei Morbus Basedowii," Ccntralbl. f. Gyniik. Leipz.
1892, xvi. 181-185. — 135. Kkonthal, P. "Morbus Basedowii bei einem zwiiltjahrigen
Madchen und desseu Mutter," Berl. klin. Jl'ocliiiselir. 1893, xxx. 650-652. — 136.
L.xsvfeNES, Geor(;es. Dc la maladie dc Basedow dcvelojipie sur un goitre ancien.. Par.
1891, 39 pp. No. 202. — 137. LEiCHrEXSTEiiN, 0. "Ueher Myxbdem und Uber
Einlettungscuren mit Schilddriisenfiitterung," Deutsche vied. Woclienschr. Leipz. u.
Berl. 1894, xx. 932. — 138. Lemke, F. "Was wir von der chirurgischen Behaudlung
des Morbus Basedowii zu erwarten haben," Deutsche vied. JVochnschr. Leipz. u. Perl.
1894, XX. 809-811. — 139. Idem. " Ueber chinirgisehe Behaudlung des Morbus
'QAS.eiiowu.," Deatschc med. Wochnschr. Leipz. 1891, xvii. 47. — 140. Idem. " Weiteres
iiber die chirurgische Behandlung des Morbus Biisedowii," Deutsche mcd. JFochuschr.
Leipz. 1892, xviii. 230. — 141. Idem. " Ueber Friilidiaguose und Tlieoriedes Jlorbus Pase-
dowii," Miiiu-hen. vied. Wochnschr. 1896, xliii. 334-33G. — 142. Lkxhox, A. A. " Myx-
cedema and Simradic Cretinism," Australas. Mcd. Gaz. Sydney, 1894, xiii. 152-55. — 143.
Leoxh.\iidt, J. S. "Case of Exophthalmic Goitre in the .Male," Memphis M. Month.
1893, xiii. 301-3D5. — 144. Liebheciit. " Benierkenswerthe Palle von Basedow'scher
Krankheit aus der Prof. Scholer"schen Klinik," Klin- MoiialshJ. f. Angcnh. Stuttg.
1890, xxviii. 492-500. — 145. Lienau.x. " Deux cas de goitre abcmnts cliiz le chien,"
Ann. dc mid. vet. Brux. 355-60.— 146. McAdam, K. L. " A Case of Post-influenzal
Graves' Disease," Australasian Med. Joitrn. Melbourne, 1S93, n.s. xv. 619-629. — 147.
McKf-k, J. H. "A Case of Exo;ihthalmic Goitre in a Child," Fhilad. Polijclin. 1895,
iv. 33. — 148. Ma(:<enzik, Hecior. "Clinical Lect. on Graves' Disease," Lancet,
London, vol. ii. 18'JJ, ])p. 545 and GOl.^149. Idem. "On CEdoma iu Graves' Disease,"
Edin. Med. Journ. 1897, n.s. vol. i. pp. 401-410. — 150. Idem. "Treatment of
Graves' Disease," Amer. Journ. Mcd. kci. Phila. 1897, vol. exiii. p. 132. — 151.
M.\nER. " Jlorbus Basedowii ; voriibergehende Besserung," .Scr. d. k. k. Krankenavst.
Rudolph-Stiftung in JFien (1889), 1890, 270-272. " Basedow'sche Krankheit ; Besse-
ruug," Bcr'. d. k. k. Krankcnamt. Ruxlolph-Stiftung in ll'icn (1890), 1891, 300.— 152.
Mannheim, P. Der Morbus Gravesii {sogenanntcr Morbus Basedowii). Berl. 1894,
A. Hirseliwald, 162 pp. 2 plates. — 153. Marcus. "Das Wesen und die Behaud-
lung der Basedow'schen Krankheit," Vcroffentl. d. Hufcland Gesellsch. in Berl. bclncol.
Gesellsch. 1893,187-206. — 154. Idem. "Das Wesen und die Behandlung der Basedow'-
schen Krankheit," JFien. vied. Wo:hnschr. 1893, xliii. 825, 871, 918, 961.— 155. Idem.
" Das Wescn und die Behaudlung der Basedow'.schen Krankheit," Z>c?(^st7ic vied. Ztg.
Berl. 1893, xiv. 529, 541.-156. .Marie, P. "Sur la nature de la maladie de Basedow,"
Ball, et mini. soc. vi(kl. des Mp. de Paris, 1894, 3 ser. xi. 132-135 ; Mercredi viid. Paris,
1894, V. 97.— 157. Idem. These de Paris, 1883.- 158. Marie, P., and G. Marixe.sco.
"Coincidence du tabes et de la maladie de Basedow ; autopsie," Rev. murol. Par. 1893,
i. 250-255. — 159. Martin, Kaymoxd. Des troubles psych iqucs dans la maladie de
Basedow, Par. 1890, 100 pp. Xo. 376. —160. Mautius. F. "Was ist die Base-
dow'sche Krankheit?" Berl. Klinik, 1896, lift. 95, 1-19.— 161. Masoix, P. "Note
sur les modifications de la quantite relative d'oxyhemoglobine contciuie dans le sang des
myxoedemateux," Comptcs ■ rend . soc. dc biol. Paris, 1895, lOme ser. ii. 73. — 162.
Ma.ssaro, D. "Su di un caso di gozzo esoftalmico," Riforma medica, Najjoli, 1893, ix.
pt. 4, 507-13. — 163. Mathieu, A. " Un cas de goitre exophth. consecutif a I'ablation
des ovaires," Gaz. des h6p. Ixiii. 70, 1890. — 164. Matiie, A. "Crises of the Digestive
Tract in Graves' Di.sease," Practitioner, Lond. 1891, xlvii. 195-197. — 165. Idem.
" CE'iema in Graves' Disease," Pmrfi7?'o?icr, London. 1891, vlvii. 401-405. — 166. Idevi.
" Xine Cases of Graves' Disease; OphthalmojOeiria : Remarks on the Lid-svmptoms,"
St. Barth. Hosp. Rep. Lond. 1891, xxvii. 133-148.— ]r,7. Idem. "A Case of Ophthal-
mojilogia, with Graves' Disea.se," Brain, Lond. 1892, xv. 121-123. — 168. Idem.
""Tremor in Graves' Di-ease," Brain, Lond. 1892, xv. 424-430. — 169. Irlem.
" Some Rare Clinical Points in Graves' Disease," St. Barth. Hosp. Rep. Lond. 1893,
GRAVES' DISEASE 513
xxix. 181-88.— 170. Idem. "On Exophthalmic Goitre," Brain, Loml. 1894, xvii.
246-62. — 171. Idem. " Periplieral Neuritis in Exophthalmic Goitre," ibid. 229-31.—
172. Idem. "Graves' Disease," Trans. Med. Soc. 1894, xvii. 12-31. — 173. Idem.
"Tetany in Graves' Disease," Brit. Med. Journ. Lond. 1896, i. 908. — 174. Idem.
"Notes on the Treatment of Graves' Disease by Thymus Ghind," Lancet, Lond. 1896,
ii. 173. — 175. Idem. "Mental Changes in Graves' Disease," Journal of Mental Science,
Lond. 1896, xlii. 27-31. — 176. Mauhice-Faure. "Etude sur le goitre exophtal-
niiq^ue," Ga.~.. des liop. Par. 1896, Ixix. 773-781. — 177. Maybai'm, J. "Kin Beitrag
znr Kenntniss der atyjiischen Fornien der Basedow'sehen Krankheit," Zcitet'/t/-. /U?- A-/i7i.
Med. Berl. 1895, xxviii. 112-116. — 178. iMicndel, E. " Zur pathologischen Anatoniie
des Morbus Basedowii," Deutsche vied. Wochnschr. Leipz. 1892, xvii. 89. — 179. Idem.
" Drei Falle von geheiltem JSlyxiidem," Deutsch. med. Wochenschr. Leipz. n. Berl.
1895, xxi. 101-103.— 180. Miudi.kton-, G. S. "A Case of Myxojdema snccesslully
treated with Thyroid Gland ; Relapse after Cessatinn of Treatinent and Death from
Tumour of the Mediastinum," Glasijoio Med. Journ. 1894, xlii. 430-42. — 181. MoBius,
P. J. " Ueber die B.isedu\v'>sche Krankheit," Deutsche Zcitsdirift f. Xercenhcilk.
Leipzig, 1891, i. 400-444. — 182. Idem. Die Bascdow'schc Krauklicit, Wien, 1896. —
183. MoXTGOMEUlE, H. "A Case of Exophthalmic Goitre, ending fatally, from
Sudden Pressure on the Trachea," Lancet, 1891, i. 306. — 184. xMookk, W. 0. "Exoph-
thalmic Goitre," Internat. Clin. Phila. 1893, 3rd s. i. 92-96.— 185. Mullee, F.
"Zur Kenntniss der morbus Basedowii," Jahrcsb. d. schles. Gesellsch. f. xaterl. Kult.
1890, Bresl. 1891, Ixviii. med. Abth. 56. — 186. Idem. " Beitriige zur Kenntni.ss der
Based ow'schen Krankheit," IJcutsches Arch. f. klin. Med. Leipzig, 1892-3, li. 335-412.
— 187. Murray, G. R. "Thyroid Secretion as a Factor in Exoj>lithalmic Goitre,"
Lancet, 189-3, ii. 1177-1179. — 188. Mu.sehold, A. " Ein Fall von Morbus Basedowii,
geheilt durch eine Operation in der Nase," Deutsche -med. JVochnsIir. Leipz. 1892,
xviii. 93-95. — 189. Neustab, J. T. "Morbus Bsmedowii," Ifeditsina, St. Petersburg,
1892, iv. 289-292.-190. Newmax, E. A. R. "The Etiology of Exophthalmic Goitre ;
a Neurosis ; with a Note on Treatment," Lancet, 1894, ii. 320. — 191. New'tox, R. S.
"A Case of Exophthalmic Goitre, Thyroidectomy," Boston Med. and Surg. Journ. 1894,
cxxx. 392. — 192. Oddo, C. " Un nouveau cas d'idiotie niyxceilemateiise traite avec
succes par la metliode thyroi'dienne," MAI. inf. Paris, 1895, iii. 3-18. — 193. Oi.iyer,
T. "The Thyroid and its Diseases ; with Siiecial Reference to Exophthalmic Goitre,"
Internat. Clin. Phila. 1893, 3rd s. i. 97-108.-194. Ord, W. M., and E. White.
"ObservatioM,s on a Case of Myxredema treated by Administration of the 'I hyroid
Gland of the Sheep, with especial Reference to Changes occurring in the Urine," I'rans.
Clin.. Soc. Lomi. 1893-94, xxvii. 37-47. 1 plate.— 195. Owen, D. "Thyroid Feeding
in Exophthalmic Goitre," Brit. Med. Journ. 1893, ii. 1211. — 196. "Pachecd, R.
"Cuatro casos de bocio exoftalmico," An. d. Circ. mM. argent. Buenos Aires, 1S91,
xiv. 648-654. — 197. Idem. "Bocio exoftalmico," An. d. Circ. mdd. argent. I^)nenos
Aires, 1892, xv. 177-187.-198. Paoe, R. C. M. "Exophthalmic Goitre," At7« York
Polyclinic, 1896, vii. 35-38. — 199. Pai.leske. " Heilung eines operativ enstandcnen
Myxodems durch Fiitterung mit Schafsschilddriise ' Deutsche med. Wochenschr. Leip.
n. Berl. 1895, xxi. 103. — 200. P.a.ssler, H. " Erfahrungen liber die Basedow'sche
Krankheit," Deutsche Zeitschrift fiir Nervenlteilknnde, Leipzig, 1894-95, vi. 210-230.
—201. Paterson, D. R. "Note on the Etiology of Graves' Disease," Zrtww^, 1894,
i. 370. — 202. Patrick, H. T. "The Bryson Symptom in Exophthalmic Goitre ; with
a Report of Forty Ca.ses," Xew York Med. Journ. 1895, Ixi. 173-76. — 203. Pattun,
.L M. " Exoiiiithalnuc Goitre," Chicago Clin. Rev. 1895-6, v. 698.— 204. Idem.
"Graves' Disease," Chicago Clin. liev. 1895-6, v. 424-427.-205. Paul, F. T. Brit.
Med. Journ. vol. ii. 1897, pp. 1-6. — 206. Pei:kegaux, E. "Ueber Morbus Basedowii,"
Cor. -Blatt. far schweiz. Aerzte, Ba.se\, 1894, xxiv. 330-343. — 207. Pkteii. " Du goitre
exoiAitalmiqnc," France mdd. Par. 1892, xxxix. 209-211. — 208. Peyron and J. Noir.
" Le dermographisme electriqne dans le goitre exo]:ihtalmir|ne," Progris mid. Paris,
1894, 2 ser. xx. 169.— 209. Philivp, A. " Kriti.sche Darstellung der lieueren Theorien
der Basedow'schen Krankheit," Allg. med. Centr. Zeitung, Berl. 1894, Ixiii. 457, 469,
481, 493, 505. — 210. Idem. Kritische Darstellung der neueren Throrien der Ba.sedov:'-
schcn Krankheit, Berl. 1894, E. Billig, 44 pp.— 211. Philippen, J. " L'etat de
la nutrition de la maladie de Basedow, ses modifications par le traitement thyroidien,"
Clinique, Brux. 1896. x. 409-415. — 212. Pisaxi, Lamberto. Delia tachicardia strtrmosa
esoftalmica, Stradella, 1891, P. Salvini, 40 pp. — 213. Pizzou, U. "Contribute
alia casnistica del morbo di Basedow," Gazz. d. osp. Milano, 1892, xiii. 970. — 214.
VOL. IV 2 L
514 SYSVEM OF ^rEDICINE
PosPELow, A. " Weitere Beobaclitungen Uber die Behandlung des Myxoedema,"
MoH'dsh. f. praki. Dermat. Haiiib. ]S94, xix. 537-41. — 215. I'otaix. " Le goitre
t'.\oplitaimii[ue," licvue internut. de vied, ct de chir. j)ntl. Paris, 189."), vi. 3(35-67. —
210. PoYKT, 0. " Goitre vasc'ulaire et snU'oi'aiit : traitfiuent jiar la thyioidollioriipie,"
Gaz. mAL dc Pimrdi<\ Amiens, 1890, xiv. r2(3-l'J8. — 217. I'lUiutAM, A. " Ziir Pro-
gnose dos Morbus Basedowii," IVien. kiin. Jiundscluiu, 1895, ix. 689-92. — 218. Idem.
" Zur Prognose des Morbus Pasedowii," J'ra;/. mcd. Jrochnschr. 1895, xx. 521-523. —
219. Idem. " Basedow'sehe Krankheit," Prcuj. med. Wucknschr. vii. 1882. p. 138. —
220. PrTN.\M, J. J. "The Treatment of Graves' Disea.se by Thyroidectomy,"
Journal of Ncrcoiis and Mental l>isc(ise, N.Y. 1893, xx. 799-821. — 221. Idem.
" Xotes on Two Additional Cases of Tliyi-oidectomy for Graves' Disease," Junru.
of Xereoas nml Mental JJisease, N.Y. 1894, xxi. 359-04. — 222. Idem. " Patlio-
logy and Treatment of Graves' Disease," Brain, Lond. 1894, xvii. 214-28. — 223.
Idem. "Thyroid Feeding," Anwr. Journ. Med. Sci. Pliila. vol. evi. pp. 125-
148. — 224. R.VMs.vY, A. M. "Exophthalmic tioitre : a Clinieal Study," Glasyoio
Mcd. Joiirn. 1891, xxxvi. 81, 178; 1 pi.— 225. Raymo.nd and Situiiiux. "Goitre
exophtalmique et degenereseonee mentale," Comjr. ann. de m&i. inent. C.-r.
1892, Blois, 1893, iii. 198 - 240.— 226. Idem. "(Joitre exophtalmiipie et iU-
genereseence mentale," liev. de vial. Par. 1892, xii. 957-994. — 227. Hkois, E.
" Un Ciis type de myx<^deme congenital au debut du traitement thyroidienne,"
Mcrcredi mid. Paris, 1875, vi. 37. — 228. Ri;hs, L. " Ueber Morbus Basedowii,"
Deutsche med. IVuehcusehr. Leipzig u. Berl. 1894, xx. 265-67. — 229. Ricxaut, J.
\ct al.'\ "Corps thyroide et maladie de Basedow; rapport de JI. le Dr. P>rissaud,"
Courrier mid. Paris, 1895. xlv. 2S1 - 83. — 230. Die Rknzi, E. "Sul gozzo
exoftahnico," Riforma Med. Napoli, 1892, viii. pt. 2, 735, 747, 759. —
231. RliCDEi,, B. " Chirurgische Behandlung der Basedow'scheii Krankheit, Handb.
d. spec." Therap. inner. Krankh. Jena, 1896, v. 2 Teil, 531-547.-232. Righi, G.
" Malattia di Basedow e corpo tiroide," Il.asse(jna vied. Bologna, 1896, iv. Ko. 5, 3-7 ;
No. 6, 4-7; No. 8, 1-4. — 233. Ripamoxti, A. " Su alcune forme frusti di morbo di
Basedow," Boll. d. Poliamhul. di Milano, 1892, v. 1-15. — 234. Idem. " L'estir-
pazione del gozzo nel morbo di Basedow seeondo il Prof. Piottini," Gazz. med.
Lomh. Milano, 1893, Iii. 2S1-283.— 235. Rockwell, A. D. "The Treatment of E.x-
ophthalmie Goitre, based on Forty-five consecutive Cases," Meel. Bee. N.Y. 1893, xliv.
417-420. — 236. Rosen'blai'T. " Drzenie czlonkow (tremor) jako pierwszy objaw
choroby Basedowa" [Trembling in the limbs as a ])henomenon in Basedow'.s disease],
Frzeffl. lek. Krakow, 1892, xxxi. 440. — 237. Sanahklli. " Le condizioni attuali delle
endemi gozzigene in Italia," Gior. d. r. soc. ital. d' ig. Milano, 1895, xvii. 173-92,
i. eh. 1 map. — 238. Sauxdky, R. " Graves' Disease," Inlernat. Clin. Philad. 1895,
5th ser. ii. 85-91. — 239. SAiiiiAzfcs and Cabaxxks. " Gaeri.son raj)ide d'un goitre
simple par I'extrait glycerique de corps thyroide, apresrechecde la medication ioduree,"
Gaz. Iicbd. dc mid. Pur. 1896, xliii. 327-329.-240. Savage, G. H. "Exophthalmic
goitie with Mental Di^oi'der," Guy's Hosjnlal Reports, xxvi. p. 31, 1883. — 241.
ScHi;xK, I'aul. Gcisleskranklicit hci Morbus Basedoirii, Berl. 1890, G. Schade,
30 pp. — 242. ScHMEY, Y. " Von der Lebensweisse der an Morbus Basedowii Er-
krankten," ylll<j. vied. Ccnir.-Ztg. Berl. 1890, Ixv. 257.-243. Schulte, J. A.
" Exo|ththalmic goitre; Anterior Poliomyelitis," Chicago M. Times, 1896, xxix.
87. — 244. SiiAiucEY, S. J. "On Graefe's Lid-sign," Trans. Oplh. Soc. United
Kingdom, London, 1890-91, xi. 204-211.— 245. Sibley, K. " Exophthalmic Goitre,"
Clin. Journ. Lond. 1895, vi. 394. — 246. Sollieu, P. " Maladie de llasedow avec
myxredeme," Rfiv. dc viid. Par. 1891, xi. 1000-1013.-247. Idem. " Un ens de
maladie de Basedow ; rauidement ameliore par la galvanisation," Rerue inlernat.
d'electroth'lrapie, Paris, 1893-94, iv. 359-62 ; Rerue d'hyg. therap. Paris, 1894, vi.
265-68. — 248. Soi'QUEs, A. " Note sur Fetendue du champ visuel dans la maladie de
Basedow," Comjit. rend. soc. de biol. Par. 1891, 9 s. iii. 353. — 249. Sottas, J.
"Note sur le goitre exophtalmique ftimilial," France mid. Par. 1896, xliii. 533. — 250.
Spexckii, W. F. " Exoj)]ithalniic Goitre with Com]ilieations," J/«/. Current, Chicago,
1894, X. 353-55.— 251. Si-evieu, W. G. " Exoplithalinic Goitre causing Death by
Aspliyxia," Brii. Med. .ronrn. LoikI. 1891, i. 521. —252. Idem. " Exoj.hthahuic Goitre in
a Girl, cau^int; Death by Asphyxia," Trans. Path. Snc. Lond. 1890-1. xlii. 299 301.-253.
Si'KNDEi'., J. K. " On Points of Aflinity between Rheumatoid Arthritis. Locomotor Ataxy,
and Exophthalmic Goitre," Brit. Med. Journ. Lond. 1891, i. 1109-1171.-254. SriCEH, S.
" Incomplete Graves' Disease with Nasal Poly[ii," Lancet, 1894, ii. 1158. — 255. Idem.
GRAVES' DISEASE 515
" A Case of Incomplete Graves' Disease, associated with Nasal Polypi," Trans. Clin.
Soc. Lond. 1895, xxviii. 265-68.-256. Stafford, H. E. "Exophthalmic Goitre,"
N. York Polydin. 1893, 1, 141.— 257. Stark, M. A. " ilyxa-dema and its Difler-
entiid Diagnosis from Clironic Nephritis," Med. Kcics, Pliilad. 1894, Ixv. 649, 683.
—258. Idem. Med. Ncivs, New York, Aprill8, 1896.-259. Steiner, D. W. "The
Heart in Exophthalmic Goitre," Trans. Ohio Med. Soc. Cincin. 1893, 227-31.— 260.
Steinlechner, M. " Ueber das gleichzeitige Vorkommen von Morbus Basedowii nnd
Tetaniebei einem Individuum," Wiener kliii. JVochenschr. 1896, ix. 5-8. — 261. Steppetat,
Karl. Ueber den galva.nischen Leitungstciderstand der Ilaut bci Morbus Bascdoicii,
Strassburg, 1890, J. H. E. Heitz, 51 pp. — 262. Stewart, Sir T. Grainger, and G. A.
Gibson. " Bulbar Lesions in Graves' Disease: a Contribution to the Morbid Anatomy of
Exophthalmic Goitre," Edin. Hasp. Ilcjiorts, 1894, ii. 275-82, 1 jilate. — 263. Idem.
"Clinical Notes on Graves' Disease," iWwi&. Husp. lie}}. 1893, i. 187-220, 1 pi.— 264.
Strubing. "Ueber mechanische Vagusreizung beim Morbus Basedowii," Wiener
vied. Presse, 1894, xxxv. 1713-17. — 265. Tayloe, J. M. "Abstract of Notes on the
Treatment of Exophthalmic Goitre," Journ. Amcr. Med. Assoc. Chicago, 1893, xxi. 488. —
266. Man. " The Treatment of Exophthalmic Goitre," J/ec^. iVcws, Philad. 1893, Ixiii.
673, 711. — 267. Theilhaber, A. "Die Beziehungen der Basedow'schen Krankheit zu
deu Veranderungen der weiblichen Geschlechtsorgane," AirJiiv filr Gyndkol. Berlin,
1895, xlix. 57-74. — 268. Thompson, J. C. " Notes of a Case of Exophthalmic Goitre,"
Pittsburejh M. Revieiv, 1892, vi. 197.— 269. Thomson, AV. H. "The Pathology and Treat-
ment of Graves' Disease." iV. York M. J. 1893, Ivii. 601-605.-270. Tompkins, E. L.
"Exophthalmic Goitre, ".-im. Journ. Obst.'N.Y. 1893, xxviii. 669-680.— 271. Toulouse,
E. '"Lesrapijortsdu goitre exophtalmique etde I'alienation nientale;lesalienes a sequestra-
tions multi])les ; le traitement chirurgical de I'idiotie," Gaz. des hop. Par. 1892, Ixv. 1495-
1410. — 272. "Traitement du goitre exophtalmique," Union me'd. Par. 1896, 4 s.
ii. 301-306. — 273. Tkoschke, Carl. Casuistisehe Beitrdge zur Aetiologie und Symp-
tomeUologie des Morbus Basedoivii, Greifswald, 1893, J. Abel, 26 pp. — 274. Vandekvelde
and Le Bceuf. " Le goitre dans la maladie de Basedow," Journ. de 7ned. chir. et
Pharmacol. Brux. 1894, 129-133. — 275. Verco, J. C. "Myxoedema," Australas.
Med. Gazette, Sydney, 1894, xiii. 156-59.-276. Vigouroux, R. "Traitement du
goitre exophtalmique par la faradisation," Gaz. des hop. Par. 1891, Ixiv. 1291; Gaz.
d. hup. Paris, 1891, Ixiv. 1325-27. — 277. Idem. ■" Le traitement ^lectrique du goitre
exophtalmique ; sa technique operatoire," Geiz. d. hop. Par. 1891, Ixiv. 494. — 278.
Idem. Gaz. des hop. vol. Ixiv. p. 140 ; Prog. mM. vol. xv. p. 43, 1887. — 279.
ViJLKEL, Adolf. Ueber einscitigen Exophthabnus bci Morbus Basedoicii, Berl. 1890,
W. Rower, 35 pp. — 280. Vossius, A. " Ein Fall von Forme fruste des Morbus Base-
dowii," Beitr. z. AurjenheiJkunde, Hamb. u. Leipz. 1895, xviii. 86-92, 2 jjlates.. —
281. Wallace, T. H. "E.xophthalmic Goitre," West. M. Reporter, Chicago, 1892,
xiv. 121-123.-282. Waterman, 0. M. "A Peculiar Case of Graves' Disease," Mil-
waukee Med. Journ. 1895, iii. 15.— 283. AVeill, A., and S. Diamantbekger. "Goitre
exophtalmique et rheumatisme," Bull. soc. de mdd. prat, de Peer. 1891, 582-596. — 284.
West, S. " Two Cases of Exophthalmic Goitre in Sisters with Morbus Cordis and a
History of Rheumatic History in both," Lancet, 1895, i. 1248.— 285. Wette, T.
" Beitrag zur Syinptomatologie unrl chirurgischen Behandlung des Krojifes sowie iiber
die Abhangigkeit des Jlorlnis Basedowii vom Kropfe," Arehiv f. klin. Chir. Berl.
1892, xliv. 652-716. — 286. Wiener, Julius. Ueber einen Fall von Morbus Basedowii
mit Tabes incipiens, Berl. 1891, 0. Franche, 31 pp. — 287. Williamson, R. T. "On
Prognosis in Exo]ihthalmic Goitre," Brit. Med. Journ. voL ii. 1896, p. 1373. —
288. WiNOKLEK, E. "Zur Beantwortung der Frage ; wann Kbnnen intranasale
Eingriffe beim Morbus Basedowii gerechtfertigt seiu ? " Wien. vied, ll'ochuschr. 1892,
xlii. 1521, 1556, 1593, 1640, 1676.— 289. Winter, H. L. "The Etiects of Thyroid Extract
in the Treatment of Graves' Disease," Am.. Med. Surg. Bull. N.Y. 1896, x. 40. — 290.
Wood, H. C. "Graves' disease. Case L : Spontaneous cure occurring during absce.«s
of spleen. Case IL : A''ery great relief apparently from the use of extract of spleen,"
Univ. Med. Mag. Philad. 1894-95, vii. 318.
W. M. 0.
H. M.
5i6 SYSTE^f OF MEDICINE
DISEASES OF THE SPLEEN
The General Pathology of the Spleen. — General Bemarks. Effects
of splenectomy in man. The cotalition of the sjileen in bacterial infection and
in toxamia. The part of the spleen in bacterial infection and in immunity.
The part of the spleen in the various forms of anoemia.
General remarks. — From a consideration of their structure and func-
tions the ductless ghmds ma}' be divided into two categories — (i.) those of
an epithelial type which have an internal secretion, such as tlie thyroid,
suprarenal, and pituitary glands ; and (ii.) those containing lymphoid
tissue which are not known to possess any special internal secretion — the
spleen and tlie thymus gland.
There appears also to be a general difference in their pathological
relations ; the spleen and thymus are affected and undergo alteration
rather as the result of disease elsewhere than as its cause ; while in the
case of the thyroid, su])rarenal bodies, etc., we haA'e chiefly to deal with
primary morbid conditions and diseases, such as myxa?dema or Addison's
disease, initiated in these organs, which lead to general and secondary
changes elsewhere. It Avould be nnwise, in the present state of our know-
ledge, to press this distinction too far, and to assert too dogmatically
that there is not such a thing as primary disease of the spleen ; for
until our knowledge of the physiology of the spleen is in a more satis-
factory state the problems of its pathology must necessarily present great
difficulties. But we may safely consider the spleen as an organ prone
to respond to disease of other parts, especially of the blood and the
haematopoietic organs of the body, and but little liable to independent
primary affections.
The two diseases in Avhich the spleen has most claim to be regarded in
the initiation of morbid processes are splenic or spleno-medullary leukaemia
and splenic anaemia. With regard to splenic leukaemia, the most careful
observations point strongly to the conclusion that the primary seat of the
disease is in the marrow of bone, and that the splenic changes are merely
secondary.
With regard to splenic an?emia, we are not at present in a position
to decide dogmatically whether the marked morbid ajjpcaranccs in the
spleen are piimary or whether they are secondary and jjerhaps the result
of a chronic toxaemia ; but the second alternative seems the more reason-
able. iVide art. "Splenic Ana-mia " in the following volume.)
Effects of splenectomy in man. — A point of some interest is
whether atrophy of the spleen, as distinguished from removal, may give
rise to compensatory changes in lymphatic glands and the red marrow of
bone, and to leucocytosis such as may be produced by splenectomy.
A\'hcther primary changes in the spleen, as a compensatory effort, and
DISEASES OF THE SPLEEN 517
subsequent functional inadequacy of the organ ever give rise to hyper-
trophy of other forms of haematopoietic tissue, we do not know ; at any
rate, this se(|uence has not been established.
That the spleen is not essential to life, and that its removal does not
affect development, has been shown experimentally in animals and
as the result of splenectomy in human beings ; whether for disease of
the organ or for traumatic rupture. During the course of disease com-
pensation gradually takes place, and when the organ is subsequently
removed the results are less marked than they are when a previ-
ously healthy organ is removed and compensation has to be effected
suddenly.
In splenic anaemia the changes in the spleen are associated with Avell-
marked symptoms, so that compensation cannot be said to have taken
place, and it is noteworthy that the lymphatic glands are not enlarged ;
whereas after removal of a healthy spleen there is anaemia for a time, as
in splenic anaemia ; bat compensation is effected by enlargement of
lymphatic glands and leucocytosis, probably also by extension of the
blood-forming marrow into the shafts of the long bones ; and eventually
recovery occurs.
Pitts and Ballance successfully removed the spleen for traumatic
rupture in three cases : the first was a boy in whom a splenunculus
was left behind, and in whom no special symptom except glandular
enlargement followed the operation ; a somewhat similar case of Reigner's
is quoted, and it is suggested that the more extensive presence of red
marrow in youth may explain this. Compensatory hypertrophy of the
splenunculus may also have played some part in bringing this about.
The other two cases, a woman aged 45 years and a man aged 3G, presented
the following definite group of symptoms —
(i.) Progressive loss of strength and of weight and emaciation,
(ii.) Extreme antemia.
(iii.) A daily rise of temperature from 1° to 3° Fahr.
(iv.) Increased frec^uency of the pulse,
(v.) Fainting attacks, with increased pallor of the surface
(vi.) Headache, drowsiness, great thirst.
(vii.) Severe griping pains in abdomen, and pains in the legs and arms ;
in the woman tenderness along the tibiae, thought to indicate
compensatory changes in the red marrow of bone,
(viii.) Enlargement of the external lymphatic glands, which remained
permanently,
(ix.) Blood changes, diminution in the number of the red blood
corpuscles, increase in the numljer of leucocytes. In both
cases a month after operation the h£emoglobin was found to
be half the normal.
Convalescence was very slow, but recovery with return to normal
weight eventually occurred.
Many of these changes correspond Avith the experimental results
obtained by Laudenbach in splenectomy in dogs.
51 S SYSTEM OF MEDICINE
Splenectomy in man for the enlargement of malaria, for -wandering
spleen, and for other morhid conditions except leukaemia, may give rise
tp temporary changes in the hlood, and very occasionally to tcmporarj^
enlargement of the lymphatic glands ; but not to the more marked results
seen when a previously healthy organ is removed for rupture. This
peihaps is due to the gradual establishment of compensation during the
])rogress of the disease. For in ■wandering spleens endarteritis and
thrombo.sis of the splenic vessels are apt to occur as the result of torsion
of the elongated pedicle ; this leads to atrophy of the Mali)ighian bodies,
and to sclerotic and fatty changes \n the pulp. An organ so altered -would
1)6 of but little use in the economy, and compensation would have taken
place before the performance of splenectomy.
In a case of wandering spleen in which Mr. Ballance performed splenec-
tomy symptoms of much severity occurred ; but this exceptional sequel
Avas probably explained T)y the fact that the spleen appeared quite
healthy, and so, presumably, no compensation being required none had
taken place.
The spleen in bacterial infection and in toxsemia. — In acute fevers
and in bacteiial infection there is a general tendency to an accumulation
of micro-organisms in the spleen ; this, foi" exanq)le, is especially well
marked in septicaemia, infective endocarditis, and enteric fever. The
micro-organisms found in the organ are by no means limited to ihe
one giving rise to the specific disease ; thus in typhoid fever streptococci
and staphylococci may be present. Some of the microbes are free, others
are enclosed in cells.
It does not follow, however, that because micro-organisms are found
in the spleen that they are necessarily present in the blood. In enteiic
fever, for example, while they are constantl}^ present in the spleen, they
are only to be found in the general circulation under exceptional condi-
tions.
This microbic occupation is accompanied by well-marked hypera?mia
and swelling of the oi-c-an, even to such an extent that* in rare cases
rupture has occurred spontaneously. In childi'cn the capsule of the spleen
is more extensible than in older people, and the enlargement therefore is
relatively better marked. This condition is sometimes spoken of as acute
splenic tumour. On section the spleen is soft and the pulp is sometimes
so difiluent as to run away. In some experiments on pneumococcal
infection in rabbits "Washbourn found that the spleen might be either
softened, as here described, or firm and normal in consistency. This
latter condition may somewhat exceptionally be met with in man ; in
cholera the spleen is firm and somewhat diminished in size, probably
from the concentration of the Ijlood.
In bacterial infection the colour of the spleen on section is cithor
that of marked congestion, or giayi.sh from increase of leucocytes
in its substance. Tlie Malpigliian bodies are prominent and .swollen
in some cases, while in others they can only be seen with difliculty.
In addition to the accumulation of micro-organisms in the spleen,
DISEASES OF THE SPLEEN 519
changes in its histological structure occur ; these are clue to the effects
of the toxic products of bacterial activity. That they are independent
of the presence of bacteria in the organ is shown by the fact that they
follow the injection into the circulation of toxalbumins only.
The JMalpighian bodies Avhen affected are SAVollen and enlarged, and
by proliferation of their constituent cells leucocytosis and phagocytosis nva
forwarded. The cells become swollen, granular, and may show the
nuclear changes of fragmentation due to degeneration set up by the
toxalbumins. As a result of the concentration of toxins, focal necroses of
the cells, either in the centre of the Malpighian bodies or in the piilp,
may follow; this is well marked in relapsing fever, and may be seen in
enterica.
The pulp becomes engorged with blood and may contain haemorrhages ;
while numerous cells, macro- and microphages containing blood cor})uscles
and bacteria, are visible. A similar phagocytic action may be taken on
by the endothelial cells lining the sinuses, which in places may. show
similar degenerative changes to those seen in the areas of focal
necroses. Fibrinous thrombi may form in the capillaries of the splenic
pulp.
The degenerative changes may eventually lead to some degree of
atrophy of the splenic tissue, to hyaline degeneration of the small arteries,
and to fibrosis.
In scarlet fever Klein described multiplication of the muscidar fibres and
hyaline degeneration of the arterial walls, leading to their occlusion ; while
the adenoid tissue around undergoes the same hyaline degeneration. In
typhoid fever also inflammatory changes in the arteries have been noted.
The proliferative, vascular, degenerative and necrotic changes that take
place in the spleen in bacterial infection may be broadly described as
inflammatory, and the condition as a form of splenitis ; but it is note-
worth}' that in the infectious fevers the condition rarely goes on to
suppuration such as is freqiiently seen in pya?mia, Avhere a fvu'ther deter-
mining factor is provided by embolism and infarction.
If, as seems a priori reasonable, the hyperemia and consecutive
changes in the spleen in bacterial infection are due to the products
of bacterial activity, it would be natural to expect that in cases of
saprajmia and in toxaemia a somewhat similar change would occur in the
spleen.
The specific albumoses of diseases have been obtained from the spleen
by Dr. Sidney Martin and others in cases where no micro-organisms were
present in the organ. Here the poisons are carried to the spleen by the
blood, while in general haemic infection they are manufactured on the
spot.
That the organ is invariably enlarged in toxaemia, apart from the
presence of bacteria in the spleen, is contrary to experience ; but in pneu-
monia, where the diplococci are very rarely present in the blood or in the
spleen, the spleen is softened or enlarged, and the same is true of some
cases of sapraemia ; while in some conditions, probably or possibly of this
520 SYSTEM OF MEDICINE
nature — such as Hanot's hypertrophic cirrhosis Avith chronic jaundice, the
earl}' stages of syphilis, Landry's paralysis, and exophthalmic goitre —
the organ is enlarged.
Flexner, in an experimental study of the tissue changes produced
by the injection into the circulation of ricin and abrin, phytalljumoses
ol>tained from the seeds of the castor-oil plant and the jequerity bean
(Abrus precatorius), found the spleen uniformly swollen and soft, the
swelling apparently l)eing of the splenic pulp. While bacterial toxal-
bumins aftect the ISIalpighian T>odies more than the pulp, the reverse is the
case with ricin and abrin intoxications. In chronic poisoning Avith these
phytalliumoses the splenic pulp is crowded with graiuiles and globules
of yellow pigment occurring inside the cells. This pigment gives a blue
colour with ferrocyanidc of potassium and hydrochloric acid, and is to
be regarded as the evidence of great haemolysis. As a result of poison-
ing dogs with metatoluylendiamin, paraphenylene and nitrate of soda,
Pillict (43) found that the jMalpighian bodies become atrophied, and
thus that a kind of cirrhotic atrophy results.
On the other hand, in ura?mia, the most familiar example of a purely
chemical tox;vmia, no splenic enlargement occurs.
In considering these discordant data, it must be borne in mind {a)
that the eflects of various poisons are likely to be difterent, and (//) that
in toxaemia the poison reaches the spleen in a ver}' dilute form when
compared with its relative concentration w'hen the spleen is occupied by
active micro-or"anisms.
We can only conclude that in tox?eniia the spleen may be aftected
in the same way as in bacterial infection, though b}' no means constantly.
As a result of long-continued bacterial infection, or toxaemia, the
spleen may show a varying degree of fibrosis.
The part of the spleen in bacterial infection. — The spleen is, gener-
ally speaking, so altered in fevers and in cases of bacterial infection, that
the question naturally arises Avhether this is merely a secondaxy change,
or whether special and defensive processes take place in the spleen, Avhose
object is to protect the organism against the infection.
Does the spleen play any special part in the defence of the organism
which is distinct from that ])la3'ed by lymphatic tissue elsewhere ?
In cases of general h?emic infection the spleen and liver are per-
haps the organs most extensively occupied by the micro-organisms. This
is well .seen in anthrax and in streptococcal septica-mia. Is this merely
a stagnation of the microbes in the lax, open tissue of the spleen 1 Or is
there in addition a midtiplication of the microbes and a manufacture of
toxins and bncterial products in the spleen, so that lenewal of the organ
might diminish the toxic process 1 The observation that in malaria
splenectomy is foUoAved l)y a diminished toxicity of the urine (Jonnesco)
lends some support to this hypothesis.
Or, on the other hand, is an extensiA'e destruction of micro-organisms
taking place in the oigan ?
Or are both these processes going on ? If so, the spleen is, so to
DISEASES OE THE SPLEEN 521
speak, the Imttlefield where the struggle between the invading micro-
organisms and the defensive powers of the body is fought out ?
That the spleen is a kind of resting-place into Avhich micro-organisms,
which have gained an entrance into the blood, may get swept and left is
shown by injecting harmless microbes into the circulation of an animal.
They rapidly disap^iear from the circulation, but may be found weeks
after stowed away in the spleen, liver, and marrow of bone.
As has been already seen, the INIalpighian bodies of the spleen contain
lymphoid tissue, and show proliferative changes in bacterial infection
leading to leucoeytosis.
Metschnikoff, indeed, regarded the spleen as a centre for the matiu-
facture of phagocytes, and of their presence there can be no doubt.
Hankin and others have obtained a bacterial substance from the spleen
which is the same as the tissue fibrinogen of Wooldridge, or Hallibur-
ton's nucleo-albumin obtained from lymphatic glands, liver, kidney, and
so on.
The question to be answered is, whether the spleen has any protection
or defensive power other than that possessed by the lymphoid or other
tissues generall}'.
In order to determine whether the spleen plays a special part in
natural immunity — in the defence of the organism against infection —
numerous experiments on animals have been performed.
Bardach came to the conclusion that removal of the spleen renders the
animal less resistant to infection ; an effect attributed to a diminution
of the area of phagocytosis. This writer considered that the part of
the spleen in infections is phagocytic, that micro-organisms are taken up
there by macrophages and microphages just as they may be seen to be
on the spleen of malaria and relapsing fever, and that they are thus
destroyed. Bardach was opposed to the view that in bacterial infection
any chemical bactericidal body is manufactured by the spleen.
The part of phagocytosis in immunity has already been discussed in
Dr. Kanthack's article in the first volume of this Avork, and has been
shown to be subordinate since it is only one, and even then not a constant
factor in the production of immunity [vol. i. p. 567].
On the other hand, to take a few of many examples, Tictine injected
the blood of relapsing fever containing the spirillum Obermeieri into the
circulation of monkeys whose spleens had been removed, and found,
contrary to the results of Soudakewitch and Metschnikoff, that they
recovered — though, it is true, not so readily as ordinary monkeys — and
that subsequently they became immune.
In like manner Orlandi finds that in rabies splenectomy does not
affect the course of the disease in any way, and assumes that it plays no
part in the defence of the organism against rabies.
Montouri found that the bactericidal power of the blood of dogs and
rabbits remained normal for fifteen days after splenectomy, as shown by
its action on typhoid bacilli and the cholera vibrio ; that it then diminished
and disappeared. This, however, was but a passing phase, and in four
SYSTEM OF MEDICINE
months from the splenectomy it had regained its normal power. These
changes were more rapid in young than in old animals.
Experiments on rabbits that liad l)Ocn splencctoniised, and were, after
varying intervals, inoculated with ditlcrent micro-organisms, led to dis-
cordant results. Thus, twenty-five days after splenectomy, a rabbit was
less resistant than normal to bacillus pyocyaneus, while it had regained
its usual resistance to staphylococcus pyogenes (12).
In a series of dogs and rabbits in which splenectomy was followed by
experimental infection with Fraenkel's pneumococcus and the bacillus
Ivphosus, the results were practically the same as in animals similarly in-
fected but whose spleens had not been removed ; any slight difllerences
that did occur appeared to depend on variations in the interval between
splenectomy and the subsequent infection (23).
In conclusion, it would appear that the spleen has no special functions
Avitli regard to natural immunity, and that if it jilays any part this can
be vicariously assumed by other organs.
Tizzoni and Cattani (59) considered that their earlier experiments
show that the spleen plays an important part in acquired immunifi/.
They were unable to render rabbits, whose spleens they had previously
removed, immune against tetanus. It thus appeared possil)le that the
spleen might have the power of manufacturing some substance necessary
to render the organism immune.
Kanthack (30), however, Avorking Avith rabbits and the bacillus
pyocyaneus, found that splenectomy, whether before or after protective
inoculation, has no efi'ect on the resulting immunitj', and does not inter-
fere in any way Avith the process, the temperature curve and leuco-
cytosis being unaffected.
Tizzoni and Cattani (60) more recently modified their ])revious opinion
considerably, and came to the conclusion, Avhich Kighi also shares, that
removal of the spleen merely acts like any other severe lesion, and
reduces the general resisting powers of the oi'ganism temporarily ; l;)ut
that it does not produce any permanent or specific change in the pro-
tective powers of the animal.
From a consideration of all these data, it appears highly probable
that the spleen has no special protective poAver, either in natural or
acquired imnuinity, Avhich cannot be vicariously assumed by other organs,
such as the lymphatic glands.
The spleen, in fact, is and behaves like a lymphatic gland broken up
and embedded in erectile tissue. The Mal})ighian l)odies and adenoid
tissue play much the same part that lymphatic glands do elscAvhcre ;
Avhile the open, loose, A'ascular tissue of the organ serves rather as a filter
in Avhich various Ijodies are deposited by the blood, perhaps to remain,
perhaps to undergo subsequent changes.
The part of the spleen in the various forms of anaemia. — Since
the s])leen is so closely associated Avirh the blood, shares in its changes, and
is at least intimately connected Avith h;vmolysis or the destruction of the
red blood corpuscles, it is only natural to inquire Avhether any causal
DISEASES OF THE SPLEEN 523
relationship may exist between changes in the spleen and an?emia. If
the normal function of the organ be connected with destruction of I'ed
blood corpuscles, might not an exaggeration of this function give rise to
anaemia 1 ^
In traumatic anaemia the spleen, of course, cannot be siipposed to play
an}^ causal part, while, with regard to the possibility of its playing any
compensating part, it is doubtful whether, even in the emergencies of
severe traumatic anaemia, the spleen can form red blood corpuscles in
adult life, as Bizzozero and others believe.
The part of the s^pleen in splenic an(emia.—^Yuh\ regards the change in
the spleen as primary, and causing the anaemia ; he believes that the
atrophy and loss of functional activity of the organ lead to an alteration
in the chemical constitution of the blood.
But if the symptoms of splenic anaemia are entirely clue to splenic
inadequacy, it is manifest that splenectomy in normal individuals should
give rise to splenic anaemia. This, however, is not the case. The effects
of splenectomy are unimportant compared Avith those of the disease.
After splenectomy in healthy persons and in animals anaemia results ;
but after a time compensation is established by enlargement of lymphatic
glands and by an extension of the epiphyseal bone marrow into the
shafts of the long bones, and the anaemia passes away ; whereas in splenic
anaemia compensation does not occur, and the disease does not tend to
gradual spontaneous cure.
These considerations render it highly improbable that splenic anaemia
is simply due to splenic inadequacy.
It has been thought, however, that splenic anaemia may be due to
some morbid process originating in the spleen ; and in support of this
view it might be urged that in a few cases of the disease removal of the
spleen led to a decided improvement. The improvement that has been
noticed in splenic anaemia after splenectomy can be explained quite apart
from the view that the change in the s])leen is the essential cause of the
anaemia. Hunter (27) found that in rabbits, after removal of the spleen,
toluylendiamin no longer gives rise to haemolysis, or only to a very slight
degree. Bottazzi, from experimental data, concludes that normally the
spleen loosens the cohesion between the haemoglobin and the red blood
corpuscles ; this he calls the haemokatatonistic function of the spleen.
When the spleen is removed the red blood corpuscles thus become more
stable than normal.
In accordance with this view, if splenic anaemia is a chronic intoxica-
tion, removal of the spleen would thus diminish the haemolysis due to the
action of a poison, by rendering the red corpuscles less vulnerable. This
view would also explain the sequence of events in a case reported by
Dr. Coupland : a woman suff"ering, apparently, from splenic anaemia
was much benefited by splenectomy, but after death most pronounced
syphilitic disease of the liver was found. Here splenectomy may simply
have prevented the toxic anaemia due to the syphilitic virus.
^ For a full account of splenic ansemia see article in vol. v.
524 SYSTEM OF MEDICINE
There is no satisfactory evidence to show that splenic ansemia is due
to loss of functional activit}' of the spleen, or to any j)rini;uy morbid
change originating in the organ.
Is there any evidence to show that splenic anaemia is the result of an
exaggerated activity of the hjemolytic function of the spleen 1 This
seems improbable, since the increased size of the organ is not due to
hypertrophy, but to cirrhotic atrophy of the splenic tissue. Moreover,
the spleen usually does not contain much pigment or show the reaction
for free iron, which might be expected if excessive haemolysis were
taking place in the organ.
If neither loss of functional activity nor exaggerated ha-molytic
activity of the spleen be the cause of splenic aniemia, it would appear
that the change in the spleen is not primary, and that it and the other
symptoms — haemolysis, anaemia, debility, and so forth — may be the results
of some common cause or causes of chronic toxaemia, for example ; the
effects of this cause being first seen and most marked in the spleen, and
subsequently in the blood, as shown by amemia ; and often in the liver, as
shown by cirrhosis.
The appearances in the spleen are quite compatible with chronic
infection or intoxication, and, indeed, rather suggest it; but of its exist-
ence there is no definite proof, since no micro-organisms or blood parasites
have been found to explain the condition.
In chlorosis all the evidence is to shoAV that the formation of red
blood corpuscles, and especially of haemoglobin, is at fault, and there are
no grounds for thinking that increased blood-destruction plays any part.
The theory of faecal anaemia, originated by Sir Andrew Clark, has been
shown by Dr. Stockman to rest on no basis of fact ; the processes of
decomposition in the intestinal tract and of haemolysis being less than
in normal conditions.
Laudenbach's recent experiments and observations on dhe gffccts of
splenectomy in dogs lead him to conclude that the spleen takes a part
in the manufacture of haemoglobin and in the complete formation of red
blood corpuscles. But this does not throw any light on the causation of
chlorosis, since the only changes seen in the spleen in that- disease are
clearly the results of the general amemia.
Ill pernicious ancemia it is perhaps less unlikely that the spleen may
play an active part in the production of the disease, l^ut there is as yet
no absolute proof that it does so. The discussion of the sul)ject is
rendered extremely difficult by the fact that our ideas of pernicious
anaemia are but a mass of shifting hypotheses. Much will depend,
therefore, on the view taken of the nature and cause of pernicious
anaemia. If it be regarded as merely an exaggerated foi-m of a
haemo^enetic anaemia like chlorosis, and due to a failure in blood-
production ; or if with Stockman it be regarded, not as a special
disease, but as a congeries of symptoms caused by many diseases and
intensified by the eficcts of multiple intermd ha'morrhages, the spleen
cannot be thought to be in any way responsible. But if Hunter's view
DISEASES OF THE SPLEEN 525
be adopted, that pernicious anpemia is essentially h.iemol^'tic in nature,
and due to destruction of the red blood corpuscles in the portal system
by means of a poison absorbed from the alimentary canal, we may
ask whether the spleen plays any part in the process. In normal
conditions the spleen, though this is far from being universally accepted,
is one if not the chief seat of blood-destruction. When there is an
exaggerated haemolysis going on in the portal system, does the sjjleen play
any si)ecial part ?
Examination of the spleen itself in pernicious anaemia does not lend
support to the hypothesis that the abnormal blood -destruction takes
place solely in that organ. Hunter (26), while mentioning four cases in
which its weight varied between 10 oz. and 19 oz.,. says that in the
majority of cases its weight is either normal or not mentioned ; and in
some cases its weight is certainly very much reduced indeed. It has
indeed been thought that any enlargement is accidental and due to
factors connected with the disease, such as fever, rather than to increased
functional activity. The appearances of the pulp are various. Hunter
(27) insists on the large amount of pigment, which is only excelled
by that seen in malaria. But, even though the amount of pigment
(haematosiderin) be increased, this fact could not prove that excessive
haemolysis had taken j)lace in the spleen ; for the products of blood-
destruction arising elsewhere, like foreign bodies such as coal dust or
particles of carmine, are commonly carried to the spleen and deposited
therein. This process may lead to what is called a spodogenous enlarge-
ment of the organ. Microscopically there is, as a rule, no marked change
in the spleen \ occasionally nucleated red blood corpuscles have been seen,
but they are compensatory and due to the anaemia, not in any Avay account-
able for it. It cannot be said that there is any positive evidence to
prove that in pernicious anaemia there is excessive haemolysis limited
to the spleen. But although pernicious anaemia cannot l)e shoAvn to
be due solely to exaggerated h;emolysis on the part of the spleen, it
is still quite conceivalde that the spleen plays some part in this
abnormal hemolysis, just as it does, in all probability, under normal
conditions.
HTuater (27) has shown that after removal of the spleen the injection
of toluylendiamin into the blood of rabbits is no longer followed by
great blood-destruction ; hiemolysis, indeed, is either abolished or greatly
reduced, so that the presence of the spleen appears to be necessary for
the haemolytic action of this poison, which under normal conditions is
well marked. Experimenting on dogs, Bottazzi found that three days
after splenectomy the red blood corpuscles parted with their haemoglobin
much less readily than before the operation. This effect lasts a long
time. He concludes that, side by side with its function of destroying
red blood corpuscles, the spleen has the power of rendering hosmoglobin
more readily separable from the red blood corpuscles. This function
of the spleen he calls haemokatatonistic.
That the spleen has some such action appeared probable from
526 SyST£.V OF MEDICINE
Hunter's experiments just quoted ; and G-abbi found that after splenectomy
in guinea-pigs the count of red blood corpuscles was increased, though in
rabbits splenectomy had no effect.
If we admit that the actual hemolysis in pernicious anaemia is the
effect of a toxin a1)sorbcd from the alimentary canal, the ha^mokatatonistie
action of the spleen would render this destruction more easy, Avhile
atrophy of the or-gan or its removal should have the opposite eft'ect.
Bottazzi, in animals rendered anemic experimentally, found the red
blood corpuscles more tenacious of their ha3moglol)in than normally ;
that is, in much the same condition as after splenectomy. This he
explained l)y supposing that in extreme anaemia the spleen attempts to
compensate the blood change by forming red lilood corpuscles (Bizzozcro),
and that while so doing it loses its ha^mokatatonistic power. This
observation and hypothesis have no bearing on pernicious anaemia ; for
it is well known, as Copeman showed, that in pernicious anaemia the
liR'moglobin leaves the red ])lood much more readily than normal. This
last fact is rather in favour of an exaggeration of the hiemokatatonistic
action of the spleen in the disease, but whether this be so we have no
further evidence at present.
In conclusion, there is no evidence that the spleen plays any part at
all in the production of chlorosis or of traumatic aniemias ; Imt it appears
possible that in pernicious aniiemia it plays an accessory though not the
chief part in haemolysis. Caution is, however, most necessary in forming
any positive opinions on the pathology of pernicious anaemia in the
present state of our knowledge.
Special Pathology
Malformations : — Atrophy ; jiost-
raorteni changes.
Capsulitis.
Clironic venous congestion.
Hieniorrhages.
Cysts.
Infarcts.
Abscess.
Tuliercle.
Syphilis.
Rickets.
Lanlaceoas disease.
Malijcuant disease.
Malformations. — Under this heading reference may conveniently
be made to anatomical altnormalities in coiiforniatioii, including the
presence of accessory spleens, and to changes in the position of the
organ.
Very consideral)le physiological variation may exist in the outline
of the organ; sometimes it is found to be elongated, and to resenil»lc the
form met with in some animals : at other times it is more compressed
and rounded than usual.
The outline of the anterior margin may show a luunber of notches
which, in enlargement of the organ, may become very accentuated ; occa-
sionally a deep notch may even paitially divide the spleen into two.
Under ordinary conditions there may be a single slightly-marked notch
DISEASES OF THE SPLEEN 527
on the anterior border near its lower end ; but it is variable in its position,
and even may occur on the posterior margin, or be absent altogether. Dr.
A. Latham has shown me a most remarkable abnormality of the spleen
found in the post-mortem room of St. George's Hospital. The spleen gave
off a long process which was bound down to the posterior abdominal wall
by the peritoneum and ran down into the left side of the scrotum. In
thickness it was equal to the little finger. Microscopically it was com-
posed of splenic tissixe. It Avas probably carried down in the descent of
the testes, just as accessory suprarenal bodies may be transported into
the neighbourhood of the epididymis.
Accessory spleens, splenunculi or lienculi, are common ; they occur
in the folds of peritoneum passing to the spleen, the gastro-splenic omen-
tum, and left pancreatic gastric fold, in the great omentum on the left
side, and even between the layers of the costo-colic fold of peritoneum
or suspensory ligament of the spleen. Usually they are close to the
hilum of the spleen, and are not more than one, two, or three in number ;
but as many as thirty or forty have been found.
It is generally thought that accessory spleens are commoner in early
life. Jolly, in eighty post-mortem examinations of patients under sixteen
years of age, found them in twenty, or one in four ; but they became
more frecpient as age advanced. It may be that though more manifest
in children they are not really more frequent. It has been stated that
accessory spleens are commoner in the south of Europe than in the north.
Mr. Bland tSutton says that, especially in cases of transposition of the
viscera, the spleen may be represented Ijy a number of splenunculi, which
may be clustered together like a bunch of grapes or be more widely
separated.
Albrecht has described a case in which an enormous number of
accessory spleens, varying in size from a hazel-nut to a pin's head, were
found scattered all over the peritoneum ; in the situation of the spleen
there was one as large as a walnut ; microscopically they Avere composed
of splenetic tissue much pigmented.
The existence of these accessory spleens admits of tAvo explanations :
some of them, those in the hilum of the organ, are probably separated
from the main body of the organ, a projecting tongue becoming
pedunculated, and, finally, connected liy blood-vessels only ; others, those
in the great omentum, may Avith probability be regarded, like suprarenal
"rests," as isolated and outlying fragments of the mesoblastic tissues
destined to form the main organ. Like other " rests," they may
become indented and embedded in other organs ; thus Dr. Biggs has
described an accessory spleen in the tail end of the pancreas.
If accessory spleens become indented on the surface, and subsequently
embedded in the substance of the spleen, they may form encapsuled
tumours in the organ. From the fact that in fetal life the left lobe of
the liver and the spleen are in contact, it might naturally be expected
that an accessory spleen might become indented and implanted in the
surface of the liver, ^)ut this does not appear to have been observed.
528 SYSTEM OF MEDICINE
They undergo the same changes as the main oi-gau. In a case of
splenectomy in a boy for rupture, recorded by Iklhuice and Pitts, an
accessory spleen was left, and by compensatory hypertrophy may have
had some share in preventing the symptoms following removal of the
organ which were noticed in the other two cases of splenectomy for
rupture recorded by these observers. Experimentally, after removal of
the spleen numerous small red masses have occasionally Ijcen found in
the omentum ; they contained nucleated red blood-cells, but there is
some doubt whether they are, as was first stated, com])osed of characteristic
splenic tissue. Laudenbach found them in a splenectomised dog, in
which the usual compensatory extension of red marrow into the shafts of
the long bones had not occurred, and he considered that they were mesen-
teric glands which had taken on the formation of red blood corpuscles in
lieu of the red marrow.
Congenital absence of the spleen is very rare in Ijodies otherwise
normal ; it has been noted in monsters. Garrod, in a paper on the
association of cardiac malformations with other congenital defects, refers to
two cases of congenital morbus coidis in which the spleen was entirely
absent ; in two other cases it was multiple, there being nine and four
spleens respectively.
In complete situs transversus the spleen is present on the right side
of the abdomen. In cases of congenital or traumatic diaphragmatic hernia
the spleen readily passes into the left pleural cavity.
Atrophy. — In old people the spleen, like the other lymphoid tissues,
undergoes atrophy, sometimes to an extreme degree ; so that instead of its
normal weight of 7 oz. it weighs only a few drachms. The same condition
of atrophy occurs in cases of very chronic diseases.
The capsule is shrivelled, thrown into folds, and somewhat opaque ;
the substance of the organ is soft and pale ; and from atrophy of tlie {)ulp
the vessels and trabecuke stand \\\) prominently. In cases of simple
atrophy there is no increase of pigment, but, if there has been any disease
giving rise to extensive h;emolysis, the substance of the organ may be
dec])ly pigmented. ^Microscopically there is atrophy of the Malpighian
bodies and of the pulp of the spleen, while the artei'ies show aiterio-
sclerosis, and the pulp is seen to be undergoing atrophy. A rather firm
fibrotic form of atrophied spleen is said to be associated with arterio-
sclerosis in the aged. This form of atrophy occurring in senile and
marasmic conditions may be spoken of as simi)le.
There are cases, however, in which, although increased in bulk and
weight, the spleen shows a replacement of its essential elements — the
])tdp and Malpighian bodies — 1)y fibrous tissue. Such a change occurs in
splenic atuemia and in chronic lymphadenoma — conditions prol)ably due to
some form of chronic toxiemia. The spleen cannot, in oidinary parlance,
be said to be atrophied, but functionally it is much in the ])osition of an
atrophied organ. In this connection Pillict's {[?>) experiments arc of
considerable interest. lie found that on dogs poisoned by metatoluyl-
endiamin, paraphenylene, and nitrate of soda the Malpighian bodies
DISEASES OP THE SPLEEN 529
became atrophied, and the splenic pulp distended with blood ; these
changes he regards as characteristic of the senile spleen.
Post-mortem changes. — Two very evident alterations which occur
after death may be I'cferred to.
(i.) When the stomach or colon contains much flatus, the surface of
the spleen in contact with them is often found to be of a black or purple-
green colour. The change is not present throughout the organ as it is in
melanaemia, but it is limited to the areas of contact with the hollow
viscera, and on section is seen to be quite superficial. A similar appear-
ance may often be found on the surface of the liver. It is due to gases,
among which is sulphuretted hydrogen, diffusing through the walls of the
stomach and intestines after death, and meeting in the spleen with traces
of iron contained in hsematosiderin, and derived from haemoglobin ; as a
result of this reaction sulphide of iron is produced.
(ii.) Occasionally the spleen is found honeycombed by small gas-
containing cysts. This emphysematous condition, when present, is usually
found in cases fatal from micro! »ic infection, such as pyaemia. It is, how-
ever, less marked in the spleen than in the liver ; to the latter condition
the term foaming liver (1) has been applied. AVelch and Flexner have
shown that this condition is due to the activity of the bacillus aerogenes
capsulatus. The infection is secondary, and is a post - mortem or
agony phenomenon. Adami doubts whether, under ordinary condi-
tions, this bacillus can grow in the human organism without the simul-
taneous presence of aerobic microbes. Kanthack has found that the
bacillus coli communis may also give rise to this emphysematous condi-
tion.
Capsulitis is a convenient and comprehensive term for a group of
pathological changes which are of but little clinical importance, though
p;iin in the left side and stitch may be explained by their presence. Under
this heading we may include (i.) adhesions, the result of some past attack
of peritonitis, local or general ; (ii.) chronic peritonitis involving the whole
or greater part of the peritoneal covering of the organ ; and (iii.) the local
thickenings, or lamellar fibromata, so commonly met with on the surface
of the organ.
(i.) Adhesions round the spleen uniting it to the diaphragm, abdominal
wall, stomach, or colon, may follow a past attack of acute peritonitis.
These adhesions are vascular, and, of course, vary in their extent and firm-
ness. Sometimes they may be filamentous and easily broken down ; they
may, in fact, become torn across as the result of abdominal movements,
and then appear as small loose tags on the surface of the organ. Occa-
sionally they are so small at their point of attachment to the surface of
the spleen as at first sight to resemble miliary tubercles. In other
cases the adhesions may be so firm as to suggest recurrent attacks of
inflammation or a prolonged inflammatory condition.
Very frequently local adhesions around the spleen are present without
any other signs of past inflammation of the peritoneum. In such cases
it will frequently be found that there are firm adhesions at the base of
VOL. IV 2 M
530 SYSTEM OF MEDICINE
the left lung ; presumably a jiast pleurisy or pneumoiiia had given rise to
an inflammation of the diajihiagni and of the pei'itoneiim ai'ound the
spleen.
In other cases local adhesions mav be due to some cause oriirinat-
ing within the spleen itself. The infarcts so frequently met with in
the enlarged spleen of leukaemia often set up local peritonitis. The
same thing occurs with infarcts secondary to endocarditis. Similarly,
tubercle or lymphadenoma, or the eidargement and attacks of congestion
of an ague cake spleen, may 1)c the cause of local peritonitie adhesions.
Mr. Henry Morris has told me of several cases operated upon by himself
in which on freeing peritoneal adhesions around the spleen a remarkable
and rapid diminution in its size had taken place. In such cases the
adhesions first became organised when the spleen was enlai'ged, and as
the result of the permanent traction exerted by them the organ was held
open and unable to contract.
(ii.) Chronic pcrifo?iiti.< attacking the whole or the greater surface of
the organ is generally ])Ut a part of general chronic jieritonitis (compare
article on " Perihepatitis "). Chronic capsiditis or perisplenitis may, how-
ever, be independent of this general cause, and be due to some local
lesion of the spleen, such as a gumma.
The macroscopic appearances are very characteristic. The organ is
tightly shrouded in a firm, opaque membrane of almost cartilaginous con-
sistency. Often, but by no means always, this fibrous membrane can be
peeled off, so as to expose the peritoneal surface of the spleen. The outer
surface of this " false " memlirane is fairly smooth, but not uniform, for
scattered irregularly over it there are round depressions resemljling the
impress of rain-spots on soft sand. Their presence can be best explained
by supposing that, after the formation of this inflammatory tissue, cicatricial
contraction took place, and that, as a result of the increased tension
thus brought about, the membrane had ruptured, either at its weakest
spots or where the tension was greatest. This condition of chronic
capsulitis may be accompanied by adhesions to the adjacent parts, Ijut
they are often absent.
(iii.) Lucalised thickenings on the peritoneal siLvf (ICC of the spleen are one
of the commonest post-mortem appearances. They closely reseml)le the
thickenings sometimes seen over the apices of the lungs, and may be
compared with the "milk-spots " so commonly present on the pericardium.
They may be aptly described as corns due to attrition. They are not
met with on the surface of the liver, or indeed elsewhere on' the peri-
toneum, except as a result of some definite local irritation. An admirable
example of a similar formation occurring in the subperitoneal tissue
covei'ing the rectum, and due to the irritation of a i)iece of iron, has
been described by Mr. Shattock (44).
The anterior surface of the liver often presents an oi)aque and
thickened condition of the peritoneum due to tight lacing or to the
friction of a hypertrophied heart ; l)ut these thickenings, which resemble
the milk-spots on the heart, are not the exact counterpart of the lamellar
DISEASES OF THE SPLEEN 531
fibromata on the spleen with which Ave have compared then^. They are
not so locaHsed, and not nearly so massive.
Their frequent occurrence on the capsule of the spleen is probably
due to the fact that this organ has the power of rhythmic contraction.
This homologates them with the milk-spots already mentioned. On section
they are seen not to invade the substance of the spleen, but to stand up
as distinct growths in the capsule. These elevations are of various
dimensions, from that of a pin's head to half-a-crown, and are seen to
thin off gradually at the edges. When of old standing they frequently
undergo calcification.
Microscopically they are composed of lamellated and well-formed
fibrous tissue, and are described as lamellar fibromata, or — from their
resemblance to the structure of the cornea — corneal fibromata.
Sometimes they are adherent to the parietal peritoneum, just as the
milk-spots on the surface of the heart are occasionally united by an
organised fibrous tag to the parietal pericardium. But more often, like
the cardiac milk-spots, they are free.
Chronic venous congestion of the spleen, such as is often seen
resulting from obstructive heart or lung disease, does not give rise to
any noticeable enlargement of the organ, as might naturally perhaps be
expected. The spleen is hard, firm, of a deep red or purple colour,
and about the normal size or slightly enlarged. The capsule is generally
somewhat thickened, there is usually an increase of the interstitial
supporting tissue — interstitial splenitis — and the venous sinuses are
dilated.
In 56 cases of nutmeg liver, all from uncomplicated cases of non-infective
heart disease, Dr. Kelynack found the average weight of the spleen to be
7 "3 2 oz. ; while in 84 cases of cirrhosis, 53 being males and 31 females, the
average weight of the spleen was— males 14-25 oz., females 11-62 oz., or
for both sexes together 12-93 oz.
In cirrhosis of the liver the spleen is generally but by no means
constantly heavier than normal. In 114 cases of cirrhosis (49) of the
]iver, of which 47 were fatal from the direct effects of the disease, the
remaining 67 dying from independent causes, the average weight of the
spleen was 9-8 oz. ; taking the normal weight as 7 oz., this shows an
increase of 2-8 oz. In the 47 cases of fatal cirrhosis the average
weight of the spleen was 1 1 oz., and in the 67 cases fatal from independent
causes 9 oz. ; so that the spleen is heavier in cases of active cirrhosis than
when this condition is latent. There did not appear to be any constant
relation between the weight of the spleen and that of the liver. Price,
however, in an analysis of cases of cirrhosis, found large livers and large
spleens associated together.
In cirrhosis of the liver — in addition to mechanical venous obstruction,
which, as shown by cases of backward pressure due to cardiac or pulmonary
disease, is not of itself sufficient to give rise to splenic enlargement —
there is frequently a toxic condition of the blood. To this latter factor
the splenic enlargement in cirrhosis is probably largely due, for it is
532 SYSTEM OF MEDICINE
xno^iX. iiKukfd ill the early stages of cirrhosis before the portal obstruction
has become very excessive. It would appear more probable, therefore,
that cirrhosis and splenic enlargement are due to the same cause, and
not that the splenic change is purely mechanical and secondary to the
portal obstruction. This ])erhaps is not exclusively the case, for when the
splenic vein Itecomes thrombosed the spleen is considerably increased in
size ; in an exam])le which came under my observation it weighed
36 oz.
If, however, any toxic or septic condition be added to mechanical
congestion, the organ may enlarge and become softened. This is well
seen in infective endocarditis, where the diffluent enlarged condition of
the organ contrasts with the cardiac spleen already described as resulting
from backward pressure alone.
Haemorrhages. — In an examination of 1.30 still-born children, Dr.
H. Spencer found a large number of visceral haemorrhages in vaiious
organs, due apparently to damage received during delivery. The spleen
only showed haemorrhages in three cases ; which is perhaps accounted for
by the small size, mobihty, and extensiljility of the organ. In later life,
traumatism may give rise to haemorrhages into the substance of the
organ.
Small haemorrhages into the pulp of the organ are commonly seen in
bacterial infection.
Cysts. — Hijdatid. — The spleen is but seldom occupied b}'^ hydatid
cysts ; according to Thomas, in only 2 jier cent of cases of hydatid
disease. In \b cases it was the only seat of echinococcus cysts, and in
43 other cases collected by him other orgjuis were also involved. In 37
out of these 43 cases the liver was also involved. In half the cases of
hydatid disease of the spleen no symptoms were noticed, and the cyst
was only discovered post-mortem.
The contracted remains of spontaneously cured hydatid cysts are
sometimes foimd.
Dermoid cysts are very rare indeed.
Serous cysts with clear contents are very rarely met with. Small
cysts on the surface, when associated with thickening of the ca])sule,
may possibly be explained as dilated lymphatic vessels ; or possibly as
some fragments of the peritoneal endothelium becoming included inside
the organ and subsequently giving rise to cystic spaces.
Cysts containing blood or the debris of extra vasated blood may some-
times follow traumatism.
Pilliet thinks that l)lood-cysts may be derived from angiomata in
the spleen, the .surrounding pulp yielding and giving way (42).
Mr. J. K. Thornton removed a siileeii containing a multilocular cyst
with 30 oz. of blood-sUuned fluid, in which there was much cholesteiin,
from a girl aged nineteen years. There was no evidence of previous
traumatism. Microscoi^ically the process of cyst-formation appeared to
be due i)artly to breaking-down of the ^lalpighian bodies, and partly to
plugging of vessels and destruction of the organ.
DISEASES OF THE SPLEEN 533
Innocent tumours, apart from c^^sts, hardly ever occur , the presence of
fibromata apparently in the substance of the organ, and not the common
lamellar fibromata of the capsule, is referred to by some authors.
Infarcts. — Clinically infarcts of the spleen manifest themselves by
pain and tenderness in the splenic region, chiefly due to the accompany-
ing local peritonitis, and by some enlargement of the organ. Occasionally
there may be sudden and severe pain, presumably at the time that the
embolus becomes impacted in the vessel. As a result of the subsequent
absorption of the necrosed splenic tissue the temperature is raised.
Causes of infarction. — Fragments of blood-clot or vegetations dislodged
from the valves or endocardium of the heart are the most frequent
source of embolism of the splenic artery. The same result may follow
detachment of particles of calcareous material set free from sclerosed
valves or from atheromatous patches in the aorta.
These emboli are divisible into tAvo kinds — (i.) infective, those which
contain pyogenetic micro-organisms, such as are present in cases of infective
endocarditis or, much more rarely, in infective arteritis. Such emboli
give rise to suppurating infarcts, and the process is essentially the same
as that of a py;emic abscess in the organ ; (ii.) simple or non-infective
emboli which give rise mechanically to anaemia, necrosis, and the changes
of a simple infarction.
Besides embolism there are other forms of interference with the
circulation which may result in the production of an infarct. Thrombosis
in the branches of the splenic artery may have this effect, as is sonietimes
seen in typhoid, typhus, and relapsing fever ; and commonly in the
greatly enlarged spleens of leukaemia.
Occasionally thrombosis of the trunk of the splenic vein may give
rise to multiple infarcts. In two instances that have come under my
own observation, the resulting infarcts have been anaemic and not hsemor-
rhagic. It might, perhaps, have been naturally expected that complete
thrombosis of the splenic vein Avould have led to a hsemorrhagic infarct,
as in Litten's experiment of ligature of the renal vein.
Morhid anatomy of a splenic infarct. — The terminal branches of the
splenic artery do not anastomose with each other except by capillaries,
each of them supplies exclusively a definite area of the spleen, they are
therefore called end arteries. When one of these terminal l> ranches has
been recently blocked by a simple non-infective embolus, the area of the
spleen supplied by it becomes anaemic, and the condition is a white or
ana?mic infarct. This is Avhat is commonly seen in the spleen ; but
occasionally this condition of anaemia becomes succeeded by one in which
the area is full of blood, a red or hsemorrhagic infarct.
The affected area is roughly triangular, the a2:)ex being towards the
hilum of the organ, and corresponding to the occluded artery and the
base towards the capsule. A thin area of healthy splenic tissue can
usually, however, be seen immediately under the capsule which, together
with the capsule itself, is nourished by the capsular arteries of the organ.
The anaemia is succeeded by coagulation necrosis ; the affected area
534 SVSTEJlf OF MEDICINE
becomes somewhat swollen or infarctcd, projects slightly above the
surrounding surface of the organ, and is of a dull white colour.
If a recent white infarct is compared with the whitish yellow scar
left by an old infarct, it will be seen that the cicatrisation and contrac-
tion of the old infarct have led to a dejiression ; while the i-eceut infarct is
on a level with or even pi'ojects above the surrounding surface.
AVhen an ana^nnic becomes a hiemorrhagic infarct the l)loo(l first
distends the vessels, which, however, from malnutrition are unable to
contain it, and allow it to deluge the afliected area. This engorgement
of the vessels Cohnhcim regarded as due to a reuurmtation of blood from
the veins of the adjacent areas, which, unlike the arteries, do anastomose.
Litten's experiments, however, pointed strongly to the blood being
derived from the arteries running in the ca^Dsule of the oigaii and not
from the \eins.
Following on coagulation necrosis and its accompanying fatty de-
generation, and probably as a result of the irritating property of the
fluids deriw'd from the necrosed cells, inflannnation is set up around the
infarction. This is shown by a zone of congestion in the substance of the
organ, and by local peritonitis on the surface. This inflammation leads
to an invasion of the infarcted area by young connective tissue cells,
phagocysts, and so forth ; and the processes of replacement fibrosis and
absorption of the necrosed tissue take place side by side. Eventually
a depressed cicatrix is left, with perhaps in the centre, if the infarct be
large, some cncapsuled caseoiis debris, the remains of necrosed tissue
which Avas too extensive to be absorbed.
Occasionally calcification of the cicatrix of the infarct may occur.
The local peritonitis may produce loose tags of fibrous tissue, or
adhesions to adjacent organs, to the omenta or to the diaphragm.
When an infective embolus lodges on the spleen, the fii-st stages are
the same as those described above for a simple embolus ; and sometimes
in infective endocarditis a definite anaemic infai'ct may be seen before the
subsequent acute inflannnation and suppuration have supervened. This
soon passes into a pyannic abscess.
Abscess. — The softened and often diftluent condition- of the spleen
seen in cases of bacterial infection may be described as a splenitis, and is
in some degree comparable to lymphadenitis. This condition of the spleen
is commonh' seen in infectious fevers, but very rarely indeed goes on to
suppuration in these diseases.
The rauHej. of abscess in the spleen. — One of the most frequent causes
of splem'c abscess is infective enilocai-ditis. In association with this
disease the spleen is enlarged and softened, in short, in the condition
seen in bacterial infection. When an abscess occurs it is the result of
septic emboli.sm in the organ, giving rise first to an infarct Avhich, instead
of ruiuiing the course of an ordinary infarct, bi-eaks down, while exten.sive
sui)puration is set uj) by the micro-organisms contained in the cmliolus.
Such an infarct in the earliest stages may bo anajmic or h;emorrhagic,
but softening and suppuration soon super^ ene.
DISEASES OF THE SPLEEN 535
In pyaemia, abscesses embolic in origin, like those in infective
endocarditis, are often met with. Thus Stephen Paget in 430 cases of
general pyaemia found abscesses in the spleen in 39.
In pylephlebitis abscesses may form in the spleen, but this is very
rare as compared with al)scesses in general pyasmia. 8. Phillips found
three abscesses in a spleen weighing 38 oz., in which suppurative
phlebitis of the portal vein was clue to perforation of the mesenteric
veins by a bristle. In suppurative pylephlebitis the aljscesses in the
spleen are not necessarily always due to the direct spread of the inflam-
matory process along the splenic vein, but may be due to general pyaemia
and septic emboli carried by the arteries.
Suppuration in the spleen has, in rare instances, occurred in typhoid
fever ; it has been shown to be due to the activity of the typhoid
bacillus, and may be due to secondary infection with other micro-
organisms. Infarcts, as mentioned above, are found very occasionally in
typhoid fever ; they may slough, and thus give rise to an abscess.
Sjilenic abscess has also been recorded as a result of malaria, but is
probably due to a secondary infection by pyogenetic micro-organisans.
Extension of inflammation from adjacent parts usually only sets up
peritonitis on the surface of the spleen ; but a perforating ulcer in the
stomach or colon may penetrate the spleen, and give rise to suppuration
in the organ.
Hydatid cysts of the spleen' are rare ; if suppuration occurred in a
cyst embedded in the organ it would closely resemble a splenic abscess.
Injury has been the only discoveral)le cause of some splenic abscesses ;
it probaljly acts by reducing the resisting power of the organ, and so
giving free play to any pyogenetic micro-organisms present.
A number of cases have been described in which no definite cause
for splenic abscess was forthcoming ; some of these cases were probably
pya-mic and embolic in origin, and secondary to suppiu'ation elsewhere.
Thus, like cerebral abscess, suppuration in the sj^leen may be secondary
to inflammation and suppuration in the thorax.
A softening gumma, and perhaps actinomycosis, may give rise to the
appearances of an abscess in the spleen. Actinomycosis, however, when
it attacks the spleen generally produces a firm growth somewhat like an
anaemic infarct.
Tuberculosis. — Generalised tuberculosis.- — In this condition the spleen,
like other organs, becomes infiltrated with miliary tubercles.
They are much more evident on the capsule than in the substance of
the organ, where there is moreover some difficulty of distinguishing
them by the naked eye from Malpighian bodies. On the surface they
appear as gray, rarely as yellow points ; occasionally they may set up
local peritonitis, and may even give rise to the formation of a fibrinous
membrane on the surface of the organ. On section of the organ, gray
nu"liary tubercules can, according to Sir S. Wilks, be distinguished from
Malpighian bodies by the fact that, when exposed to a stream of water,
the normal splenic tissue is dislodged sooner and more easily than the
536 SYSTEM OF MEDICINE
tubercles ■which cliiii^ lo the tnibecuhe. In geiicrulised uibcrculosi.s the
spleen is enlarged and soft ; when of rather older date, the tubercles
may caseate ■while still remaining discrete.
Chronic tuberculosis. — Large caseous masses, though common in the
spleens of animals, are by no means common in man ; Avhen they do
occur, they arc more often met Avith in children than in adults.
Large, round, caseous masses, with some smaller miliary tubercles near
them, are somewhat loosely embedded in the spleen substance. After a
time they softeji down in the centre, and can then be recognised at once.
Caseating tuberculous material, before it has softened down, cuts with a
firm section, and to the naked eye so closely resembles the " hard-bake "
spleen of chronic or hard lymphadenoma that a microscopic examination
may be reijuired to distinguish between them.
The caseous masses are not, as a rule, stuTOunded by fibrous tissue ;
but in cases of exceptional chronicity the spleen may be extensively fibrosed,
and so pigmented as to resemble lymphadenoma ; especially when there is
little caseation. Calcification may occur in the caseous tuberculous patches.
Microscopically, giant cells are usually abimdant ; but the giant-cell
system is often incomplete, and the demonstration of tubercle bacilli may
be difficult.
Syphilis.— Acquired syphilis. — During the exanthem the spleen is often
found to lie ^'ularged, presumably as the result of the local action of the
syphilitic toxin.
In the tertiary stage gummata are rarely met with ; Dr. Still has
only been able to collect twenty recorded cases. "When present, they
may reach a very large size ; thus, in a case recorded by Drs. Delrpine
and Sisley, one-third of the spleen, Avhich, though it Avas not lardaceous,
weighed 38 oz., was occupied by a large gimima ; numerous smaller
gimimata were present, and there was general fibrosis of the organ.
Over a gumma capsulitis and adhesions to the diaphragm and adjacent
parts are found, especially if it impinges on the surface. Apart from
gummata capsulitis is often found in the bodies of syphilitic subjects.
Cicatrices involving the substance of the organ may result from gummata
which have undergone absorption.
As a consequence of sy2)hilis lardaceous change in the sjileen often
results.
In congenital syphilis the spleen is generally enlarged, and firmer than
normal ; sometimes the splenic enlargement is excessive and may be
associated with hepatic enlargement. Dr. Gee found enlargement in one-
fijurth of all cases of hereditary syphilis.
Structurally there may be a general fibrosis, sometimes attacking the
pulp especially, at other times radiating from the filirous trabecul:\3.
Lardaceous disease may occur as in acquired syphilis. Gummata
appear to be very rare, rarer perhaps than is usually thought ; Dr. Still
was only able to collect six cases in children. Of these, four occurred in
late hereditary syphilis between the ages of six and eleven years, and the
other two in early infancy. In four of the cases there were gummata in
DISEASES OF THE SPLEEN 537
the liver, and in a fifth in the kidney. In none of the cases was there a
solitary gumma in the spleen ; usually they were numerous, and in three
miliary.
Rickets. — The spleen is generally regarded as enlarged in rickeis ,
thus T. Colcott Fox and Ball record sixty-three cases of enlarged spleen
in children, all of whom were rickety, and quote Gerhardt, who found
splenic enlargement in thirty-five out of fifty-four rickety children, and
Kuttner, who found it forty-four times in sixty cases of rickets ; lower
estimates put it at 40 per cent.
On the other hand, Henoch, Donkin, and V. Starck regard enlarge-
ment of the spleen in rickets as merely accidental, and not due to the
sime cause that produces the skeletal and other characteristic features of
the disease.
The enlargement may in some cases be apparent rather than real, and
due to downward displacement of the organ as the result of rickety
deformity of the thorax. In other cases some other disease may have
been present ; thus, in one of Sir W. Jenner's cases of " albuminoid "
change in rickets, the spleen of a very anaemic boy, barely two years of
age, weighed 9|- oz. ; the details of the case are cpiite compatible with
the view that he had splenic antemia in addition to rickets. The enlarge-
ment of the spleen can also be explained as the result of some toxic
absorption from the intestines, or lungs, which, in rickets, are both fre-
quently in a condition of catarrhal inflammation. Dr. Hogben ascribed a
form of biliary cirrhosis in the livers of rickety children to this cause,
and the hypothesis might be extended to explain any fibrosis that might
chance to be found in a rickety child's spleen. To sum up, the spleen is
frequently found enlarged in rickets, but it is of no special importance,
and presents no definite pathological lesions.
Lurdaceous disease. — The spleen seems to be the organ most frequently
attacked ; thus, in fiftj'^-eight cases of lardaceous disease tabulated by Dr.
F. C. Turner, the spleen was involved forty-eight times, the liver thirty,
the kidneys fifteen, and the intestines ten. In twenty-three of these cases
the spleen was the only organ invaded.
Lardaceous disease attacks the spleen in two ways : —
(i.) The "sago" spleen; the capillaries of the Malpighian bodies are
the parts affected, the arteriole in the centre of the corpuscle being as a
rule healthy. The Malpighian bodies are enlarged to three or four times
their normal size, and, being translucent, to the naked eye resemble
grains of sago. The pulp and the lymphoid cells are unaffected. The
sago spleen is firm, somewhat anaemic, and increased in size.
(ii.) The ditfuse, waxy spleen, uniformly lardaceous or bacony spleen.
This is much less common than the sago spleen. The chief changes are in
the walls of the blood sinuses, which become much thickened and swollen.
The lining endothelium is not affected. The small arteries are aff"ected,
but the trabeculse remain unattacked. The Malpighian bodies are un-
aff'ected, or affected but rarely ; they may be present, but more often they
have disappeared. The splenic pulp becomes lardaceous secondarily. The
53S SYSTEAT OF MEDTCINE
diffuse, waxy s])leen is enlarged, and is heavier than tlie sago variety ;
it is resistant, and presents a dry surface on section.
For a detailed account sec article on " Lardaceous Disease," vol. iii.
p. 2")").
Malignant disease of spleen. — It is doubtful Avhethcr primary carci-
noma of the spleen ever occurs. In 1S8G Xotta collected nine cases, and
gave a clinical account of a case, in which, however, no post-mortem
examination was made. It may possibly have been a sarcoma of the left
kidney with secondary growths in the spleen and liver, inasmuch as the
first symptom was hivmaturia.
A few cases have been described, which, like Gaucher's (20) I'ejiitMliome
primitif de la rate, are probably examples of the splenic lesion of splenic
ananiiia. Reeentlv Picou and llaniond have iriven a careful account of
this condition, and regard it as a carcinoma derived fi-om pancreatic cells
included in the spleen during fcetal life. They had seen such cells in a
three months' ftetus, and Peremeschko had described the same appear-
ance in the spleens of cml)ryos, young children, and suckling women.
This hypothesis is a reasonable explanation of the presence in the spleen
of a tumour thought to be cai'ciuomatous ; but it cannot be said that the
existence of primary carcinoma of the spleen has yet been positively
I^roved.
In Picou and Ramond's case an eiilai-ged spleen was removed by
laparotomy from a woman who had been ill for four years ; it contained
large cells 16-30/x, with nuclei i-S /i. A similar appearance is described
by Collier in the enlarged spleen of a child who had been ill for two
years. Clinicalh', the long duration of the disease and the general
resemblance to splenic anaemia are against the malignant nature of the
change in the spleen, and in favour of its being the lesion of chronic
splenic anajmia. Gaucher (21), in fact, in Debove and Bruhl's description
of splenomegalie j)rimitivc or splenic anaemia, recognised the condition
which he had previously called Vcpitlidliome priuiiti/ de la rate. Moreo^■er,
from a pathological point of view, the lai'ge cells resemble those seen in
chronic inflammatory conditions of lymphatic tissue. This enables us to
explain the fact that in Eamond and Picon's case the adjacent glands in
the hilum of the spleen showed the same characteristically large cells,
without being driven to the conclusion that the splenic condition Avas
necessarily carcinomatous because there Avas a secondary growth in the
adjacent lymphatic glands. In other instances, as in a case reported on
by the Morbid Growths Committee of the Pathological Society {^), and
found to be carcinoma, the j^ossibility of a primary growth has not been
definitely excluded.
With regard to primary sarcoma of the spleen, there is no a jviori
rea.son against its occurrence, as there is against ])i'iniary carcinoma.
Possibly it may occur, Hamilton says that it undoubledly does ; but it
must be extremely rare. Dr. Norman Moore has described a mixed celled
sarcoma of the spleen which grew directly into the stomach, and "Wcichsel-
baum a fibro-.sarcoma.
DISEASES OF THE SPLEEN 539
A pulsating cvavernous angioma with a secondary growth on the liver
has once been seen.
Secondary growths are hy no means frequent in the spleen. Thus,
in 735 autopsies of carcinoma of the mamma the spleen was the site of
secondary growths in seventeen cases; and in 244 cases of cancer of the
uterus there was only one case in which a secondary nodule was found in
the spleen (39). Of 161 cases of carcinoma of all parts of the body collected
from the post-mortem records of St. George's Hospital by Dr. A. Walker,
secondary growths were met with in the spleen in seven, Avhile in fifty-
four cases of sarcoma from the same source there w^as but one instance
of a secondary splenic growth.
In fifty cases of melanotic sarcoma quoted by Von Ziemssen the spleen
contained secondary growths in thirteen.
In cases of carcinoma of the caixliac end of the stomach the spleen
may become invaded by continuity of growth ; it may also, of course,
become infected from the surface in cases of general malignant disease of
the peritoneum.
For spleen in malaria, hjmphadenoma, splenic anccmia, and leukcemia
the reader is referred to the special articles on those subjects.
Wandering spleen is dealt with in the article on " Enteroptosis."
H D. EOLLESTON.
REFERENCES
1. Adam I. Ifontrcal Medical Jo^mud, August 1896.— 2. Albrecht. Wien. med.
Woch. Way 2, 1895.— 3. Arnott, H. Trans. Path. Soc. London, vol. xxiv. p. 222.
—4. Ballance. Brit. Med. Journal, 1897, vol. i. p. 145.— 5. Bardach. Ann. de
rinst. I'astcur, vol. iii. p. 577. — 6. Biggs. New York Path. Soc. Oct. 11, 1893.—
7. P>0TTAZZI. Archivesital.de hiolog. 1895, p. 462.-8. Bruhl. Archives gin. denied.
1891, vol. clxvii. p. 168.-9. Collier. Trans. Path. Soe. London, vol. xlvi. p. 148. —
10. COPEMAN. St. Thos. Hasp. Reports, vol. xvi. p. 155.-11. Coupland. Brit. Med.
Journ. 1896, vol. i. p. 1445. — 12. Courmont and Dufface. Conipt. Bend, de hiolog.
June 19, 1896. — 13. Debove and Bruhl. Bull, et mim. mdd. soc. des ho}). Paris, 1892,
p. 596. — 14. Delepine and Sisley. Trans. Path. Soc. London, vol. xlii. p. 147. —
15. Flexner. Journal of Experimental Medicine, vol. ii. p. 197. — 16. Fox, T. C, and
Ball. Brit. Med. Journ. 1892, vol. i. p. 854. — 17. Friedrich. "Acute Splenic
Tumours," German Clinical Lectures, New Sydenham Soc. vol. Ixxi. 1877. — 18. Gabbi.
Zieglcrs Beitrdgc, xix. p. 647. — 19. Garrod. St. Bartholomew's Hospital Bcports, yq\.
XXX. — 20. Gaucher. These Paris, 1882. — 21. Idem. Semaine midicale, 1892, p. 331.
— 22. Gee, S. Brit. Med. Journ. 1867, p. 435. — 23. Gueorgaievsky. Gazcta Botkina,
1896, lip. 1313, 1343, quoted in La Prcssc medicate, Jan. 30, 1897.-24. Hamilton.
Pathology, vol. ii. part ii. p. 789. — 25. Hogben. Birminghain Med. Bcviciv, vol. xxiv.
p. 65.-26. Hunter. Lancet, 1888, Sept. 22.-27. Idem. Lancet, 1892, vol. ii. p. 1259.
—27a: Idem. Journal of Path, and Bacteriology, vol. iii. p. 259. — 28. Jolly. Bull.
Anat. Soc. Paris, 1895, p. 745.-29. Jonne.sco. Progres medical, No. 12, 1897.-30.
Kanthack. Centralhlatt f. Bakt. v. Parasit. xii. -p. 227. — 81. Kelynack. Birming-
ham Medical Revien\ Feb. 1897. — 32. Kj,eix. Trans. Path. Soc. London, vol. xxviii.
p. 439.-33. Laudenbach. Archives de Physiolog. 1897, p. 385.-34. Montouri.
Pdforma Med. 1893, p. 472.-35. Mooke, N. The Bradshaw Lecture 1889, p. 46.-36.
Mosler in Von Ziemssen s ^Encjjclopxdia of the Practice of Medicine, vol. viii. p. 349,
English translation 1878. — 37. Not'I'a. Archives gen. de med. 1886, i. p. 166. — 38.
Oulandi. Ri for ma Med. 1893, p. 195.-39. Paget, S. Lancet, 1889, vol. i. p. 571.—
40. riiiLLiPS, S. Trans. Clin. Soc. vol. xxviii. p. 222. — 41. Picou and Ramond. Archives
S40 SYSTEM OF MEDICINE
de mid. experiment ct d'anat. 2mth. 1896, p. 168. — 42. Pilliet. Compt. llnul. Soc.
de Biulog. Paris, 1895, p. 679.-43. Ibid. 1894, p. 331.— 44. Ibid. 1892, p. 905.-4.5.
PliTs and Ballance. Trans. Clin. Soc. vol. xxix. p. 102. — 46. Price. Guy's Hasp,
llepurts. Series III. vol. xxvii. p. 295. — 47. Ri'.mNEK. Berlin, klin. JFocJi. Feb. 20,
1893.— 48. RiGHi. lii/orma Med. 1893, p. 170.-49. Rolle.stox and Fenton. Bir-
mimjham Med. Eev. Oct. 1896. — 50. Staklk. Dcutsches Archiv f. klin. Med. Ivii. p.
265. — 51. Shattock. Trans. Path. Soc. London, vol. xliv. p. 151. — 52. Svenceu, H.
Trans. Obslct. Soc. vol. xxxiii. p. 284. — 53. Spencer, W. G. Lancet, 1897, vol. i. p.
651. — 53rt. Still, G. F. Trans. Path. Soc. London, vol. xlviii. — 51. Stockman.
British Medical Journal, 1895, vol. ii. p. 1473. — 55. Sutton, J. B. Travis. Clin. Soc.
London, vol. xxvi. p. 48. — 56. Thomas. On Ilt/dntid Disease, vol. ii. p. 21, 1894. —
57. Thornton. Trans. Path. Soc. London, vol. xxxv. p. 385. — 58. Tictine. Medis
obozrcnie, No. 18, 1893. — 59. Tizzoni and Cattani. Centralhlatt f. Bakt. u. Parasit.
xi. p. 325.-60. Idem. liiforma Med. 1893, p. 189.-61. Turner, F. C. Travis. Path.
Soc. London, vol. xxx. j). 517. — 62. Washboukne. Trans. Path. Soc. London, vol. xlvi.
p. 325.-63. Wkichselbaum. Virchovfs Archiv, Bd. Ixxxv. S. 562.-64. Welch and
Flexner. Journal of Expcr. Med. No. 1, p. 1896.
H. D. K
ADDISON'S DISEASE
Synonyms. — Morbus Addisovii, Melasma Addisonii, Bronzed disease,
Asthdnie surrdnale, Mclahodcrmie astlmiique.
Definition. — An exaggeration of the normal pigmentation of the skin,
associated with extreme prostration and a tendency to syncope, nansea
and vomiting. During life no morbid lesion is discoverable, and post-
mortem alteration of the suprarenal caj^sules is the chief or only change
found.
History. — In searching for the cause of pernicious an?emia Thomas
Addison of Guy's Ho.spital discovered the association between disease
of the suprarenal bodies and the train of symptoms that bear his name.
This observation was first reported ])ublicly in a paper (4) read in 1849
before the now extinct South London Medical Society ; but it attracted no
attention until 1854, when Addison (3) ])ublished a monograph of thirty-
nine pages "On the Constitutional and Local Effects of Disease of the
Suprarenal Capsules." The discovery was slow to receive general recogni-
tion, and in the prefatory remarks a])pended to the reprint of this paper
on Addison's collected A\Titings, published by the New Sydenham Society
in 1868, eight years after his death, it is stated that "even now it
(Addison's disease) does not find a place in the nosology of some
■writers."
To the loyal and unselfish efforts of Sir S. Wilks the general accepta-
tion of this remarkable discovery is largely due ; he collected, sifted, and
descri>)e(l the clinical features and pathological details of numerous cases
of the disease in the Guy's Hospital Ileports (56).
Trousseau, in his widely-known cliin'cal lectures, gave honour to
ADDISON'S DISEASE 541
whom honour is due in naming the morbid entity Addison's disease
(52). The late Dr. Headlam Greenhow wrote largely on the subject,
more especially in the Croonian Lectures on Addison's disease before the
College of Physicians in 1875, in which he collected a large number of
cases, and gave a very complete revicAV of the subject, to which little was
added for fifteen years.
Within the last few years the great adA^ance on our physiological
knowledge of the so-called ductless glands has led to corresponding
interest and research in connection with their diseases. This has
resulted in considerable attention being paid to the pathology and treat-
ment of Addison's disease.
Comparatively little has been added to our knowledge of the clinical
aspect of the disease since it was first described by Addison. The nature of
the lesions found and the mechanism by which they lead to the symptoms
characteristic of the disease have, however, been interpreted in different
lights.
Addison in his original memoir considered that any lesion of the
suprarenal bodies which interfered sufficiently with their function would
give rise to the disease. AYilks narrowed down this broad conception,
and insisted that all genuine cases of the disease are due to one and the
same lesion, which he considered to be a primary inflammation of the
suprarenal bodies homologous to hepatic cirrhosis ; and that the symptoms
Avere not due to the changes in the suprarenal bodies, but to the effects
thus secondarily induced in the adjacent sympathetic. These views were
endorsed by Dr. Greenhow, and for many years were accepted without
demur.
Since the theory of the internal secretions of glands has become
established on an experimental basis, and especially as a result of the
Avork of Abelous and Langlois (1) in France, and of Schiifer and Oliver (-tS)
in this country, opinion has reverted, in a more definite form, to the A'iew
first expressed by Addison, that the symptoms are due to interruption
of the functional activity of the suprarenal capsules.
Etiology. — The disease is decidedly rare ; Osier (38) thinks it is eA^en
less common in America than in Europe. It occurs much more frequently
in males ; of 193 cases tabulated by GreenhoAA^, 125 (or 65 per cent) Avere
males, and 68 (or 35 per cent) females.
It occurs on an aA'erage at about thirty-one years of age, and is
extremely rare late in life ; Avhile only a very few examples in infants
haA^e been recorded.
It does not seem to be proved that the disease is more frequently
seen in tuberculous families, or that it is in any way hereditary. It is
interesting, however, to note that AndreAves (8) has recorded tAvo cases
in brothers.
Tuberculous disease of the suprarenal bodies may be associated Avith
tubercle elseAvhere in the body, and may spread, by a process of exten-
sion, from tuberculous osteitis of the neighbouring lumbar A^ertebrae.
Alexais and Arnaud (6) Avere able to refer to tAventy-three cases of
542 SYSTEM OF MEDICINE
this association of morbid changes. On the other hand, the suprarenal
bodies are often the sole site of tubercle in the body. Strains or
injuries to the back and l)lo\vs on the abdomen have seemed to be the
cause of the disease ; this may be explained by supposing that the
injury so impaired the vitality of the organs as to render them vulnerable
to the tubercle bacilli : or, again, traumatism may have given ri.se to
haemorrhage into the substance of the suprarenal capsules ■; the destruction
of the glands, and the subsequent fibrosis, leading to the development of
Addison's disease. Ha^iiorrhages into the suprarenal bodies, prob;il)ly
due to trauma, were found in 26 out of 130 still-born children examined
by Dr. Sjiencer (47). Wainwright (54) has recorded the case of a child
aged two months, in whom the organs showed changes probably due to
imperfect absorption and organisation of blood extravasated into their
substance. Possiblv, in some instances, Addison's disease may be the
result of extensive damage received from the extravasation of blood into
their substance during birth ; the slighter cases probably end in recovery,
or no signs of the disease appear.
Grecnhow was of o})inion that Addison's disease Avas more rarely
seen among the upper ranks of society than among the labouring classes,
who are more exposed to Injury. It must be remembered, however, that
it is far from l)eing a common disease ; and that if its incidence in the
labouring and leisured classes were proportionately equal we should see
many more cases among the former.
Morbid anatomy. — Condition of the suprarenal capsules in Addismi^s
disease. — In Addison's original paper (published in 1854) 11 cases are
recorded; in five of these cases there was caseous tul)ercle in l)()tli
suprarenals, and in one case tubercle was present in one suprarenal. One
case (Xo. 4) appears to have been an example of cirrhosis and atrophy. In
three cases there were secondary carcinomatous growths in the suprarenals ;
bilateral in one case, unilateral in the other two. In one additional case
there Avas a secondary nodule of carcinoma blocking the right suprarenal
vein and associated with haimorrhage into the corresponding capsule, but
there were no growths in either.
Addison took a characteristically broad view of the relation of the
symptoms to the morbid lesions, and expressed himself to the effect that
any morbid lesion of the suprarenals mwy produce the same result, and
that the result depends not so mucli on the nature of the organic change
as upon the interruption of some special function of those organs.
After the publication of his original memoir, Addison appears to have
been inclined to modify his views in resjjcct of tlie nndtiplicity of morbid
conditions of the suprarenal capsules and the unit'oiinity of the series of
symptoms, and to have desired to remove from among the cases in his
monograph those of malignant disease of the suprarenal cnpsules. With
regard to the cause of the .symptoms, he conjectui'cd that the intimate
connection of the suprarenal bodies with the sympathetic was largely
concerned in their ])roduction ; thus in some degree throwing over
his original opinion that the interruption of some special function of
ADDISON'S DISEASE 543
the suprarenal capsules was the exDlanation of the characteristic features of
the disease.
According to Sir S. Wilks (Guy's Hospital Reports, 1862), Addison at a
discussion at the Roj^al Medical and Chirurgical Society expressed himself
as follows : — " We know that these organs (the suprarenals) are situated in
the direct vicinity and in contact with the solar plexus and semilunar
ganglia, and receive from them a large supply of nerves, and who can tell
what influence the contact of these diseased organs might have on these
great nerve centres, and what share that secondary effect might have
on the general health and in the production of the symptoms presented?"
Wilks taught, and with no uncertain voice, that all genuine cases
of Addison's disease are due to one and the same lesion of the suj)rarenal
bodies. This view might be called the unity of Addison's disease. The
lesion would now be considered to be tuberculous, but Dr. Wilks con-
sidered it to be a primary inflammation comparable to hepatic cirrhosis,
and regarded the atroj^hied cirrhotic condition of adrenal bodies, some-
times seen, as the last stage of the fibro-caseous change.
Dr. Greenhow was a follower of the doctrine of the unity of Addison's
disease, and therefore criticised severely all the recorded cases in Avhich
the morbid condition of the suprarenal bodies Avas other than the fibro-
caseous change ; and concluded either that the symptoms (especially the
pigmentation) were not characteristic of Addison's disease, or that the
lesion found was incorrectly described.
The conditions of the suprarenal bodies recorded in cases of Addison's
disease are the followina; : —
(i.) The fibro-caseous lesion due to tuberculosis — far the commonest
condition found.
(ii.) Simple atroph}^, sometimes so extreme that the organs cannot be
found after death.
(iii.) Chronic interstitial inflammation leading to atrophy.
(iv.) Malignant disease invading the capsules, including Addison's
case of a malignant nodule compressing the suprarenal vein.
(v.) Blood extra vasated into the suprarenal bodies.
(vi.) No lesion of the supiarenal bodies themselves, but lesions,
pressure, or inflammation involving the semilunar ganglia.
The first is the only common cause of Addison's disease. The others,
with the exception of simple atroi)hy, may be considered as very rare.
(i.) The fibro-caseous or tuberculous change in the suprarenal bodies
begins in the medulla. It has been said to start in the cortex, but this
must be exceptional. Care must be taken not to regard as small tuber-
culous masses the fatty adenomata which are frequently present on the
surface of the cortex. Miliary tubercles, at first scattered in the substance
of the medulla, increase in size, and, by coalescing, gradually replace the
whole or varying amounts of the organs, which thus become enlarged —
weighing several times the normal amount — nodular, and deformed. After
destroying the cortex this morbid process readily sets up inflammation in
the contiguous tissues, and is the cause of adhesions to the surrounding
544 SYSTEM OF MEDICINE
organs. When it is of old staiuliiiii;, fibrous tissue is developed around
the caseous or mortar-like tuljereulous masses, which from calcareous
infiltration may become cretaceous. On the other hand, the caseous
material may soften down so as to form an abscess in the enlarged
suprarenal capsule.
Tubercle bacilli have been found very frequently ; though, on the
other hand, repeated and careful examinations may fail to demonstrate
their presence. Delepine inoculated caseous material from the suprarenal
bodies of a case of Addi.son's disease into guinea-jngs after Yilleniin's
method, but no tuberculosis resulted. From this it may be concluded
that, although the lesion is generally tuberculous, it is not necessarily so
in all cases, or at least cannot be proved to be so.
Generally the lesion is present, though often in diflferent stages, on
both sides ; but .since its discoverer's time, cases of well-marked Addison's
disease have been found associated with a unilateral lesion.
The fibro-caseous change is the one usiially met with in Addison's
disease. In 285 cases collected by Lewin it was present in 211.
As in the lungs so in the suprarenal bodies, the tuberculous is more
frequently seen than any other form of chronic inflammation.
Tuberculous change in the suprarenal bodies is frequently found
without any signs or symptoms of Addison's disease, present or past.
Such cases should not be described as " Addison's disease without any
symptoms " ; for the affection is a clinical and not a pathological entity.
Of 131 cases in Avhich death Avas chiefly or directly due to tubercle
this was the case in 18. In 11 the lesion Avas unilateral, bilateral in the
remainder. In contrasting the comparative liability of the suprarenal
bodies to tuberculosis with the marked immunity of the thyroid gland
it is noteworthy that the physiological actions of their respective extracts
are opposed.
(ii, ) Well-established examples of simple atrophy (43) of the supra-
renal capsules, without any fibrous increase in the sul)st:ince of the
organ, or of any fibi'ous adhesions around them, have often been descril)ed
as giving rise to the clinical picture of Addison's disease. The
atrophy in some of the cases was extreme, the organs in many cases
reipxiring very careful and minute dissection. In some instances they are
described as being of the size of peas. It cannot be wondered at that in
some cases, as in Dr. Spender's, they are described as being absent.
These cases are of great importance, as will be seen later, in supporting
the view that the symptoms of the disease are due to the absence of the
functional activity of the organs, and not to irritation of the neighbouring
inifjortant sympathetic nerves. In these cases of atrophy the sympathetic
plexuses and semilunar ganglia were in most instances carefully examined,
and stated to be normal.
(iii.) Chronic inteistitial inflammation of the .suprarenal bodies,
leading to atrophy, and homologous with atrophic cirrliosis of the liver,
has given rise to typical Addison's <lisease. The fibrosis is quite un-
connected with the production of any caseous material, and does not
ADDISON'S DISEASE 545
show any evidence of tubercle, such as bacilli. The late Dr. Iladdon (20)
compared this change in the suprarenal bodies to those met with in the
thyroid gland in myxoedema, and expressed his opinion that the essential
factor in Addison's disease is, as in myxcedema, a destructive change, the
anatomical condition being of no consequence as long as it is destructive.
(iv.) Malignant disease of the suprarenal capsules occasionally gives rise
to some of the symptoms of Addison's disease ; such as gastric disturb-
ance, extreme debility, and pigmentation. Characteristic cases of Addison's
disease are naturally those in which there is no other organ affected, and in
Avhich the disease runs its own course without any complications. When
growths develop secondarily in the suprarenal bodies the primary gi^oAvth
may give rise to symptoms which throw into the shade or obscure any
that may be due to interference with the suprarenal bodies. The com-
paratively rapid progress of the primary malignant disease may kill the
patient before the secondary affection of the suprarenal bodies has had
time to lead to any distinct symptoms. Again, in many cases the presence
of malignant disease, if ascertained, would be quite sufficient to explain
any symptoms which otherwise might be due to sujorarenal disease.
Still, from Addison's time dowuAvards, examples of secondary malignant
growths in the suprarenal capsules associated with the symptoms,
especially with the pigmentation, of Addison's disease have been
recorded ; and it is to be l)orne in mind, therefore, that new growth in the
suprai'enal bodies may produce symptoms comparable to those met with
in definite cases of Addison's disease.
It is undoubtedly true that the suprarenal bodies may apparently be
almost completely destroyed by carcinoma, and yet no special symptoms
result. Tlie same, however, is true of tubercle, and especially where
there is extensive tuberculous disease elsewhere. Perhaps in both cases
death occurred before symptoms characteristic of Addison's disease have
had time to develop.
In primary malignant disease of the suprarenal bodies there seems
little evidence that the symptoms of Addison's disease occur.
(v.) A few cases have Ijeen recorded, showing an apparent connection
between hemorrhages into the suprarenals and blood -cysts occupying
them, on the one hand, and the symptoms of Addison's disease on
the other.
(vi.) Definite lesions of the suprarenal bodies are present in about 88
per cent of the cases of Addison's disease (23). Apart from disease of the
suprarenals of the various kinds already mentioned, there are cases in
which symptoms like those met with in Addison's disease are found
in association with alteration of the semilunar ganglia or abdominal
sympathetic ; the suprarenal bodies appearing healthy. Thus the
solar plexus and semilunar ganglia have been surrounded by lymph-
adenomatous growths, while the suprarenal bodies were found to be intact.
In such instances there must be considerable interference with the vas-
cular connections of the suprarenal bodies, more especially with the thin-
walled veins or lymphatics.
VOL. IV 2 N
546 SYSTEM OF MEDICINE
Condition of the adjacent si/mpathetic, etc. — The condition of the semi-
lunar ganglia and sympathetic plexuses has been the suliject of much
attention. They have been found iiiA-aded by the inflammatory process,
sclerosed, and degenerated.
Dr. Greenhow descril)cd two stages in the process : ('() a stage of
irritation of the semihuiar ganglia and the nerves connecting them ■with
the suprarenal capsules, as shown by redness and swelling; and (A) a
furtlier stage of atrophy and fatty degeneration.
On the other hand, the absence of any alteration of these same
structures has been repeatedly recorded. Thus 4D cases of Addison's
disease due to tuberculous disease of the suprarenal bodies, in all of which
the condition of the sympathetic was specially exaniinecl, were collected
from various sources 1)y Alexais and Ai'iiaud. In at least 12 — that is, 24:
per cent — of these cases the nervous structiu'cs were described as normal.
An intimate knowledge of the normal anatomy of the parts is of great
importance. The extremely careful examinations made by Dr. Robinson
for Dr. Mann (32) on two cases of Addison's disease serve as a model for
such investigations ; since a control examination was made at the same
time of the same structures from a patient of the same age in whom there
was no reason to suspect anything abnormal.
Yon Kahlden has described hyaline degeneration and thickening
of tlie vessel walls, small-cell infiltration, and haemorrhages in connection
with their adventitia, and pigmentary atrophy of the ganglion cells and
thickening of their capsules. He considers that these changes have a
direct causal relation to the symptoms of Addison's disease. He found
the splanchnic nerves in the two cases quite healthy. Jurgens and
Fleiner, however, have described degeneration of the splanchnics in
Addison's disease. The bearing of these observations must be considered
in tlie light of Hale White's description of the normal histology of
the semilunar ganglia in adults. The cells are pigmented and atrophied,
the degree of atrophy increasing with age ; the fibrous tissue was often
very much inci-eased in amount, and in a few instances the section was
crowded with leucocytes without any apparent reason.
The condition of the semilunar ganglia and of the adjacent sympathetic
being so inconstant in cases of disease, the changes descrilied in them
have no satisfactory claim to be considered as causal factors in the pro-
duction of the disease.
Changes in the central nervoTis system have been described in a few
casi'S only, and, if they had any relation at all to the disease, were the
result i-ather than the cause of the morbid state. A softened condition
of the l)rain, with an increased amount of cerebro-spinal fluid, has been
recorded in some cases of Addison's disease, and was probably accidental ;
but its occurrence is of interest from the marked inflammatory changes
resulting from removal of the suprarenal bodies in animals in Tizzoni's
hands. Tizzoni quotes two cases of Addison's disease in which lesions
of the central nervous system were found: 1. Bourredi's case: Caseous
change in the suprarenal bodies associated with hyperiemia of the cord.
ADDISON'S DISEASE 547
perivascular inflammation, degeneration of nerve fibres, and changes of
varying degree in the ganglion cells. 2. Semmola's case : A normal
condition of the suprarenal capsules, accompanied by mucoid degeneration
of the stroma of the abdominal ganglia of the sympathetic, and small-cell
infiltration around the central canal of the spinal cord.
In connection with the view that Addison's disease is of the nature of
a toxaemia, it would be natural to expect to find changes corresponding
to those described recently in the spinal cord in pernicious ansemia.
Neuritis of the posterior root ganglion and sclerosis of the cord have
been described in some cases, but further observations are required.
Other anatomical lesions. — Hypertrophy of the • lymphoid follicles
of the stomach and intestines, enlargement and softening of the sj)leen,
and occasionally persistence of the thymus, may occur. Dr Green-
how spoke of the prominence of the lymphoid follicles of the intestinal
tract as one of the characteristic, though perhaps not quite invariable
lesions of the disease.
Pigmentation of the peritoneum has been recorded in a few isolated
instances, but is proljably the result of inflammation, and not therefore
of any special importance. Similar change is not met with in other
serous membranes. Pigmentation of the pia mater (24) has once been
observed ; but here again it may possibly have been due to some accidental
or concomitant cause, such as the melansemia of ague.
Pigmentation of the peritoneum and mucous membrane of the intestine
occurred in a case of Addison's disease under Dr. Allchin (7) ; there were
old peritoneal adhesions, but the specimen is quite free from any ulceration.
Anatoinical distribution of cutaneous pigment in Addison's disease. —
Microscopically the pigment is found in the cells of the stratum Malpighii,
the more superficial layers of the epidermis being quite or almost free
from any pigment.
The dermis shows a few pigmented cells, " carrier cells," which, it is
thought, convey the pigment from the blood-vessels of the dermis to the
stratum Malpighii. These wandering cells are found around the vessels
in the superficial parts of the dermis, where they absorb pigment from
the blood-vessels, the mode of absorption being doul)tful. That
haemoglobin is not absorbed directly is shown by the absence of iron
from the pigment of the skin, both in normal conditions and in Addison's
disease. If eventually the pigmentation of normal skin is derived from
the blood pigment, very considerable metabolism must interA^ene. Possibly
the skin pigment is not derived from that of the blood, but is manufactured
by the activity of the cells of the tissue, which itself depends on the supply
of lymph. This supply of nutrient lymph would in its turn vary with
the conditions of the neighboixring vessels.
Further, it has been suggested that the pigmentation of Addison's
disease is due to an increased formation of pigment in the stratum Mal-
pighii depending on excessive or altered nervous stimulation ; bixt it is
evident that it is extremely difficult to eliminate vascular changes as a
factor in pigmentation, since in all probability increased nervous stimulation
548 SYSTEM OF MEDICINE
and increased functional activity of the skin Avould both be accompanied by
vascular dilatation. The existence of special nerves infiuencing pig-
mentation, through their action on cells like chromatoblasts, has not yet
been proved.
The view that the pigmentation is due to an increased supply of
blood pigment passing into the skin as a result of functional or organic
changes in the vessel walls is perhaps that generally accepted.
Situation of the j^iff'^i^nt on the mucotis membrane. — According to Dr.
GreenhoAv, the pigment in the tongue is found in the same layer as in
the skin ; namely, the stratum Mali)ighii or mucosum. Haddon found
the pigment quite as plentiful in the corium as in the stratum mucosum
of the buccal mucous memlirane. Tizzoni, in the pigmentation produced
experimentally in the buccal mucosa of ral)bits, found pigmented carrier
cells in the corium, and pigment in the deeper layers of the stratum
mucosum.
Dr. Dixon Mann draws a sharp distinction between pigmentation of
the mucous membrane and that of the skin. Pigmentation of mucous
membranes is not general ; it requires certain local conditions (friction,
local hypcra?mia) for its development, and the pigment has a difi'crcnt
histological site. The coiium contains pigmented carrier cells, as is the
case in the skin, but the stratum mucosum contains no pigment, possibly
because the cells composing it do not have the finger-like processes which
in the skin are thought to receive the pigment from the carrier cells.
When, exceptionally, pigment was found in the stratum mucosum, it Avas
seen to be not in but between the cells.
Pathology. — The association Ijetween the morbid lesions on the
adrenals and the characteristic symptoms of Addison's disease has given
rise to much discussion. There are two distinct theories which require
consideration.
The nervous theory of Addison's disease. — The early experimental
work of Phillipeaux, Harley, and, more recently, of Tizzoni, pointed
to the absence or unimportance of any function on the part of the supra-
renal bodies. This negative view of the functions of the suprarenal
bodies held the field from Addison's discovery until quite recent times.
On such a physiological basis the connection lietween disease of the
suprarenal capsules and Addison's disease was explained by the secondary
morbid changes, induced by the lesions of the suprarenal bodies, in the
neighbouring semilunar ganglia, solar plexus, and sympathetic nerves.
This conception will be for ever associated with the name of Sir Samuel
AVilks. It was leased on ])Ost-morteni investigation, showing the spi'oad
of inflammation from the tuberculous suprarenal bodies to the semilunar
ganglia and other branches of the sympathetic.
Dr. Grecnhow inferred that at least all the more important features
and prominent symptcmis of the disease were due to m()rl)id changes in
the nerves, the changes in the nerves being first of the nature of iiritation
and later of atrophy. The collapse and the extreme state of debility arc
thus explained as the result of the altered condition of the sympathetic in
ADDISON'S DISEASE 549
the abdomen. The vomiting and pigmentation are referred to the direct
irritation of the sympathetic hy the caseous material in the suprarenal
bodies, or to the same cause acting reflexly through the cerebro-spinal
system.
The view of Wilks and Greenhow may be summarised thus : — The
lesion is primary in the suprarenal bodies, and always of the same nature ;
while the symptoms of the disease are due to the secondary effect on the
adjacent sympathetic, the solar plexus, and the semilunar ganglia. Arnaud
and Alexais accepted the principle, but, l:)y limiting the nervous changes
to the ganglia in the fibrous capsule of the adrenal 1)odies, they were able
to explain the fact that in Addison's disease the solar plexus and semi-
lunar ganglia may be healthy.
A natural modification of these views is that Addison's disease is due
to changes in the abdominal ganglia and sympathetic, which may be due
to disease of the suprarenal bodies, but are independent of a sj^ecial,
or indeed of any lesion in them. This theory was supported by Jaccoud,
von Kahlden, and others, from the clinical and morbid anatomy points of
view, and by the experimental researches of Tizzoni. It has l:)een
suggested that the irritation of and subsequent changes in the ganglion
cells and sympathetic fil^res enclosed in the filjrous capsule of the supra-
renal bodies give rise to the symptoms of Addison's disease (G). In this
Avay the nervous theory of Addison's disease can be upheld even in cases
Avhere the semilunar ganglia and abdominal sympathetic are not found to
have undergone any abnormal change. The comparative rarity of these
ganglion cells in the capsule of the organ renders this view unlikely, and
in any case it would not explain the symptoms when the capsules are
merely atrophied. The unimportance of the part played by the supra-
renal bodies themselves was carried to an extreme by Semmola. He
believed that not only had changes in the suprarenal bodies nothing
to do with Addison's disease, but that also when they did exist, they Avere
trophic lesions due to disease of the nerves which presided over their
nutrition.
The nervous theory does not explain the numerous cases recorded of
typical Addison's disease, in which special attention has been paid to the
condition of the semilunar ganglia and adjacent sympathetic, and in which
they have been found to be normal ; since continued irritation could not
last for any time without setting up local inflammatory changes. Still
less does it explain the occurrence of the symptoms of Addison's disease
associated with simple atrophy of the adrenal bodies.
Conversely, there are numerous examples of slow irritation of the
abdominal sympathetic by enlarged glands, spinal caries, surgical and
tuberculous kidney, abdominal aneurysm, and chronic peritonitis, where
no symptoms of Addison's disease appeared, except, perhaps, some pig-
mentation.
Experimental cutting of all the nervous connections of the supra-
renal body does not give rise to the symptoms, produced either by its
removal or by ligature of its efferent vein (Thiroloix), which are some-
550 SYSTE^r OF .^fEDICINE
■what analogous to those of Addison's disease in man. Experimental
removal of the co'liac plexus leads to rapid emaciation, low temperature,
diminution in the amount of the lu-ea in the urine, acetonuria (though
this is disputed), and acetonemic coma. These results do not support
the view that Addison's disease is due simply ami solely to an irritating
and destructive lesion of the sympathetic around the supi-arenal liodies.
As has lieen already seen, the nervous theory is untenable, at any i-ate
in any exclusive sense, for the sympathetic in the neighbourhood of
the suprarenal bodies is not constantly altered.
The theory of suprarenal inadequacy.^ — If the purely nervous theory
of Ad(li.son's disease cannot be reconciled Avith the facts, attention must
be directed to Addison's first and original view, that the symptoms of the
disease are due to interference with the functional activity of the supra-
renal bodies. This is to say in other words that Addison's disease is the
outcome of suprarenal inadequacy. Before considering the functional
activity of the suprarenal bodies it will be well to clear the ground by
inquiring whether the facts of morbid anatomy arc consistent with the
hypothesis that Addison's disease is due to interference with or loss of
function of the suprarenal bodies.
Bearings of morhid anatomy on the theorij of adrenal inadcqnacij. —
It is known that destructive tuberculous lesions and atrophy of the
suprarenal bodies may give rise to the symptoms of Addison's disease.
But the following objections may be raised to the theory of supra-
renal inadequacy : —
(fl) The existence of cases where after death the suprarenal bodies are
found to be extensively destroyed by tubercle or new growth, and in
which, nevertheless, definite clinical symjitoms of Addison's disease hiixQ
been absent during life, {h) That there ar-e cases, clinically of Addisf)ii's
disease, in which post-mortem caseation of comparatively small amount is
found in the suprarenal capsules — pei'haps only in one, and in which the
amount of damage is even less than in cases Avhich have presented uo
sign of Addison's disease. Since a comparatively small part of the
available suprarenal sulistance is thus rendered functionless, it has been
argued that the concomitant symptoms cannot be due to abolition of the
function of the organs. And (c), lastly, that there are examples of
Addison's disease in which the suprarenal capsules themselves are healthy,
though the surrounding sympathetic nerve plexuses and semilunar ganglia
are involved in dense adhesions or in a growth, such as lyniphadenoma.
In reply to these oljjections the following considerations may be
brought forward : —
((0 In cases Avhere the organs are extensively destroyed l\v tubercle,
or invaded by new growth, the absence of symptoms may be explained in
two ways : (a) the change in the adrenal Ijodies is us\ially a secondary
result of advanced disease in other organs, which kills the patient before
the symptoms of Addison's disease, usuall}' a cbronic aflcction, have time
to develop, (ft) That some compensation for the destruction of the
suprarenal glands is present in accessory suprarenal bodies, ami that, as
ADDISON'S DISEASE 551
in the case of the thyroid gland, symptoms due to the destruction of the
main glands are thus avoided.
(1)) In reply to the objection that when the lesion of the suprarenal
substance is not of considerable amount the remaining part of the organ,
if healthy, should produce compensation, and thus prevent the develop-
ment of symptoms, it may be urged that failure in this power of compen-
sation may be due to inherent want of vitality, to concomitant atrophy,
or possibly — and this is a point requiring investigation — to an interference
with the efTerent vessels by the tuberciilous growth. The common
tuberculous caseous change always begins in the medulla, and thus might
easily obstruct the vascular and lym})hatic connections of the organ, and so
render it impotent, even though a sufficiency of secreting gland tissue
were left. For it should be noted that the medulla is the part of the
organ which provides the active secretion, the function of the cortex not
being yet known.
(c) In the few cases of Addison's disease, where the suprarenal bodies
are described as healthy, while the sympathetic and semilunar ganglia
were involved in dense adhesions or in a growth, it is possible that the
vessels and lymphatics of the suprarenal capsules were thus interfered
Avith, and so the organs were practically placed outside the circulation
and rendered functionless. The sequence of events, then, may be com-
pared to Boinet's experimental ligature of the pedicle (and veins) of the
suprarenal bodies, with its resulting fatal toxic effects. Hence it may
be concluded that obstruction to the efferent vessels of the suprarenal
capsules is a possible cause of Addison's disease. The facts of morbid
anatomy, then, appear to be compatilile with the view that Addison's
disease can be explained by suprarenal inadequacy.
rhijsiology of the siqwarenal bodies.- — Brown-Sequard (10) shoAved in
185G-1858 that the suprarenal bodies are necessary to life, and that
when deprived of them animals die rapidly. This observation has been
amply confirmed by subsequent observers. In cases where their removal
has not led to a fatal result, it is probable either that the glands were not
entirely removed, or that accessory suprarenal bodies were present, which, as
Stilling has shown, are capable of undergoing compensatory hypertroph}^.
As the result of all modern work, it is clear that the suprarenal
bodies are active functional glands. This is not the place to describe in
detail the physiology of suprarenal glands ; for this the reader is
referred elsewhere (21) (43) (45): but two conclusions as to the function
of the glands are possible as the outcome of this work. (A.) That the
suprarenal bodies are excretory or katabolic in function : that they pick
up and remove from the circulation effete blood pigment and toxic bodies,
and destroy them. (B.) That these organs are secretory or anabolic : that
they manufacture some fluid, an internal secretion Avhich passes into the
blood-vessels or lymphatics, and is of use in the economy.
Addison's disease, then, is either an auto-intoxication due to the
deficient excretory activity of the suprarenal capsules, or the result of an
inadecjuate internal secretion on their part.
552 SYSTEM OF MEDICINE
A. Tliat Addhms disease is an anfo-infimcittion due to inadeqvate execretory
actirity of the suprarenal bodies. — Of this first alteniati\c there is no
proof. Dr. MacMunn (30) believes that, normally, hemoglobin and histo-
hneraatins become changed into ha?raochromogen in the suprarenal bodies.
Ha'mochromogon, according to him, is blood pignicMit in an excretory
stage and is found also in the bile. He holds that in Addison's disease
the failure of this function of the suprarenal bodies is shown by the
presence of a j^iK^^ieiit — uroha^matoporphj'rin — in the ui-ine. This
body, M-hich MacMunn also found in various other conditions, has
been shown not to be a definite chemical body, but to be a mixture
of a larger quantity of hwmatoporphyrin and a smaller quantity of
urobilin (15), both of which are among the normal urinary pigments. It
has also been shown that the urinaiy pigments are not increased in
Addison's disease, and that hrematoporphyrin may only be pi-escnt as a
trace (16). It is highly improbable, therefore, that the sujjrarenal bodies
have any action on the effete blood pigments.
"What evidence is there that the suprarenal bodies remove toxic sub-
stances from the circulation and then destroy them ? Large doses of
suprarenal extract certainly kill animals, and Abelous and Langlois find that
if the suprarenal bodies are removed from an animal the blood becomes toxic
to other animals, of the same species, the suprarenal capsules of which have
been removed, the transfused animals dying sooner than they otherwise
Avould. Blood from a few control animals, dying from other causes, did
not appear to possess this toxic effect ; but more observations are required
as to the question whether the blood of dying animals is toxic or atoxic.
It is conceivable that this toxa^mic condition was the result of a suspension
of the excretion of poisonous bodies l)y removal of the sui)rarenal
capsules. But Tizzoni and Nothnagel crushed the suj^rarenals, and left
them to be absorbed without any resulting signs of toxsemia ; so that, at
any rate, the suprarenal bodies do not contain the poisonous substances
which they might be siqiposed to remove. This same hy])otliesis is
further opposed by the experiments of Al)elous and Langlois, who
showed that the toxaemia due to ablation of the organs can be counter-
acted by injection of suprarenal extract. Now, if the suprarenal bodies
excrete a poison which, wh(!n accumulating in the blood, gives rise to
toxic symptoms, injection of su^^rarenal extract should increase these toxic
. effects.
These two observations, then, are both opposed to the h3''pothesis that
the suprarenal Ijodies excrete a poisonous substance. On the other hand,
it is known that injection of very large quantities of suprarenal extract,
equal to several times the weight of the suprarenal bodies, produces death.
Now this at first sight might seem to tend in the opposite direction, but
it does not really do so. It only ])roves that an abnormal and poisonous
dose of suprarenal extract or secretion has been used.
Again, Al)elous and Langk)is shoAved that after removal of the supra-
renal bodies a toxic body, with pi'oportics like curare, appears in the
blood. But, on the other hand, Schiifer and Oliver (45) found that the
ADDISON'S DISEASE 553
effect of suprarenal extract was not at all comparable to that of curare.
These two experiments are not contradictory : they only show that
the body or bodies extracted from the suprarenal capsules are not the
same as those present in the blood of animals whose adrenals have been
removed. This is a strong argument against the hypothesis that the supra-
I'enal bodies are excretory glands.
There is, then, no satisfactory evidence that the suprarenal bodies
remove effete blood pigment from the blood, or absorb toxic bodies and
render them harmless.
B. That Addison^s disease is due to an inadequate secretion on the part
of the sujyrarenal bodies. — Since the function of the suprarenal bodies is
not excretory we are left with the alternative view that they are secretory
glands providing an internal secretion like the thyroid. The researches
of Abelous and Langlois and of Schiifer and Oliver form the basis for this
belief.
Abelous and Langlois come to the conclusion that the internal
secretion normally antagonises or renders harmless toxic bodies formed by
the general metabolism, but especially in the muscles of the body. On
removal of the suprarenal bodies these toxic substances accumulate in
the body and give rise to an auto-intoxication. They compare the action
of these poisonous substances to that of curare. In the light of
these views Addison's disease might again be regarded as an auto-intoxi-
cation which, except in the way in which it is produced, is the same as
that which would result from an accumulation of poisons not excreted.
Schiifer and Oliver have shown that the medulla of the suprarenal
bodies yields a substance possessed of marked physiological properties :
it increases the tone of muscular tissue generally, and especially of the
heart and arteries. Removal of the suprarenal bodies leads to extreme
muscular weakness and loss of tone in the vascular system. On these
data Addison's disease is a condition of general atony and apathy duo
to absence of the internal secretion of tlie suprarenal bodies, which
nominally keeps up the vascular and muscular tone of the body.
To recapitulate. The nervous hypothesis of Addison's disease" as an
exclusive explanation of the symptoms has. already been shown to be
untenable. The two remaining hypotheses are —
(i.) That it is an auto-intoxication due either (a) to imperfect excretion
on the part of the suprarenal bodies — the objections to this view have
already been stated at length ; or (b) to a deficient internal secretion on
the part of these glands.
(ii.) That it is merely a condition of atony due to an absence or
deficiency of the normal internal secretion.
The two hypotheses which are based on an inadequate internal secretion
of the glands will now be stated.
That Addisoji's disease is an auto-intoxication. — Since there is no evi-
dence that the suprarenal bodies are excretory, this theory implies that
as a result of a deficient internal secretion a toxsemic condition results.
It is conceivable that the internal secretion might normally antagonise
554 SVSTEjV of MEDICINE
toxins resulting from the metabolism of the body generally in several
■ways — {a) In a manner analogous to the neutralisation of aii acid by
an alkali ; of this there is no proof, (i) By exerting a fei'mciit-like
action on these hypothetical toxins and destroying them. Schiifer
and Oliver's researches are, however, opposed to the view that the active
pi'inciple of the internal secretion is a ferment, so this hy]K>thcsis falls
to the ground, (c) By regulating the metabolism of the tissues, and
preventing their running liot and producing abnormal or toxic bodies.
((/) By increasing the resistance and defensive powers of the cells of the
body, including the Avhitc blood corpuscles, so that they arc able to
withstand the poisonous bodies possibly resulting from the general meta-
bolism of the body, and to destroy them.
Of the two latter views there is no proof in either direction. The
symptoms of Addison's disease are so far analogous to those of diseases due
to a toxic condition of the blood, such as urttmia and pernicious anaemia,
as to suggest that the disease is a toxaemia.
The extreme debility may be considered either as a result of a toxic
condition, or as a state of atony due to the absence of a necessary
stimulus. The vomiting, gastro-intestinal disturbances, and pigmentation
point rather to some positive irritation than to a mere absence of a normal
stimulus.
The experimental basis for the opinion that Addison's disease is an
auto-intoxication consists partly in the observation that, after the removal
of their suprarenal capsules, animals die with symptoms reseml)ling curare
poisoning (Abelous and Langlois). It has been shown, however, that the
motor nerve endings are not paralj'sed even up to the time of death
(18). The auto-intoxication theory has l>een supported on the ground
that the blood of animals from Avhich the supraren;d capsules ha\e been
removed is toxic for o^her animals Avho have undergone the same opera-
tion, hastening their death ; while blood fi-om an animal dying from a
different cause did not accelerate the fatal termination. Schiifer (44),
however, has pointed out that it is probable that the blood of any animal
dying slowly becomes toxic, and that acapsided animals would be
especially susceptible to it. • Until we have further evidence on this point
it is not satisfactorily proved that the blood of acapsuled animals becomes
specifically toxic.
If Addison's disease is an auto-intoxication the urine should contain
the toxic material, since the kidneys are practically always healthy, and
are not, as in uraemia, incapable of performing their excretory function
properh*. Hero a sufficient amount of evidence is luifortunately wanting.
Schiifer and Oliver have found that extracts from the lU'ine of jiatients
HuflTering from Addison's disease have the same effect as normal urine.
Geoffredi and Tinno have foimd the toxic coefficient of the urine in-
creased, but this was in a case where there was in addition caseous
tuberculous pneumonia; so that no real importance can be attached to this
observation. Neurin has been said to be present in the urine, and the
phenomena of the disease have been referred to its action (33). This
ADDISON'S DISEASE 555
statement especially is in need of more general confirmation. More
recently Miihlmann has put forward the view that the symptoms of
Addison's disease are due to chronic poisoning with pyrocatechin. More
extended observations are required, and until they are forthcoming judg-
ment must be suspended. That Addison's disease is an auto-intoxication
is no doubt an attractive supposition, but as yet there is l)ut little
positive evidence to support it.
That Addisoris disease is a condition of atony due to absence of
the stimulating effect of the internal secretion of the suprarenal glands.- — ■
Schafer and Oliver have shown tliat the medulla of the suprarenal
bodies provides an internal secretion which exerts a marked tonic effect
on the muscular system, especially on the heart and blood-vessels ; while
removal of the suprarenal bodies leads, as might be expected, to an
extreme condition of want of muscular tone. They also found that the
supi^arenal capsules in Addison's disease did not contain any of this active
principle. From these data it appears probable that Addison's disease is a
condition of debility due to an absence of the internal secretion normally
supplied by the suprarenal l)odies.
It should be remembered, however, that we are as yet far from a full
understanding of the method of action of internal secretions. The
secretion of the suprarenal bodies, by its interaction with other glands,
might produce the equilibrium we know as health. Absence, deficiency,
or perversion of the suprarenal secretion appears to lead to a profound
disturbance of normal processes in the body. This disturbance might
easily lead to the production or accumulation of poisons in the system —
in other words, to an auto-intoxication. The problem is a complex one,
and at present the data for solving it are wanting.
To sum np. Addison's disease is due to an inadequate supply of
suprarenal secretion. But whether the deficiency in this internal secretion
leads to a toxic condition of the blood, or to a general atony and apathy,
is a question which must remain open. It should be added that Byrom
Bramwell and Boinet have recently argued in favour of Addison's disease
being due partly to direct irritation and neuritis of the sympathetic and
partly to suprarenal inadequacy. According to this view, the nervous
and insufiiciency theories are combined, and neither is exclusively right
or wronij.
Onset. — The onset of the disease is generally insidious and not
marked by any special symptoms or features. The patient has been
gradually losing energy and strength for a considerable time before seek-
ing medical advice, which he does perhaps chiefly for the relief of
gastric symptoms. Pigmentation may occasionally precede the manifesta-
tions of constitutional symptoms, and so be the first thing to be noticed ;
but the constitutional sj'mptoms of general debility and gastro-intestinal
iiTitability usually precede it.
In a few cases the rapid occurrence of severe symptoms may suggest
a sudden onset ; it is probable, he n-ever, that this is rather a well-marked
exacerbation in the course of this insidious disease than absolutely its
556 SYSTEM OF MEDICINE
first manifestations. The apparently acute onset of Addison's disease
has been known to follow some sudden shock or depressing circumstance,
and has been put down to the administration of a severe purge or to
distress or Avorry.
Symptoms. — Pir/menfatio7i is the sj^mptom which most often arouses
the su.spifion of the disease. Unfortunately it is A'ariable both in the
time of its a{>|Dearance and in its degree.
Usixally it follows the constitutional symptoms, and it may only
occur shortly before the fatal termination, and be then but slightly
marked or even entirely absent. In some infrequent instances the
pigmentation appears to precede any subjective symptoms by years. In
a case of Dr. ]\Iunro's, quoted by Dr. Greenhow, there was an interval of
seven years between the appearance of pigmentation and the onset of
constitutional symptoms. In some cases it is so marked as to resemble
that seen in the dark races ; such cases are, however, rare : more often
it resembles the bronzing of sunburn, or the dirty sallow tint so frecpiently
seen in association Avith dyspepsia : the patient himself is often quite
unaware of its presence. It may attract little notice even on the part of
the patient's friends, who are generally the first to oliserve it ; or it
may be put down by them to exposure, or to insufficient attention to
personal cleanliness.
The pigmentation is an exaggeration of the normal, it has, generally
speaking, the same regional and anatomical distribution, and is suljject to
the same influences, being increased by any local irritant applied to the
skin.
Hilton Fagge (25) thinks it probable that it avouIcI be absent in a
patient kept in the dark. This experiment, so far as I know, has not been
intentionally tested; but the light to Avhich patients arc exposed may very
Avell play a part in determining pigmentation at an early or a late stage
of the disease.
It Avould be interesting to knoAv Avhether Addison's disease has ever
been observed in an all)ino. The probaljilities are against the concur-
rence of tAvo such rare conditions ; but, theoretically, there should be no
pigmentation in such a case.
Pigmentation is sometimes almost universal, but is usually partial, and
is then first noticed on the face, neck, and the backs of the hands and
fingers ; especially over the joints, Avhere it throAvs into relief the nails,
Avhich appear remarkably Avhite : in this last point the pigmentation of
Addison's disease differs from that of the dark races, Avhich it otherAvise
closely resembles.
The tint of the face is of A'cry A'aryiiig intensity, and contrasts Avith
the sclerotics, Avhich usually appear someAvhat anaemic. In rare instances
the conjuncti\'ie shoAv foci of intense ijigmentation.
The staining of the neck and face, like that seen occasionally in preg-
nant A\'omen, may shoAV considerable irregularity in its degi-ee. There
may be darkening of the hair during the progress of the disease, but
according to AVilks (57) the colour of the hairy scalp is not altered ;
ADDISON'S DISEASE 557
and the same is true of the skin where it is covered by the Ijeard, etc.,
and of the eyelids.
The lips, along the line where they come in contact, may in some
instances show pigmentation ; and similarly, as the result of irritation most
commonly due to carious teeth, the cheeks, the gums, or the tongue may
become pigmented. Pigmentation of mucous surfaces is often absent,
and though it is generally regarded as a sign of considerable value, it is
probalile that the factor of local irritation is a powerful one in its
development.
Should pigmentation of the mucous membrane of the mouth be found
without any source of irritation, it may perhaps be regarded as an
exaggeration of some trace of the condition seen in Lascars, in l)lue-
gummed Negroes, and, exceptionally, in healthy persons (39). A similar
example of pathological reversion to a past type is seen in the occasional
occurrence of melanotic sarcoma of the palate, or is more nearly paralleled
by a case, recorded by Dr. Mott (34), of a melanotic tumour of the lip.
The tongue may show purplish inky stains near the free border,
stains so arranged as to suggest contact with the teeth as a causal factor.
Passing from the exposed parts of the body, the pigmentation is found
on the dorsal surface of the forearms and on the anterior folds of the
axilla? ; these, it should be remembered, are apt normally to show pig-
mentation.
The areolae around the nipples show a marked alteration in tint, com-
parable to that seen in pregnancy ; but of course the glandular activity
and development of the mammary veins are absent.
The lower part of the linea alba riiay belie its name, and become a
dingy or brown streak.
The genitals and groins are darkened in tint, sometimes to a marked
degree. It is said that the mucous membrane of the labia minora and
vagina may present changes similar to those seen in the mouth.
The dark areas pass by a gradual transition into the paler parts of the
skin ; the pigmented regions have no sharp margins. If, however, any
part of the cutaneous surface have been irritated, as for example by a
blister, the resulting increase in pigmentation has a comparatively sharp
definition. Parts of the body which are exposed to friction or pressure
show an increased pigmentation in an especial degree. Thus the waist
Avhere it is compressed by corset or belt, the knee where the garters are
tied, the shoulders under the braces, or the prominent vertebral spines,
present a darker hue. The palms of the hands and the soles of the feet,
which are subject to as much if not more pressure than other parts,
are very rarely pigmented.
The tissue of scars remains unaflfected, but the surrounding skin shows
an exaggeration of pigmentation. Dr. B. Bramwell has reported a case
in which the pock-marks of variola were pigmented.
Dr. Greenhow attached considerable diagnostic value to the presence
of small, well-defined specks, like small moles, on already discoloured parts
of the skin. Dr. S. West has recently recorded a case in a woman
558 SYSTEM OF MEDICINE
which, in 1891, was diagnosed as Addison's disease. She then presented
these pigment spots ; four years later she came under treatment for
anaemia secondary to menorrhagia ; the skin was sallow, almost bronzed,
but the ])ignient spots had disappeared. The patient may have had
Addison's disease, for cases of longer duration, even lasting for ten years,
have been recorded. . It may, however, be questioned whether these
spots should be considered pathognomonic of the disease.
Generally speaking, pigmentation, though suggesting the disease, is
not of itself, apart from constitutional symptoms, sufficient to warrant a
positive diagnosis.
The presence of pigment in parts of the body not available for clinical
observation, and its histological relations in the tissues, are referred to
under the heading of morbid anatomy.
Asthenia. — This is perhaps the most frequent and important of the
constitutional symptoms. At first the patient is easily tired, never
feels rested, even after a long night, and gradually becomes more and
more indisposed for any exertion, however slight, whether of body or
mind. As the disease advances, life becomes a burden, but the sufi'erer
has not even sufficient vitality to complain of its weight. Impotence is
seldom referred to in the reported cases, but is probably not infrequently
present. The muscular feelileness is not accompanied by any corre-
sponding emaciation ; there are no signs of periphei-al neuritis. This
condition of invincible languor has been compared to that brought about
by the action of a poison like curare in a minor degree.
Langlois (27) lays stress on the total loss of sustained muscular effort
which distinguishes Addison's disease from phthisis and other causes of
great debility. In fact, in cases of doubtful diagnosis he recommends
recourse to Mosso's ergograph.
Symptoms referable to the vascular system. — The want of muscular tone
and contractility is not limited to the voluntary muscles. The systole
of the heart is greatly enfeebled, as is shown by the small, extremely soft
and compressible pulse which, in some cases, may even become imper-
ceptible at the \mst.
The temperature is generally subnormal and the extremities cold, so
that the patient's state has been compared to that of chronic collajise.
The depressed state of the circulation is fiu-ther seen in a tendency to
syncope ; especially when the patient's head is raised. There is consider-
able danger that one of these fainting fits may prove fatal.
Cardiac weakness is also sometimes shown l.)y palpitation and distressed
breathing on movement. Sighing and yawning are sometimes present.
An offensive or cadaveric smell is occasionally noticed to emanate from
the patient
Although the temperature is usually below normal this is by no means
universal ; Mac]\Iunii and others have drawn attention to the association of
Addison's disease with fever, which, however, may not ap})ear till shortly
before death.
Addison, probably from the fact that he discovered this disease when
ADDISON'S DISEASE 559
looking for the cause of pernicious anaemia, considered ansemia as one of
the chief symptoms. AVilks (57), however, expressly states that neither
the clinical features nor the post-mortem appearances are those of ansemia ;
and Osier (40) says that the blood count is usually 50 to 60 per cent of
the normal. It is true that the contrast of the bronzed skin with the
sclerotics, which are usually pearly, may give the impression of anaemia.
But though anaemia and Addison's disease may coincide, they are not
especially, mUch less inseparably, connected.
The sul)jects of Addison's disease retain about as much subcutaneous
fat as they had before the onset of the disease. They may be thin or
spare and lose Aveight, but they do not become remarkably emaciated.
Gadro-intedinal symptoms. — The tongue is usually clean and moist, but
the appetite is poor and may be capricious. The loss of the healthy
desire for food is an early symptom, and accompanies the insidious onset
of general debility and loss of tone. In the later stages this indifference
may pass into positive loathing. Nausea and retching are generally
met with. Vomiting may occur throughout the course of the illness, but
" is rarely absent in advanced stages, and may be spontaneous, and so
irrepressible as to cause death from exhaustion " (Greenhow). Persistent
hiccup may be a troublesome featui'e.
The bowels are usually confined, but severe attacks of diarrhoea may
supervene, and are sometimes so uncontrollable as to carry the patient off.
The constipation is but one more manifestation of the general loss of
muscular tone already referred to.
Nervous sijiiq)toms. — The general loss of vitality is shown by the
depressed functional activity of the nervous system. The acuity of
vision may be impaired, flashes of light may pass before the eyes, and
the perception of auditory sensations is sometimes dulled. The mental
processes remain clear to the end, or until a final coma or delirium super-
vene. In such a condition of unconsciousness signs of irritation of the
nervous system may show themselves in muscular twiteliings or rigidity,
or even in general convulsions. Headache and vertigo are by no means
rare, and are most often associated with faintness. Pain is sometimes
complained of in the limbs, and is often present in the loins, epigastrium,
or hypochondriac regions. The extension of inflammation from the
adrenal bodies to the neighbouring organs and tissues is probably
responsible for much of the lumbar pain.
Urine. — There are no constant or characteristic features in the urine.
It is usually normal, or slightly diminished in amount, though there may
be polyuria. Albumin and sugar are absent. As an occasional residt of
intestinal disturbance indican may be present in the urine, but is not of
any further significance.
MacMunn described a pigment, urohaematoporphyrin, as being present
in the urine ; this body, however, is not a definite chemical compound, but
is a mixture of a large quantity of haematoporphyrin with a smaller quantity
of urobilin, both of which are among the normal urinary pigments. The
observations of Thudichum and Dixon Mann show that there is a diminu-
S6o SYSTEM OF MEDICINE
tion rather than an increase of the nrinary pigments. Cordone has re-
centl}' described a pi^mient in the urine of cases of Addison's disease
with the same characters as the melanin of the skin and of mehmotic
sarcoma.
The excretion of urea, as might be anticipated from the depressed
metabolic processes, is prol)al)ly diminished.
Neurin has been described in the in-ine by observers (33) who believe
the disease is due to an intoxication set up by this body, but this descrip-
tion requires furtlicr confirmation.
Course of the disease. — The course of the disease is not luiiform, and
though progressive is not regularly so, even in the same individual. As
in pei-nicious anaemia, there are exacerbations or paroxysms, during which
all the symptoms become accentuated. After each of these crises the
patient rallies, but is generally left in a worse position than before. Dr.
Greenhow laid stress on these alternate exacerbations and remissions,
and pointed out that the pigmentation follows the same lines, being
exaggerated together with the symptoms ; and that, though it diminished
durinir the succeedinLC remission, it still remained more marked than it was
before the last attack.
Usually the constitutional symptoms are the earliest to appear and
the more prominent throughout.
Cases may prove fatal without any pigmentation ; in these examples
of Addison's disease without bronzing the symptoms usually run a rapid
course. On the other hand, the pigmentation is occasionally the first, and
for a varying time the only manifestation of disease. Sometimes one of
the constitutional symptoms is more especially noticeable, sometimes
another ; thus thei-e may be a tendency to vomiting and diarrhoea, the
disease presenting a gastro-intestinal character ; or fainting fits and ex-
treme breathlessness on movement constitute what may be called a cardiac
type. But all the while there is intense and increasing asthenia.
Duration. — The period over which symptoms refeiable to the disease
occur is very variable. The onset is genei-ally extremely gradual and the
progress may be very slow ; cases, indeed, have been recorded in Avhich the
duration appeared to be as long as seven or even ten years. .Post mortem
the changes in the suprarenal capsules are as a rule of old standing —
caseous or cretaceous tubercle. Whether after the development of definite
symptoms the course of the disease can become arrested, and be considered
cured, is a difficult question. The extremely prolonged course of some
cases might well suggest that the morbid lesion had become arrested, and
a certain degree of compensation effected ; and that a recrudescence of
tubercle, analogous to that often met with in the lungs, was responsible
for the finally fatal is.sue.
There is no doubt that considei-able destruction of the suprarenal
bodies by tubercle is not infrequently met with in peisons who have died
from other causes, and in some of them the early symptoms of the disease
may at some period, perhaps long antecedent to death, have been present ;
though possibly not sufficiently prominent to arrest attention. In any
ADDISON'S DISEASE 561
case of apparent recovery the difficulty of diagnosis and the possibility
of the disease being latent must ahvays be taken into consideration.
Be this as it may, the duration in the great majority of instances is
long. The average length of time, in a number of cases collected by
Wilks, during which symptoms were present was eighteen months. This
calculation, however, included the rarer instances where the disease runs
an apparently acute course. In the latter the lesion has been progressing,
as seen at the autopsy, for months or even years, but no prominent symp-
toms had been manifested, and the disease has been spoken of as being
latent. Suddenly, perhaps from some depressing conditions, the symp-
toms burst out in full force, and the patient dies in a few days or
weeks. Between the very chronic and these remarkably acute cases
there are intermediate grades which will be found to contain most of the
cases met with in practice.
Termination. — Death may be quiet and gradual from asthenia, the
patient being conscious to the last ; or a " typhoid " or semi-comatose con-
dition may precede it. Not infrequently sudden syncope extinguishes the
flickering flame of life ; this event, howcA'cr, may occur long before the
patient becomes bedridden; as in an instance recorded by Osier (38) of a
physician who had hardly completed his arrangements for retiring from
practice when he died from sudden syncope. Severe attacks of vomiting or
diarrhoea may so exhaust the already debilitated patient as to be the
immediate cause of death. Sometimes delirium, muscular t^\^tching, or
general convulsions may precede death.
Prognosis. — The disease when sufficiently advanced to warrant a
positive diagnosis is probably always fatal. It must be admitted, hoAV-
ever, that diagnosis in an early stage is not only difficult but uncertain.
Its recognition by its features, when well marked, is much like the dia-
gnosis of malignant disease by the cachexia, in which case it is equally
true that the prognosis is hopeless.
As hinted in a preceding paragraph (Duration), it is quite conceiv-
able that arrest may sometimes occur after initial symptoms of slight
intensity have shown themselves. But though this is possible, it is diffi-
cult to prove. In 800 cases collected by Lewin, five cases are recorded as
being cured, and twenty-eight as having shown improvement.
The bearing of treatment by suprarenal extract on prognosis will have
to be considered in the light of a more extended experience. At present,
though somewhat encouraging, it cannot be said that it bears any com-
parison with the effects of thyroid feeding in myxoedema.
Diagnosis. — The diagnosis of Addison's disease is by no means easy ;
we may suspect it, but to go farther and give a dogmatic opinion is often
somewhat hazardous, and not warranted by the facts at our disposal.
Advanced and well-marked cases may be recognised at once ; but the
disease in its early stages, or cases in which either the pigmentation or
the constitutional symptoms are absent or ill developed, may be regarded
as the evidence of trivial ill health, or biliousness, or as merely accidental.
Conversely minor ailments, especially the protean manifestations of dys-
VOL. IV 2 0
562 SYSTEM OF MEDICINE
pepsia, may sinmlate it. Althougli Addison's disease is sometimes revealed
only on the })ost-mortem table, and this is especially so Avhen the course
is rapid and pigmentation is absent, it is probable on the whole, perhaps
from the interest attaching to this comparatively rare atlection, that it
is more often diagnosed than proved to exist.
The diagnosis is rather one of exclusion, espcciall}' of abdominal
disease, some forms of which may produce a passable imitation both of
the pigmentation and of the constitutional symptoms of Addison's disease.
Since pigmentation is the most objective sign, and therefore the one
which most frequently arouses a suspicion of Addison's disease, it will be well
to consider first those conditions of pigmentation which may be mistaken
for the melasma Addisonii. Chronic tuberculous peritonitis and malignant
disease of the peritoneum, without apparently interfering Avith the functional
activity of the suprarenal bodies, may be accompanied by considerable
pigmentation of the face. The rare condition recently described as
Acanthosis nigricans may supervene in cases of malignant disease within
the abdomen. This pigmentation of the skin is most marked on the face,
in the axilla^ and crroins : it differs from Addison's disease in the fact
that the skin is thickened and shows an exaggeration of its normal folds.
Acanthosis nigricans has been thought to be caiised by pi-essure on the
sympathetic. In some cases of malignant abdominal disease there may be
compression of the vessels and lymphatics of the organ Avhich is tanta-
mount to rendering them functionless. The condition then is one of
Addison's disease. A similar result has been met with occasionally in
lymphadenoraa involving the glands aroxind the suprarenals. More rarely
disease of the stomach may bring about darkening of the skin. I have
recently had under my care a man with dilatation of the stomach, whose
skin showed very considerable darkening which diminished as he improved.
Hepatic disease, and especially that rare condition, hypertrophic cir-
rhosis, associated with diabetes and jiigmentation, or as Hanot, who first
describoil this disease in 1882 with Chauft'aud (22), now calls it, diabete
bronze, may produce very marked pigmentation of the skin. The after-
effects of jaundice must be borne in mind in the diagnosis. Jaundice
appears in former days not infrequently to have been confounded with
the discoloration of Addison's disease ; examination of the conjunctivaj
and of the urine shoidd at once settle any doubt.
Pancreatic disease, according to Fitz (13), may occasionally give rise
to bronzing of the skin.
Pregnancy and uterine irritation in certain cases lead to very notice-
able pigmentation of a somewhat patchy character.
To a slighter degjee the skin may occasional!}' be affected in graiuilar
kidney.
In chronic ])hthisis pigmentation may be very considerable, but here,
as in abdominal tuberculosis, it is chiefly found on the face.
Malarial meJana'mia produces a general darkening of the skin, and in
melanotic sarcoma marked pigmentation_of the skin, (piite apart from the
presence of growths, has been noticed (29). According to Wagner, the
ADDISON'S DISEASE 563
histological position of the pigment in the skin in such cases of melanotic
sarcoma is the same as in Addison's disease. Carbone considers that
the presence of sulphur in the pigments of Addison's disease and of
melanotic sarcoma distinguishes them from that resulting from the
destruction of red blood corpuscles such as occurs in the melanjemia of
malaria.
In exophthalmic goitre the skin may become so pigmented as to give
rise to a diagnosis of Addison's disease combined with Graves' disease.
Recovery in such a case may give rise to the erroneous impression that
Addison's disease has been cured.
In chronic rheumatoid arthritis not only a darkening of the skin but
the appearance of black freckles also may be noted. Occasionally in this
disease a well-marked collar of pigment is seen on the neck.
Argyria is rare, but this discoloration, which follows on the absorption
of silver salts and their subsecjuent deposit on the skin, is A'ery striking.
It is permanent, and has resulted from the medicinal use of nitrate of
silver internally for nervous disease such as locomotor ataxia, or from its
external application to sores.
Lastly, long-continued irritation of the skin and the accompanying
hyperemia may result in a general discoloration which has been confused
with that of Addison's disease. Greenhow laid stress on that seen in
" elderly persons of very indigent circumstances and uncleanly habits,
especially when infested with vermin," or " vagabond's disease." In these
cases the pigmentation could Ije partially, or wholly, removed by soap
and water, and the constitutional symptoms of debility, sinking at the
epigastrium, and languor, by food and tonics.
The medicinal use of arsenic, if persisted in, may lead to a cutaneous
pigmentation which may have much the same distribution as that of
Addison's disease.
In syphilis, also, the skin may become discoloured, and some cases of
Addison's disease that have improved under a course of iodide of potash
may have been of this nature (11).
The distrilnition of tinea versicolor should prevent any confusion
between it and melasma Addisonii. In pellagra the skin may be darkened,
while the dyspepsia, pains, and early paralytic symptoms might simulate
those of Addison's disease ; pellagra, however, is an endemic disease not
met with in England {vide article "Pellagra," vol. ii.)
Lastly, the darkening of skin due to hereditary influences, exposure
to the sun, or to tar, or to the heat of furnaces in gas-Avorks, etc., must
not be regarded as evidence of suprarenal disease. Addison's disease in
blacks would be a matter of very great difficulty. Dr. W. S. Thayer has
kindly given me the details of a negro who died with tuberculosis, the
primary focus being on one of the adrenals, in the Johns Hopkins Hos-
pital. At the autopsy Professor "Welch thought there was a definite
relation between the primary lesions and the rather excessive pigmenta-
tion of the gums, palate, and tongue. Beavan Eake (41) described Addison's
disease in a syphilitic Hindoo, who Avas also the subject of leprosy.
564 SYSTEM OF MEDICINE
Addison's disease without pigmentation can only be diagnosed after
the elimination of any other satisfactory cause. A few such conditions
may be mentioned. Gastric disorders, especially some cases of carcinoma
leading to vomiting and asthenia, may resemble Addison's disease without
pigmentation. Osier (38) speaks of difficulty having arisen in distinguish-
ing some cases of typhus from Addison's disease. Pernicious anaemia
does not present the facies of Addison's disease, and in any case of doubt
its characteristic blood changes would at once settle the question. The
early stages of splenic amemia — the extreme debility, and the loss of
muscular power — perhaps resemble Addison's disease ; but on examining
the al^domen the splenic enlargement would 1)C detected at once and would
thus prevent any mistake. In Addison's disease the spleen is sometimes
found enlarged at the autopsy, but it is rarely a clinical phenomenon,
and has no resemblance to that seen in splenic an.Tmia.
The debility and sickness in those exceptional instances of Bright's
disease, in which a low-pressure pulse is found, would be accompanied
by oedema and albuminuria, and so would be distinguished at once from
Addison's disease.
Treatment. — The treatment naturally falls into two categories : —
1. The special form of treatment l)y suprarenal gland substance in
various preparations. An attempt is thus made to combat the results of
suprarenal inadequacy ; and,
2. The symptomatic treatment on general principles.
Suprarenal extract. — It was administered first by subcutaneous injection
in the form of an extract or juice. Oliver and Schafer (45) have shown
that the activity of the extract is not in any Avay impaired by pepsin and
hydrochloric acid, so that the simpler and more convenient method of
giving it by the mouth should be equally efficacious. Kaw sheep's supra-
renal bodies have been given, and a tincture has been prepared and given
by the mouth ; but the most convenient form is a dried extract in the
form of pills or tabloids, 1 gr. of pill corresponding to 15 gi-s. of the gland
substance. . The glands of the sheep are usually employed.
The treatment should be begun by one pill, equivalent to 15 grains
of the gland substance, three times a day. The amount should be
gradually but considerably increased. Since no bad results have yet
l)een observed it is possil)le that they are not prescribed in sufficient
amounts. Einger and Phear (42) gave their patient as much as 2
drachms of suprarenal sulxstance daily with benefit. No cases have been
recorded in which bad results could l)e definitely ascribed to the use of
the extract, but such a possibility should not be forgotten. Dr. Osier
(40f') has recounted a case in which a girl with Addison's disease died
on the 9th day of treatment with delirium and collapse. The quantity
of the glycerine extract (equivalent to half a gland per diem) given was
not excessive, and since ])atients die with these symptoms without such
treatment, it did not appear that death was due to tlic toxic efl'cct of the
extract. It should be remembered in this connection that the medulla
alone contains the active physiological principle, the cortex appearing to
ADDISON'S DISEASE 565
be inert ; and that the extract is at present largely made from the whole
gland, and not, as would be physiologically more correct, from the
medulla alone. This must lead to a certain amount of uncertainty as to
the amount of active principle contained in any pill or tabloid.
Rinsier and Phear have collected the results of the treatment of
Addison's disease by suprarenal gland substance. As compared with the
effects of thyroid treatment in myxoedema they are at present disappoint-
ing. The results vary ; sometimes there is no perceptible improvement,
but the general tenor is of temporary improvement in strength and
appetite, and some diminution in pigmentation ; but relapse takes place
even though the treatment is continued. In some instances remarkably
good results have been obtained ; it should be borne in mind, however,
that the course of the disease is sometimes much proloiiged. It is highly
desirable that the future progress of such cases should be recorded as
well as the immediate result. Dr. G. Oliver (35) has mentioned, and the
same thing has occurred in a case under my care, that when the treat-
ment is interrupted the pigmentation increases. It appears that, as in
myxoedema, the treatment should be continued and not remitted when
improvement, however well marked it may be, takes place. Dr. Byrom
Bramwell, who regards the symptoms of Addison's disease as partly due
to glandular inadequacy and partly the result of irritation of the
sympathetic in the neighbourhood of the suprarenal bodies, explains the
failure of the extract in some cases by supposing that in these instances
there are adhesions to the sympathetic plexus and irritation of it ; while
the cases which react satisfactorily to the extract are those in which there
is only glandular inactivity or inadequacy.
General lines of treatment — ^yhen there is marked muscular weakness
and debility the patient Avill naturally keep in bed ; but even apart from
this the slightest tendency to syncope should be regarded as an urgent
indication for perfect rest in the horizontal position. Death has occurred
from this cause long before asthenia had become a prominent feature.
Great care should in such cases be exercised in raising the head. During
an exacerbation of the symptoms, and for some time after, the patient
should be kept in bed. Worry, over-exertion, exposure to cold, and all
danger of exhausting the patient's feeble strength, should be vigilantly
guarded against.
A simple, easily digested, and nutritious diet should be provided, and
constipation warded oft' on the one hand, and diarrhoea on the other.
Strong purgatives should be avoided, from the danger of syncope
resulting from shock after their use ; in one case, quoted by Dr. Green-
how, the administration of a purge rapidly led to a fatal issue in a case of
Addison's disease previously latent. Diarrhoea should be restrained by
opium, bismuth, or other appropriate remedies.
Vomiting may be almost incontrollable in some cases, and rapidly
brings about a fatal termination. Ice, fluid food in small quantities
frec|uontly repeated, effervescing draughts, soda water, and chamjDagne
may be given to combat it. As drugs, oxalate of cerium, bismuth,
566 SYSTEM OF MEDICINE
and opium should be tried. Hydrocyanic acid ma}- act as a cardiac
depressant.
Tonics such as strychnine, arsenic, or iron, if there be anaemia, may be
given ; and if the stomach Avill tolerate it, some palatable combination of
cod-liver oil, maltine, should be tried. Stimulants will almost always be
required.
Oestreich has recorded a case in which surgical removal of a tuber-
culous suprarenal body was followed by disappearance of symptoms
resembling those of Addison's disease. Before the operation a mass
regarded as eidarged glands was felt close to the s])ine and was thought
to be the cause of the symptoms. If the symptoms were due to the
tuberculous adrenal they must have been the result purely of irritation
of the sympathetic and not in any way due to suprarenal inadequacy.
REFERENCES
1. Abelous and Langlois. Archives dc Physiol. 1892. — 2. Ideyn. Soe.de hiolog.
1891, 1892. — 3. Aduison. On the Con slit iilional and Local Effects of Disease of the
Suprarenal Capsules. London, 1^54. — 4. Idem. London Meillcal Gazette (new series),
vol. viii. 18-19, p. 517. — 5. Alkxanueh, C. Ziegler's Beilrdijc, vol. xi. No. 8. — 6.
Alexais and Aknaud. Mevue de mMecine, 1891, p. 281. — 7. Allchin. Trans.
Path. Soe. London, xlii. p. 302. — 8. Anuuewes. St. Itart.'s Hospital lieports, vol.
xxvii. — 9. BoiNET. Rev. dc vied. 1897, p. 136. — 9a. Byiium Bkamwell. Ilrit. Med.
Journal, 1897, vol. i. — 10. Buowx-Sequakd. Journal dc la Phtjsivloyie, 1858. — 11.
Debove and Achaud. Manuel de mMecine, vol. vi. p. 937. — 12. Fexwick, B.
Trans. Path. Soc. vol. xxxiii. p. 351. — 13. FiTZ. Pepper's Text-Book of Medicine,
vol. ii. p. 977. — 14. FoA and Pellacaxi. Archiv. della scienz. med. vol. vii. fasc.
ii. 1883. — 15. Gaurod, A. E. Journal of Physiology, vol. xiii. p. 598. — 16. Idem.
British Medical Journal, 1895, vol. i. p. 747. — 17. Geoffkedi and TiXNO. liiforina
Med. April 15, 1895. — 18. Gourfein. Bev. mid. de la Suisse rom. March 20, 1896.
— 19. Gkeenhow, H. Croonian Lectures at Boyal College of Physicians. Loudon,
1875. — 20. Haddox. Trans. Path. Soc. London, vol. xxxvi. p. 436. — 21. Halli-
BUKTOX. Science Progress, Feb. 1896. — 22. Haxot and Chauffai-d. Bemie de
medecine, 1882, p. 386.-23. Haxsemaxx. Berl. klin. JFoch. April 6, 1896.— 24.
Hakley, G. Brit, and For. Medico-Chirurg. Rev. vol. xxi. p. 204, 1858. — 25. Hilton
Fagge. Principles and Practice of Medicine. — 26. Kaiildex, v. Virchoivs Archiv,
Bd. cxiv. S. 91. — 27. Laxglois. Archives dc Physiol. 1892. — 28. Idem. Diet, de Physiol.
1895, vol. i. — 29. Legg, Wickham. Trans. Path. Soc. London, vol. xxxv. p. 367.
—30. MacMuxx. British Med. Journal, 1886, vol. i.— 31. Idem. Phil. Trans. 1886.
—32. Maxx, D. Lancet, 1894, vol. i. p. 652.-33. MAUixo-Zrccb and Ditto.
Bull, della r. Accad. med. di Roma, 1891. — 34. Mott. Trans. Path. Soc. London,
vol. xxxvii. — 34a. Muhlmaxx. Deutsche med. IVochenschr. 1896, Bd. xxviii. — 346.
Oestueich. Ztschr. f klin. Med. Bd. xxxi. S. 123. — 35. Oliveu, G. Pulse Gauging,
Loudon, p. 89. — 36. Idem. Biitish Medical Journal, 1895, vol. ii. p. 653. — 37.
Oi.iVEK, T. International Clinics, Philadel])hia, vol. ii. (4th series), p. 23. — 38. Oslek.
Pepper's Text- Book of Medicine, vol. ii. p. 234. — 39. Idem. Text-Book of Theory and
Practice of Medicine by American Teachers, 1894, vol. ii. p. 237. — 40. Idem. Inter-
national Med. Magazine, vol. v. No. 1. — 40a. Idem. Johns Hopkins Hosp. Bull. Nov.-
Dec. 1896, p. 208.-41. Rake, Be.a.van. Lancet, 1889, vol. ii. p. 214.-42. Rixger
and Phear. Trans. Clin. Soc. London, vol. xxix. p. 68. — 43. Roi.leston. British
Medical Journal, 1895, vol. i. — 44. ScHAFER. British Medical Journal, 1895, vol.
i. — 45. Si'HAFER and Oliver. Journal of Physiology, vol. xviii. j). 202. — 46. Sem-
MOLA. Trans. Internal. Med. Congress, 1881, London, vol. ii. p. 71. — 47. Spencer,
H. Trans, of Obstetrical Society of Loiulon, 1892, p. 276. — 48. STILLING. Rev. de
med. 1890, p. 830.-49. TiiiRoLuix. Bull. Soc. anal, de Paris, Feb. 2, 1894.— 50.
TnuDlcHCM. Report of Officer to the Privy Council, 1868.— 51. TizzoNl. Ziegler's
Beitrdge, vol. vi. No. 1, 1889. — 52. Trousseau. Clinical Lectures, vol. v. p. 150.
DISEASES OF THE SUPRARENAL BODIES 567
New S^'deiiham S jciety. — 53. Yixcext, S. Birmi7igJiam Medical Review, August
1896. — 54. AVainwright. Trans. Path. Soc. London, vol. xliv. p. 137. — 55. West, S.
St. Bart.'s Hosp. Reports.— oQ. Wilks, S. Gw/s Hospital Reports, 1859, 1862, 1865.
• — 57. Idem. Rejniolds' System of Medicine, vol. v, p. 359. — 58. "White, Hale.
Jour real of Physiology, vol. x. p. 345 ; 1889.
OTHER DISEASES OF THE SUPEAREXAL BODIES
In the preceiling article on Addison's disease reference has been made, in-
cidentally, to many morbid conditions of the suprarenal bodies. Although
certain of these changes need not necessarily give rise to clinical symptoms,
it is desirable, nevertheless, to include a general account of them in a
system of medicine.
Atrophy of the suprarenal bodies. — The organs vary considerably
in size, but they are relatively larger in early life. They share in the
general growth of the body, and as old age approaches participate in its
involution.
Occasionally atrophy takes place without any evidence of inflammation,
and may be so extreme as to reduce them to the size of peas. In such
cases all the symptoms of Addison's disease may be present {vide p. 541).
Fatty change. — In the suprarenal bodies of adults fatty change is so
common as to be a physiological condition. The fat occurs as large
globules in the cells. This change may be present throughout the whole
of the cortex, or be best marked in the zona fascicidata. The medulla is
occasionally seen to be occupied by fat, but never to the same extent as
the cortex ; while in chilch-en there is little fat normally. Attlee found,
however, some, though slight, fatty change in still-born children. In
children dying from marasmus there was marked fatty change, which
was more frecpient than in the liver. The cortex was affected in all,
and the medulla in six out of the nine. Experimentally he found that
starvation, suppuration, or poisoning, whether acute or chronic, gave rise
to marked fatty changes.
Fatty change does not give rise to any symptoms.
Hsemorrhage into the suprarenal capsules. — As the result of severe
injuries, such as fracture of the spine or rupture of the liver and spleen,
blood is often poured out around the suprarenal bodies. Haemorrhage
into the suprarenal bodies is not infrequently met with under these
conditions, and is almost always into the medulla.
As the result of traumatism during birth, haemorrhages frequently
occur into the suprarenal capsules. On an examination of 130 still-born
children Dr. H. Spencer found extravasations into these oi'gans in 26 ;
in 2 of these the haemorrhage had occurred in the cortex, in the remaining
24 into the medulla ; in half the cases it Avas bilateral ; in 3 cases the
haemorrhage had ruptured the capsule. These haemorrhages occurred
568 SYSTEM OF MEDICINE
more often in difficult laltours, and were more frequently met ^\^th in
pelvic than in cephalic presentations.
Apart from traumatism, hemorrhage into the medulla of the suprarenal
capsules has been recorded in a variety of conditions, in which the most
common factor is chronic venous congestion. In a few cases haemorrhage
has been associated with definite symptoms, such as pain in the back,
severe collapse, or even Addison's disease.
Lardaceous disease. — AVhen attacked by lardaceous disease the
suprarenal capsules appear but slightly increased in size, and have a
somewhat translucent appearance on section. "With the iodine test the
cortex becomes a dark broAvn, Avhilc the medulla remains of a gray or
grayish yellow. The contrast thus presented is the reverse of that seen
in health. The suprarenal bodies are among the organs which undergo
the lardaceous change Avith comparative frequency. In twenty-one cases
of well-marked lardaceous disease the suprarenal capsules were affected in
nine ; in four of the cases it was so slight that microscopic examination
was necessar}' to determine its presence. According to Cornil and Ran-
vier it is rare, and only attacks the vessels of the medulla. In my
cases, however, it was always best mai-ked in the vessels running vertically
through the cortex ; and, though it may be present in the medulla, it
is always less marked there than in the cortex. Orth describes the
lardaceous change as occurring chiefly in the region of the zona
fasciculata.
Cloudy swelling-. — Softening and cloudy swelling of the suprarenal
capsules occur in febrile conditions; and it is noteworthy that the spleen and
the adrenal bodies show very similar changes under these circumstances.
The medulla apjiears sodden and l)lood-stained, and, microscopically, small
exti-avasations may be found in the cortex. The softening disposes to a
separation between the cortex and the medulla, and thus even slight
manipulation may produce a cavity. This finds a permanent record in
the name " capsule " as applied to the suprarenal gland.
In pyaemia small vascular streaks in the cortex, or more rarely minute
abscesses due to embolism, may occur.
Tubercle — In generalised tuberculosis miliary tubercles may be seen
in the suprarenal bodies.
In chronic tul)erculosis, whether primary or secondary, the process
begins on the medulla. Care must be taken not to regard as discrete
caseous tubercles the small fatty adenomata so often seen projecting from
the cortex.
In the early stages of chronic tiiberculosis the inflammatory granulation
tissue has a firm speckled appearance, and, microscopically, contains
numerous vessels. Caseation, softening, or calcareous infiltration may
all follow as in other tuberculous formations ; but it is highly improl)able
that caseous material is ever absorbed or disap])cars. Tubercle is
frequently found without any signs or symptoms ha\ ing been present.
In 157 cases of tuberculous disease of various parts of the body,
secondary tuberculous caseous foci were found in 20 without any signs
DISEASES OF THE SUPRARENAL BODIES 569
of Addison's disease. Arranging the cases in decennial periods, it is seen
that in 25 cases in which death occuiTed under 10 years of age no tubercle
was found in the suprarenal bodies; in 18 cases occurring between the ages of
10 and 20 years tubercle was found five times; in 34 cases between 20 and
30 years three times; in 36 cases between 30 and 40 years seven times;
in 25 cases between 40 and 50 years once; in 12 cases between 50 and
60 years twice ; in 6 cases between 60 and 70 years twice. There appears,
therefore, to be a marked immunity from tubercle during the early years
of life, that is, at a time when the suprarenal bodies are relatively larger,
freer from fatty change, and possibly more active than in later life.
Syphilis. — Single or, more rarely, multiple small gummata are occasion-
ally seen in the suprarenal bodies, and general fibrosis may be due to the
syphilitic poison.
Simple tumours of the suprarenal bodies may be divided into two
gi'oups : {a) adenomata which are not uncommon, and (b) cysts and other
rare growths.
Adenomata. — Several kinds of adenomata occur ; the first two,
especially the first, are common, the others are rare.
i. Multiple small yellowish nodular projections, situated on the
cortex of the organ ; they are not marked off by any capsule from the
surrounding tissue, but diff"er from it in being the seat of very advanced
fatty change. In other respects the cells composing them are like the
cells of the cortex. These adenomata pass by gradual transitions into
the irregularities often seen in the suprarenal bodies of adults. They are
sometimes mistaken for tubercles undergoing caseation ; in this connection
it is well to remember that chronic tuberculosis begins in the medulla.
ii. Large adenomata are almost always found singly in the suprarenal
capsule, though they may be bilateral. Virchow described them under
the name of " struma lipomatosa suprarenalis " ; and recently from
analogy they have been named adrenal goitres ; though it must be
regretted that a name of such purely local application as goitre should
be applied to a tumour in the alidomen. They do not involve the
whole of the organ, but form distinctly localised tumours which may
attain a very considerable size. They arise in the cortex, and in arrange-
ment usually resemble the zona fasciculata. They are a magnified edition
of the small multiple suprarenal adenomata. Small ones may coexist
with them in same organ. The cells contain a large amount of fat, and
this accounts for the pale yellow colour of the adenomata. Occasionally
the fatty change is so advanced that they appear softened or necrosed.
When this is the case, some extravasation may occur into the substance
of the organ. Commonly they have no more supporting fibrous tissue
than the rest of the organ ; but in other cases the quantity of fibrous
tissue is much in excess, so that the term fibro-adenoma may be used.
I have seen an example of this variety in which the cells did not show
any fatty change, and in which hyaline degeneration of the vessels, which
were numerous, was well marked.
iii. DilTuse fatty adenomata arising from the cortex and containing
SYSTEM OF MEDICINE
much blood are described by Letiille. To the naked eye they resemble
malignant growths, but difi'er from them in not infiltrating the tissues,
or leading to secondary growths. The}' are probal)ly an exaggeration of
the preceding kind. According to this author, they have been erroneously
described as angio-lipomata and sarcomata.
iv. Pigmentary adenomata arising from the zona reticularis. The
cells contain pigment granules, but never show fatty change. They may
be multiple. Lctvdle described three cases, all in plithisical subjects.
V. Adenomatous tumours of the medulla containing numerous vessels
and epithelial cells. The veins may contain the hyaline material found
in the veins of the medulla l)y Manasse (7). These tumours are rare, and, as
they have probalily been described sometimes as sarcomata or gliomata,
some doubt exists as to their classification.
6'//.s/.s. — Cysts in the suprarenal body are very rare ; the occurrence
of echinococcus rnay be mentioned, and cysts the result of former
haemorrhages have been met with. I have seen a C3^st the size of a
cherry containing tenacious fluid. Virchow has suggested that cysts
may be formed \>y a, softening down of adenomata of the suprarenal
capsules.
Other tumours of the suprarenal bodies, such as fibromata, fibro-
myomata, ganglionated neuroma, and angioma, have been recorded, but
are pathological curiosities.
Simple tumours arising in accessory suprarenal bodies, or in suprarenal
"rests." — Accessory suprarenal bodies are very commoidy present in the
connective tissue in the immediate neighbourhood of the two organs
They are found when looked for; but otherwise, as they are so small,
they do not, as a rule, attract attention. They are yellow in colour, oval
or round, and usually about the size of a grain of corn. I have seen one
as large as a cherry, but this is very exceptional.
The accessory suprarenal bodies may be found among the fibres of the
renal or solar plexus and in close relation to the semilunar ganglia.
They have been found in the broad ligament of the uterus, on
the spermatic vessels near the inguinal canal, and even the epididymis.
The larger accessory suprarenal bodies contain a medullary portion, and
Enrich has described a tumour arising in the medulla of an accessory
suprarenal body.
Instead of being in the loose connective tissue, accessory suprarenal
bodies may be found embedded in the kidney or liver, and are then often
spoken of as suprarenal " rests." Though Schmorl records four examples
of suprarenal "rests" occurring in the liver in 510 examinations, they
are much more commoidy recognised in the kidney than in the liver.
Personally I have failed to find them.
In the kidney, by taking on adenomatous growth, they may give rise
to innocent tumours; some so-called renal adenomata and "li})()mata"
are thus explained (4). In the case of "lipomata" the adenoma of the
suprarenal " rest " undergoes exten.sive fatty change. l\ofci-encc will be
made later to malignant tumours arising in suprarenal " lests."
DISEASES OF THE SUPRARENAL BODIES ■ 571
Maligna.nt disease. — Primary. — Botli sarcoma and carcinoma are de-
scribed, and tumours conforming in structure to a glioma have been re-
corded as arising from the medulla. The tumours are usually hasmorrhagic
and soft, have a tendency to undergo fatty degeneration, and frequently
contain necrotic areas and hsemorrhagic cysts. Letulle, as already men-
tioned, has described, under the name of diiTuse adenoma, growths of a
somewhat similar structure, but Avithout Siwj tendency to infiltrate the
surrounding parts. It must be admitted that there may lie considerable
difficulty in determining whether a tumour of the suprarenal body, un-
doubtedly malignant as shown by the presence of secondary gi'owths,
should be referred to the sarcomata or to the carcinomata.
Malignant disease of the suprarenal body rnay spread into the
suprarenal vein, and so into the renal vein or inferior vena caA'a. The
growth may eat its way directly into the upper part of the kidney, and,
by involving" the pelvis, ma}'- give rise to haematuria, and so simulate a
primary lesion of the kidney. On the right side it may directly invade
the right lobe- of the liver. In several cases it has displaced the colon
downwards instead of carrj'ing the gut in front of it, as is the case in
renal tumours. Clinically, too, suprarenal tumours rather resemble cysts,
while malignant renal tumours are usually solid. Secondary growths
occur in the liver, lungs, kidneys, bones, lymphatic glands, and skin.
In 36 cases collected by R AVilliams, more than a third occurred in
children ; they may be congenital, and have been found to be bilateral.
On the other hand, in 20 cases of primary sarcoma collected by Affleck
and Leith the average age was 45 years. In young children precocious
development of hair and of the genital organs has been occasionally noticed
in connection with suprarenal growths. The temperature may be de-
pressed, or may, on the other hand, be continually raised. Diagnosis is
difficult in these tumours, and they most resemble the more commonly
occurring primary growths of the kidney; in fact, when a suprarenal growth
has extensively invaded the kidney, it may be difficult, even at the autopsy,
to say where it began. These soft hsemorrhagic tumours of the
suprarenal body may simulate hydatid cyst, a hsemorrhagic abdominal
cyst, and on the left side a pancreatic cyst or disease of the spleen.
Treatment is that of malignant disease of the kidney, which it
clinically resembles. H. Morris has published the details of a case
operated upon by him.
Maligncmt tumours of other organs arising in suprarenal " rests." —
Besides giving rise to " lipomata " or adenomata of the kidney, displaced
accessory suprarenals or " rests " may be the origin of malignant growths
in the kidney. Their structure resemljles that of primary malignant disease
of the suprarenal bodies, and they show the same tendency to the forma-
tion of hsemorrhagic cysts, and to undergo necrosis. Lubarsch and
M'Weeney have recently given admirable summaries of our knowledge
of the subject. The same difficulty arises here, as in the case of malignant
disease of the suprarenal bodies, in definitely assigning the tumour either
to the group of the sarcomatous or to that of carcinomatous growths.
572 SYSTEM OF MEDICINE
M'Weeney, while iiiflining to the view that they are carcinomatous,
cautiously prefers to call them " kidney tumoiu-s derived from suprarenal
rests."
Lubarsch has found glycogen in these tumours.
Clinically their course is usually slow at first, but they may suddenly
become extremely active and rajiidly cause death.
Secondary growths occur in two-thirds of the cases, most frequently
in the lungs.
The only treatment is, of course, removal ; but so far this has not
been very successful.
Schmorl suggests that some of the primary tumours of the liver
may similarly be due to active proliferation, and new growth in a suprarenal
" rest " embedded in that organ. Such a view certainly explains the
origin of large-celled vascular growths on the liver, and might also be
extended so as to include similar retroperitoneal sarcomata. '
Secondary groidhs in the suprarenal bodies are not uncommon. In
100 cases of carcinoma of various parts of the body secondary
growths in the suprarenal bodies occurred ten times, and in 35
cases of sarcoma five times. Dr. Norman Moore, in 102 cases of
carcinoma, found secondary growths in three ; and in 21 cases
of sarcoma five times — three sarcoma, two endothelioma. It appears
probable, therefore, that secondary growths are commoner in sarcoma ;
this is easily explained by the extensive blood-supply of the suprarenal
bodies taken in conjunction Avith the spread of sarcoma by the blood-
vessels. The relation of Addison's disease to secondary growths in the
suprarenal bodies is dealt with on page 545.
H. D. KOLLESTON.
REFERENCES
1. Affleck and Leith. Edinburgh Hospital Reports, vol. iv. p. 278. — 2.
Attlee. Med. Chron. New Series, vol. iii. p. 374. — 3. Eitkich. Journ. of
Path. vol. iii. p. 502. — 4. Grawitz. Virchow's Archiv, Bd. xciii. — 5. Letulle.
Archives de Science medicale, 1896, p. 80. — 6. Lubaksch. Virchow's Archiv, Bd.
cxxxv. p. 141.— 7. M'Weeney. B. M. J. 1896, vol. i. ]). 323.-8. Manasse. Vir-
cliow's Archiv, Bd. cxxxv. p. 263.-9. Mooue, N. Medical Pathology, p. 355. — 10.
Morris. B. M. J. 1893, vol. i. p. 2.- 11. Schmorl. Ziegler's Beitr. vol. vi. p. 523.
— 12. Spencer, H. Obstet. Trans. 1892.-13. Targett. Path. Soc. Trans, vol.
xlvii. p. 122.-14. Williams, R. Lancet, 1897, vol. p. 1261.
H. D. R
HODGKIN'S DISEASE 573
HODGKIN'S DISEASE
Synonyms. — Lymphadenoma, Lymphadenosis, Pseudo-leuccemia (Cohnheim,
Wunderlich), Anmmia lymphatica (Wilks), Ancemia splenica (Griesinger),
Lymphatic cachexia., Lymphosarcoma, Lymphoma, Lymphosarcomatosis. French
— AdSnie (Trousseau), Lymphadinie (Ranvier), Cachexia sans leucdmie
(Bonfils). German — Pseudoleukdmie.
Short deseription. — Hodgkin's disease is characterised by a general
enlargement of one or more groups of lymphatic glands, frequently
accompanied by enlargement of the spleen and anaemia. The enlarge-
ment of the lymphatic glands is due to an overgrowth of adenoid tissue,
which in some cases becomes largely converted into fibrous tissue.
Lymphomata, or disseminated growths of adenoid tissue, may arise in
various organs, but more especially in the spleen, liver, kidneys, and
alimentary canal. In the blood the red corpuscles may be diminished
in number and deficient in haemoglobin, while, in some cases, thei'e is an
increase in the number of the leucocytes.
History. — The earliest description of the general enlargement of the
lymphatic glands, together with the presence of nodules in the spleen, was
given by Malpighi in 1669 ; but apparently he did not consider that the
combination of these two morbid conditions constituted a definite disease.
Craigie, in 1828, defined the anatomical characters of the glandular en-
largements, and pointed out how they differed from those of scrofulous
enlargement and from those of cancer of the glands. To Dr. Hodgkin
rightly belongs the credit of having first described, in 1832, the main
clinical features of the disease which now bears his name. He described
the association of the enlargement of several or of many Ij^mphatic glands
with changes in the spleen as an important characteristic of the disease.
Velpeau, in 1839, described the enlargement of the lymphatic glands which
was not associated with scrofula. In 1856 Sir Samuel AYilks drew atten-
tion to some cases and to their similarity to those described by Hodgkin
twenty-four years before. In the same year Bonfils described a case
of hypertrophic gangliomure g4n4rale, cachexie sans leucdmie, with an account
of the necropsy, and gave a clear description of the characters of the
disease. In 1858 Billroth described the structure of the enlarged glands,
and Wunderlich published two cases. The following year further contri-
butions to the subject were made by Pavy and by Cossy. Virchow
gave a short description of the disease in 1864. In 1865 Wilks gave
a further description of his cases and of the general characters of the
disease. Cornil collected the eases which had already been observed,
and recorded two others with a careful account of their pathological
anatomy. The same year Trousseau devoted a chapter in his Clinique
574 SYSTEM OF MEDICINE
rrnldiraJe to a dcscriptioii of tlic characters and nnture of the disease, to
which he gave the name of adihtie. In l^GG Wunderlich gave the first
thorough account of the disease in German. The year foUowing, Midler
described seven a(hlitional cases from Niemeyer's clinic. In 1870 Dr.
Murchison related the history and the ,synij)toms of the disease, and
gave the results of Dr. Burdon Sanderson's microscopical examination of
the diseased organs. The disease was described as pseudo-leuchiemia by
Mosler in 1878. The disease was discussed at the Pathological Society
of London in 1878 (Tran^. vol. xxix.), and a most comprehensive account
of the disease was given by Sir William Gowers in 1879. In 1892 Dr.
Dreschfeld published a clinical lecture on acute Hodgkin's disease, Avhich
contains valua1)le observations upon the condition of the l)lood. In
addition to these contributions many single cases and collections of cases
have been ])ul)lished from time to time, to Avhich I cannot now refer.
Etiology.— Our knowledge of the etiology of Hodgkin's disease is very
scanty. Of the immediate causes wc know nothing definite as yet. By
some physicians it is suj)posed to be due to a micro-organism ; and the
course of acute forms of the disease is highly suggestive of an acute in-
fective process. The present state of our knowledge of this part of the
subject will })e considered more fully in dealing with the pathology of the
disease. When we examine the circumstances under which the disease
arises we find that in more than half of the recorded cases none of the
remoter causes can be traced. Thus Gowers found that in. 64 out of
114 cases the patients were in good health up to the beginning of
the disease, and no etiological factor could be discovered to account for
the onset. In some cases, however, there are certain antecedents which
aj^pear to l^e concerned in the event, and to these I shall now refer.
Ileredifij. — Evidence of direct transmission from parent to child is
almost entirely wanting. Midler recorded one case in which all the
children of a father who sufTered from Hodgkin's disease were subject to
enlargement of the lymphatic glands. The disease shows no tendency to
occur in the more distant l)lood relations of the joatient. Tuberculosis is
the only disease which appears to cause any proclivity to it, and, whether
as pulmonary phthisis or as tuberculous disease of the lymphatic glands,
may l)e found in one or more members of the same family. But when
we consider the great frequency of tuberculosis we caiuiot assume that
such cases are more than coincidences.
Sex. — The male sex is much more liable to the disease than the
female ; it occurs three times as often in men as in women.
LoraUfi/. — The disease occurs independently of any special local con-
ditions, and there is no evidence that any one kind of climate favours
its occurrence more than another.
Personal antccedf.ais. — Tuberculosis. — Tulierculous disease of the
lymphatic glands may dispose them to a later development of lymph-
adenoma ; for in a few cases the onset of the disease has been preceded
by scrofulous enlargement of the glands with suppuration.
Syphilis. — Three cases are mentioned by Gowers in which the onset
HODGKIN'S DISEASE 575
of the disease had been preceded by syphilis, but the relationship of the
one to the other is doubtful.
Parturition. — The disease rarely occurs during pregnancy, but several
cases have occurred shortly after childbirth, and have run a very acute
course, ending fatally within a few weeks. Parturition thus has an un-
favourable influence upon the progi'ess of the disease.
The onset has sometimes been preceded by exposure to cold. In a
few instances want of food, excess of alcohol, over-exertion and mental
depression aj^pear to have contributed somewhat to the initiation of the
disease.
Local irritation. — Trousseau pointed out that in some cases the en-
largement of the lymphatic glands was, in the first place, due to some
local source of irritation in the neighbourhood of those glands which first
become afi'ected. Thus a local glandular enlargement, due to otorrha-a,
chronic nasal catarrh, and a carious tooth, has been followed by the
general appearance of the disease in other glands. In other cases the
disease has been preceded by an increase in the size of the respective
glands in inflammation of the pharynx, inflammation of the lachrymal
sac, and in soft chancre.
Varieties. — Different forms of Hodgkin's disease occur which maj^ be
classified in various ways. The chief points in which cases differ from
one another are the distribution of the glandular enlargements, the
consistence of the enlarged glands, the condition of the spleen and other
■viscera, the state of the blood, and the course of the disease. Thus in
some cases one group of glands only is enlarged ; in others, several
groiips ; in others, again, almost all the lymphatic glands. When the
disease is general the enlargement may be uniform, or some glands ma}'
be much more increased in size than others. In some cases the glands
are soft, in others hard ; but no sharp distinction can be made between
the two, as both hard and soft glands may occur together in the same
patient, and the glands may be hard at one stage of the disease and soft
at another. It has been thought that when the glands are soft the blood
contains an excess of leucocytes, and the name lymphatic leuchsemia
has been applied to such cases. This distinction, however, does not hold
good ; for in some cases with soft glands there is no leucocj'tosis, while
on the other hand it may exist when the glands are hard. In any of the
varieties I have mentioned there may or may not be enlargement of the
spleen or changes in the other organs due to adenoid growths in them.
The condition of the blood varies ; anaemia is nearly always present ;
but the leucocytes may be normal or may be excessive in number.
When leuchaeraia occurs, the leucocytes are chiefly mononuclear, though
eosinophile cells are sometimes present also in fairly large numbers. The
course of the disease varies considerably, and it is convenient to speak of
an acute and a chronic form of Hodgkin's disease. Dr. Dreschfeld
describes three types of the acute form : one in which the superficial
glands are enlarged, a second in which the intrathoracic, and the third
in which the intra-abdominal glands and abdominal organs are affected.
576 SYSTEM OF MEDICINE
Symptoms. — General. — The most important symptoms which occur in
Hoclgkin's disease are enlargement of the lymphatic glands, antemia, enlarge-
ment of the spleen, rise of temperature, progressive loss of strength and
emaciation. Some other less frequent symptoms Avill also be considered
presently. Enlargement of the superficial lymphatic glands is the most
frequent of the early symptoms, as in more than half of the cases it is
the first change which attracts the attention of the patient. AVhen the
glands, which are deeplj^ situated, are enlarged early, the symptoms caused
by their pressure upon the surrounding organs may occur l)cfore any
other sign of the disease. Thus pain in the chest and cough, i)ain in the
abdomen, pain or tedema of the leg, according as the thoracic or abdominal
glands are first aftected, may be the earliest symptoms. In other cases
the general constitutional symptoms, such as antx^mia, loss of weight and
weakness, are the first indications of loss of health ; and the glandular
enlargement may not become apparent until later. Earely an irregular
form of fever may precede the glandular enlargement.
Lymphatic glands. — Early enlargement. — The superficial lymphatic
glands are usually enlarged before the deeper glands ; thus Gowers found
in fifty-two out of seventy-eight cases that enlargement of these glands
was the first detected symptom of the disease. Of the superficial groups
of glands the cervical are more often enlarged at the beginning of
the disease than any other group. The enlargement may be limited at
first to one side of the neck. In some cases many months, or even three
years, as in a case recorded by Osier, may elapse before those on the
opposite side become involved. Less frequently the inguinal glands, and
rarely those in the axilla, are the first to become affected.
Characters of enlargement. — The lymphatic glands increase in size at
first independently of each other, and remain separate. This condition
may continue until they are as large as pigeons' eggs. The skin is freely
movable over the superficial glands ; and in the early stages of the
disease the different members of a group of glands can be moved one
upon another. Later the glands often become firmly adherent to each
other, as the result of periadenitis, or of the extension of growth from one
gland to another. In this manner large lobulated masses or tumours are
formed which may attain the size of a cocoa-nut. The consistence of the
enlarged glands depends chiefly upon the rate of growth. If the enlarge-
ment take place slowly, they remain firm to the touch ; if the increase in
size be rapid, they are soft and contain a large quantity of lymph. As a
rule the enlarged glands do not cause any pain, nor are they tender when
pressed. Occasionally some pain may be felt in the glands if they are
undergoing rapid enlargement, and an enlarged mass of glands may cause
direct or referred pain by pressing upon a nerve or nerve-trunk. The
progress of the enlargement varies considerably in different cases, and also
in different groups of glands in the same patient. Thus enlargement
may take place more rajjidly at one time than another, or one set of glands
may increase considerably in size while others remain nearly stationary.
In some cases the glands get larger and larger until death takes place.
HODGKIN'S DISEASE 577
111 othei's the growth becomes arrested, and in a small number the size of
the glands diminishes before death occurs. In the neck the enlargement
generally begins in the glands of the posterior triangle, or in those which
lie beneath the lower jaw.. The suboccipital glands are often enlarged
also. Frequently the submaxillary glands arc enlarged on Ijoth sides.
The natural contour of the neck is then much distorted by the masses of
enlar2;ed glands, M'hich may reach a lar2;e size and greatly increase its
circumference. When the enlargement of the cervical glands is consider-
able, serious secondary symptoms may be produced by the pressure whicli
they exert upon important structures in the neck. The larynx may be
disj)laced laterally, or the trachea may be so much narrowed by pressure
that great dyspnoea and even death may occur. Diihculty in swallowing
and death from starvation may be caused by compression of the oesophagus.
Pressure on the blood-vessels may lead to anremia of the brain if the
carotid arteries be concerned, or to venous congestion if the veins are
affected. The vagus nerve is sometimes compressed, and this may
lead to irregularity of the pulse and cardiac failure. The glandular
growth may extend into the pharynx, so that swallowing becomes difficult
and hearing imperfect. Extensive enlargement of the submaxillary
glands impedes the movements of the lower jaw. If the enlargement of
the axillary glands be considerable, movement of the arm is difficult.
Pain and swelling may be caused by pressure upon the nerves and veins
in the axilla. In the groin the enlarged glands may compress the femoral
vein so as to produce oedema of the leg, or even thrombosis in the vein
itself. The thoracic veins may be enlarged, and all the symptoms of
an intrathoracic tumour may be present ; the most frequent being
spasmodic cough and dyspnoea. The organs in the chest may be com-
pressed by the glands. The superior vena cava may be narrowed or
even occluded, leading to oedema of the head and arms, when a collateral
circulation may be established by the mammary and epigastric veins, as in
a case recorded by Osl6r. When the glands in the abdomen are much
enlarged they can be felt through the abdominal wall. They may press
upon the inferior vena cava, or the common iliac veins, and may thus
cause oedema of the legs. The solar plexus may be implicated, with
bronzing of the skin, as in Sir W. Jenner's case, in which Sir W. Gowers
found that the solar plexus was concerned, though the suprarenal capsules
were unaff"ected. Dr. Coupland mentions another similar case observed
by Sir J. Paget. Fereol and Osier also have each observed a case of this
kind. Vomiting may be excited by pressure upon the stomach, or sciatic
pain by pressure upon the sacral plexus. The enlarged glands may
compress the ureters, or they may become adherent to the uterus and
simulate a uterine myoma.
Tlie Spleen. — The spleen is frequently enlarged, but the enlargement
is not an early symptom, and as a rule it cannot be detected until the
glandular enlargement has become well marked. The spleen never
reaches the enormous size which is so frequently seen in cases of splenic
leuchaemia, though it is generally large enough for the lower end of it
VOL. IV 2 P
578 SYSTEM OF MEDICINE
to be felt l)eiie;ith tlic costal margin. It sometimes extends as far as the
middle line, but it rarely causes any pain or discomfort. Occasionally it
is irregular in outline owing to the large size of the nodiiles of adenoid
growth.
CircuJatonj sj/steni. — Blood. — Anaimia, ■which may be profound, is a
common symptom. It fre([uenl]y ai)j)ears \evy early ; but in some cases
it may not appear until after the glanils ha\e become enlarged. The
consequences of the ansemia are weariness, lack of energy, cedema of
the feet or even of the subcutaneous tissues generally. Ha?morrhages
ma}'' occur from the mucous membranes, and s])ecially from the nose, in
the subcutaneous tissue, or in the retina, ^^'hen the blood is drawn it
looks pale, but clear, if there be no excess of leucocytes. If there be an
excess of leucocytes it looks rather milky. Coagulation takes j^lace
slowly and imperfectly.
lied blood corpuscles. — The microscopic appearances of the blood vary
in different cases, and the anaMuia is much more maiked in some cases
than it is in others. In many there are 50 or 60 per cent of the
normal nundjer of red blood corpuscles, while in a few severe cases
they arc as few as 25 per cent. Changes in the red corpuscles themselves
sometimes occur both in the acute and in the chronic form of Ilodgkin's
disease. Small red corpuscles or microcytes may occur in varying
numbers ; in some cases they arc numerous. Their presence may be
readily determined by comparing their size with that of the red corpuscles
in normal blood which have a diameter of about -yrsW o^ ^^^ inch.
Irregular forms of red corpuscles which are generally included under the
name of poikilocytes may also be observed. Nucleated red corpuscles
are rarely seen. Dr. Dreschfeld found none in the cases which he
examined.
Leucocytes. — In the majority of cases there is no excess of leucocytes
in the blood. Thus Gowers found that out of sixty-four cases there was
no leucocytosis in thirty-nine, although in twenty-five there was some
excess of white corpuscles.
In normal blood five different varieties of leucocytes have been
described by Ehrlich. (a) Lymphocytes — small leucocytes Avith a diameter
of 7 {M, being thus about the same size as a normal red corpuscle. This
form has a large single nucleus which stains deeply and is surrounded by
a narrow margin of protoplasm without grainiles. (/') Large monomiclear
cells several times as large as the lymphocyte. The nucleus is oval in
shape, and does not stain deeply, while the protoplasm is non-graimlar
and relatively more abundant, (r) Inteiinediate ft)rms resembling the last
variety, but having an irregularly-shaped nucleus, (d) These arc gener-
ally described as multinuclear cells. It is only under the action of certain
reagents, however, that the nucleus breaks up into parts, and normally it is
a long, irregular body which, as Muir ])oints out, is more ajUly desci'ibed
as being " multipartite." The protoplasm contains granules which are
stained l)y both acid and basic stains, and so these leucocytes are
often called "ncutrophiles." (e) Eosinoijhilcs — cells about the same
HODGKIN'S DISEASE 579
size as the last-mentioned variety, with a single nucleus. The protoplasm
contains large refractile granules which take up acid colouring agents and
stain deeply with eosin, to which property they owe their name. In
healthy blood the average number of leucocytes is 6000 in each cubic
millimetre. The different varieties occur in the following proportions :
lymphocytes, 15 to 30 per cent; multinuclear, 65 to 80 per cent; mono-
nuclear and intermediate forms, about 6 per cent ; and eosinophiles, 2 to
4: per cent.
If there be leucocytosis, it is due to the presence of an increased
number of the lymphocytes in the blood. Ehrlich considers that the
presence of an increased number of eosinophile leucocytes in the blood is an
important characteristic of the blood in Hodgkin's disease and in leuchsemia.
Dreschfeld has found the eosinophiles to be fairly numerous in some cases,
but scanty in others; and concludes, in opposition to Ehrlich, that they are
not of much value as an aid to diagnosis. Dr. Kanthack considers that
the eosinophile cells are of no diagnostic value either in Hodgkin's
disease or in leuchgemia, because they have been found in large numbers in
gonorrhoeal pus, in many specimens of piis l^oth from men and from
lower animals, in sputum, and in muco-purulent nasal secretions. As the
eosinophiles are much increased in numbers in splenic leuchiemia, it is
probable that in tliese mixed cases of Hodgkin's disease or lymphatic
leuchasmia, in which both lymj^hatic glands and spleen are enlarged with
leucocytosis, the eosinophiles will be found more numerous than in the
more simple uncomplicated cases.
Heart. — The action of the heart may be weak if there be fatty
degeneration from anaemia. In fever the frequency of the joulse is of
course increased, and it may be irregular if the vagus nerve is compressed
by enlarged glands in the neck.
Alimentary system. — Ijymphoid growths may develop in different
parts of the alimentary canal, and also in the organs connected with it,
giving rise to various symjDtoms according to their situation.
In the mouth the gums may be soft, pale in colour, and swollen,
and blood may be extravasated beneath the mucous membrane. The
tonsils may be considerably enlarged, and there may be extensive adenoid
growths in the pharynx ; these may cause deafness (by occluding the
Eustachian tube), difficulty in swallowing, and in rare cases they may
completely obstruct the pharynx so as to prevent the passage of
food. The presence of lymphoid growths in the wall of the stomach
leads to dyspepsia and vomiting ; when there is ulceration of the growths
the symptoms resemble those of simple gastric ulcer ; vomiting may
also be excited by the pressure of enlarged lymphatic glands upon the
stomach itself. Lymphoid growths in the intestine may cause no
inconvenience, or they may be accompanied by diarrhoea and haemorrhage.
Constipation may be caused by the pressure of enlarged abdominal
glands upon the bowel. As a rule there are no symptoms of hepatic
disorder. Obstructive jaundice sometimes occurs from the pressure of
enlarged glands upon the bile-duct. The liver is uniformly enlarged,
SSo SYSTEM OF MEDICINE
OM'ing, in some cases, to the excessive development of lymphoid growths
in the substance of the organ.
lU'siAratunj system. — Dyspnoea is a frequent symptom ; it may arise
either from narrowing of the ti-achea by the pressure of enlarged glands,
or from the antemia. Bronchitis is often present. The lymphoid growths
may give rise to crepitations Avhich are audiltle in different ])arts of the
chest, but do not otherwise interfere with respiration. Etiusion into the
pleural cavity often takes place, either as part of a general anasarca or
as a result of pressure upon the azygos or bronchial veins.
Xerroxis sijstem. — In some cases delirium and coma have occurred.
One of ^losler's patients died from tedema of the bi-ain, which he regarded
as the result of a cerebral haemorrhage. Various symptoms may be pro-
duced by the pressure of the enlarged lymphatic glands upon the nerves.
Thus pressure upon the cervical sympathetic may cause inetpiality in the
size of the pupils. Pains in the nerves of the arms and legs may also be
the result of pressure. Osier has observed one case in which there was
paraplegia from pressure upon the spinal cord.
Genito-urinary system. — As a rule there are no renal symptoms even
when h^mphoid growths are found in the kidney after death. The urine
may contain traces of albumin ; but anything more than this may be
taken as evidence of ulterior changes in the kidney occurring as a com-
plication. Lymphoid growths are rarely found in the ovaries or testicles.
Amenorrhoea in women is common, and is j^robably a result of the
anicmia. In some cases pregnancy has occurred after the commencement
of the disease.
Temperature. — The temperature incases of Hodgkin's disease has been
very carefully studied by Gowers, who found that fever was present as a
symptom of the disease itself in two-thirds of the cases in which the
temperature had been taken. It is rather more frequent in acute than in
chronic cases, and it occurs in nearly all patients under twenty years of
age. When general swelling of the glands occurs at the beginning
of the disease, fever is often an early symptom. Gowers describes three
modes of pyrexia which may occur. In the first the temperatiu'e is
continuously raised from two to five degrees above the normal, and only
varies a degree or a degree and a half during the twenty-four hours. In
the second mode there are periods, several days in duration, of high fever
alternating with periods of normal temperature. In a third there are
marked daily variations, the temperature rising to 101° or 103° each
evening, and falling to 100° or even to normal in the morning.
SJdn. — Owins: to the aiuemia the skin and nmcous membranes are
pale, often from the beginning of the symptoms. Sometimes there
is a general subcutaneous wdema. Bronzing of the skin, as in Addison's
disease, has been observed in a few cases, to which reference has already
been made. Profuse perspiration occurs during the night in some
cases.
Pathological anatomy. — The most important morbid changes in
cases of Hodgkin's disease are enlargement of lymphatic glands, enlarge-
HODGKIN'S DISEASE 581
ment of the spleen, and the presence of nodules of adenoid gi'owth in
various organs of the body.
Lijrnphatic glands.- — The most striking feature of the morbid anatomy
of Hodgkin's disease is the enlargement of the lymphatic glands. In
health the lymphatic glands may be conveniently divided into primary,
secondary, and tertiai-y groups. Of these the primary and secondary are
always to be found, whereas the tertiary glands are usually so small that
they may escape observation ; but they become enlarged under special
circumstances. The inguinal glands are a primary group, the popliteal
are secondary glands. Gulland states that in the axilla there are tertiary
glands which ordinai'ily only measure 1 or 2 millimetres in diameter, but
which in woman during lactation become temporarily enlarged. They
afterwards disappear, as Stiles has found, by a process of fatty involution.
These tertiary glands may also become enlarged if carcinoma develop in
the mamma. It would appear from Bay lis' experiments that under special
circumstances entirely new glands may be formed to take the place of
others which have been removed.
In Hodgkin's disease the extent of the lymphatic enlargement varies
considerably in difterent cases. In some it is confined to a few groups of
glands ; in others a large number are involved. The primary lymphatic
glands are the most liable to be enlarged. The cervical glands are more
frequently affected than any others ; after these in order of frequency
come the axillary, inguinal, retroperitoneal, bronchial, mediastinal, and
■ mesenteric glands. In addition to these, smaller groups of the secondary
glands are often affected along with the primary groups with which they
are connected. Thus with the inguinal the popliteal glands, and with
the axillary the epitrochlear glands may be afiected. Tertiary glands
may also become afiected, and thus large glands may be found along the
line of lymphatic vessels in unusual situations ; as, for instance, beneath
the pectoral muscle. The same set of glands is usually affected on both
sides of the body, liut the enlargement may be greater on one side
than on the other, or may affect one side only. A single gland may
become as large as a hen's egg, and a group may reach the size of a
cocoa-nut. The enlarged glands are oval in shape, and movable in the
earlier stages of the disease.
Later, adjacent glands become firmly adherent either by the direct
extension of the adenoid growth from one gland to another, or by
adhesive inflammation of the capsules of the glands and the surrounding
tissues.
The enlarged glands may be either soft in consistence or firm. The
consistence does not depend upon their size, as both large and small
glands may be either soft or hard. On section the colour is a gi-ayish
white, with red spots at the points where dilated vessels have been severed
by the knife, or where hfemorrhages have taken place. In some cases
where the glands are firm a considerable quantity of fibrous tissue can be
seen on section. Sometimes a gland is found to be caseous, but this is
exceptional. When the cut surface of a soft gland is scraped, a juice is
5S2 SYSTEM OF MEDICINE
obtained which contains lymphocytes, larger cells which are often
miiltinuclear, red corpuscles, and spindle-shaped cells from the walls of
the vessels. The firm fibrous glands, when scraped, yield little or no
juice.
In the neck the glands which lie above the clavicle are most frequently
afrected, and may reach a large size. The glanrls along the sterno-mastoid
muscle, the submaxillary and the sul)occipital glands may be affected.
Chains of enlarged glands may also connect this group with the axillary
or with the intrathoracic group of glands. Various secondary effects
may be produced by enlargement of the cervical glands ; the larynx may
be pushed to one side, the trachea may be narrowed, the internal jugular
vein may be compressed and thrombosed, or the recurrent laryngeal
nerve may be involved. The glands in the axilla are frequently affected,
and may reach a large size. They are generally eidarged on both sides
of the body, but to a greater extent on one side than the other.
In the thorax the anterior mediastinal glands are often found enlarged,
and may form a mass extending the whole length of the pericardium. In
some cases the growth extends into the region of the thymus or into the
pericardium. Both the heart and the left lung may l^e pushed out of place
by the enlarged glands. The bronchial glands often form large masses
which may compress the bronchi to a considerable extent, and the growth
may extend into the lung itself. When the glands of the posterior media-
stinum are affected they rarely cause any compression of the aorta, oeso-
phagus, or thoracic duct ; though in some cases the wall of the oesophagus
or even the vertebrae may be invoh'ed by the growth of the glands.
In the a1)domen the glands most frequently affected are those which lie
behind the peritoneum along the spine. The pelvic glands may also be
enlarged and compress one of the ureters. GoAvers mentions one case,
recorded by Bonfils, in which the lumbar and pelvic glands together
weighed eight pounds. The mesenteric glands are seldom affected, and
when diseased thev do not reach anv great size. The inguinal glands
arc enlarged in about 50 per cent of the cases, and often form lai-ge
masses in the groin, compressing both vessels and nerves in that
region.
Mirrnarnpirql appearance of enlarged glands. — In the early stages of
the glandular enlargement, when the glands have not inci-eased much in
size and are soft in consistence, the various parts, as seen in the normal
gland, are easily made out. The cortex, medulla, follicles, and septa
maintain their normal relationships ; but the lymphocj'tes, which lie in
the meshes of the reticulum of the gland, are greatly increased in
numbers. In some specimens, which are probably examples of a more
advanced stage of the process, the cells are seen to have penetrated the
septa and caused their division. A section of such a gland shows a
uniform structure con.sisting of a fine network of filirils, the spaces of
which are filled with leucocytes, which can be washed out, leaving the
stroma with a few nuclei behind. The network, Avhich Schultz thinks
is formed by the splitting-up of the septa by the multiplication of the
HODGKLVS DISEASE 583
cells wliieh penetrate them, is irregular in form, and the spaces may-
contain single lymphoid cells, or groups of six or more cells closely
packed together. The cells present the same appearance as ordinary
lymphocytes. Sometimes multinuclear cells are seen as a result of
nuclear multiplication without cell division.
In the firmer s;lands there is an increase in the fibrous tissue stroma
as well as multiplication of the cells. The septa which run between the
follicles are thickened, as are also the fibres of the medullary network.
In some the process of fibrosis continues till the gland becomes hard
and firm in consistence. The cells are then present in much smaller
numbers, there is a laige excess of fibrous tissue in the stroma, and the
capside is thickened. Finally only a mass of fibrous tissue may remain
in the place of the adenoid tissue of the gland (G-. Sharp).
Spleen. — In a large majority of the cases the spleen is diseased.
In 100 cases in which the condition of the spleen was noted, it
was found affected in 78. In the other 22 no chano-e was described.
This organ is thus more or less changed in four-fifths of the cases.
The enlargement, as a rule, is only slight or moderate in degree ;
in a few rare cases it has reached a large size. The weight, however, is
seldom more than thirty ounces. The enlargement may be a simple
hypertrophy, or it may Ije due to the presence of lymphomata
of various sizes in the substance of the spleen. In 78 cases in
which the spleen was affected, these growths were found in 57 ;
in the remaining 21 it was only described as being enlarged. When
there is simple increase in size of the spleen it is generally firm in
consistence ; it may be hard, but it is rarely soft. The Malpighian
corpuscles are often easily seen, being rather larger than in a normal
spleen. AYhen the lymphoid growths which originate in the ]\Ialpighian
bodies are present, they do not, as a rule, cause any great enlargement of
the spleen. They vary in size and may be no larger than peas, or as big
as crab-apples. The appearance of the growths is peculiar, and they have
been compared to masses of suet or cold fat. In one case, in which I
made the post-mortem examination, the cut surface of the spleen which
contained these growths resembled a piece of brawn in appearance. The
masses are often irregular in shape, and may even bulge out the capsule
of the overlying spleen. Infarctions also are often seen in the spleen :
their appearance varies with their age ; if seen early, they are red, and
are surrounded by an area of congested splenic tissue. Later they
become pale red, and ultimately cream-coloured. Chronic inflammation
of the capsule of the spleen is not uncommon, and leads to the formation
of adhesions to surrounding organs and thickening of the capsule itself.
When the spleen is examined microscopically the fibrous trabeculae are
found increased in size owing to an increase in the amount of their fibrous
element. The lymphoid growths Avhich are developed in the Malpighian
corpuscles resemble the enlarged lymphatic glands in structure. As in
them there is a reticulum, in the meshes of which lie small round cells.
New fibrous tissue is developed in which the connective-tissue eorpuscles
5S4 SYSTEM OF MEDICINE
are seen ; the amount of fibrous tissue may increase till the i\Ialpiii;liian
bodies consist almost entirely of it. In this stage the lymphoid cells are
few in number. liound the edges of the !Mal})ighian bodies may be seen
masses of brown pigment ; this pigment is derived from degenerated
and broken-up red blood corpuscles which were included in the growth of
the fibrous tissue. When the nodules of new growth ai-c large, they
compress the surrounding splenic pulp ; it is then frequently atrophietl,
and contains cells which have undergone fatty degeneration and granules
of pigment. In scmie cases there is hyperplasia of the splenic pulp.
Lardaceous degeneration of the spleen has rarely l)een observed.
The medulla of bones is sometimes altered, but in other cases it
is normal. Changes in the medulla may or may not be associated
with leucha}mia during life. By microscopical examination it has been
determined that the altered condition of the marrow is due to a growth
of adenoid tissue in the i)lace of the normal bone marrow.
Alimentary canal. — Along the whole length of the normal alimentary
canal are scattered numerous patches of adenoid tissue. In almost any
of these centres a development of lymjihadenoid tissue may tal<e place in
Hodgkin's disease ; and, once started, it may extend considerably beyond
the original patch. The follicles at the back of the tongue may be
enlarged, and the adenoid tissue of which the tonsils jirincipally consist
may become consideraljly increased in amount, leading to enlargement
of the tonsils, sometimes followed by ulceration.
Adenoid gi'owths have been found in the mucous membrane of the
pharynx and of the (rsophagus. In the stomach there may be extensive
overgrowth of the adenoid tissue and general thickening of the mucous
membrane in consequence. Ulceration of this thickened mucous membrane
may occur at several different points. In the intestines the special aggre-
gations of adenoid tissue, which occur in the solitary glands and in the
Peyer's patches, may become considerably enlarged from overgrowth
of adenoid tissue. This change is most marked in tlie lower part of the
ileum, but it may extend beyond the ileo-ca'cal valve into the ascending
colon. The adenoid growth may extend considerably in the mucous coat
of the intestine without involving the muscular coat. The intestinal wall
may be much thickened, but the lumen of the bowel is not diminished.
Lirer. — In a considerable number of cases changes are found in the
liver Avhich may or may not be sufficient to cause an actual increase in
the size of the organ. ]\Iost frequently lymphoid growths are found
scattered throughout the liver ; these are generally small, varying in
size from a pin's head to a cherry-stone, and pink or gray in colour ; in
some cases the growths may reach the size of a cherry, but these are
fewer in mimljer. In appearance they resemble the nodules which have
been already (lescril)ed in the spleen. On mici'oscopical examination the
miiuite adenoid growths are found, as elsewhere, to consist of lymphatic
tissue. They lie in the interlobular spaces, but may also extend into the
lobules ; when a growth extends into the hepatic lobules it develops
between the liver-cells, and causes atrophy of the latter by pressure.
HODGKIN'S DISEASE 585
Prof. Burdon Sanderson considers that the growth may sometimes originate
in the tissue of the acinus itself. In some cases there is a general diffuse
growth of nucleated tissue in the interlobular spaces, from which extensions
may also take place into the tissue of the acini. Occasionally the enlarge-
ment of the liver is partly- due to congestion of the capillaries. Effusion
into the peritoneal cavity is not uncommon as a result of portal obstruction
by l}-mphoid giowths ; in some cases the peritoneum is studded with
small growths.
Bespiratorij sijstem. — In the lungs, growths of adenoid tissue are found
which may occur either as the result of direct extension of growth from
bronchial glands already affected into the lung itself, or as separate ceni"res
of growth scattered throughout both lungs. The scattered growths which
generally originate in the peribronchial lymphatic tissue are small in
size, and resemble tubercles in appearance. They have the same structure
as the growths in other organs, and seldom soften or break down. Effu-
sions into the pleural cavity are found in some cases, and may contain
blood. Adenoid growths are rarely found beneath the pleura.
Heart. — The heart is often small, and fatty degeneration of the
muscular wall is not uncommon. Occasionally adenoid growths have
been found in the substance of the heart or on its surface.
Genito-urinary system. — Lymphomata, similar in structure to those
which are found in other abdominal viscera, occur also in the kidney.
These are usually small in size, and rarely grow larger than a
cherry. The growths generally develop between the tubules in the
cortex of the kidney, and as they enlarge they may, by pressure, cause
atrophy of the epithelium lining the tubules. The kidney may be
enlarged as a whole ; it is, as a rule, pale in colour, and sometimes it is
the scat of fatty or lardaceous degeneration. The testicles, like other
glands, may contain lymphoid growths, which lead to atrophy of the
epithelium by compression. The ovai-ies are rarely affected.
Ductless secretory glands. — The thymus may be enlarged, or it may
contain adenoid growths, which may extend to the surrounding parts.
More frequently the anterior mediastinal glands are primarily affected,
and the thymus by extension of the growths from them.
The suprarenal capsules were affected in one case recorded by Gowers.
The thyroid gland may also be involved (Stengel).
Nervous system. — Lymphadenomatous growths occasionally occur in
the dura mater, but rarely in the brain or any other part of the nervous
system.
Skin. — In rare cases adenoid growths have been found in the skin.
Pathogeny. — "We have as yet very little definite knowledge of the
pathogeny of Hodgkin's disease. Experimental research, which of late
has thrown so much light tipon the nature of many obscure morbid
processes, has not as yet succeeded in elucidating this complex problem.
The study of the morbid anatomy of the disease has given us much
information as to the nature and distribution of the lymphadenoid
growths which form so prominent a feature in it ; but as yet we pos-
586 SYSTEM OF MEDICINE
sess no explanation of the alinormal development of the lymphatic
glands and adenoid tissues generally in the body. An examination of the
comparative anatomy of lymphatic glands shows that true lymphatic
glands are found only in the higher vertebrata. In fishes, reptiles, and
amphibians there are no lymphatic glands. In birds and in mammals
true lymphatic glands are fniuid. Gulhind has shown that leucocytes
ai)pear in the adenoid tissue of the th3-mus gland of mammalian embryos
some time before the lymjihatic glands are developed. In man Ave find
that the lymphatic glands arc more highly developed than in an}'' of the
lower animals.
Adenoid tissue, which is the principal seat of the morbid changes in
Hodgkin's disease, is widely distributed in the tissues of man. It is a
specialised form of connective tissue, the fibres of which form a fine net-
work and receive an altundant blood-supply. The special characters of
adenoid tissue are found most clearly marked in certain parts of lymphatic
glands known as " germ-centres " ; in these germ centres the connective-
tissue fibres form a very fine network, supporting the numerous cainllaries
which enter it. At the i)eriphery of each germ-centre the fibres lie chisc
together and form a kind of capsule containing only minute openings.
Leucocytes escape from the capillaries in the germ-centres into the
reticulum, in which they are for a time arrested. Hei-e they undergo
division, and the young cells thus formed gradually find their Avay to the
edge of the germ-centre, from which they ultimately escape and pass
through the lymphatic gland into the general lymph-stream. The same
process appears to go on in all adenoid tissue, though less actively than
in the special germ-centres. Thus an important function of adenoid tissue
generally, and especially of lymphatic glands, is to enal)le the leucocytes
to multijjly according to the demands of the part in which the adenoid
tissue is situated.
In speaking of lymphatic " glands " it must be remembered that we
are dealing with organs Avhich diti'er Avidely, both in structure and in
function, from many other organs in the body which are also called
glands. The term " gland " includes all the secretory glands Avhose
function may be either to supply an external secretion, as ii^ the case of
the salivary glands, or to produce both an external and an internal
secretion as is done by the pancreas, or to form an internal secretion only
like that of the thyroid gland, ^\'e ha\e no evidence at present that
lymphatic glands form any special secretion, nor from their structure
siiotdd we expect them to be capable of forming any true secretion. It
is important to l>ear this in mind ; for in dealing with diseases of secretory
glands we have to take into account the effect of the disease in decreasing,
increasing, or altering the secretion of the gland, and the consequent effects
of these changes upon the body as a whole.
We have seen that adenoid tissue generally is the scat of nndtiplica-
tion of the leucocytes ; and when Ave remember the very important part
which leucocytes play in the blood and elsewhere Ave should expect that
such Avidespread disease of adenoid tissue as Ave encounter in Hodgkin's
HODGKIN'S DISEASE 587
disease would modify, more or less, the production and condition of the
leucocytes. An increase in the size of the lymphatic glands does not,
however, necessarily bring about an increase in the number of the leuco-
cytes in the blood ; and it is in some cases only that an increased formation
of leucocytes takes place in the lymphatic glands. As we do not as yet
know the immediate cause of Hodgkin's disease, we can but surmise what its
probable nature may be. It would seem to be due to the presence of some
agent capable of exciting the growth of the adenoid tissues, and the conse-
quent enlargement of the lymphatic glands. When we examine the known
causes of enlargement of the lymphatic glands we find them to be of more
than one kind. Enlargement of lymphatic glands may be a normal
physiological process ; thus in the axilla Stiles has found that during
lactation very minute lymphatic glands become increased in size, and at
the end of lactation undergo involution ; so that evidently in the require-
ments of the mammary gland during lactation Ave find a cause of lymphatic
activity. Many morbid j^rocasses, such as infective inflammations of
various kinds, are accompanied by enlargement of the lymphatic glands
connected Avith the part affected. There may be actual infection of the
glands themselves, as in cancer or tuberculosis, leading to their enlarge-
ment ; in the latter case Ave find the immediate cause in the tubercle
bacillus. In the case of tuberculosis the lymphatic glands often foi-m a
line of defence in which phagocytes containing tubercle bacilli are arrested ;
these bacilli may then be either destroyed or, if they continue to live,
their advance toAvards more important organs is arrested for a time.
When Ave consider the many points of analogy betAveen Hodgkin's disease
and tuberculosis, and the other infective processes, it seems very probable
that Hodgkin's disease is also due to infection. The clinical features of
the disease, and especially the acute course of it, the hiemorrhages, the
ansemia, and the presence of fever in some cases tend to si;pport this
probability. The changes Avliich Ave find in the adenoid tissues and
1} mphatic glands are most easily explained by assuming that they are
the result of the action of some pathogenetic parasite. EAadence of direct
infection in Hodgkin's disease is almost entirely Avanting ; but one case,
Avhich was under the care of ObratzoAA', is of importance in this respect.
An assistant, who helped to plug the nose and also to examine the urine
and fseces of a patient Avho Avas suffering from acute Hodgkin's disease,
soon afterAA'ards AA'as attacked by the same disease, and died a month after
the time of the alleged infection.
Another fact which supports the infectiA^e nature of Hodgkin's disease
is the occurrence of the same disease in the loAver animals : the lymph-
adenoma of cattle, dogs, and horses appears to be identical Avith that of
man. In this respect again it resembles tuberculosis. In horses especially
the disease presents many of the same symptoms as in man, for in equine
lymphadenoma there is enlargement of the lymphatic glands, and in some
cases adenoid groAvths in the spleen, liver, kidneys, and lungs. Emacia-
tion, anaemia, and leuchaemia may also occur.
If the disease be due to infection Ave haA^e as j'ct no knoAvledfce
588 SYSTEM OF MEDIC THE
of the organism -which is the immediate cause of it. AVc do not
even know whether it is an animal ])arasite, like the plasmodium
of malarial fever, or a vegetable parasite like the tidiercle bacillus.
As Dr. Dreschfeld points out, there is a strong analogy between the
diftereiit varieties of chronic and acute Hodgkin's disease and the
various forms of tuberculosis. Thouiih Dreschfeld found small bacilli in
the kidney of one case, these were not present in specimens examined
from other cases ; and he was unal)le to obtain any growth of micro-
organisms from pieces of the diseased glands placed in various culture
media. The experiments of Dell)et tend to show that the disease is due
to a certain baciUus, but they require further extension and confirmation.
This observer found a bacillus in the blood of the spleen of a woman
who was sutrering from Hodgkin's disease {lymplHulenome gdndraUsd), in
which the spleen was also ati'ected. He obtained pure cultivations of
this micro-organism, with which he made experimental inoculations in a
dog. Large doses of a pure culture of the bacillus were employed, and
the inoculations were repeated several times at various intervals. This
method of experiment was adopted by Dclbet, as he considered the
bacillus to be one of feeble virulence, and unable to nudtipl}^ in the
tissues of a healthy animal unless reinforced by repeated doses of the
culture. The animal emaciated rapidly, and in fifteen days it lost
more than one-fifth of its weight. When the dog Avas killed, a month
after the commencement of the inoculations, the lymphatic glands in the
mesentery and in the mesocolon, the thoracic and vertebral glands, as
well as those in both axillae and in the right groin, were found enlarged.
On examining the enlarged glands Delbet was able to show that they
contained the same bacillus which he had inoculated as a pure culture.
On the strength of this experiment he claims to have ])X'oduced a
generalised lymphadenoma by inoculations of this bacillus. Other
ol)3ervers have foiind micrococci, and no bacilli, in the enlarged glands.
Thus it is evident that the whole matter requires far more extensive
experimental investigation before any satisfactory explanation of the
pathology of this disease can be given.
Ordinary course. Duration, and Termination. — The onset of the
disease varies considerably in different cases. In some there is at first
only a localised swelling of one group of glands, and this condition
may persist even for several years without further extension. A
primary local disease may be followed at a variable interval by a
general enlargement of the glands, or there may be a general enlarge-
ment of most of the lym])hatic glands in the beginning. Generalisation
of the disease is accompanied, or soon followed, by progressive ana'mia ;
the anaemia may appear, however, before the glands are appreciably
affected. In acute cases the onset may be marked by shivering, pains
in the back and limbs, cough and expectoration, and rapid loss of
strength.
In acute cases the patient rapidly becomes worse. In chronic cases
the disease may remain stationary for considerable periods. The dura-
HODGKIN'S DISEASE 589
tion of the disease varies from five or six weeks, in very acute cases, to
several years in the chronic forms of the disease.
Sir W. Gowers (10) gives the following talile, drawn up from fifty
fatal cases, in which the duration of the disease had been ascertained : —
Less than 1 year in IS cases.
Between 1 and 2 years in 15 cases.
2 3 6
>, 3 ,, 4 ,, 6 ,,
Over 5 years , . 1 case.
Sex appears to have little or no influence upon the duration of the
disease. Before middle life the duration does not vary at different ages ;
it is shorter, however, in the second than in the first half of life.
Recovery may take place under treatment. This is more likely to
occur in chronic than in acute cases, though marked improvement or
arrest may occur even in the latter.
Sooner or later, in most cases, the ansemia becomes more intense, the
patient loses strength, and dies from exhaustion. In some cases the
immediate cause of death has been asphyxia from the pressure of enlarged
glands upon the trachea or bronchi. Death has also taken place from
starvation owing to pressure upon the oesophagus. In a few cases coma
and convulsions have occurred at the end. Loss of blood and diarrhoea
may also take part in bringing about a fatal termination. Death may
also l)e the result of some such complication as pneumonia, asdema of
the lungs, or pleural effusion.
Diagnosis. — The enlargement of the lymphatic glands which takes
place in Hodgkin's disease has to be distinguished from other kinds of
enlargement. In advanced cases the number of glands involved and
the general cachexia render the diagnosis easy. In the early stages of
the disease, when only a few glands may be affected and the severe
constitutional symptoms not fully manifested, the enlargement has
to be distinguished from those of acute adenitis, tulierculous lymph-
adenitis, sarcoma, and carcinoma. The disease, as a whole, has also to
be distinguished from splenic leucha^mia, and from those mixed
cases in which the symptoms of that disease appear in combination
with those of Hodgkin's disease. In very acute cases the symptoms
may resemble those of the known infections, especially when the abdo-
minal glands are principally affected ; in these cases we may have to
distinguish between acute Hodgkin's disease and typhoid lever, tuberculous
peritonitis, or septicaemia ; or again, the symptoms of Hodgkin's disease
may suggest purpura or pernicious anremia.
In acute inflammation of the Ij'mphatic glands — acute adenitis — the
enlargement takes place rapidly, and the glands are painful and tender.
The surrounding tissues are also frequently inflamed at the same time.
A few glands only are affected, and, as a rule, they are directly con-
nected with some part in which inflammation, suppuration, or a breach
of surface open to microbes is already known. In Hodgkin's disease
590 SYSTEM OF MEDICINE
the cnlarL,a'mont is puiuless ; it is unaccoiiii)anicd by inflammation, and
it freiiucntly affects a large number of glands, not necessarily in con-
tiguity.
Tuberculous disease of the h'mi)hatic glands is generally limited to one
or more groups. It frequently begins in glands which, like the cervical
glands, are connected with some surface through which the tubercle
bacillus may enter. Thus, if the enlargement of the lymphatic glands
be general, it is almost certainly not tuberculous. Again, in the several
groups of glands we find that in tuberculous disease there is often peri-
adenitis, which leads to matting of the glands ; whereas, in Hodgkin's
disease, as the surrounding tissues are not inflamed, the glands remain
freely movable. In tuberculous disease the glands soon begin to caseate
or suppurate, the skin is implicated, it gives way, and the abscess dis-
charges through the opening ; in Hodgkin's disease the glands neither
caseate nor suppurate, nor is the skin inflamed about them. Lymph-
adenomatous glands, as a rule, reach a larger size than tuberculous glands,
probably because degenerative changes generally occur early in the latter.
AVe may note also a characteristic cachexia commonly known as
" scrofulous." Not infrequently, however, when the enlargement is
confined to a few glands a diagnosis cannot be made until some further
manifestation of the true nature of the enlargement appears.
In the early stages of Hodgkin's disease, when the enlargement of
lymphatic glands is confined to a small area, there may be a difliculty in
distinguishing it from sarcoma of the glands. In sarcoma, however, there
is a slow extension of the growth to neighbouring glands and into the
surrounding tissues, Avhereas, in Hodgkin's disease, fvu'ther extensions
will probably arise in a difterent part of the body. So generalised an
enlargement would not be sarcoma. In saicoma, again, the presence of
secondary or primary growth elsewhere may help to clear vip the
diagnosis.
By some writers the name lymphosarcoma has been used as another
name for Hodgkin's disease; by others this name has been given to a special
form of sarcoma of the lymphatic glands. This confusion should be guarded
against. Sharp, who distinguishes between lymphosarcoma and lymph-
adenoma, considers that each starts from a lymphoma. If, as the tumour
grows, it is found to contain very large numbers of round cells, and but
little fibrous tissue, he considers it to be a lymphosarcoma. If, on the
other hand, the fibrous tissue is abundant, and the cells not numerous,
it is a lymphadenoma. J. L. Steven also di'aws a sharp distinction
between primary lymphosarcoma in the mediastinum and the genera]
affection of the lymphatic glands which we call Hodgkin's disease.
Secondary carcinoma of the lym})hatic glands is not likely to be con
founded with that due to Hodgkin's disease, as the presence ot thi
primary growth indicates the tiue character of the glandular swelling also.
In some cases, when the nature of the enlargement of the lymphatic
glands is doubtful, the administration of arsenic may aid the diagnosis.
Any marked diminution in the size of the glands under the influence of
HODGKIN'S DISEASE 591
this drug would indicate Hodgkin's disease rather than sarcoma or
carcinoma.
Leuch?emia is, strictly speaking, only a symptom and not a dis-
ease. As a symptom Ave have seen that it occurs in some cases of
Hodgkin's disease. This name has, however, been given to some forms
of disease in which an excess of white corpuscles in the blood is a pro-
minent symptom. Thus there are several kinds of leuclisemia, and a
distinction must be drawn between these and Hodgkin's disease.
Splenic or spleno-medullary leuchiemia is distinguished from Hodgkin's
disease l)y the absence of any early enlargement of the lymphatic
glands, by the great enlargement of the spleen, and by the presence
in the blood of myelocytes or large Avhite corpuscles with a single
nucleus. These corpuscles may measiu'e nearly 16 /* in diameter; they
occur in large numbers in the blood. Muir has found that in this form
of leuchfemia they may form more than 50 per cent of the white
corpuscles present in the blood.
In some cases of splenic leuchaemia an enlargement of the lymphatic
glands takes place as a late event. The enlargement is then secondary
to that of the spleen and to the leuchaemia, and thus differs from the
primary glandular enlargement of Hodgkin's disease.
In another disease, " spleno-lymphatic " leucha^mia, to which Gowers
draws special attention, there is a simultaneous enlargement of the
lymphatic glands and of the spleen accompanied by leuchaemia. In these
cases we seem to have the two diseases, splenic leuchsemia and Hodgkin's
disease, combined. With the exception of the concurrent increase of the
spleen such cases are closely allied to those of Hodgkin's disease, in
which leuclisemia is found ; and Avliich, by some writers, have been de-
scribed as cases of " lymphatic " leuchiBniia.
Sijphilis. — Enlargement of the lymphatic glands, most directly con-
nected with the primary seat of infection, is a constant primary symptom
of syphilis. In the male the usual primary enlargement of the glands in
the groin is not likely to be mistaken for Hodgkin's disease, as in all
such cases a careful inspection of the genital organs would natin^ally be
the first stej) in the examination of the case, and the discovery of a sore
with an indurated base Avould at once explain the condition of the
lymphatic glands. In the female and in cases of primary syphilitic
infection of other parts of the body the true cause of the enlargement
might be overlooked, so that it is important in any doubtful case to
remember the chief characteristics of this form of enlargement. In con-
sidering the possibility of syphilis as a cause of any glandular swelling,
careful inquiry and search must be made for the 23resence of the original
indurated sor'e, which develops about twenty-four days after infection
has taken ]ilace, and is followed by the enlargement of the nearest
lymphatic gland in seven to fourteen days. One gland is usually enlarged
first, the other members of the same group becoming affected soon after-
wards. The glands are hard in consistence, and seldom exceed a marble
in size.
592 SYSTEM OF MEDICINE
The inguinal glands on each side are hy far the most commonly
affected groups, but the axillary antl cervical glands are involved in cases
of primary infection of the upper limb or face. The enlargement rarely
extends beyond the nearest group of glands, and even if untreated tends
in time to subside. In Ho<lgkin's disease the glands soon reach a larger
size, and are softer in consistence, while the disease tends to spread to
other groups of glands. Some enlargement of the lymphatic glands
may occur in the later stages of syphilis, but its nature Avould be
explained by the i)resence of some secondary or tertiary manifestations of
the disease in the neighbouihood of the enlarged glands.
Li/iiiphoma. — A simple enlargement of a single lymphatic gland or of
several glands of the same group is usually regarded as a local growth
only, and as such is called a simple lymphoma or lymphadenoma. As
Hodgkin's disease may also start as a similar local enbirgement presenting
the same characters, Ave arc unable to separate the two in the early
stages. It is not till later, when no extension of the disease occurs, and
constitutional symptoms remain absent, that a distinction can be made.
It is quite possible that the difference between the two lies in the clinical
course rather tha;i in the nature of the disease, lymphoma being a localised
form of Hodgkin's disease, the further extension of which is prevented by
the natural resistance of the tissues.
Projnosis. — In cases of acute Hodgkin's disease the prognosis is very
unfavourable] t!ie patient rapidly loses strength and dies of exhaustion.
Pulmonary complications frequently occur in these cases, so that pneu-
monia, pleurisy, or phthisis may be the actual cause of death. But acute
cases are not always fatal. Dr. Dreschfeld has recorded that in one
acute case Avith cough, fever, intense anpemia, rapid enlargement of the
lymphatic glands causing obstruction of the right bronchus, enlargement
of the s^jleen, leucocytosis and rapid loss of Aveight, the lymphatic glands
decreased, under treatment by arsenic, nearly to their normal size : the
spleen fell to its usiial size, the temperature became normal, the blood
improved, and the patient became convalescent. If the glands be enlarged
in several regions, and reach a large size, the prognosis is grave. The
actual progress of the disease is not uniform. If the patient's health
has been good up to the time of the beginning of the disease, its adA'ances
appear to 1)C less rapid than in patients in whom the onset Avas preceded
by some ill-health. Thus in cases in Avhich the symptoms have first
appeared after pregnancy, or after a loss of blood, the doAVnward progress
has generally been more rapid than in cases in Avhich the health had
previously l)ecn good. A marked decrease in the number of red
corpuscles in the blood, and a distinct increase in the number of the
AA'hite, severally indicate that the case is a serious one. So long as the
enlarged glands remain soft there is a better prospect of recovery.
Hardness of the glands indicates fibrosi.s. Fever, especially if it be con-
tinuous, is an indication that the disease is acute. CRlema is a graA'c
symptom ; it generally indicates that death is not far distiint.
Treatment. — In the treatment of Hodgkin's disease Ave have tAvo
HO DG KIN'S DISEASE 593
main oujects in view. In the first place, "we must endeavour to combat
the disease by treatment of the structures which have already become
affected, so as to prevent its spreading to other parts of the bod}^ ; in
the second place, we have to increase the resisting power of the patient as
far as possil)le. We have seen that in some cases the disease is local at
first, tending to become general at a later stage. In this respect it
reseml)le3 tul^erculous disease of the lymphatic glands, in which we have
abundant evidence that early local treatment is frequently successful
both in curing the local disease and in averting general tuberculosis. As
it is probable that Hodgkin's disease is likewise due to the presence of
some infective agent, the strictly localised forms of the disease in super-
ficial glands appear to be suitable for surgical treatment. The special in-
dications for removal of the glands will be considered presentl}'.
General hygienic treatment. — It is important that those who suffer
from Hodgkin's disease should lead cpiiet, regular lives and avoid all
bodily fatigue. The diet should be light, nourishing, and easily digested.
It is doubtful whether climate has much infiuence upoii the course of the
malady, but bathing in mineral waters, as at Kreuznach or Woodhall
Spa, has seemed beneficial in some cases.
Loral treatment. — In certain cases of Hodgkiii's disease there can be
no doubt that removal of the diseased glands is the right method of
treatment to adopt. The clinical course of some cases appears to in-
dicate clearlv that the disease in the first instance is local, and confined
to a few lymphatic glands ; moreover, that the further spread of the dis-
ease takes place from the part first aftected, by a process which we may
provisionally call secondary infection. In such cases the early removal
of the enlarged glands may arrest the disease. One of our chief
difficulties is to select the most suitable cases for such treatment. If the
disease be general from the first, or if it has spread to deep lymphatic
glands which cannot be removed, radical surgical treatment is no longer
possible. By some physicians, however, removal of as many of the diseased
glands as possible has been recommended even in cases in which several
distinct groups are affected ; not so much with the object of eradicating
the disease, as of diminishing the number of the diseased glands in the
hope that medicinal treatment may thereby be better able to deal Avith
the remnant. In such cases, however, operative treatment has proved
unsatisfactory, and when several groups of glands are affected, it is
very doubtfvil whether partial removal is advisable. Evidence is still
wanting to show that medicinal treatment is rendered more efficient by
removal of some only of the enlarged glands.
Operative treatment to give relief from urgent symptoms due to
pressure will be considered presently.
The most suitable cases for radical operation are those in which the
enlargement is confined to one group of glands, in which the spleen is
not enlarged, and in which there is neither fever nor wjll-marked anaemia.
The presence of a few enlarged glands in other situations, or a slight
enlargement of the spleen, need not preclude operation if other
VOL. IV 2 Q
594 SVST£A/ OF MEDICINE
conditions seem favoural)le ; Init the results are not likely to be so good.
It is important to take the temperature night and morning for a few
days before deciding upon an operation, that the a])sence of fever may be
definitely ascertained. Gowers considers that when the numl)er of the
red corpuscles is below GO per cent, removal of the glands should not be
attempted. A marked excess of white corpuscles in the blood is also
unfavourable to operation.
The success which may attend the removal of the diseased glands in
suitable cases is well illustrated by three cases, mentioned by Gowers, in
which the operation was performed by the late M. Verneuil. In one
case a large glandular tumour, which compressed the trachea, was
removed from the neck ; seven years afterwards the patient remained in
good health. In another case the glands in the axilla had been enlarged
for two years, and had reached the size of a child's head when they were
removed. Subsequently another enlarged gland Avas removed from the
neck, and one or two glands afterwards became enlarged and suppurated.
The operative treatment Avas supi)lemented by the administration of
arsenic, and the patient remained free from the disease up to the time of
his death, from acute pneumonia, six years after the first operation. In
a third case the removal of the enlarged glands stayed the progress of
the disease for some years, though it finally became generalised and ended
fatally.
As already mentioned, there are certain circimistances under which an
operation becomes necessaiy in order to relieve urgent symptoms. Thus,
if the trachea, or an important nerve or blood-vessel, be compressed by an
enlarged gland which can be removed, this should be done ; although
the operation may not be likely to check the general progress of the
disease.
The difficulty of the actual operation for removal of the glands varies
very much. In some cases the enlarged glands are easily separated from
the surrounding structures ; in others the deeper parts of the glandular
mass may be adherent and the removal by no means easy.
Many other means of local treatment have been advocated and
carried out in practice. None of them, however, has proved so effectual
as extirpation ; so that, when possible, removal is the most efficient
method. Various solutions have Itecn injected into the substance of the
glands. Thus, among other drugs, arsenic, iodine, potassium iodide,
silver nitrate, carbolic acid, and chromic acid have been employed. Such
injections are often painful, and may lead to inflammation and suppuration
of the diseased glands; very little benefit has been obtained by such
methods, and the inflammation excited may prove troublesome. Galvano-
puncture has likewise proved to be of little service in reducing the size
of the glands. Various simple methods of local treatment have also
been employed, such as massage, alternate hot and cold douching, and
the application of ice. Such means of treatment are less harmful, liut
they lead to little diminution in the size of the glands. The application
of blisters to the skin, over the enlarged glands, has in some cases been
HO DG KIN'S DISEASE 595
followed by a reduction in size. The application of iodine to the skin
over the enlarged glands is of little or no use.
Medicinal treatment. — Of all the dru«;s which have been used in the
treatment of Ilodgkin's disease, arsenic has most frequently proved to be
of service. I have seen marked improvement follow the administration
of arsenic, and cases have been recorded in which the glandular swellings
have disappeared, and the patient has recovered under its influence. Not
only may arsenic do good in chronic cases, but even in acute cases very
good results may follow its use. This is well illustrated by a case
recorded by Dreschfeld : in this case there were at first marked ansemia,
fever, and a slight cough. After a few days the cervical and left axillary
glands become enlarged, and soon afterwards signs of obstruction of the
left bronchus appeared. The spleen became enlarged, the number of
leucocytes in the blood increased to a marked extent, and eosinophile
cells were also found. In a fortnight the patient lost 10 lbs. in Aveight.
Under treatment by arsenic rapid improvement took place ; the tem-
perature became normal, the superficial glands "almost completely sub-
sided," the spleen diminished in size, the condition of the blood improved,
the patient gained 14 lbs. in weight in a month, and was convales-
cent at the time the account Avas Avritten. A very similar case under
Dr. Allbutt's care recovered quickly under arsenic. Arsenic may most
conveniently be given in solution; the dose being increased gradually.
It is a good plan to begin with five minims of liquor arsenicalis three
times a day, and this dose may by degrees be increased up to fifteen or
twenty minims three times a day, provided that the jiatient exhiljits no
toxic symptoms. It should be given in milk with or just after food. If
symptoms of intolerance arise, the arsenic should be discontinued for a few
days. In some cases the I'owler's solution has been injected directly into
the enlarged glands, but the injections may cause pain, and even inflam-
mation and suppuration ; and the results have not been so good as Avhen
given by the mouth. Reclus has recorded one case in which the cervical
glands on each side of the neck were aff'ected ; arsenical solution was
both given by the mouth and injected into the glands, and these diminished
in size until only some small nodules remained. In two other cases this
treatment proved successful, but in three others the result was unfavour-
able. Valuable as arsenic proves in the treatment of some cases of
Ilodgkin's disease, there are others in which little or no benefit appears
to come from its use. The mode of action of arsenic in this disease is
not known. It may have a germicidal action, comparable with that of
mercury in syphilis and quinine in ague, or it may be an antidote to some
chemical poison.
Iodine has been frequently used both as tincture of iodine and as
potassium iodide. There is, however, but little evidence to show that
it has had any useful influence upon the progress of the disease. In some
cases the depressing effect of potassium iodide may be distinctly harmful.
Phosphorus has been used Avith good eflfects in a fcAV cases, but it is
certainly less useful than arsenic. One patient under the observation of
596 SYSTEM OF MEDICINE
Professor Alll)iitt recovered from a grave and apparently extreme attack
of the disease while taking tungstate of soda, but this drug jjroved useless
in all cases subsequently under his care. Mercurial iiumctiou was found
beneficial in one case by Dreschfeld, Ijut it nuist l)e used with caution so
as to avoid any symptoms of mercurialism. Iron, cod-liver oil, and quinine
have been used as general tonics. Organic extracts prepared from various
glandular and other tissues have of late been extensively used in the treat-
ment of disease; but in the present state of our knowledge of the pathology
of Hodgkin's disease, it is difficult to conceive that any organic extract
can be of special service in the treatment of this malady. We have
seen that the lymphatic glands, spleen, thymus gland, and bone-marrow
are all liable to be affected in certain cases of Hodgkin's disease. For
this reason both spleen and lymphatic gland and thymus extract, as well
as bone-marrow, are lacing tried, but as yet with no very decisive result.
Bone -marrow has been shown bv Professor Fraser to l)e of threat
service in the treatment of pernicious amemia in which arsenic has also
proved useful, and so is worthy of trial. To an adult one ounce of fresh
ox bone-marrow may be given three times a day.
George R Murray.
REFERENCES
1. Billroth. Beitrdge zur path. Histologic, 1858, p. 168. — 2. Cornil. Archives
ghi(^ralcs dc m&l. Aug. 1865. —3. CossY. Echo medicale, k.v. Keuchatel, 1858. —
4. CouPLANU. Fowler's Dictionary of Medicine, p. 477. — 5. Cuaigie. Pathological
Anatomy, 1828, "Diseases of Glands," p. 250. — 6. Delbet. La semaine mMicale,
June 1895, p. 271. — 7. Dheschkeld. British Medical Journal, April 30, 1892, p.
893. — 8. Ehrlich. Fdrbcnanalytisclic Untcrsuchungen zur iristologic vnd Klinik dcs
Blutes, pt. i. — 9. Fkaser. British Medical Journal, June 2, 1894, p. 1172. — 19.
GowEiis. Reynolds' System of Medicine, vol. v. p. 306. — 11. Gulland. Journal of
Vathology, vol. i. ji. 447. — 12. Hodgkix. Medico-Chirurgieal Transactions, vol. ,\\ii.
p. 69.— 13. Kanthack. British Medical Journal, July 16, 1892, p. 120. —14.
Leslie. Lancet, August 24, 1895, i>. 492. — 15. Malpighi. De Visccrum, Loud.
1669 ; De Bene, caj). v. p. 131.^ — 16. Moslek. Von Ziemssen's Cychvpccdia of Medicine,
vol. viii. p. 470. — 17. Ml'ik. Journal of Pathology, vol. i. j). 123. — 18. Muller.
Berliner klinische Wochenschrift, 42, 43, 44, 1867. — 19. Mtughison. Pathological
Transactions, vol. xxL 1870. — 20. O.sler. Principles and Practice of Medicine, p. 704.
— 21. Pavy. Lancet, August 1859, ]>. 213. — 22. Sharp. Journal of Anatomy and
Physiology, October 1895, p. 59. — 23. Spexcer, W. G. Pathology of the Lymph-
adenoid Structures, Tlie AVilson Lectures, Roy. Coll. Surg, of England, Lancet,
March 6, 13, and 20, 1897. — 24. Stexgel. Tivcntieth Century Practice of Medicine,
vol. vii. p. 443. — 25. Steven. Mediastinal Tumours, p. 9. — 26. Stiles. Edinburgh
Midical Journal, 1892. — 27. Thayer. Boston Medical and Surgical Journal,
pL-biuary 16 and 23, 1893. — 28. Troi'sseau. Cliniijue mddicale, t. iii.— 29. Velpeau.
Leeons oralcs de clinique, t. iii. — 30. Virchow. Kranl-haftcn Gesc/nriilste, vol. ii. —
31.' WiLKR. Guy's Hospital Beports, vol. ii. 1856, p. 114.— 32. Jln'd. Third Series,
voL xi. 1865, p. 56. — 33. Wunderlich. Archiv dcr Hcilkunde, 1866.
G. R. M
SCROFULA 597
SCKOFULA
When under the teaching of M. Bazin in Paris, in the year 1859, my
attention was strongly drawn by him to the subject of scrofula ; and its
frequency, its pitifulness, and its marring of fair young lives, served to
keep the subject jirominent in my thoughts. It may seem strange to my
younger readers to hear that the secondary or bubonic nature of this
disease was not then recognised. It was supposed to take its rise in a
" vice of the system," and accoidingly elaborate medicinal or magical means
were wholly relied upon in the treatment of it. Of these means the only
two which commanded any degree of success Avere cocl-liver oil and sea
air. Thus in the sixties and the seventies it was as common to see
persons marked by the scars of scrofula as it still was to see the marks of
the ravages of small-pox.
It Avas a common warning of careful parents that this girl or
that Avas to be shunned as a wife because she carried on her neck this
signal of a constitutional vice. I may have gone to an extreme in com-
bating this opinion, and in declaring that scrofula is but a secondary
event or "bubo," dependent upon some alien source or ix^itation,
generally peripheral and generally avoidable ; and I need scarcely say
that at the time of which I speak the tubercle bacillus Avas neither dis-
covered nor suspected. AVhether scrofula is ahv-ays due to this bacillus,
or always associated Avitli it, is not yet decided ; almost up to this
moment the penetration of the microbe into the tonsil and its implanta-
tion thence into the cervical glands has been a matter of doubt. It seems
probable that scrofula may arise by the agency of microbes other than
tubercle ; again that, originating independently of tubercle, on it tubercle
may afterAA^ards supervene ; and, once more, that scrofula may be due to
tubercle, primarily or even exclusively. No doubt these problems will
soon be settled. MeauAvhile, fortunately, the practical bearings of the
process are sufficiently established to perfect our therapeutics. Whether
primarily tuberculous or not, eccentric irritation in the teeth, the throat,
the nasal passages, the ear, the skin of the face, head, or neck may set
up scrofula in the clinical sense of the Avord ; and the enlightened practice
of modern physicians, dealing more promptly and more radically Avith
these extraneous sources of poisoning, may so prevent scrofula that our
improved method o. treatment by surgical means may happily be less
and less in demand. Such, I think, is already the case ; scrofula is far
less common than it used to be. Of these susceptible peinpheral parts it
Avas alAA'ays my belief that the tonsils were the most important, and I
taught hypothetically that these Avere the prevailing sources of scrofula ;
that scrofida, indeed, Avas but the further stage of tuberculosis or suppura-
tion of the tonsil. This opinion received little support ; for some time
after 1882 pathologists failed to find tubercle bacilli in the tonsils, or even
598 SYSTEM OF MEDICINE
in the discharges from scrofulous glands. Eecently, however, this negative
position lias liocome considerably modified ; pathologists doubt no longer
that tubercle of the tonsil, so far from l)eing rare, is an ordinary mode of
constitutional infection, and that scrofula is a common consequence of
such tonsillar diseases. In a thesis for the degi-ee of ]\I.l). in the
University of Caml)ridge, Dr. AValsham recently dealt with this question
fully, and produced a lai-ge series of microscopical pi-eparations in
support of his statements concerning tonsillar tuberculosis. J)r. "Walsham
says that the tonsils, so far from being immime from tubercle, as has
been alleged, are very frequently aflected by this evil. Tubercle, he
says, may be primary in the tonsil, with secondary infection of the lungs
or other parts, the cervical glands being often allected thus secondaiily.
Out of thirty-one cases of tuberculosis, acute and chronic. Dr. Walsham
discovered tuberculosis of the tonsils in twenty cases. In 1884 I made
the same assertion, Avith the use of the Avord "])articles" instead of
"tubercles," and I had insisted upon the same order of things in 1881.
Koch discovered the tubei-cle bacillus in 1882.
Dr. Batten, another of our younger graduates, in making a general
survey of the course of tubercle in the glands of child I'cn, says of the
cervical glands that out of 100 cases of tidwrculosis in children noted at
Great Ormonde Street, the cerA'ical glands presented evidence of tuberculous
infection in fourteen. This estimate, I gather, was founded upon records
of nahed-eye observation only or chiefly ; no doubt microscopic investiga-
tion would have increased the proportion greatly. Krueckmann found
tul)ercle in the tonsils in 60 per cent of cases of tuberculosis, and he
asserts that tuberculosis of the cervical lymjDhatic glands almost always
depends u])on the invasion of the glands by way of the tonsils. I have
often surmised that the sinuses of old scrofula are likewise the seat of
tubercle ; I can offer no more than a surmise, but Dinochowski's
results are to the same eff"ect. Strassmann's observations led him to ])nt
the percentage higher still. Ruge arrives at the conclusion that the
tonsils are an ira})ortant primary seat of tuberculous infection, whether
the mischief follow in the cervical glands or elsc\vhei"c. ]\Iany French
observers (Peter, Cornil, La1)oulbene) have brought forward ' similar evi-
dence, though I have not preserved accurate references to these sources,
nor is it necessary now to add to this part of the evidence. For,
whether primarily tuber-culous, septic or ])yogenetic, that micro-organisms
infect the system through the tonsils, and that in this Avay the cervical
glands are often invaded, rest upon a strong basis of proof ; and thus the
etiology of scrofula leads to the recognition of the im]iortance of pr(i])hy-
laxis as a fundamental part of the treatment of sci'ofula and as a method
of preventing its imj)lantation. Sedulous attention to any faucial dis-
order in childi-en, sedidous attention 1o the drainage of their homes, the
avoidance of aural or pharyngeal catari-hs, the i-emoval of olistacles to
free respiration, such ns adenoids and the like, constitute the outworks
of the cam])aign against this pla<^ue ; and it is ])l;iin that the recognition
and the revision of the co.nditions of health which have marked our times
SCROFULA 599
have already reduced the incidence of scrofuki to no small extent.
Nevertheless scrofula is not yet abolished, and I am tempted by my
own inclination, the importance of the subject, and its bearing on
the work of the pathologist, to include a section on the surgical
treatment of the disease. Before passing on to this section, however,
I woxdd refer to a remarkable tract by John Browne, a surgeon of
Norwich, reviewed ])y Mr. D'Arcy Power, in his interesting series entitled
" Archseologica Medica," in the Britkh Medical Journal of 31st August
1895. Browne, after some remarks on treatment by diet, and so forth, in
which in, many respects he seems to have been in advance of his time,
saj^s of surgical means: "These tumours (scrofulous glands) do require
extirjDation and extraction^ — to be so dexterou.slj^ performed as that no
part be left behind. The glands are to be extracted with great care and
caution, so that every part of the cystus or bags thereof are perfectly and
thoroughly eradicated and extracted, the which being done, and the part
clean, mundifie the ulcer, digest, incarn, and then induce a cicatrice." " It
is only in this after-treatment," says Mr. Power, " that his method differs
from that of Professor Clifford All butt and Mr. Pridgin Teale." .
T. Clifford Allbutt.
REFERENCES
1. Allbutt and Teale. Scrofulous Xeck and its Surgery. Loudon, 1885. — 2.
■Batten, F. E. St. Bartholomew's Hospital licports, vol. xxxi. — '3. Dieulafoy.
" Tiiberculose larvee des trois aniygdalis," i)wi^. Acad. Mccl. 3 ser. t. xxxiii. 189.T. — 4.
KiiUECKMANN. Virckoiu's Archiv, Bd. cxxxviu. I). 53'i. — rt. Ruge. Virchow's Archiv,
Bd. cxliv. 1896. — 6. Sokolowski and DinocHowski. DeutsA. Arch. klin. Med. Bd.
xlix. Hft. 6. — 7. Stewart, Purvis. "Tuberculosis of Tonsil," Brit. Med. Journ. May
4, 1895. — 8. Walsh am, H. Latent Tuberculosis of the To7isils. Thesis for degree of
M.D. Camb. May 1897.
T. C. A.
The Surgery of Scrofula
There are probably few subjects in which the ground common to the
physician and surgeon is so clearly marked out as in scrofulous disease of
the cervical glands, and there are few departments of surgery in which of
recent j^ears such a definiteness of aim, such a development of surgical
detail, and such a profitable reward for careful work have been dis-
played.
Until the last fifteen or twenty years the treatment of suppurating and
caseating glands of the neck was as unsatisfactory as it well could be ; the
resources of the physician were little more than poultices and iodine paint,
and the resources of the surgeon were limited to opening with a bistoury
an abscess ready to break through the skin. The result to the patient was,
in the words of Professor Allbutt, that " in the continuance of his local
malady over and above his faidty inheritance he ran three risks : namely,
first, of a tedious local disease followed by a peculiarly unwelcome dis-
6oo SYSTEM OF MEDICINE
figurement ; secondly, of ;i deterioration of his gonei'al health so that his
best jx'ars of adolescence are spoiled, and his hold upon manhood thwarted
and weakened ; thirdl}', of an inoculation of the system w^ith elements
which favour the dissemination of a more general tuberculosis."
The first clear note of the chanure which was beiiinninfi to revolutionise
the practice of the physician and the surgeon in this disease Avas struck
by Professor Clifford Allljutt in a i)ai)er Avhich he read at the International
Medical Congress in London in 1881, a paper which was followed up by
the publication in 1885 of a clinical lecture, by Dr. Allbutt and myself,
in which our further experience was set forth.
The mode of dealing with such glands, w liieli at that time was scarcely
known in surgery, has now become general ; and al)le papers have been
written by various surgeons discussing the details of the practice and the
best methods of carrying them out. It is my intention in the ])resent
article to reaffirm the principles originally laid down, with such comments
on details as the experience of myself and others may suggest.
Let me introduce the question of treatment by a definite case, which
Avill be none the less telling that it Avas under the surgical care of a
colleague.
In January 1880 I was requested by Mr. "Whcelhouse to meet him at
Dr. All butt's chaml)ers, that Ave might consult about a fluctuating swelling
in the neck of one of his jxitients, a young lady about sixteen years of
age, and perform a radical operation if possible. There Avas a large soft
SAvelling below and behind the right ear ; this had been emptied of pus
by incision a year before. The incision soon healed, and in spite of
iodine and other applications the SAVclling reappeared. She had now
returned home after a year at Southport Avith the swelling as large as ever.
Hence the consultation. The decision Avas that the jjus-containing cavity
should first be emptied by the aspirator, and then if it refilled, as it prob-
ably Avould, that it should be opened, scraped, and drained. The cavity
refilled, and in February I assisted Mr. AVheelhouse in his "radical"
operation. The swelling, about the size of a duck's egg, Avas situated over
the sterno-mastoid muscle behind and l)eloAv the lobe of the left ear. Mr.
Whcelhouse made an incision about li inch long in the posterior border
of the swelling. The pus having escaped, the subcutaneous cavity Avas
scraped out thoroughly, and no gland Avas found. Now Ave come to the
cardinal point in the surgical treatment — I may say in the radical cure —
of a large mnnber of these cases of degenerating glands. Profiting by
our ])revious experience Ave searched Avith the point of a director, and
found, as Avas sus])ected, a small hole through the deep cervical fascia
that Avould barely admit the tip of the little finger. This led to a
diseased gland in its hiding-place beneath the sterno-mastoid; the
opening Avas enlarged, and the caseous, half-decayed lymphatic gland Avas
luiearthed by Lister's scraper. After vigorous scraping, cleansing, and
Avashing l)y carbolic lotion (we had not then arrived at iodoform), a
drainage-tube Avas inserted. The tube Avas left in nearly two months ; its
removal Avas rapidly followed by healing, and the neck has been perfectly
SCROFULA 60 r
sound ever since. Four years afterwards the scars of the two opera-
tions were faint white lines barely an inch long, with hardly a suspicion
of dimple. Having been pallid and pasty before the operation she was
now healthy and had a good colour, and her friends said " she is not like
the same girl at all."
Now, what do we learn from this case % We learn first of all the
absolute inutility of merely incising or otherwise opening an abscess,
which probably depends on a degenerate gland which may lie beneath the
deep cervical fascia.
We learn, in the second place, that the visible abscess, which would
often be called a strumous suppurating gland, is merely a subcutaneous
storage reservoir of pus, and that its source, a degenerate gland, is not only
subcutaneous, but subfascial also, that is, under the deep cervical fascia, and
perhaps even submuscular; the communication between the two being by
a small opening just large enough to admit a probe, and easy to overlook
if it be not carefully sought for. Herein lies the explanation of the
chronic sinuses discharging for years, and healing, if they do heal, with a
conspicuous depressed scar ; or perhaps issuing in subcutaneous burrowings
lined by ill-favoured granulations, or an open indolent sore healing at last
with a cheloid deformity.
We learn, in the third place, that suppuration of long standing may
be brought to an end in the course of a very few weeks if the source of
it be recognised and vigorously attacked.
We learn, in the fourth place, that the mark left by prompt surgical
interference is not deforming, scarcely dimpled, and is utterly insignificant
in comparison with the ugly scar resulting from a sinus allowed to heal at
its own leisure after discharging, it may be, for months or years.
Another illustrative case was sent to me in October 1877. INIr. S ,
of K , aged twenty-seven, having been advised to winter abroad on
account of symptoms of early disease of the lungs, was urged by Dr. Allbutt
to have a chronic discharging sinus in the neck surgically attended to before
leaving England. For several years he had been subject to enlargement
of the cervical glands, for which he had undergone all kinds of medicinal
and external (local) treatment, but Avitli no good result. The sinus in
the neck was incised and enlarged, and cheesy remnants of degenerate
gland tissue were found and scraped out. This sinus, from which,
according to his account, there had been a constant discharge for several
years, was quite healed in five weeks after the operation. A year later
the scar was pale, non-adherent, and scarcely visible. There had been
no further enlargement of glands, there was no evidence of disease of
lung, and he was in robust health. Can there be any reasonal)le doubt
that in this case the half-decayed gland, with its septic track, was a
serious factor in his depraved condition of health ; and that, even if it
were not the direct cause of his threatening pulmonary disease, it must
have proved a serious impediment, if not an absolute bar, to the happy
recovery of lung which took place ?
A special lesson to be learned from this case is that it lies with
6o2 SYSTEM OF MEDICINE
the physician to appreciate the vital importance of any infective com-
plication in a patient suliering from, or threatened with, visceral disease ;
that it is possible for the surgeon quickly to put an end to many sources
of chronic poisoning of the system, and so to give fair play to the means
of restoring health which arc at the command of the ph3^sician.
The next case which I shall bring forward is that of Walter Speight,
an infirmary patient. He had l)een ojierated upon by us nine times during
five years, and seemed to have come to the end of his troubles. On the
first occasion the gland had suppurated, and was discharging. In all the
other operations the glands were removed or scooped out before the skin
had given way. In some instances the glands were suppurating ; in
others, enlarged glands were enucleated before they had broken down.
So great was the discomfort he had endured, so marked was the relief
that he ol^tained by operation, that as soon as a fresh gland inflamed he
came and begged me to remove it.^ "We learn from this case the A'alue
of persistency both in patient and surgeon ; in the i)atient, Avho Avas not
content until every source of discomfort and of deformity had been
removed ; in the surgeon, who held not his hand as long as work remained
to be (lone. If it be YvAxt to remove one deii;eneratinir frland, it is right to
work on to the logical conclusion, that all compromised glands, if removable,
shall be got rid of. The case teaches us also that we need not be deterred
from oiu" good work by fear of a deforming scar ; and that it is possible,
provided the skin be sound, so to remove a gland as to leave a scar that
shall be insignificant. In two other instances, the patients being 3'oung
ladies, such repeated operations have l)een performed with most gratifying
results. Both were most eager to have their encuml)rances removed, and
they reckoned the mark as nothing compared Avith the increase in comfort,
rapid recovery, and improvement in health Avhich they had experienced.
Again, Miss B., aged eleven, Avas brought to me in July 1879 Avith
chronic enlargement of the cervical glands folloAAdng an attack of sore
throat, probal)ly caused by bad drains. A sinus connected Avith the
glands had been discharging for six months, and at another point an
al)scess AA'^as making for the surface. Operations Avere performed on tAvo
occasions ; on the first the siuTis Avas enhirged and scraped, and the
remains of a decayed gland Avere remoA^ed ; the Avound healed in four
Aveeks. The al^scess, still covered by sound skin, Avas opened at the
same time, and the gland in Avhich it originated Avas dissected out : this
wound healed in ten days. At a second operation, a feAv Aveeks later,
another unbroken suppurating SAvelling Avas dealt Avith in like manner,
and the Avound healed in three Aveeks. The i-esult, as reported tAvo years
later, is that there is a puckered thickened cicatrix over the situation of
the sinus ; but that the scars of those gland abscesses Avhicli were not
allowed to open spontaneously, Avere linear and fading in colour.
The lesson here taught is clear — that, ajiart from the question of ill-
' Tliis man is still living and at work. He lias had about sixteen ojuTations Viy myself
and others, including listula in ano, and removal of inguinal and axillary glands. — T. P. T.,
Oct. 1896.
SCROFULA 603
health dependent upon the presence of long-continued discharge from a
sinus or gland, it is of supreme importance in the matter of scar that the
offending gland or pus should be eradicated whilst the skin is sound, that
is, before the skin has been damaged by inflammation and thinning ; and,
above all things, that we should anticipate the formation of a sinus
which, by the contraction of its cicatricial lining, draws to a pucker the
scar in the skin.
Now there are two aspects of the question, both of which must be
kept steadil)'- in view — the pathological and the festhetic. Our guiding
principle must be, in the Avords of Professor Allbutt, "that, whenever
septic material is contained in the system, we rest not until it is expelled,
and its burrows are laid open and disinfected." In doing this the surgeon
must make it an artistic study to effect his piirpose with the smallest
possible amount of blemish. The ugly scars and unseemly depressions,
once so familiar in scrofulous neckr,, should be deemed an opprobrium of
surgery ; whilst to delay operation until the skin is thin, red, and ready
to break down, or has already given waj-, should be looked upon as
mischievous trifling. May we not hope, moreover, that the time is not
far distant when the absolute inutility of painting the skin in the hope
of influencing a caseating gland, perhaps deeply seated beneath muscle
and deep fascia, and the injury which may be done l)y this practice to the
skin itself, wall be fully brought home to the professional mind ? The
sesthetic question may be stated in the following propositions : —
{(i) Whenever fluid — that is, pus — can be detected in connection
with a diseased lymphatic gland, the operation should be done before the
skin becomes red and thin ; that is, before the skin has been spoiled by
advancing suppuration.
Qi) "When the diseased gland is subcutaneous^ — that is, not beneath
the deep fascia or muscle — and has been completely removed, the least
scar will result if neither stitches nor drainage-tube be used ; especially
if it be possible to leave the wound uncovered by dressing and exposed
to the air so that the edges may be drawn and glued together by drying
lymph.
(c) If the diseased gland be beneath the muscle or muscular fascia,
then a drainage-tube must be used, or a temporary drain of cyanide
gauze, and the edges of the wound united by suture. For this purpose
probably horse-hair or silkworm gut well soaked in carbolic lotion are the
best sutiu'es. The best tube for prolonged drainage is a specially selected
gilt spiral Avire, as it may have to remain from two to eight or ten Aveeks,
according to the dejDth of the Abound, or the completeness of the removal
of the gland.
{d) Where many glands have to be remoA-ed it is better, so far as
may be, to remoA'e them through a series of small incisions, and thereby
to avoid A'ery extensive ones.
On the " pathological aspects " the following points are Avorthy of
attention : — •
(c) That all sinuses and suppurating cavities should be thoroughly
6o4 SYSTEM OF MEDICI XE
cleansed In- iiu'aiis of scraper or lint, so as to leave a fresh suiface free
from granulation or decayed or decaying tissues ; and that a di'ainage
outlet should be maintained until all the deep parts are healed.
{/) It is essential to bear in mind, as I have said, that the visible
abscess, which has often been called a suppurating gland, and treated as
such, is frequently but a subcutaneous reservoir of pus, the source of
■which (a degenerate gland) may be not subcutaneous but suljfascial ; that
is, under the deep cervical fascia, and often submuscular, under the sterno-
mastoid : tlie communication between the two being a small opening in
the deep fascia just large enough to admit a probe or director. This open-
ing may readily be overlooked, and is not always easily found even when
searched for, but it must be found, or the operation Avill be a failure.
This opening is often more easily detected by the touch than In' a
probe or director. After thoroughly cleansing the cavity the finger
should search tlie whole bottom of it, and will often detect a slight
depression, or the bare suspicion of a depression.
On introducing a director into the depression it is found that the
director travels more deeplv, and on Avithdrawal brings in its groove a
little pus or caseous matter from a deejjly-seated broken-down gland.
Such an opening may be cautiously enlarged by the knife, or, if necessary,
by a Bigelow's dilator, until the finger can test the new cavity in its turn,
and decide whether the end has been reached or not. The education of
my finger in the detection of this " critical pit " has recently proved of
great service to me when dealing with two cases of abscess at the upper
part of the thigh, enabling me after careful search to detect the very
small opening near Poupart's ligament which led to the source of the pus :
in one instance it was near the ctecum, in the other near the kidney ;
neither of the cavities, so far as I could make out, extending farther, or
being connected with disease of the spine.
{(j) As it is mere trifling and bad surgery simply to incise an abscess
in the neck Avithout searching for and thoroughly eradicating the gland
that is the starting-point of the altscess, no such al)scess should l)e opened
Avithout putting the patient under ether, and being prepared with all
necessary means for eradicating the diseased gland.
(/f) It sometimes happens that after the extirpation or evisceration of
a gland, the finger detects in the Avail of the capsular cavity the slight
convex bulging of a contiguous gland. This should be pricked through
the wall of the cavity, and so reached and extirpated or e\ascerated. In
this way in several instances I have emptied from one external opening a
group of three or four glands, massed together and suppurating, or other-
wise broken down.
(i) What has been said hitherto concerns glands which are suppurat-
ing or obviou.sly breaking down. As to caseous glands the conclusions
I have arrived at are as follows: — "When Ave have dealt AA'ith a broken-
down gland Avhich has proAcd to be uiulergoing caseous degcjieration, Ave
may infer that any other enlarged glands, then present or subsequently
appearing, are becoming caseous also ; in my opinion, therefore, it tends
SCROFULA 60s
to promote better health of the patient if, in the absence of reason to the
contrary, such glands are removed as soon as the surgeon is convinced
that the enlargement is persistent and not merely transitory, without
waiting for evidence of fluctuation or pus.
{]) What shall be done with enlarged glands which are neither
caseous nor suppurating ; glands indicated by the names lymphadenoma,
hypertrophy, and so forth % I am not clear as to the answer to l)e given,
nor whether their remoA-al is an advantage or otherwise. Probably this
Cjuestion will remain open for some little time to come \yide p. 593].
(/j) In a very laige number, indeed in a majority of the instances of
scrofulous neck which have come under my care, there was no evidence
of any constitutional taint or weakness. The origin of the ailment was
often clear and defined, bad drains in many instances, scarlet fever, mumps,
tAbercle of the tonsil, and the like in others. The cases were frequently
isolated instances in families free from any tendency to constitutional
disease, and health and perfect vigour were restored after the destruction
of all degenerate or infective material.
There are two more points of surgical practice on which a word
should be said. The first is on the use of large incisions, combined with
division of the sterno-mastoid, enabling the surgeon to see and dissect
away deeply-seated glands. The testimony of those w^ho advocate such
incisions is that the eradication of the diseased glands is thereby rendered
very effective and comparatively easy. Perhaps I have not met with
disease of deep glands extensive enough to call for these large incisions,
my exjserience, of late years, having been amongst people above the
poorest classes. At any rate I have not employed them, and I have
divided the sterno-mastoid in but a few cases, and in these only partially.
I am therefore unable to state from my own experience whether the
scar resulting from the more extensive operation is such as would lead
me to restrict the employment of the large incisions to the very extreme
cases only. To form a judgment on such a point Avould need the com-
parison of a series of cases of each kind after the lapse of two or three
years from the time of the operation.
The second point is the bold suggestion of Mr. "Watson Cheyne,
that in dealing A^th large masses of glands adherent to the sheath of the
cervical vessels, the whole of the imderlying internal jugular vein should
be removed. Here, again, it may be that I have not met with the extreme
cases in which such a course would be advisable. On one occasion, in
stripping a gland adherent to the sheath, I tore open the internal jugular
vein, much to my dismay. I tied the vein above and below, and divided
it between the two ligatures, and the wonnd gave me no more anxietv.
It is important to know from the experience of Mr. Cheyne, and of ]\Ir.
H. J. Stiles, who has adopted the same plan, with what impunity such
a step may be taken. Indeed, it would seem to be a point gained in
recent surgical procedure, although the need for adopting it may be very
rare.
T. Peidgin Teale.
6o6 SYSTEM OF MEDICINE
REFERENCES
1. ALLBfTT, T. Clifford. "On the Treatment of Scrofulous Glands," Trans.
Intcmat. Med. Congress, 1881, vol. ii. j). 82.-2. Idem. "On Scrofulous Keck,"
Med. Times and Gazette, Jan. 3, 1885.— 3. Allhutt and Teale. Uii Scrofulous
Keck, and On the Surgery of Scrofulous Glands. London, 1885.-4. Cheyne,
Watson. Treatment of Wounds, Ulcers, and Abscesses. 1894. — 5. Idem. King's
College Hospital Reports, vol. i. — 6. Rentox, Cuawfoud. "Treatment of Tuber-
culous Glands," i>'n/!. Med. Journ. Sept. 12, 1896.-7. Stiles, Harold J. Ibid.—S.
Teale, T. Pridgix. "On the Surgery of Scrofulous Glands," Med. Times and
Gazette, Jan. 10, 1885.— 9. Treves, Frederick. "On the Pathology of Scrofulous
Lymphatic Glands," Brit. Med. Journ. April 30, 1881.— 10. Idem. Scrofula ami Us
Gland Diseases. 1882.
T. P. T.
OBESITY
Introduction. — Obesity — sometimes, but improperly called polysarcia, a
name introduced by Coelius Aurelianus in the sixth century — may be
defined as a condition in which, owing to one cause or another, an over-
growth of fat takes place in many parts of the body. The nosological
position of this state is rightly assigned amongst the several hyper-
trophies. The body in health is more or less covered with fatty tissue,
and certain parts are well clad, both without and within. 'Improved
nutrition of the whole body increases the fat, and diminished nutrition
is rapidly indicated by a loss of it. We are only concerned noAV to take
note of such adipose overgrowth as constitutes an unwholesome or morbid
state, leading to undue bulk, disproportionate body-weight, and inter-
ference with due performance of various functions. " Le developpement
de la grasse ne constitue une maladie que lorsqu'elle entrave le jeu
d'un organe quelconque " (P. Legendre).
In this case we have to deal with a definite tissue-proclivity, which,
as in other instances, may be either inherited or acquired. A family
tendency to obesity is well recognised ; but tlie several members of such
a family may not all become the subjects of it. Mode of life has much
to do in determining the occurrence of obesity, and thus singular unlike-
ness ma)^ exist amongst the individuals of a predisposed stock. Such a
tendency may be noted in certain members of a family inheriting the
arthritic diathesis ; gout or glycosuria, for example, occurring in some
mcml)ers, and an extraordinary obesity in others.
The sexual relations of pinguesence are noteworthy, and must be con-
sidered in taking a complete view of the subject. Adipose development
is as normal a mode of nutrition at puberty in the Avoman as is the
development of the breasts and ovaries. In this connection we note also
the increased tendency to fatty deposition which is apt to ensue on the
removal of the testes in male animals, and of the ovaries in the female.
Towards the age of forty years the same tendency is to be noted in both
sexes — the change in such cases being partly due to diminished bodily
activity and the easier life not seldom enjoyed at this period.
Undue obesity is, as a rule, no indication of soundness or robustness
of constitution. In infancy an excess of fat is not a sign of general good
nutrition. Thus, a child may be at once very rickety and very fat ; and
6o8 SYSTEM OF MEDICINE
the latter state is apt to deceive the unwary as to the serious underlying
condition. In hysterical girls there may be noteworthy obesity in spite
of a miserable appetite and a very small supply of food. The breasts
may become very fat in women the subjects of amenorrhcea ; and the
condition subsides on re-establishment of the menses. Atrophy of the
testicles has l)een known to be associated Avith inordinate groAvth of
mammary fat in males. The sexual appetite is distinctly lowered in oliese
persons ; and inertness of the sexual organs certainly favours the deposit
of fat.
Lean and elderly spinsters not infrequently grow plump after
marriage. As pointed out by Sir James Paget, after the age of forty
years persons either diverge into spareness or become more or less.
obese ; the former, as a rule, enjoy the hnpi^icr and longer lease of life.
Heredity apart, the conditions Avhich determine obesity in a morbid
degree are diet, exercise, and habits of life. In cases presenting a strong
hereditary tendency to fatty hypertrophy, haljits of diet count for less,
and the proclivity may be little influenced by measures Avhich prove
effective in other cases.
"We are not now concerned to discuss cases of local overgrowths of fat
or fatty tumours. These may be single or multiple, of slow or of rapid
growth. Such tumotirs are commonly hereditary, as much so as are
atheromatous cysts or Avens. Hal)its have little, if anything, to do Avith
these. Two exceptions may, however, be mentioned : first, cases in Avhich
local irritation, long continued, indtices a fatty groAvth ; and, secondly,
cases of symmetrical fatty tumours (lipoma), above the occipital region,
due to excessive beer-drinking, descril)ed by the late Mr. Morrant Baker :
of these I have seen a good many examples.
We may also note some racial peculiarities in respect of obesity. The
peculiar glitteal development of the Hottentot Avomen deserves mention ;
and the common tendency to obesity in the HcbrcAv race is remarkable.
A singular contrast is to be observed betAveen the Teutonic races and the
people of the United States of America. The former often present
examples of obesity ; the latter, although largely recruited from the
former, exhibit markedly less tendency to this condition amidst the
environments of the Xcav World. Climate may have to do Avith this
result ; but habits and diet are probaljly much more concerned in it.
In the East remarkable examples of obesity are met Avith, but amongst
Hindus rather than Mohammedans. Customs and diet account for this
difference; and P]urope;in indulgences, including alcoholic habits, united
Avith Oriental indolence, not seldom atl'ord the explanation of these
anomalies.
In a moderately fat man the fat has been estimated at one-eighteenth
or one-twentieth of the total body-Aveight ; and in Avoman the relative
proportion is larger. It is naturally found in the face, in the orbits,
jialms of the hands, soles of the feet, flexures of joints, around the
kidneys (suet), in the mesentery and omentum, in the appendices
epiploicae, the subcutaneous areolar tissue ; in certain situations, such as
OBESITY 609
the abdominal wall, mammary region, and in the cancellous and canalicular
tissue of bones, esjDecially in yellow marrow. No fat is met with on the
scrotum or penis, or on the nympha? ; nor is there any between the
rectum and bladder. None is found within the cranium.
In the viscera fat is normally met with in the intimate cells of the
liver, and in the cells and tubules of the brain and nerves.
The sources of fat in the system are dependent on the supply of
food ; fatty matters reach the blood from both animal and vegetable
pabulum, but especially from non-nitrogenised materials, such as starch,
sugar, gum, and alcohol. Fat itself aftords an immediate supply ; but
only a small portion of the stored fat in the body Comes directly from
that consumed with the food. Excessive pinguescence is normally kept
in check by the means which induce full oxygenation of the blood and
tissues. Hence, if organic compounds rich in carljon are fully supplied,
and oxygon but inadequately, favouring conditions exist for fatty deposi-
tion. Diminished exercise and close confinement lessen oxygenation by
preventing the dissipation of carbon compounds. These facts are well
illustrated by the results of captivity on animals, and by examples only
too common in the social systems of the human family ; and they afford
a clue at once to the nature of the proper remedial measures.
As pathologists and clinical ol^servers Ave have to distinguish, as far
as we can, between fattiness due to infiltration and that due to degenera-
tion. In the former case infiltration (lipomatosis) should be regarded as
an excessive deposition in the cells which normally contain fat, as in
the subcutaneous areolar tissue, omentum, perinephric region, liver, and
parts between muscular fasciculi in the voluntary and cardiac muscles.
Such an infiltration, though general, may in certain parts be in excess ;
it is then met with, especially in the abdomen and in the integuments
about the mammary region and the buttocks.
In the heart, infiltration is common, and is not inconsistent with
vigorous action of this organ. The visceral layer of the pericardium is
a common seat of it ; so also is the interstitial connective tissue. This is
not to be regarded as an example of " fatty heart," since the muscular
(sarcous) elements may be quite healthy in such a case. Obese persons
may have abundant fatty accumulation amongst their muscular bundles,
and such muscles, though hampered and weak, may be sufiiciently sound
to resume full function if they be relieved of their fatty encumbrance.
Obesity tends to induce inaction and muscular inability, and so there is a
vicious circle of malign events in such instances.
The liver becomes fatty under similar conditions, as where persons
eat fatty food or much carbohydrate material ; and especially if they are
immoderate in alcoholic fluids, which combine more readily with oxygen
than does fat.
Fatty degeneration is a more serious matter. In this case fat is
found in the tissue-elements themselves, as in the sarcous particles of
muscle or the walls of blood-vessels ; and it is not necessarily introduced
by the blood. Decay of structure is in progress here as a result of a
VOL. IV 2 R
6io SYSTEM OF MEDICINE
malign metabolism, albuminates being broken clown into fat ; a process
which has been likened to that occurring in the "ripening" of cheese,
where fat is formed at the expense of aUnimin. Arcus senilis, cataract
of the lens, and fatty change in small arteries arc good examples of fatty
degeneration ; and the truly " fatty heart," in -which the sarcous elements
change into fat drops, is an exquisite one.
We are only concerned here to consider fatty deposit and infiltration
in excess ; it falls to others to describe the lesions and the eti'ects induced
by fatty decay or transformation \_vide vol. i. p. 185].
Fat is apt to be deposited in excess after anaemia due to repeated
haemorrhages or otherwise ; and is commonly met with in chlorotic young
women. Deficiency of haemoglobin in the red globules of the blood
entails insufficient supply of ox3'gen, and thus leads to storage of fat. In
Addison's disease the fat i-emains. In wasting disease fat is lost early ;
and in cases of inanition it is observed to disappear early from the face,
giving rise to a characteristic starved and gaunt aspect.
Fat is often fluctuating in quantity ; much of it may disappear in
a very short time, and no less rapidly may it be again deposited. Human
and animal fat contains olein or liquid fat, and stearin or palmitin Avhich
are solid fats. The sources of it, as already stated, are from various
articles of diet, and an ordinar}^ dietary contains from one to two and a
half ounces of fat. Carbohydrates, such as starch and sugar, especially
tend to produce it. It is probable that fat can be also converted into
carbohydrates, such as dextrose, its carbon being thus transformed for
use in the tissues as a soluble and readily diffusible carbohydrate. This
may conceivably occur Avhen the body has to draw upon its own store of
fat and so lose its undue corpulence.
Albuminous matters are certainly capable of transformation into fat.
Some of these, after conversion into peptones by the stomach and
pancreas, pass under pancreatic influence into Jeucin, a fatty body. The
ferments of the salivary glands and i)ancreas convert starch into sugar ;
but the method of conversion of sugar into fat is not yet precisely
ascertained. The fats are partly saponified and partly emulsionised by
the pancreatic and other secretions. This secures a very fine molecular
division of them, so that absorption may readily proceed, by means of the
epithelium of the villi, into their lymph-sjjaces, and so reach the lacteals,
mesenteric lymph-glands, and the thoracic duct.
Normal blood contains about one-half per cent of fat, the muscles
more than three per cent, the brain eight per cent, and the nerves twenty-
two per cent. The nerves are the last to lose their fat in cases of general
atrophy, and the large amount normally present in them is significant of
the high importance of fat to their well-being and potential activity.
The amount of fat in the blood may be readily increased by certain
articles of food — mostly by fat, sugar, and starchy matters; in less degree
by animal food, and least of all by bread.
Fat is a bad conductor of heat. Warmth is retained in the body by
the panniculus adijiosus, and the intestines are especially protected by
OBESITY 6ii
the fat in the omentum and appendices epiploicae. Hence the stout require
less warm clothing than lean persons ; and the latter suffer more readily
from chills and exposure. Normal radiation of heat is checked in the
obese.
It is not sufficiently recognised that fat deposits are constantly under-
going change by decomposition and reformation. As with all other
tissues, intimate change proceeds even in the densest layers of fat ; and in
no part of the body does any fatty deposit lie out of the current of
life and unaltered.
That the proteids possibly constitute a source of fat is proved by the
fact that while the urea which is excreted represents all the nitrogen
which is thus passed through the body, it represents much less carbon
than is found in a quantity of the proteid yielding the same amount of
nitrogen. This surplus of carbon, if not otherwise disposed of, remains
as a possible source of fat to be deposited in the body. It has been
calculated that thus 100 grms. of j^roteid food might furnish 42 grms.
of fat (M. Foster).
I have said that heredity has largely to do with the occurrence of
obesity ; according to Oertel of Munich this influence can be traced in
50 per cent of all cases. We have, then, to deal with a very definite
diathetic condition in which a special trophic process is at work — one as
definite in its course and outcome as in that in which a gouty or a
strumous disposition prevails. It is of high importance to realise this fact,
and, if possible, to come to some clear understanding of it before under-
taking a line of treatment for any obese person ; for a marked diff'erence
is to be noted between cases in which obesity is the outcome of heredity
and those in which the encumbrance is acquired by certain habits and
modes of life. Where hereditary disposition is potent and effective we are
less hopeful by far of good and lasting results from any plan of treatment.
When the disorder is acquired by bad habits, improper diet, and indolence,
we may readily modify it ; and, in patients who co-operate intelligently and
honestly, we may largely and permanently dissipate the fatty encumbrance.
The mental peculiarities and temperament are deeply concerned in every
case ; the difficulties of treatment are greatly enhanced in persons of
indolent and phlegmatic habit, and proportionately diminished in persons
of active and energetic disposition.
The relation between gout and obesity is one of much interest. Gout
figures largely in many cases. It is not unusual for certain members of
a family with gouty inheritance to become obese. This may occur in
either sex and sometimes before puberty. After the age of thirty
obesity may set in, and within ten or fifteen years glycosuria. Such
persons belong to the class of fat or gouty diabetics, and in them
the glycosuria is but a mild form of chronic diabetes. The presence
of glucose in the urine is almost the only symptom which such
patients have in common with those who are the subjects of the graver
disorder. They often have no thirst and but little polyuria, and for
many years they lose very little weight. These are the patients who
6i2 SYSTEM OF MEDICINE
gain much benefit from recourse to spas, and the disorder may be arrested
sometimes, or become intermittent. Carefully regulated dietary may
occasionally remove all glucose from the urine, or a small percentage of it
may i)ersist.
If neglected, such cases may drift into incurable forms of diabetes,
with thirst, polyuria, wasting, poor health, and great vulnerability of
texture. Pulmonary tuberculosis, furunculosis, or gangrene of the
extremities iisually terminates life. Diabetic coma is not a very
frequent mode of death in these cases. Such patients may live for
fifteen or twenty years, or even longer ; and occasionally present
acute or chronic phases of gout in some of the joints, with temporary
alleviation or removal of the glycosuric state. Such cases are peculiar,
and especially striking when met with in families where other members
may be either spare or more overtly gouty ; or exhibit other features of
gouty inheritance, such as hemicrania, biliary calculi, or mere lithiasis.
Here Ave may note again the strong hereditaiy tendency both to obesity
and to glycosuria in the Hebrew race. I shall return to the discussion
of these cases when considering the appropriate treatment of obesity. A
moderate degree of obesity in early life may disappear during adolescence
and never recur.
Two leading kinds of obesity are met with in practice, and may be
classed as (A) the plethoric, and (B) the anaemic. The former prevails
more in men, the latter in women.
A. The plethoric kind. — In this kind there is a general over-nutrition,
the muscles are large and well developed, and the blood rich in red
globules and hsemoglobin. The heart hypertrophies and acts at first with
A-igour, but subsequently it dilates and loses power. The pulse becomes
infrequent and of high pressure. Arterial sclerosis is set up, and the
vessels become tortuous. As in ordinary cases of heart disease associated
with much vascular peripheral resistance, circulatory troubles gradually
ensue in the lungs and other organs. Albumin ma}- appear in the urine.
Anginal attacks may supervene, and progressive dropsy. Cardiac asthma
sometimes occurs, especially at night. The respiration in the later stages
may assume the Cheyne-Stokes form. Cerebral hyperivmia, indicated by
throbbing of the carotids, vertigo, and tinnitus aurium, is not uncommon :
epistaxis may relieve it. Rupture of an artery in the brain may occur
on a sudden increase of intravascular pressure ; and in such cases this
event is commonly fatal. As cardiac failure progresses arterial pressure
falls, and the pulse becomes intermittent or dicrotous.
B. The anaemic kind is characterised mainly by an associated
impoverishment of the blood : cases of the plethoric kind may eventually
present hydraemic conditions and fall into this category. The obesity
may be extreme ; but the fatty masses are fialjliy, and the muscles are
ill-developed and feeble. The heart partakes of this muscular inadequacy
and acts feebly, the pulse being small. Some elevation of arterial
pressure, due to peripheral resistance, may, however, be met with as in
ordinary cases of anaemia. In short, we have all the prominent features
OBESITY 613
of anaemia, together with excessive fatty deposition : great incapacity for
exertion, ready induction of palpitation and dyspncea, and small appetite.
These patients are neither gross feeders nor always large drinkers. They
have often, indeed, an aversion from animal food, and prefer a dietary rich
in carbohydrates. The deficiency of haemoglobin in the blood and the con-
sequent inadequate oxygenation maintain and increase the tendency to
obesity. As already stated, women are the common subjects of anaemic
obesity ; and the disorder may be manifested before full growth of the
body is established, namely, before the age of twenty-two. Menstruation
is generally disordered, or may be absent. Menorrhagia, or losses of
blood after child-bearing, may lead subsequently to anaemia and to obesity.
This variety is sometimes met with in men after exhausting illnesses,
and is not infrequent after enteric fever, acute rheumatism, or pneumonia.
It is also witnessed after submission to full mercurial courses for the
purpose of eradicating venereal taint ; but it is not met with in cases of
operatives suffering from hydrargyria.
Dropsy is commonly associated with anaemic obesity. The arterial
pressure falls at last, the flow of urine becomes scanty, and, in spite of
free perspiration, the tissues become Avater-logged.
Such patients are altogether more seriously ill than those of the
plethoric kind, since the latter may bear with their condition for many
years before the blood becomes impoverished and hydraemia sets in.
The muscular debility is a factor of supreme importance in the former
cases, and adds to the difficulties of successful treatment of the symptoms.
Whether anaemic or plethoric, the subjects of obesity are ill adapted
to bear the inroad of acute diseases. Fever, in particular, is very badly
borne by them : fatty investment interferes seriously "with the dissipation
of the heat generated in the body, and thus there is in these cases a
special tendency to hvperpyrexia to an amount incompatible with life.
Acute fevers and pneumonia are therefore very dangerous maladies for
obese pei'sons. Antipyretic measures are seldom effective ; and drugs
such as quinine, antipyrin, and salicylates are badly borne, and may
induce collapse. Cold baths in cases fit for it are more successful. If
life be saved, convalescence is tardy ; and an increase in obesity may occur
in response to the necessary supporting alimentation. This is due to the
inherent vicious metabolism which pertains to the trophic habits of such
patients.
The line of progressive failure in all these cases may be traced into
almost every system of the body. Heart failure and arterial sclerosis
have already been referred to. The lungs become the seat of bronchial
catarrh, and emphysema may supervene. Gastro-enteric catarrh and
gastrectasia from over-eating and drinking may prove troublesome com-
plications. A gouty tendency may lead to lithiasis and to the forma-
tion of stone in the kidney. The latter disposition has long been recog-
nised as an appanage of the obese. The liver becomes fatty and greatly
enlarged, adding much to the general discomfort and to respiratory in-
capacity. Gall-stones may form in the gall-bladder, and biliary colic
6i4 SYSTEM OF MEDICINE
occur. Tlie skin becomes lanctuous, and comedones and flat greasy warts
may be formed. Eczema, erythema intertrigo, and furuncles are not
infrequent ; and if alcohol be freely taken, gutta rosacea and hypertrophy
of the nose may be present. The causes of death in cases of o])esity are
syncope, cerebral apoplexy (from degenerate arteries), cardiac rupture,
angina pectoris, and unTmia.
Due consideration of the foregoing facts should convince any careful
practitioner of the futility of treating obese persons by any uniform
method. In these cases, as in all cases of disease, reg.ard must be had to
the individual and to the personal factors present ; and the particular
nature of the obesity must be accurately discriminated before any thera-
peutic measures are attempted. The question of iidieritance or of ac(iuire-
ment must be settled, and the patient, and not his symptoms merely,
must be treated. Without doubt much harm may be done if a hard and
fast line of treatment be indifferently instituted. In this vrnj it is that
patients, to reduce their obesity, are sometimes set to pursue dietetic and
other measvu'es which may prove not only unavailing but positively
mischievous ; and others venture to carry out vaunted methods on their
own responsil)ility, not seldom with risks to their general health, which,
if unrecognised, are none the less grave.
We must understand, in the first instance, that obesity may be
little more than the normal trophic equilibrium for a certain person ;
and any efforts, seriously jiushed, to alter this special conformation
may be fraught with risk to his general well-being. As Dr. Michael
Foster says: "The same tissue has in different races and different
individuals specific and individual characters of nutrition. The flesh of
the dog is not the same as that of a man, the muscle of one man lives
differently from that of another."
On the other hand, to quote the words of Sir James Paget, " the
over-fat are certainly a bad class, especially when the fatness is not
hereditary, but may be referred in any degree to their over-eating,
soaking, indolence, and defective excretions. The worst of this class are
such as have loose, flabbj^, and yellow fat ; and I think jow may know
them by their bellies being pendulous and more prominent than even
their thick subcutaneous fat accounts for ; for this shape tells of thick
omental fat, and I suppose of defective portal circulation. I know no
operations in which I more nearly despair of doing good than in those
for umbilical hernia or for com[)ound fi-actures in people that are over-fat
after this fashion. Nothing short of the clearest evidence of necessity
or of great prol)able good should lead you to advise cutting operations
in people of this kind. Do lithotrity for them rather than lithotomy ;
determine very carefully whether it is absolutely ad\isable that you
.should do either ; incline against amputations for even bad compound
fractures, and, whenever you can, — as, for instance, for cutaneous cysts,
haemorrhoids, and the smaller examples of scirrhous mammary cancers, —
use caustics rather than the knife or ligature."
Hence it is that I strongly urge that the conduct of all such cases
OBESITY 6iS
should be conducted by the clinical skill and under the constant super-
vision of a well-trained medical practitioner. This much being conceded,
it is not too much to affirm, further, that there is nothing special or
peculiar in the subject of obesity which any well-educated medical man
may not be trusted to deal with. It is necessary to assert this much,
because of late years this matter has been absurdly exalted into a
"speciality " — a pretension unworthy of our profession and misleading to
the general public.
Obesity is recognised by medical officers for life-assurance as an indica-
tion of imperfect health. If the body-weight bear an undue proportion
to the height of the individual, such cases are either " loaded " or declined
as second or third class lives. Obese persons bear accidents badly, are
unsatisfactory subjects, as we have seen, for surgical operations, and are
apt to succumb to serious illnesses. Adults of medium height and fair
symmetry, who weigh over fifteen stones, may be considered moderately
obese. A weight of twenty stones and over constitutes a grave case ; but
examples are on record where weights of over thirty stones Avere scaled.
Daniel Lambert weighed thirty-two stones at the age of twenty-three,
and reached fifty-two stones and eleven pounds in later years.
Occupation and habits of life are familiarly known to induce obesity
in certain classes of persons. Sedentary life, whether in or out of doors,
favours it. Active members of any profession are not prone to become
corpulent unless there be a strongly-inherited tendency. Coachmen are
apt to suffer unless they groom their horses. Soldiers and sailors do not
become obese until they retire from active duties. Sea-captains, owing to
their good appetites and limited locomotion, are often victims in spite
of their open-air life. In all these cases habits of lieer-driidcing or of
spirit-drinking (even if well diluted) are certain to aggravate the tendency.
Cases of extreme obesity may be noted amongst monks, whose duties do
not entail much muscular activity ; and who, if they eat little meat, often
partake largely of fats and carbohydrate matter. Mental activity, worry,
and anxiety all tell against obesity, and so do grief and the irritable
or nervous tempei^ament.
Treatment. — Preventive. — The main indications are to secure habits
of strict temperance in respect of food and drinks, and to ensure a
life of activity, both mental and bodily. This is especially important
when a hereditary tendency to corpulence is present ; and it applies
to young children and young adults no less than to persons in the
third or foiirth decades of life. An obese mother is a bad nurse for
her infant ; a good wet-nurse will be better. If the latter cannot be
secured the mother shoidd be dieted, and fatty and carbohydrate foods
be restricted as far as possible. Beer should not be taken. Artificial
feeding with sterilised cow's milk is probably better than the maternal
milk, and farinaceous food should be excluded, or much reduced in amount,
malted food being preferable. In early adult life fat-forming food is to
be restricted, and abundant muscular exercise in the open air en-
couraged. Seaside residence is especially favourable and sea-bathing
6i6 SYSTEM OF MEDICINE
Avhen practicable. Later, active exercises are of much value ; and
athletic pursuits in moderation, such as gymnastics, tennis -playing,
riding, rowing, and swimming, may be enjoined with great advantage.
Dietetic. — Without doubt the most remarkable results in diminishincr
eor])ulency due to undue formation and storage of fat in the body are
secui'cd by the modification of the ordinary dietary. JModern physiology
and chemistry alike indicate the main lines to be followed in this respect.
In recent times professional and public attention has been specially
devoted to this matter by the successful treatment which was instituted
some thirt}'^ j'ears ago in the case of ]\Ir. Banting liy his medical adviser
Mr. Harvey. The essential feature of it consisted in the withdrawal of
fat-forming food. Mr. Banting took freely of animal food, but ceased to
take bread, butter, milk, sugar, potatoes, and sweet Avines. Xo limit Avas
placed on the amount of water, and from six to eight ounces of light red
wine were taken daily. On this system forty-six pounds of weight were
lost within a 3' ear, and although the patient was sixty-six years of age he
recovered a large measure of health and comfort. This plan of treatment,
while it secures the absence of food that most readily induces obesity, is
also characterised by a very large ingestion of nitrogenous matters which
are difficult of complete digestion and assimilation. In other cases in
which it Avas employed it provoked indigestion, and caused depression and
various nervous symptoms. The quantity of albumin Avas partly con-
sumed in the production of heat. This method, then, is unsatisfactory
in principle and in practice ; partly because of the digestive inadecpiacy
of the body to deal Avith so much nitrogenous matter, and partly because
of the slender value of it as a heat-producer Avithin the organism. The
nervous system also suffers from deprivation of fatty matters in such
a diet. Fatty food is less liable than carbohydrates to cause obesity,
being less easily oxidised, and interfering less Avith the disposal of
albuminous matters. In a given Aveight it contains more potential energy
than the carbohydrates.
Experience has plainly shown that a small proportion l)Oth of fat and
carbohydrates must be combined Avith the nitrogenous ingesta in order
to ensure normal metabolism; and, to secure a consumption of fat already
deposited in the body, muscular exercise must be freely taken to induce
increased nitrogenous decomposition. Under these conditions the obese
patient loses fat. Muscular activity promotes oxidation of fat, and the
small amount consumed in the diet is thus readily disposed of. Carbo-
hydrates are more digestible than fats.
The influence of fluids, more especially of A\-ater, upon fatty deposit
is prolxibh^ considerable Avhen large (juantities are consumed. The evil
effects of diluted alcohol and saccharine matters arc avoU ascertained.
In many cases of obesity there is a marked disposition to drink
copiously.
The appetite for food is found to be normal in about half the cases,
Avhile it is increased in a someAvhat smaller number. In some cases the
appetite is beloAv the normal.
OBESITY 617
Eestriction of fluid food Avill certainly assist greatly in reducing
corpulence in such cases as may be properly treated in this way.
" Bantingism " then, as a system, is both unphysiological and im-
practicable. Its failure led Ebstein to recommend a modification of
it in which fat was permitted, but starchy and saccharine matters almost
withheld. Oertel's system of dietary practically corresponds with this ;
but he enjoins with it graduated exercise, restriction of fluids and fat,
and with measures to fortify the muscular system generally and the cardiac
Avails in particular. Schweiniger's system is very similar, but he forbids
fluids at meal-times, and prescribes them two hours subsequently. The
Salisbury treatment consists in a very free allowance of animal food and
entire absence of carbohydrates, large quantities of hot water being taken
to wash out the excessive nitrogenous metabolic products from the body.
In any case particular attention is to be paid to the condition of the
heart, with a view to reinforce it as much as possible. The urine no less
demands careful attention ; when lithates are abundantly thrown down,
the amount of nitrogenous food must be diminished. Deficient excretion
of urea demands a similar procedure until a fair percentage is passed,
Avhen the diet may be altered in this respect. Bouchard recommends
fruit and fresh vegetables, that contain potass salts, to encourage a more
free oxidation of cax^bohydrates in the diet.
Weir Mitchell and Bouchard recommend a dietary of milk and eggs,
and the exclusion of all other food. Thus, for three weeks they prescribe
half a pint of milk and an egg every three hours five or six times in the
twenty-four hours. At the end of this period they vary the diet in
accordance with the general principles just mentioned. The proper ratio
between the nitrogenous and carbonaceous elements is fairly maintained
by this early treatment. Constipation is likely to occur, and the patient
is unfit for much exertion. The monotony of this diet may prove hard
to enforce in patients of feeble jDurjiose.
The general principles to be observed in treating cases of obesity
relate, then, so far as dietetic measures are concerned, to the restriction of
fats and carbohydrates, and no less to a certain increase in the proteids.
The latter augment the metabolism of the whole body.
Of food-stuff's a healthy adult requires — of proteids 100 to 130 grms.,
fats 40 to 80 grms., carbohydrates 450 to 550 grms., salts 30 grms., and
water 2800 grms. The carbohydrates should thus be four or five times
in excess of the proteids. Experience shows that all these elements are
necessary for perfect nutrition, fatty matters in particular. The fats and
carbohydrates, though chemically allied, are subjected to divergent meta-
bolism, and are not mutually interchangeable without risk to the economy.
The carbohydrates are believed to supply heat more rapidly than fats
— the latter requiring more time to afford this form of energy, having
probably first to be converted into sugar. Both in health and disease, it
is to be borne in mind that no isolated organic principle is by itself
capable of supporting life. Instinct and knowledge prove alike that
6i8 SYSTEM OF MEDICINE
there must be .a combination of ])rinciples furnished to the system for
due nutrition.
In treating cases of obesity the patient should be accurately weighed.
A careful physical examination of all the organs and secretions of the
body should be made, especial attention being paid to the condition of
the muscular walls of the heart, the state of the arteries, and the urine.
The question as to heredity or acquirement must be noted ; the tempera-
ment, and the habits of life in respect of food, exercise, and occupation,
the age and sex, and the form of the disorder, Avhether plethoric or
anjemic, are to be considered. An inquiry as to gouty proclivity or to
ha?morrhagic tendency is necessary. The presence of glucose in the
urine demands careful attention, and its significance must be gauged as
far as possible. Any indication of renal insufficiency, as evinced by a
persistently deficient output of urea, is particularly to be noted ; because
this condition plainly demonstrates the unfitness of the patient to bear
a dietary rich in proteids.
Two objects are to be sought in treating any case : /rs/, to reduce
excess of fatty deposits; secondly, to prevent reaccuviulation of it. The first
is often more or less easy, but the second is often rendered difficult by
restiveness and Avant of due control on the part of the patient.
The following dietary may be usefully enjoined in many cases : — Six
or eight ounces of hot or cold Avater may be taken half an hour before
breakfast. Bi'eakfast should consist of one or two ounces of well-toasted
stale bread without butter, grilled white fish, grilled mutton chop or beef-
steak, or cold chicken, game, beef, tongue, or lean ham. One or two small
cups of tea or coffee, with a little skimmed milk and without sugar, may
be taken. Saccharine may be used as a sweet-flavouring agent, but is
commonly disliked. Six ounces of bouillon or clear soup may be taken by
weakly patients between breakfast and luncheon, and a gluten or almond
biscuit with it. For luncheon order cold meat, or a poached egg Avitli
spinach or lettuce, or other green vegetable, as water-cress and mustard
and cress, or a small omelette. Ciiist of bread or hard biscuit in small
amount is allowable, and a small quantity of fresh butter. A glass
of good Bordeaux or ]\Ioselle wine (dry) may be taken with as much
water. A cup of tea, with a little skimmed milk and a rusk or
gluten biscuit, may be taken in the afternoon. For dinner, no soup
is to be taken as a rule, but occasionally about eight ounces of a thin
consomme may be allowed ; then a little gi'illed or boiled fish, without
starchy or fatty sauces, but flavoured sometimes with anchovy or some
other sauce, oysters, or caviar, a little grilled or roasted meat, mutton,
game, or fowl, with a small proportion of fat, green vegetables, no potatoes,
and some stewed fruit flavoured with .saccharine, or made less tart by
the addition of half a toaspoonful of Eochelle salt. Two glasses of
claret or of a dry ^Moselle diluted with water aie allowable. Later
in the evening a cup of hot Aveak tea Avithout milk, or as much hot
Avater, should be taken.
Such a dietary, adapted for an adult man, is little irksome to any
OBESITY 619
serious patient. It should be continued for some weeks. Women will
naturally require smaller quantities of each article. Exercise of any kind
is most desirable between meals, and life in the open air is to be carried
out as far as possible. Seven hours' sleep is commonly sufficient, and no
sleep should be sought except in bed. The patient should lie on a hair
mattress and in a well-aired room. Tepid bathing and a cold shower
bath on rising, with good subsequent friction, should be employed daily.
Alcohol in the form of diluted brandy or AA'hisky is unadvisable.
Accordingly as weight is lost, the general health being good in all
respects, this dietary may be varied with suitable precautions, and a more
or less strict attention be paid to the various details of it. If the treat-
ment succeed, increased capacity for exercise, brain-work, and a general
sense of relief and comfort, perhaps long unfelt and enjoyed, will be
experienced. The action of the heart should become more vigorous, the
pulse fuller and firmer, the expiration easy, and the urine remain
clear on cooling. Tobacco-smoking should be restricted, and used only
after meals. The bowels must be relieved daily ; if constipated, moved
by two drachms of Carlsbad or Homburg salts, or by a dose of white
mixture (haustus albus) while dressing in the morning. If digestion is
languid or uncomfortable, a mixture containing dilute nitro-hydrochloric
acid and nux vomica, or chiretta, may be taken in the forenoon and after-
noon before meals.
Cases of anaemic obesity require iron in some form, and the scaly
preparations of it are perhaps the most serviceable, given in calumba or
quassia infusion.
If fatty accumulation is found to recur with relaxation of the enjoined
dietarj-, either in its quantity or quality, stricter measures will be indicated
with a view to maintain as good general health as possible, and also to
control the persistent tendency to pinguescence. One article after
another in the diet must be left out till a fair balance of nutrition is
permanently secured. For an adult in early and middle life the relative
quantities of food required should average 12 to 14 ounces of meat, 6 to
8 ounces of toasted bread, rusk, or gluten and almond biscuit, 4 to 5
ounces of green vegetable, 1 to \\ ounce of butter and fat, and 30 to 35
ounces of fluid, including wine, tea, and water. As a disciplinary
measure it is proper to measure and weigh the food at the outset of
treatment. This method also prevents an insidious tendency to excess
in some articles of the dietary. The patient should be weighed, in the
same clothing, or better still without clothes, once a Aveek.
Treatment Inj diminution of fluids (dry diet). — It is certain that the
Aveight of the body and over-storage of fat can be reduced more or less by
a reduction in the amount of fluid consumed. To take an example : I
treated a hospital out-patient some years ago, a woman under forty years
of age, presenting the plethoiic type of obesity, who Aveighed tAventy-one
stones, Avith a dietary in AA'hich Avhite bread, potatoes, and sugar Avere
largely reduced, but not excluded, and the consumption of fluids of all
sorts limited to thirty ounces per diem. The patient AA-as an intelligent
620 SYSTEM OF MEDICINE
and ti-ustwoi-thy person. She often took less th;iu the prescribed amount
of lluid. For medicine I ordered some dilute nitro-hydrochloric acid and
nux vomica. Within eight months there was a loss of between seven
and eight stones, the diet being maintained ; and no increase in corpu-
lency took j)lace for another year or longer while the patient Avas under
observation. The genci-al health and comfort secured were very note-
Avorthy.
One may not always succeed so well ; but in restricting liquids, as in
limiting anything else, there is often great difficulty in securing co-opera-
tion and o!)edience from patients accustomed to self-indulgence, especially
if treatment be cariied on at home.
The plan of restricting fluids may l)e applied in any case of obesity
presenting no contrary indications. In cases with weakness and dilatation
of the cardiac Avails, Avhere hydra^mia and tendency to dropsy exist, as in
the aniemic type of cases, the Iienefit from a so-called "dry diet" may be
very marked. It is Avell to limit the fluids of all kinds to thirty ounces,
but the amount must vary a little according to the time of year and the
particular food taken. Cardiac tonics, such as digitalis, are found to act
Avith more efficiency Avhen restriction of fluids is practised.
This plan is not practicalile nor advisable in cases in Avhich glycosuria
is present. It may be noted that obesity may long precede the occur-
rence of glycosuria, and that early treatment for the former may not
improbably stave off the latter condition.
Increased water-driiikiiuj sometimes necessary. — More free dilution,
especially by water-drinking, is advisable, and indeed necessary, to remove
excess of glucose from the system. Not less than three pints per diem
may be considered the normal amount of fluid for consumption, and
seventy ounces or more may often be taken. Persons of large frame
require larger quantities of fluid. Cases of gouty diabetes AAdth corpu-
lency Avill be benefited by a larger rather than smaller supply of fluid,
proA'ided there be no cardiac or renal complications. In albuminvu'ia,
Avhich is not infrequently present in obesity, a restriction of fluid is often
called for to meet associated cardio-vascular difficulties. If proteids be
given in large quantity it is necessary to enjoin abundant AA^ater-drinking
to carry off" the products of nitrogenous metabolism, Avhich would other-
wise become noxious. This is an essential featiu-e of the Salislmry plan
of treatment. Fats and carbohydrates are elements of food Avhich induce
much less metabolism than proteid matters. Proteid food increases both
proteid and non-nitrogenous metabolism, and may thus reduce the fat of
the body. The gouty habit, Avith lithiiemic tendency, if associated AA'ith
obesity, demands free dilution. In all these conditions it is proper to
take fluids freely about three hours after the larger meals, and not Avith
them. Half a pint of coUi or hot Avater may be also taken early in the
morning and late at night. Water taken into an empty stomiich is nearly
all passed on to the duodenum, but little apparently seems to be absorbed
from the gastric surface. To drink freely of Avater ccrtaiidy increases
metabolism, more urea being discharged than can otherAvise be accounted
OBESITY 621
foi\ If the skin act freely, as often happens in obese persons, more fluid
will necessarily be demanded.
Treatment hy spa icaters. — Certain spas are in repute and much resorted
to for treatment of obesity The springs of Carlsbad and Marienbad are
well adapted for many cases. The plethoric form of obesity is that in
which most benefit is likely to accrue. Hot alkaline sodium sulphate
waters ai'e available at the former, and cold ones at the latter spring. At
Carlsbad there are many supplementary measures available for diminish
ing corpulency : hot mineral, mud, and vapour baths, massage, gymnastics,
and electricity are within easy reach of the patient. The functions of
the skin, muscles, and gastro-intestinal tract are all stimulated, and active
metabolism encouraged.
The Marienbad course is more bracing. The dietary is well arranged,
and a general disciplinary regimen is admirably carried out, which is
commonly very desirable for obese patients yet difficult to secure to the
same extent in other watering-places. This course is not desirable in the
case of jiatients with cardio-vascular derangements, nor in the anaemic
class of obese persons. No routine course is, however, pui'sued, and,
under skilled medical supervision, there is no need to fear that any
injury may be done by over-treatment.
When a milder course appears desirable, it may be carried out at
Homburg, Ems, Kissingen, Tarasp, or Brides-les-Bains. It is often asserted
that the special advantages of spa treatment are but temporary. This
need not be the case. An obese patient may be set on a right course,
but he must continue to pursue it under medical guidance, and carry
out the particular diet and habits necessary for his peculiar condition.
Relapses are only too common under any method of treatment unless
due and permanent precautions are taken. Oertel lays great stress on
regulated exercises, such as the gentle climbing, especially in mountain
districts, known as the " terrain " cure. He regards spa treatment
alone as no specific in these cases, but only adjuvant to other measures,
and even harmful when overdone or carried out so as to starve the
patient. It is well to repeat visits to such spas as are found suitable
whenever possible. In anaemic cases aperient waters containing a little
iron are of especial value. AVhere there is any cardiac weakness or dilata-
tion great care is necessary in enjoining any but very gentle spa treat-
ment, and the fluids should be restricted. The same rule holds good
where arterial sclerosis prevails.
If glycosuria is present, Carlsbad treatment, or that pursued at
Neuenahr, is advantageous ; and the same maj^ be said in respect of the
multiform phases manifested by a gouty proclivity.
Roman or Russian vapour baths are available in cases presenting
hydraemia, when restriction of fluids is called for. Not more than three
baths should be taken in each week while undergoing treatment. Cardiac
disturbances may be aggravated by vapour baths.
It is stated by Lahnsen that there is an absolute immunity from
obesity on the sea-coasts. This is, perhaps, too general a statement, but
622 SYSTEM OF MEDICINE
there is probably a basis of truth in it, and a seaside residence may be
recommended with advantfige in some cases of strong predisposition to
obesity. Persons of gouty inheritance, many of whom are disposed to
inidue corpulence, are not, as a rule, well affected by marine influences,
and enjoy better health inland, in hill}' and breezy countries.
Treatment by thi/roid extract. — Some satisfactory results have been
obtained of late in the treatment of obesity by the use of thyroid extract.
There can be no doubt that this agent has a very marked influence on the
nutrition of the skin and integumentary system generally. There is, as
yet, however, no certain knowledge as to the particular class of cases in
which benefit may be expected. Hence it is not advisable to resort to
such treatment indiscriminately. That it is universally applicable can
hardly be expected ; but it may sometimes prove serviceable in default
of other well-recognised methods of treatment, or in addition to them.
In any case it must be used with the same strict precautionary measures
as are necessary in treating patients for myxoedema.
Dyce Duckworth,
REFERENCES
1. Duckworth, Dyce. "Diabetes in Relation to Arthritism," S(. Barth. Rosp.
Hep. 1882. — 2. Ebsteix, W. Die Fettleibigkeit und i/irc Behandlung. Wiesbaden,
1882. — 3. FosTEK, Michael. Text-Book of Physioloijn, vol. ii. 6th edit. 1895. —
4. Harvey, W. On Corpulence (Banting treatment), 1872.— 5. Legendee, P. Art.
"Obesite," Traite de mMecine, tome i. 1891. — 6. Mitchell, Weir. Fat and Mood,
and how to make them. 1878. — 7. Oertel. Art. " Obesity," XA7A Century Practice
of Medicine, vol. ii. 1895. — 8. Paget, Sir J. Clin. Lectures and Essays, 1879, p. 14.
— 9. Pavy, W. Physiology of the Carbohydrates. 1894. — 10. Yeo, J. Burxey. Food
in Health and Disease. 1889.
D. D
DISEASES OF THE RESPIRATOKY ORGANS
GENERAL PATHOLOGY OF RESPIRATORY DISEASES
In this chapter a short account will be given of the action of the
mechanism of breathing, in health and in disease, and also of certain
phenomena which commonly occur in the course of respiratory diseases,
and Avhich are partly concerned in their pathology : such incidents as
cough, dyspncea, and asphyxia ; the carbonisation, so-called, of the blood ;
and, in each case, the results of these actions, as seen in the lungs and in
the general system, will be traced. With regard to these subjects, it is
needfid to call attention to the peculiar structure of the lungs, and to
their relations Avith other parts of the frame.
The lungs are, to some extent, set apart from the rest of the body.
Suspended from the trachea and blood-vessels, they are indeed connected
with the general system by vessels and nerves, and by the mucous mem-
brane ; but, under normal conditions, they are kept in apposition with
the walls of the thorax by atmospheric pressure only. They have a
separate heart, and special muscles to control the influx and efflux of the
air. As Claude Bernard was fond of repeating, they are an artifice of
construction, by which an animal, otherwise aquatic, can exist and move
in the open air. " Les tissus vivans sont aquatiques sanguinaires, ils se
repaisent du sang dans lequel ils sont plonges. lis y vivent comme des
animaux aquatiques " (2).
Again, no organ in the body contains such a variety of structural
elements as the larger-sized bronchial tubes. Both large and small tubes
are provided with an epithelium, an iinier connective layer, a circular
muscular layer, and a well-marked outer fibrous tissue layer ; and the
larger have, in addition, a compound epithelial layer, a well-marked base-
ment membrane, hyaline cartilages, and mucous glands. In consequence
of this complication of structure, and of the relations existing between
the lungs, heart, and brain, it follows that all long-continued affections of
the pulmonary organs have an extremely complex ]mthology. Yet in
most respii'atory disorders, in spite of their great complexity, there is
much in common ; certain disturbances of the normal functions of the
body which arise during their course are closely similar, and these, not-
withstanding much difference in the modes of their inception, often bring
in their train a series of related changes between the central and remote
portions of the frame which in their final results are strikingly alike.
VOL. IV 2 s
626 SYSTEM OF MEDICINE
In illustration of this statement we may compare the results of certain
serious diseases of the lungs with those that have, at the outset at any
rate, a comparatively trivial origin.
The more serious diseases of the lungs are visually the result of
inflammation due to some irritant ; this, if repeated or long continued,
impairs the lung-tissues, and may do permanent damage to the heart
and nervous system. It matters very little that these actions may
have been produced by different causes — by the direct influence of
heat or cold, liy mechanical or chemical agents, by micro-organisms or
their products — the consequences will often be very similar. The struggle
of the elements of the animal body to overcome or to remove the sources
of irritation, to clear away the effects of their presence, or to buttress the
tissues against them, may entail structural changes in the lungs them-
selves of more or less gravity ; but they also often lead to cough, dyspnoea,
and ultimately to serious consequences in distant organs.
On the other hand, a simple mental distiu'bance, as in hysteria,
a strong emotion, or a purely reflex irritation, as in certain forms of ear-
disease, or an intestinal irritation, may excite the respiratory centre in
the medulla and induce dyspnoea : or again, these accidents may cause
a violent spasmodic cough, which, in certain weakened conditions of the
lung-tissues, may do serious injury to the system.
The similar results which arise from these special factors we are
presently to study ; and, in the first place, it is important to note the
mode of action of the ribs and of the muscles acting upon them.
The mechanism of breathing-. — In healthy breathing a large part of
the inspiratory act is accomplished, both in men and women, simply by
the contraction of the diaphragm ; and expiration takes place, as soon as
this muscle is relaxed, by means of the natural elasticity of the lungs.
The extent of movement of the ribs in these actions is very small,
especially in the upper parts of the chest, — a fact- we may note at any
time by Avatching the tranquil breathing of a healthy person during
sleep.
The natural stimulant of the respii-atory centre in the medulla is the
carbonic acid of venous blood ; and when the need for oxygen has been
satisfied by inspiration, the inhibitory action of the vagi brings about the
act of expiration. But as soon as, from any cause, such as extra exertion,
the oxygen tends to fall below the normal, or the carbonic acid to rise
above it, the automatic action of the vagi comes more strongly into play,
and forces the breathing.
In forced breathing not only the diaphragm, but the intercostals, the
scaleni, and other accessory muscles also, come into action ; and the ribs
begin to play an important part, both in inspiration and expiration.
Not only are these bony levers raised during inspiration, and lowered
during exj)iration, but in the final forced eflbrts at expiration there is
also a distinct shortening of their chord-lengths.
The flexibility of the living rib, and its liability to be bent, even per-
manently, is shown clearly enough by the sinking in of the thoracic wall
GENERAL PA f I JO LOGY OF KESPLRATORY DISEASES 627
OA^er the site of a dried-up vomica ; when the lung does not expand on
the absorption of pleuritic tluid ; by the barrel like distension of the chest
Fig. 11.— Thoracic cailipers.
in emphysema ; by the indrawing of the lower ribs in dyspnoea ; and by
the defomiity of the rachitic thorax.
Fig. 12. — Rib goniometer.
In forced expiration the inbending of the ribs has been demonstrated
by the following means : — ^
^ A full accouTit of the investigations on this point will be found in the author's 'work
atethoiitetnj, published by Macniillan, London, 1S76.
628
SYSTEM OF MEDICINE
(i.) By actual measurement of the chord-lengths of the ribs, after full
inspiration, and again after forced expiration, by means of the thoracic
callipers (Fig. 11). (ii.) By calculation of ihe, jwssible extent of motion of
the ribs, considered as rigid levers ; the angles made by the plane of the
ribs with the vertical being ascertained by means of a specially designed
goniometer (Fig. 12). (iii.) By a comparison of the extent of forward and
upward movements of the anterior ends of the ribs in young children, in
adults, and in old people. The forward motion is in jiroportion to the
flexibility of these levers, (iv.) By the explanation which this bending
WATKINSON.S
Fio. 13. — Two-plane stoUiograpli.
of the ribs affords of the meastiremcnts of the movements of the chest wall
in various diseases, and of the deformities produced in the thorax by such
diseases as whooping-cough. The cyrtometer shows the extent of these
deformities clearly enough, (v.) By the shape of the tracings, made with
the stethograph, of the course taken by the anterior ends of the ribs, in
forced breathing, and in the various acts of coughing, sneezing, and yawn-
ing ; and by the differences in the rib-tracings of movements voluntarily
produced.
The last-named method has so important a beai-ing upon our present
subject that it will be bi-ietly described.
The action of the stethograph will perhaps ])e sufficiently shown by
the accompanying diagram (Fig. 13).
GENERA L PA THOL OGY OF RESPIRA TORY DISEASES 629
mmmmmmwjAmmmmwmmMWdw^
mwmmr.ifwmmmmmmwKfAWmmmm
Fig. 14. — Movement of the clavicle iu a healthy man, set. 39.
IIW
IM
lIKi
vm
■■■
■■■
■■■
■■■
^■^
Sii
■K
■■
■■
■■
■■
■■SI
■■■f
■■■1
1 ss
■!«■■■■■■■■■■
■!■■■■■■■■■■■
■»■■■■■■■■■■
Fig. 10. — Muveuieut.s of the third ribs in a healthy woman, tet. 2t>.
issanorasssmsss
■■^/■■■■■■■■riii
■■KfiMBBBJaaaii
■SHUiP!2^igiBBBiif:il
■■■■i^y^Biiiiii^iii
{■■■■■F^i^BBL^..^^^
Pl^iSSSSSS^
f'li.. 10. — Hnalthv adult ii:an. JMuvi-meuts of third rilis.
Pig. 17.— Same case, fifth ribs.
■■■■■■I
WMfmwsm
■savJagBgi
Jaaiaaaa^aBBgagagaBi
Fig. 18. — Same case, seventh ribs.
Fig. 1;». — Same case, eighth ribs.
630 5" ) :V 7 EM OF MEDICINE
The tracings are taken by snpj)oi-ting the hack, by means of a pad
phiced opposite to the spinal articulation of the ril) under examination.
The button of the stethograph is then kept in apposition to the anterior
end of the rib, and the pen is adjusted to the screen, which, in the more
delicate experiments, may be of smoked glass or of i)aper ; it is divided
into squares of iV^h inch of side.
The preceding curves (Figs. 14-1 9) are selected lo illustrate the results,
but I shall do no more now than just advert to the 2)roofs they afibrd of
the elastic property of the rib-levers themselves.
In these ri]>tracings a steady increase in the degree of horizontal
compared with the A'crtical motion is apparent, from the clavicles to the
eighth ribs ; and in all there must have been a considerable indrawing of
the anterior ends of the ribs in forced exjjiration.
Acts of forced breathing, such as we have now surveyed, are, in health,
only temporary. As soon as the occasion passes the respiration returns
to its former tranquil character.
But in most respiratory disorders, at any rate during a portion of
their course, the movements of breathing, although diminished on the
whole, yet approximate to the forced type ; in other Avords, to a trut-
dyspnoea : and, usually, an entirely new set of actions is also introduced —
the spasmodic, or, as Cohnheim appropriately calls them, the " explosive "
expiratory impulses of sneezing and coughing.
It will be convenient to take the latter set of actions first, both
because of the assistance that we shall gain in their study from the
stethographic tracings ; and because cough, for the most part, precedes
the subsequent dyspnoea, and is often the cause of it.
On coug-hing" and sneezing". — The primary intention of these acts
is doubtless the remoAal from the air-passages of matter lodging in them
and irritating the sensory nerves.
When the source of irritation is in the mucous membrane of the nose,
sneezing is usually the result, the sensory fibres of the fifth pair of nerves
conveying the impulse to the brain.
When the oft'ending body is in the larynx, or near the epiglottis, the
Avave of sensation follows the superior laryngeal nerve.
The posterior wall of the larynx seems to be a very sensitive part,
but the trachea is also easily irritated, and, again, both sneezing and
coughing may l^e started by reflex irritation from regions outside the
respiratory apparatus. In disease this sensitiveness is often greatly in-
creased, owing both to causes in the bi"onchial mucous membrane itself, and
to external impulses, such as exposui'c of the skin to diaughts of cold air.
On the other hand, after repeated irritations, there may l)e a diminished
sensibility of the parts, as in snuft-takers ; or after repeated catarrhs ;
and, usually, in bronchitis, secretion must reach a certain quantity in
order to excite coughing, and must, moreover, come into contact Avith
some sensitive spot in the bronchial tubes.
This sensitiveness of the mucous membrane is of considerable import-
ance, since, if it be absent, or if the lima glottidis l)e kept permanently
GENERAL PATHOLOGY OF RESPIRATORY DISEASES 631
open by any cause, foreign bodies can penetrate into the inmost part of
the lungs, and set up much mischief.
This accident happens not infrequently in cases of coma, or in paralysis
of the adductors of the vocal cords ; and it must be remembered that
after the foreign body has passed the bronchi, its irritation will no longer
excite the act of coughing. Vagus pneumonia, as it is called, which
follows section of the vagi in the rabbit, often arises in this manner.
Often, too, the particle thus entering may be too small, or too unirritating
to cause cough ; thus, fine coal-dust may lodge in the textures of the lungs
and give rise to anthracosis. Other pneumonoconioses arise in a similar
fashion ; Init, in the case of sharp and irritating dusts, there is another
safeguard in the outpouring of mucus from the mucous membrane. This
envelops the particles, and by ciliary action they are carried up to the
more sensitive parts of the air -passages, where they are expelled by
cough. This safeguard, however, often fails, and then, as in occupations
involving the constant inhalation of such irritating particles, cirrhotic
conditions of the lungs supervene \y\de art. " Pneumonoconiosis," vol. v.]
Similar remarks apply to the inhalation of putrefactive and patho-
genetic bacteria. The former, if they escape the mucus, and are not
discharged by cough, may remain embedded in stagnant secretions, and
may give rise to putrid instead of simple bronchitis, or even to gangrene
of the lung. Phthisis is usually the consequence of the inhalation of
tuberculous dust, and other specific poisons probably enter the system
through the air-passages.
Mechanism of the actions. — In sneezing, after inspiration, there is no
complete closure of the air-passages, but a sudden, swift effort of expiration.
In coughing, the preliminary inspiration is followed by more or less
complete closure of the glottis ; then, by a sudden expiratory effort, the
air in the chest is compressed, the block at the larynx is. suddenly lifted,
the ribs rapidly descend, are drawn downwards and inwards, at their
anterior ends, so as to compress the lungs, and the air is forced at high
pressure through the upper air-passages. The action is something like
that of a pop-gun ; and the offending material is usually thus expelled from
the larynx, and often into the mouth. This sudden and energetic effort,
aided slightly, perhaps, by the natural elasticity of the lung-tissue, is
mainly effected by the united forced efforts of the thoracic and abdominal
muscles compressing the yielding bony cage.
The action of the ribs, both in sneezing and coughing, is made very
clear by a glance at their respective stethographic tracings, which are
here appended ; and tracings of the course of the anterior ends of the
ribs, in the acts of nose-blownng and yawning, are also given.
In one set of experiments, after an inspiration and sudden closure of
the nose and mouth, the air was allowed to escape rapidly, as in the
action of nose-blo^ving. The results were as shown below (Fig. 20) ;
curves a, h, and c being the course taken by the third rib whilst the nose
was blown once, and curve cl when it was blown twice, during one ex-
piratory effort.
632
SYSl'EM OF MEDlChYE
In vo:<i'-hli»riit,i^ I lie I'ocord wiis taken in order to ascertain the effect
of suddenly closing the air-passages at the enil of a deep inspiiation. It
Avill be seen that, in every instance, there is a slight forward bulging of
l-'ia. 120. — Action of tlie ribs in nose-blowing.
the end of the rib ; owing probably to the pressure of the compressed nir
in the chest, followed by the simple descent of the lever without any
indrawing at the end of expiration.
A series of shoi't, voluntary coughs Avas then made, with a general
result such as may be exemplified bv the four tracings here given
(Fig. 21).
Fig. 21. — .Sinsili; acts of cou''hinjj
In each case the tracings were taken from the ends of third, ribs.
In yawning, the irregularity of the up-strohe shows the wavering,,
half-gasping nature of the inspiratory effort ; and there is no anterior
bulging at the end of the up-stroke, but an immediate descent of the rib-
lever (Fig. 22).
In meezing there is first the almost rectilinear track of quick inspira-
tion, and afterwards the downward drop of the rih, foHowed by a very
strong indraAving of its end. There is no stoppage at the beginning of
expiration, and no bulging of the chest wall (Fig. 23).
In cnvghing there is ap])aT'ently a combination of the efTorts made
during nose-blowing and sneezing. IJut there arc at least two distinct
ways of coughing — the first, in which closure of the glottis takes place
immediately after inspiration (as in Fig. 21); the second (Fig. 24, a),
in which the act of violent inspiration is commenced, and the glottis is
GENERAL PATHOLOGY OF RESPIRATORY DISEASES
633
not closed until the rib has made some progress in its descent. A
stoppage in the exit of the air then occurs, the rib is first bulged forward,
{{■■■■■■■■I
liSSSiSSBiii
BnuuniHl
Fig. 22.— "A yawn."
Fig. 23. — " A sneeze."
■BBBMBBBBBBBip^aBI
■BBRMBBBBBBBI^aBBI
■BBfJ^BBBBBBRai
BBflrJBBBBBBRifBI
■PBBBBBBRUiBI
■BI'iBilBBflSBilJBBBBI
and then, on the opening of the glottis, is drawn inwards with a violent
expulsive effort. Again, it seems probable that in some cases there is no
complete closure of the glottis, but that
the air is driven forcibly through its
narrow aperture. In this case there is no
forw.ird push of the rib (Fig. 24, l>).
\\\ the acts of compoimd coughing
(Figs. 25 to 27) the glottis is closed
several times during one expiratory effort.
Yet the tracings of these complicated acts
present a strong family resemblance. In
most of them, as we have seen, there is a
slight forward bulging of the rib at the
end of the inspiratory act, amounting in
Figs. 25 and 27 to about 0-05 in.
This appearance must probably be attributed to the expulsive efforts
of the respiratory muscles, which compress the air in the chest and so
force the ribs outAvards. No sooner, however, is the air released from
the windpipe, than there is at once a downward fall of the rib, for a space
of from 0'2 to 0*5 in. with a barely perceptible inward
inclination ; then comes a sudden change in its course,
and it is drawn almost horizontally inwards, until it
iBflBlBBflBBH is caught by the second sudden stoppage of the
Fig. 24. — Varieties of cough.
IBHHBBBBBB
lflflfi!9BBBBH
IBBBBBBI^Sa
■BBBBBBBHM
glottis.
Fig. 25.— Double cough.
At the beginning of a second act of coughing
the motion of the rib is either arrested for the moment,
as in Fig. 25, or it is pushed forwards and even
upwards by the compressed air in the chest (Figs. 26
and 27) ; and then, when it is again released, there is usually a still further
bulging forward, together with a downward drop ; and finally there is the
almost horizontal indrawing of the rib. It is interesting to note that the
extent of the forward bulging is greater the lower the rib gets in its descent
— as if the rib yielded to the pressure within the chest more easily when
in the position of partial expiration than in that of full inspiration. This
is seen in Figs. 24 a and 27.
634
SYSTEM OF MEDICINE
The followinu ti-;iciii<rs of the movements of the third ribs and of a
cough in u c;ise of ehioiiic ])litlu.sis sliow the strong contrast between
■■■■■■■rJHaHmifll
■■■■■ fMmmmmmwMMrmmm
^
■■
mmmwdmmmmmmmmwMi^
wmwiiiimmmmmmmw'AmmSmmmm
■■^■riBBHBBBB^Ii ■■■■■■■
■RBBBBBBBBBBBRIBBBBBB
■flKaBBBBiiBBSSMBBBBBi
Fig. 26. — Double cough.
iibSbbbbi
&WI&3IBBBI
BBHINaiBBI
BBS9BSIBI
Hsai
Fio. 27. — Three acts of coughing.
these movements and those already given in a healthy j^erson (Figs. 28
and 29).i
The effects of coug-hing- in different diseases. — In the early stages
of acute hroucliitU, the expiratory inbending of the ribs adds to the force
with which the air is driven over the dry and inflamed surfaces of the
lining membrane of the trachea and bronchi, and increases the pain.
After the first twenty -four hours, when proliferation and desquamation of
IIBBBI
I^^BBBI
B^BBI
BBBSI
BiBBI
Fio. 2S. — Cliroiiic i)htliisis. Movements of third ribs. Fig. 29. — Cough in chronic phthisis.
the epithelium begin, the cough, if not too violent, may even exert a
l*eneficial influence, assisting in the removal of suppurative or decompos-
ing secretions, and thus tending to j^revent the destruction of ti.ssues ;
this action is all the more im2)ortant as in this disease ciliary action is
early arrested.
These latter remarks ajiply also to chronic hrcmcliUh ; but the tem-
porary relief atlbrded by coughing is then often followed by injury tn the
bronchial wall, especially Avhen atrophic and indurative changes have
taken place, and the bronchial wall becomes a mere fibroid tissue.^
^ This is not the place to discuss the possible causes of the expiratory shortening of the
choril-lengths of the riii.s in forced e.x])iratory efforts ; I l)elievc tliat it is accomplisht-d \\y
tlie combined action of l)oth sets of interco.stal niuscK-s. actiuf,' in concert witli tlie alxloiiiinal
muscles, the iiitercostals acting like the coni]iressnrs of the })liaryii.\, or tlie two oblique
muscles of the abdominal walls. Suttlce it to point out that its etiect is to intensil'y all tlie
coiiseijuences of ordinary e.xpiratory efforts. It is true that, in disease, the respiratory
function is greatly weakened (see "Prognosis in Lung-disease"), but all the more on this
account is it necessary to take account of any additional aid to the exjiulsive forces engaged
ill the acts of forced breathing or coughing, and to note the effect of the compression that is
thus exerted upon the thoracic contents.
'^ Dr. Auld remarks {Palli(i/iii/i/ i,/' Jironrhial AJfecfioiis and Pneumonia, Ijondnn, 1S91,
]). 56) "that ill dironic bronchitis also, tlic retention of decomposing secretions has a con-
.siderable influence over the changes." These are removed by coughing.
GENE RA L PA THOL OGY OF RESPIRA TO R Y DISEASES 635
In imeumonia, cough is often not a prominent feature ; when it is, it
may do but little harm to the inflamed portion of lung. In this
disease, it is most likely that the inflammation is precipitated upon
the organ by some specific irritant, which causes the general symptoms
of a fever, and has its own special site of local manifestation. The con-
solidated lung cannot be compressed, but it may be injured by the
respiratory efforts. Moreover, in most cases, the bronchial epithelium
is uninjured in the non-inflamed parts of the lung, and hence there is
the less need of cough to deal Avith the stained muco-pus.
During the stage of resolution the cough may be lieneficial by clearing
the blocked-up bronchioles ; and in subsequent stages, if not too violent,
it may do more good than harm, even when resolution is imperfect, and
degenerative changes are taking place.
In the early stages of pleurisy the painful, irritable cough can
scarcely do anything but harm, since it tends greatly to increase the
friction between the folds of pleura. Usually, when effusion has taken
place, cough diminishes in intensity.
In fibroid or cirrhotic disease, and in broncho-imeumonia, the cough, if
at all pronounced, which is unusual, is likely to be harmfial in pro-
portion to the disorganisation of the lung-tissue, and to the tearing action
that it may have upon bands of indui^ated interstitial material.
In phthisis the cough may be chiefly of laryngeal origin ; in this
case it is purely distressing, and can do little or no good ; but when the
patient coughs, as often he does voluntarily to relieve the lungs of secre-
tion, the action is remedial and cannot be checked without harm.
It is in the production of emphysema and bronchiectasis that cough
plays the most pernicious part. Whether inspiratory or expiratory forces
be chiefly concerned in the result is still in dispute ; but there can be no
doubt as to the powerful influence of cough in the permanent dilatation
of the alveolar walls and air-vesicles. An admirable account of this
result of cough is given by Sir W. Jenner in his classical article on
"Emphysema" in Reynolds' System of Medicine (13). He further points
out that, as the disease progresses, the relative positions of the lungs and
the chest walls are being continually shifted, and that fresh portions of
the lungs are thus being continually brought opposite to ribs and to inter-
costal spaces respectively ; thus, ultimately, the air- vesicles of the whole
lung may be over-distended. I would venture to point out, however,
that as the ribs are raised there is less and less power in the expiratory
efforts. The movements are diminished in all the dimensions, and the
progress of the disease may often be measured by the extent to which
this impairment of motion has gone. It is very striking in this regard to
compare the movements of a healthy chest with that of an emphysematous
person ; the following figures (30 and 31) give a graphical representation
of these movements : —
In consequence of this loss of respiratory movement of the thorax,
both in inspiration and expiration, the chest walls can only assist in pro-
ducing the earlier stages of the disease : as it advances, the chief influence
636
SYSTEM OF MEDICINE
in determining the evil effects of congh mnst be that of the diaphragm
and of tlie alulominal muscles.
Ultimately, owing to the extreme distension of the lungs, even the
diaphragm is pressed downwards and rendered almost useless : under
o iQ 203(noso60TBao'io 0 lo^oia to so 0 itioioAosotmo to so o totoii>*osi
BHHBBHI
10 LjJMa[e.ce<f.32.
\remxxU.(tt.2.9[
USll
■■■■■■■■■■■I ■■^[■■■■■■■■■■■lll ■■[;]■
■■■——■■■I ■■'^■■■■■■■■■iiii mwM
iHgnHanni ■^■■■■■■ragBninii wAmm
Fio. 30. — Relative diuieusious of healthy iiioveuieiits.
these circumstances the further progress of the disease would seem to be
impossible. But, both at this stage and at an earlier period, the disten-
sive force of the dilated king itself comes into play. The air, either
partially or entirely shut up by thickened secretions Avithin the distended
alveolae and air- vesicles, is compressed with constant and elastic force
Fig. 31. — Dimensions of movements in a case of advanced emphysema.
by the elevated ribs, and under this pneumatic pressure the Aveakened
walls of those portions of the lung that are unsupported by. bony or
cartilaginous structures are steadily dilated still further. The importance
of this persistent pneumatic pressure, after a certain degree of distension
has been attained, must not be lost sight of in estimating the morbid
influence of cough.
In hrtmrJiiecfdsiH the damage done to the air-tubes may also be cither
inspiratory, from a stretching of the Avails of the bronchi by fibrous tissue
bands in cirrhotic lungs — the pleuritic adhesions acting as a fixed point
— or expiratory, and due to pressure of the air, as a cough may
act upon bronchi Avhose Avails ha\(> been damaged by inflammatory or
atrophic changes. In cither case, the huitful ctlcct of the cough mny be
intensified by any inbciuling power in the rib-lcA'ers, as such indraAving
by pneumatic pressure may reduce the calibre of some portions of the
bronchial tube, and dilate others. Dr. Auld (op. cit.) thinks that too much
GENERAL PATHOLOGY OF KESPIKATORY DLS EASES 637
stress has been laid on the thoracic changes and on the air-pressure, and
too little on the changes in the pulmonary tissue. Most true bronchi-
ectases are of the nioniliform type, and the pressure of air is inadequate
to account for this. Where portions of the lung are collapsed and
atrophous, the bronchial -wall will expand to fill up the vacancy.
The more remote eonsequenees of eoug-h. — When cough is at all
violent in character, its remote results are mainly due, first, to pressure
upon the heart and great vessels, and next, to changes in the lungs
causing an impediment to the flow of blood through the pulmonary
capillaries. Owing to the powerful action of the expiratory muscles,
a paroxysm of coughing causes a rise of arterial pressure ; and this,
together with the direct pressure of the thorax upon the vessels,
greatly impedes the entrance of the blood from the systemic veins
into the heart. Hence, in convulsive coughing, such as we observe in
whooping - cough and some forms of bronchial irritation, we often
see enormously swollen jugular and facial veins, and, not infrequently,
haemorrhages from the nose, or ecchymoses into the conjunctiva ; and,
although these effects are xisaally temporary, if they are frecpxent, they
may end in permanent mischief.
Cough also influences the chemistry of respiration ; in his Croonian
Lectures for 1895, Dr. Marcet has shown that in coughing, as in
asphyxia, there is a tendency to a want of oxygen and to a distinct
excess of carbonic acid in the blood. Thus, he says, " In coughing a
long breath is taken, which is exactly like a deep or forced inspira-
tion, in Avhich, as I have shown, a certain amount of carbonic acid is
produced for work done — the oxygen being derived from that pre-existing
in the contracting muscles, while a larger volume is displaced from the
blood by a purely physical process ; but, though forced breathing is
attended with but comparatively little work in coughing, the respiration
is laboured, the muscles having to strain against the closure of the larynx,
and forcibly expel the air from the lungs. This results in the production
of an excess of carl>onic acid ; hence, at the end of the expiration, there is
an increased amount of carbonic acid in the circulation. After the forced
expiration of coughing, a deep breath is taken to supply the blood with a
fresh quantity of oxygen, and to rid it of the excess of carbonic acid pro-
duced, and this process goes on till the fit of coughing comes to an end,
then deep inspiration and expiration follow till the blood is again perfectly
aired, and the carbonic acid in excess is completely eliminated." The
frequent repetition of this concentration of carbonic acid in the blood is
sure, sooner or later, to end in damage to the tissues and to the heart.
In the heart, as a consequence of incessant cough, the first
changes are usually hypertrophy and dilatation of the right auricle
and ventricle ; and the second is engorgement of the whole venous
system. The systemic circulation is next aff"ected, and organic changes
in the left heart ensue. Sooner or later, in consequence of these im-
pediments to the circulation of the blood, changes follow in other organs,
such as the liver and kidney. The liver is first enlarged from simple
63S SYSTEM OF MEDICINE
congestion, then its tissues undergo alteration, and finally grainilar atroph}'
is the result. Tlie kidneys suffer congestion and undergo structural
change, and albuminuria is not infrequently the ultimate result. The con-
nective tissue throuLjhout the body also suffers from the mechanical
obstruction to the blootl-tlow, and anasarca and other consequences
supervene.
In brief, the results of coughing fits, frequently repeated, or long-
continued, in debilitated persons with -weakened and ludiealthy tissues,
are, first, changes in the lungs themsehes, next in the heart, and after-
wards in the system generally.
Many of these consequences of the " explosive " respiratory actions
are also to be observed in the course of protracted dyspntea, and the
mechanism of this action must next be considered.
Dyspnoea, or difficulty of breathing, ensues to some degree Avhenever
the natural interchange of gases fails, from any cause, to take place to
the satisfaction of the needs of the body.
(1) When the air is deficient in oxj^gen, or overcharged with carbonic
acid, or otherwise rendered partially or entirely irrespirable ; as in rare
faction of the air in mountain or balloon ascents, in poisoning by carbonic
acid or other gases \ykle art. " Mountain Sickness," vol. iii. p. -458].
(2) When the air-passages are not sufliiciently pervious, or the re-
spiratory movements are inadequate from any cause ; as in the case of
such mechanical and physiological impediments as new growths, or
spasmodic closures of the air-inlets or air-tubes ; or of defects in the action
of the bones and muscles of the thoracic wall, as in paralyses of the re-
spiratory muscles, meteorism, or abdominal tumours.
(3) When l^y extensive disease or injury the lung-tissues are so damaged,
or otherwise so deficient, as not to expose a sufficient surface to the air.
(4) When the blood, either from cardiac or pulmonary defect, cannot
fiow freely through the ca])illaries of the lungs ; or when these vessels are
thickened and rendered luifit for the passage of gases across their walls,
as in emphysema and inflammatory deposits.
(5) Finally, when the respiratory centre in the bulb is irritated, as in
fevers ; or when the vagi are so affected by disease as to convey undue
stimulus to the medulla. In any of these many contingencies the rate of
breathing, or the labour of accomplishing this act, will be increased.
In a word, the current need of the body must be under-supplied before
dyspnoea can take ])lace. The absence of this condition may account for
the absence of serious symptoms even when grave injury has been in-
flicted upon the respiratory apparatus.
Degrees of di/spnrea in different diseases. — Dyspnoea may not arise even
after considerable tracts of lung-tissue have been rendered useless.
In the true sense of the word, it is seldom a prominent .sym]>tom
in the course of diseases of the respiratory organs, with the exception
of asthma, emphysema, pneumothorax, and certain thoracic tumours ;
and yet it is in most cases the immediate cause of death.
It is interesting in this respect to compare cardiac with pulmonary
GENERAL PA THO LOGY OF RESPIRA TORY DISEA SES 639
diseases. In the former, the difficulty of breathing, as a rule, is con-
stantly present, more or less, even when the patient is confined to bed ;
in most lung diseases it only appears on exertion, and in the latter
indeed it is rarely true dyspnoea, except in those cases of obstruction
of the air-passages, which are liable to be confounded with heart disease,
Avhen the breathing is laboured and retarded in frequency.
The respiratory movements are often rapid and shallow in •pneumonia
and tubercular disease: but the patient is scarcely conscious of effort.
The air enters easily into the pervious portions of the lungs, but it has
to be carried thither more frequently.
In advanced cases of pulmonary tubercle in which considerable destruc-
tion of lung substance has taken place, it is often remarkable how tranquil
the breathing remains unless when harassed by cough. It is only upon
the supervention of pneumothorax, or some other accident, by which
large tracts of lung-tissue are suddenly made useless, that actual difficulty
of breathing comes on. Even the onset of acute tuberculosis is un-
attended by true dyspnoea, quickened respiration alone showing the
gravity of the case.
Similar remarks apply to most of the acute inflammatory diseases of
the lungs, but towards the close of a fatal attack true dyspnoea generally
supervenes, owing to the presence of one or more of the conditions
already mentioned.
In the following disorders it may also be present throughout a large
part of the illness. Thus, "in actde bronchitis the act of breathing is
usually laboured, and there is a sense of tightness and oppression about
the chest. In severe cases of capillary bronchitis also, especially in
children, the dyspnoea may be extreme, and may amount to paroxysmal
or constant orthopnoea with cyanosis and venous congestion ; and, finally,
asphyxia may set in more or less rapidly. In piulmonary embolism and
thrombosis, in collapse of the lungs and in pneumothorax the suddenness
of the accident and the rapid cutting oft' of the supply of air to the blood
usually cause extreme dyspnciea, which often ends in general collapse
and death. In pneumothorax the full extent of the dyspnoea is con-
ditioned by the presence or absence of pleuritic adhesions, or by their
position. In some cases of empya^ma both pleural cavities have been
opened and drained ; and yet the lungs have expanded sufficiently for
the aeration of the blood, and even without much dyspnoea following.
In these cases pleuritic adhesions must have been present.
But, apart from stenosis of the air-passages and sudden accidental
loss of breathing poAver, it is in advawed emphysema that the most visible
signs of dyspnoea are apt to appear. The constant position of the ribs in
emphysema is that of full inspiration ; and hence all the voluntary muscles
are continually in play. In this disease, therefore, it is not unusual to
find the patient, during a paroxysm of coughing, sitting up in bed or in
an arm-chair with all the signs of orthopnoea ; the lips and hands blue,
the face livid, the eyes protruding, the jugular veins distended, the body
bathed in cold, clammy perspiration. In many cases the signs of venous
640 SYSTEM OF MEDICINE
congestion and of more or less cyanosis remain permanent, and the
dyspnoea is apparent even during rest.
Again, in asthma and in blockage of the air-passages from any cause,
dyspniea may be extreme for a time. But in asthma, although inspiration
be forcible, even to the extent of causing indrawing of the epigastiium
and of the lower ribs, it is not often much impeded. Expiration, on the
other hand, "presents the picture of a most lal)orious and tormenting, and,
at the same time, fruitless struggle " (Baml)ergcr). All the expiratory
muscles, indeed most of the muscles of the l»ody, are brought into play,
and sometimes the urine and faeces escape involuntarily during the attack ;
yet even then sufficient power to empty the lungs may not be oljtained.
The resulting dyspnoea is usually extreme, the patient sits up or stands,
leaning upon his arms and holding on with his hands in order to secure
a purchase for the auxiliary muscles of expiration ; the alse nasi are
agitated, there is intense anxiety, and more or less venous congestion and
cj'anosis of the face. All this is due to the expiratory efforts, and, if the
attacks recur at all frequently, often leads to serious damage to the lungs
and circulatory system. Dr. Marcet has suggested that an attack of
asthma may sometimes be precipitated by the " momentary Avant of air
produced by a bad fit of coughing " ; asphyxia being occasionally pro-
ductive of other forms of spasm.
The mechanism of an attack of true spasmodic asthma is, in fact, an
irritation of some part of the reflex arc controlling the circular muscTular
fibres surrounding the bronchial tubes ; and it is well known that the
specific irritation may arise from many points in the vascular bronchial
mucous membrane ; from the stomach, heart and kidneys, or even
l^erhaps from a gouty condition of the blood.
Dr. Foxwell has also suggested that in asthma there is " sudden
peiipheral tension" (spasm) of the pulmonary arterioles, and consequent
jiulmonary anaemia (8).
On the other hand, in spasms of the glottis, in paralysis of the
posterior crico-ari/tenoid muscles of the larynx, in cnmp, and in plastic
hronchitis, the dyspnoea is chiefly inspiratory, as in other modes of
blockage of the upper air-passages. In these cases, as the patient cannot
introduce the necessary quantity of air into the lungs without severe and
almost convulsive efforts, there is always, during the attempts at inspira-
tion, considerable retraction of the epigastrium, and of the yielding por-
tions of the thorax ; the lower ribs are drawn in ; the intercostal spaces
and the supraclavicular fo.ssa3 are deepened. The dyspntwi in these cases
is often as pronounced and as severe as in cases of asthma, and leads to
the same serious consequences ; but it is more likely to lead to atelectasis,
and to some form of bronchiectasis, than to emphysema. In jilcnr/si/ the
.shortness of breathing is mainly voluntary ; it varies with the pain and
the extent of the effusion, and if effusion take place rapidly it may oven
cause fatal asphyxia.
J-Jfft'iis of dijapnmi. — Koseiithal has proved by experiment that dyspnica
and asphyxia are mainly due to the deprivation of oxygen, and not
GENERAL PA THOLOGY OF RESPIRA TOR V DISEASES 641
to the r.ccumulation of carbonic acid ; that diminution of oxygen in the
air breathed does produce the phenomena of dyspnoea, and that excess
of carbonic acid does not. But at the same time there can be little doubt
that the COo has an important influence ; CO., certainly, as we have seen,
is the natural stimulant of the respiratory centre. It also excites the
vaso-motor centre, and thus leads to rise in the blood-pressure, but as it
paralyses the vaso-constrictor influence the blood-pressure soon falls. In
this way it concurs Avith defect of oxygen in producing the phenomena
of asphyxia.
The immediate result of deficient oxygenation of the blood is that
the respiration is quickened and becomes deeper ; and as the venosity of
the blood progresses so do the respiratory movements increase, both in
force and frequency, all the auxiliary muscles being brought into play.
Very soon, however, the expiratory movements become more pronounced
than the inspiratory, and finally pass into expiratory convulsions.
Professor Burdon Sanderson thus explains these phenomena : — " One of
the effects of diminishing the proportion of oxygen in the circulating
blood is to excite the vaso-motor centre, and thus determine general
contraction of the small arteries. The immediate consequence of this
contraction is to fill the venous system, in the production of which result
the contraction of the expiratory muscles of the trunk and extremities
powerfully co-operates. The heart, being abundantly supplied with
blood, fills rapidly during diastole and contracts A'igorously, in conse-
quence of which, and of the increased resistance in front, the arterial
pressure rises. This last eff"ect is, however, temporary ; the diastolic
intervals being lengthened by the excitation of the inhibitory nervous
system, and the heart itself weakened by defect of oxygen, the organ
soon passes into a state of diastolic dilatation. Its contractions become
more and more ineffectual till they finally cease, leaving the arteries
empty, the veins distended, its own cavities relaxed and full of blood."
As the absorption of oxygen by the blood is to some extent influenced
by the pressure, it is evident that we have, in inspiratory dyspnoea, a
double impediment to the due aeration of this fluid ; for the air is pre-
vented from reaching the air-cells and the inspiratory efforts diminish
the pressure within them. The symptoms in these cases should, therefore,
be the more urgent, and I think that experience teaches us that this is
the case. But the effect of dyspnoea upon the circulation soon equalises
the results of all forms of difficulty of breathing, and hence we get very
similar effects from dyspnoea, whether this primarily arise from the
heart or from affections of the lungs.
It is possible that these observations may to some extent serve to
explain the various degrees of intensity of dyspnoea in diseases of the
lungs. In many of these affections the heart's functions are unimpaired,
and hence the l)lood is driven evenly through such portions of the lungs as
are pervious and to a great extent performing their natural functions.^
^ Colniheim (3) quotes some experiments of Lictlieim to show that a quarter the norrrial
united sectional area is sufficient to allow the normal amount of blood to jiass through the
VOL, IV 2 T
642 SYSTEM OF MEDICINE
With a certain increase in the rate of breathing, therefore, it is ]Jossible
for the blood to be aerated sufficiently for the verj^ moderate amount of
exertion usually made by those suHerers. Such conditions obtain, for
instance, in phthisis, in many cases of pneumonia and bronchitis, and in
one-sided pleurisy.
Compeiisahrrti actions in di/spnoea. — There is also, in most of these
disorders, a natural tendency towards compensation. The quickened
breathing does more than bring increased supplies of oxygen to the
air-vesicles. The increased supply of air -would be of but little use
unless sufficient l)lood Avere flowing through the capillaries of the lungs
to fill the left auricle. But it is well known that even the ordinary
movements of respiration materially assist the work of the circulation ;
much more then, in disease, will the quickened and forced effoi'ts at
breathing augment the velocity of the pulmonary circulation, and cause
a larger surface of blood to be exposed to the air.
In his Croonian Lectures for 1895, Dr. Marcct shows that simple
volition greatly increases the mechanical power of the muscles of the
body ; and he suggests that ])erhaps, in forced breathing, there is really
an excess of oxygen absorbed, which is taken up by the lirain centres of
forced breathing, and gives " volition " the power of doing so much
additional muscular work through increased respii'ation.
This hypothesis was submitted to experiment ; and from the I'csults ob-
tained it "appears that, whenever volition is applied towards anj' form of
exercise, there is an absorption of oxygen in the cerebral centres concerned
in the phenomenon ; and apparently with an excess of oxygen absorbed,
more work can be done than if the excess be wanting." Here then we
have at least two more forms of almost automatic compensation.
In long-continued cases, also, this compensatory action of dyspna?a is
presently assisted by an increase in the power of the heart. If the
nourishment of the general .sj^stcm, and Avith it of the hcail, be not
interfered with, its increase of Avork Avill gradually lead to increase of
power and to increase of substance ; in other words, to hypertrophy of
the organ. In spite, therefore, of a certain loss of permeal)le sul)stance
of the liuig, and a consequent smaller vascular area, the blood-stream
may be forced more rapidly along the channels that remain, and the
necessary degree of aeration may be accomplished.
Unfortunately these means of compensation are not ahvays adequate.
The balance of the ])ulmonary circulation Avith respiration is in a position
of unstal)lc equilibrium, and is liable, at any moment, to be upset Ity
such causes as a slight cold, some little over-exertion, and .so on.
Patients may indeed discoA^er that it is necessary to restrict their move-
ments, and to alter the quantity and quality of their food ; l)ut, if life is
to be carried on, they cannot reduce the metabolism of the tissues beyond
a certain })oint. Sooner or later a greater degree of dyspnoea is sure to
occur ; nutrition becomes impaired, the heart loses poAver, the structural
lungs. "Tliis, however, is the lowest limit, beyond which the power of compensation
fails" (Lancei, Feb. 23, 1895).
GENERAL PA T HO LOG Y OF RESPTRA TOR V DISEASES 643
elements of the blood are affected, and either anaemia or cyanosis
makes its appearance.
It must not be forgotten, also, that when, as we have seen, dyspnoea
raises the general arterial blood-pressure throughout the body, the
coronary circulation is not likely to escape its influence ; hence the
nutrition of the heart itself is carried on under difficulties, and is liable
to fail at a critical moment.
The cyanotic condition. — One of the most frequent results of
dyspnoea of a certain degree of se^'erity is carbonisation of the blood,
or the cyanotic state ; (so called, probably, on account of its resemblance
to the true cyanosis, the morbus ceeruleus of the old writers, caused by
the intercommunication of the right and left sides of the heart).
In respiratory diseases, characterised by a sufficient degree of
dyspnoea, the symptom is due both to a deficiency of oxygen and an
accumulation of carbonic acid in the circulating fluid, to an extent, in
some cases, of a more than venous condition of the blood.
In ordinary venous blood, according to Stroganow (20), there is nearly
1 9 per cent of oxygen and from 6 to 9 per cent of carbonic acid ; but
in the blood of asphyxia the oxygen may entirely disappear, and the
carbonic acid may rise to about 50 per cent.
It is certain, also, that in most cases of cyanosis there is an excess
in the number of blood corpuscles. This has been observed by
Toeniessen, Carmichael, Gibson, and others, and is ascril^ecl by Gibson
to an attempt at compensation. " In venous stasis, the corpuscles,"
he says, "are insufficiently oxygenated, they cannot perform such an
active part as oxygen-carriers, and they cannot jdeld so much oxygen to
the tissues. It must further be remarked that in cj-anosis there is less
metabolism in the tissues, and therefore less waste produced. In a word,
the functions of the corpuscles being lessened, the wear and tear which
they undergo is reduced, and the duration of their individual existence
increased. The number of the corpuscles must in this way be propor-
tionately augmented, and this must lead to the numerical increase, as
well as to the high percentage of haemoglobin " (9).
It seems certain that the oxygen in the blood is in a state of loose
chemical combination with the lipemoglobin, and that the blood corpuscles
can take up a sufficient supply of oxygen under circumstances of both
low and liigh pressure of the atmosphere. It is thus difficult to exhaust
the store of oxygen in the capillaries.
It has been shown by Miiller that blood outside the body may be
completely saturated with oxygen in atmospheric air of only 75 mm. of
pressure ; but at the temperature of the body decomposition of the
haemoglobin begins at a higher pressure.
Fraenkel and Geppart showed that it is not until the atmospheric
pressure sinks below 300 mm. that a considerable decrease in the oxygen
of blood takes place.
It is probably owing to these facts that on ascending high
mountains dyspnoea is not observed until the mercurial barometer
644 SYSTEM OF MEDICINE
marks a pressure of less tlian 400 mm., and that ^Ir. AVhymper in the
Andes, and Sir Martin Conway in the Himala3'as, were able to move in
altitudes over 20,000 ft. {vide art. " Mountain Sickness," vol, iii.).
Drs. Haldano and Lorrain Smith also found in their experiments
that cyanosis was not produced until the oxygen inspired fell below 9
per cent ; and in one instance the air was breathed until the oxygen
was reduced to 6 to 7 per cent. Tliey remark that the tension of
oxygen then found corresponds to that obtained by rising to a height of
about 29,000 feet.
The occurrence of cyanosis may be due, then, either to an insufficient
supply of air to the blood, or to a defective exposure of the blood in the
capillaries to the air in the alveoli. It may consequently arise from
deficient action either of the lungs or of the ciiculatory system. In the
former case it may arise from stoppages in the air-passages, defective
muscular power, and injuries to the lung-structures, or from destruction
of or defects in the pulmonary blood-vessels ; in disorders of the
circulation it may come from imperfect propulsion of the blood through
the pulmonary arteries, as in dilatation of the right heart or embolism
or cedema of the lungs, or from backing up of the blood-stream going to
the left heart, as in mitral stenosis.
From whatever cause it is impending, however, like dyspnwa, it may
be staved otf for a time, except in the case of complete occlusion of the
air-passages, (a) by the respiratory efibrts of dyspmva, or (6) by limiting
the demand of the body for oxygen. Dyspno^ic efforts tend not only to
increase the sui)pl3' of air in the lungs, but also to increase the suction
power of the thorax, and thus improve the pulmonary circulation. The
production of carbonic acid and the need for oxygen may be dimiiu"shed,
and often are so diminished, in these cases, by reducing the muscidar
work as far as possiljle, and by regtilation of the diet.
A third mode of resisting the tendency to cyanosis, and also to dyspnoea,
is to augment the power of the right ventricle. By means of hyper-
trophy of the heart, the system gains the advantage of sending the blood
more rapidly through the capillaries of the lungs, and exposes the necessary
amount of blood to the air. It is marvellous for how long a period
the existence of an extreme degree of mitral stenosis may thus be over-
come.
The difference in the tolerance by the system of cyanosis originating
in heart and lung troubles respectively may possibly be explained by
these facts. I have often been struck by the long endurance of the
cyanotic condition in cases of mitral stenosis, years passing with more
or less blueness of the lips and extremities ; but in advanced lung disease
the onset of permanent cyanosis usually takes place but a short time
l)efore the end of life. The heart, in its diseased conditions, usually
has the advantage of a very gradual onset of the symptom, and of
being able to find unimpaired tissues in the lungs and an unlimited
supply of pure air ; but in Inng diseases not only are these tissues in a
more or less damaged condition, but the heart itself has also undergone
GENERAL PATHOLOGY OF RESPLRATORY DISEASES 645
some impairment of its powei", and thus dyspncBa and cyanosis frequently
come on very rapidly.
It is important to observe, however, that there may be no marked
cyanosis even in very advanced disablement of the respiratory function,
as, for instance, in the advanced stages of phthisis. In these cases, the
hectic fever and the great emaciation lead to such a condition of anoemia
that cyanosis cannot show itself. The blood corpuscles are too few in
number to display either their red or their bluish tints, and extreme
pallor is the only sign visible ; moreover, there is little or no venous
congestion, for the right heart easily sends on the scanty blood-current
I'cceived from the general system.
In these and in other cases, therefore, there may be none of the usual
evidences of asphyxia, dyspnoea, convulsions, dilated pupils, or other
signs of irritation of the vaso-motor and vagus centres.
The muscular weakness may be so great that there is no response to
the nervous impulses ; or the brain, in the absence of sufficient oxygen to
carry on its functions, may lose its irritability, and the respiratoiy
centre cease to respond to the stimulus of over-abundant carbonic acid in
the venous blood. Under such circumstances, as Cohnheim points out (5),
" there is no extraordinary increase of dyspnoea and no convulsions ;
similarly the exophthalmos and the dilated pupils are absent, as well as
the evidences of irritation of the nervous centres. Rather the pulse of
such patients is usually small and easily compressible, very frequent and
sometimes irregular ; the pupils are normal or even contracted, and all
the bodily movements feeble and languid.
" Instead of the cyanosis, which it is easy to see wall be more apparent
the more full-blooded and vigorous the individual, the face, skin, and
visible mucous membranes of such patients take on a bluish gray, dull,
almost leaden hue ; the temperature is low, and the skin feels cool to the
touch ; for not only do the movements, but all the other functions gi'adu-
ally become paralysed : the patients grow markedly apathetic, or CA-en
somnolent, are unaware of all that goes on around them, and unconscious
of their own need for air."
I have hitherto attributed the symptoms of asphyxia to absence of
oxygen and superabundance of carbonic acid \ but it is by no means
certain that other poisonous materials are not present in the blood, which
either themselves affect the respiratory centre, or intensify the influence
of deficient aeration of the blood.
Thus Zuntz, and Lehmann, and F. L. Smith point out the influence
of the products of muscular metabolism produced during exercise, and
Jacquet shows that lactic acid acts as a direct excitant to the respiratory
centre of the rabbit.
Dr. V. Harley shows that after the intravenous injection of sugar
there is a marked decrease both of carbonic acid and oxygen in the blood ;
but the resulting coma and convulsions were not due to this cause, for the
oxygen increased and the carbonic acid remained low before their onset.
It has long been known that a certain amount of organic matter is
646 SYSTEM OF MEDICINE
given olV in the breath, and various attempts, especially by Ticdeman,
Valentin, and Angus Smith, have Ijeen made to determine its nature and
quantity. I have myself made a number of analyses of the aqueous
vapour of human breath condensed by means of freezing mixtiu-es,
and have ascertained that, although remarkably constant in health, it
varies greatly in ditterent diseases. For our ])resent pur])ose it may bo
surticient to point out that the total quantity was much reduced in
affections of the lungs, and that it was considerably increased in albumin-
uria and ozsna. There is still nnich difference of opinion as to the
poisonous influence of this organic matter : Biown-St'-quard and d'Arsonval
may be cited on the affirmative side, and Haldane and Lorrain Smith
recently on the negative. But to my mind it is at least important to
remember that there is a possible danger from such retention in cases
of defective respiratory jDower.
It is probable that, even in health, toxic substances are constantly
excreted by the cells of the body, and that under certain circumstances
they may accumulate in the system ; as, for example, after over-exertion,
disturbances of secretion or excretion, or as a result of diminished respira-
tory action. It is well known that malaise, headache, and other nervous
sjnnptoms often arise as a consequence of these conditions, and may with
]n-obability be ascribed to some toxic cause. Toxic alkaloids have been
extracted from healthy bodies by Bouchard, Gautier, Coppola, Mosso,
and Guareschi.
Dr. Farquharson gives a number of references to researches under
pathological conditions in which toxic substances were extracted from
the urine, intestines, and other parts, in various respiratory disorders,
enteric fever, progressive pai'alysis, pernicious anaemia, uranuia, and so
on. It is generally acknowledged, also, that many of the symptoms in
diphtheria, phthisis, and tetanus ai-e due to toxines derived from the
specific bacteria. On the whole, we may say that a case has been made
out for the assumption that some, at least, of the symptoms arising in the
course of dysi^ncea and asphj'xia are produced by substances other than
carbonic acid.
Cheyne-Stokes breathing. — Amongst the most interesting of the
results of derangements of the pulmonary circulation must be i)laced the
occurrence of "periodic," "tidal," or "Cheyne-Stokes" breathing.
Attempts to explain this occurrence have hitherto been without
complete success. It seems to be acknowledged that one condition must
be some lowering of the functional activity of the respiratory nervous
mechanism , but this in itself cannot account for the rei^ular periodicity
of the phenomenon.
It is necessary, moreover, to bring within the scope of any satisfactory
theory all the very diverse conditions under which it is known to occur
— diseases of the heart, l)rain, and lungs, blood-poisoning of different
kinds, the action of narcotics, insolation, nay, even the fact that it has
been observed during apparently perfect health. It must also account
for the concurrent symptoms that have been observed.
GENERA L PA THOL OG Y OF RESPIRA TOR Y DISEASES 647
At present physiologists seem inclined to fall back upon the hypo-
thesis that when, from any cause, the activity of the automatic centre is
reduced, its functions have a tendency, common to all vital structures, to
become periodic. Under ordinary conditions this tendency to periodicity
in the respiratory movements is kept under control by the higher
regidating centres ; but when from an}' cause this influence is weakened,
the natural rhythmical action of the centre comes into play. The
phenomenon is thus brought into line with what is known as the
Traube-Hering rhythm in the vaso-motor system ; both rhythms are
originated by medullary centres, and both are closely associated in their
degree of frequency. Dr. Gil:)son (10), in his elaborate examination of all
the hypotheses, sums up the matter thus : — " They are instances, among
many others, of the common tendency toAvards 'pulsatile or rhythmic
activity' manifested by all living matter."
There only remains a l)rief consideration of the rare but still possible
occurrence of spasmodic breathing in the course of Bright's disease. Sir
W. Roberts gives a case of this kind in his work on Urinary Diseases
(p. 480). The accident is in truth more likely to arise in consequence of
changes in the circulatory system, than from the supposed urremic
alterations in the composition of the blood itself. Yet it cannot be
overlooked that the circulation of irritating refuse materials in the blood
may lead to changes in the vessels of the lungs, as in other parts of the
body. Moreover, it is at least significant that, in the analyses of the
aqueous vapour from the lungs in cases of albuminuria, to which I have
already referred, I found both more distinct traces of urea and a much
larger quantity of oxidisable organic matter than in health, or in other
diseases. These substances must interfere to some extent with the
normal processes of oxidation (16).
A. Ransome.
REFERENCES
1. AuLD. Path, of BrmicMal Affections and Pneumonia. Lond. 1891.— 2. Berxaed,
Cl-ATJDE. Revue des deux mondes, Aout 1865. Mars 1868.— 3. Cohnheim. Led. on
Gen. Path. vol. iii. p. 1072. Syd. Soc— 4. Ihid. p. 1085.— 5. Ihid. p. 1097.-6.
Fkaexkel and Geppakt. Ueher die WirMmyen dcr Verdiinnten Luji. \%%Z. — 7. Far-
QUHAKSON. Ptomaims. Bristol, 1892. — 8. Foxwell. Essays in Heart and Lung
Disease. London. 1895, pp. 19, 20.-9. Gamgee. Phys. C'hem. vol. i. p. 15. — 10.
Gibson. Lancet, Jan. 5, 1895, p. 25.-11. Gibson, G. A. Cheyne-Stokes Respiration.
Edin. 1892.-12. Harlicy, V. Proc. R. S. Ko. 337. — 13. Jacquet. Arch, fur exp.
Path. u. Pliarm. 1892, Bd. xxx. p. 11.— 14. Jenner, Sir W. Reynolds' System of
Medicine, 1871, vol. iii. p 475.-15. Marcet. Croonian Lectures, 1895. — 16. Martin.
Amcr. Jonrn. Med. Sci. March 1896.-17. Ransome, A. Proc. Lit. and Phil. Soc. —
18. Ide^n. Stethometry, p. 187.-19. Rosenthal. Pfluijcfs Archir, vol. i. p. 94.
—20. Sanderson, Bukdon. HamJbook, p. 323.— 21. Smith, F. L. Jonrn. of Phys.
1890, vol. xi. — 22. Stroganow. Pfliiger's Archiv, vol. xii. p. 2:?.
A. R.
648 SYSTEM OF MEDICINE
THE TREATMENT OF ASPHYXIA
The treatment miist necessarily depend upon the causes in each
jiarticular case ; especially whether the symptoms of partial suffocation
l)e due to mechanical obstruction of the upper air- passages, to immersion
in -water or irrespirahle gases, or to some more deeply -seated allections.
Cessation of the heart's action is a complete bar to any hope of resuscita-
tion from asphyxia, however produced ; but it has been clearly shown
by Sir B. Brodie and others that in some cases, after the cessation of
breathing, the heart may continue to act for two or even four minutes.
Moreover, it is not always easy to ascertain the exact moment at which
either of these actions ceases, for partially effective efforts to breathe may
have been made for some time after apparent stoppage.
Death from drowning may, however, occur in spite of the continuance
of the heart's beat, owing to the presence in the lungs of irremovable
watery froth ; or the gases causing asphyxia may be poisonous in their
nature, and death may take place from shock or semi-paralysis.
We cannot, therefore, be quite sure when hope must be abandoned ;
and we are bound to use all the means of resuscitation, even though ten
minutes or more may have elapsed since apparent death.
Before any special treatment can be adopted, the passage for the air
to the lungs must be made clear ; foreign bodies must be removed from
the pharynx or larynx, preferably with the finger, after the mouth has
been wrenched open, and any handy gag inserted between the teeth :
failing the finger, a blunt hook, such as a large button hook, or
lar3'ngeal forcei)S, or a probang, if available, may ha^'e to ha used. If
the air-passage is not speedily opened up, intubation of the larj-nx or
even tracheotomy may have to be performed on the spur of the moment.
Similar means must also be used in cases of obstruction from other
causes ; such as occlusion by diphtheritic membranes, or tumoiu's about
the rima glottidis, or palsies of the alxluctors of the vocal cords.
Wheii the air - ])assages are free, efforts at resuscitation must
immediately begin : at first, Ave make simple pressui-e upon the thorax
and abdomen simultaneously every two or three seconds, l>ut if this do
not speedily produce signs of air passing in and out of the lungs, one
of the methods respectively known by the names of Marshall Hall,
Sylvester, and Howard should be put in practice.
Mari<hall JIall's remb/ vielhod simply consists in placing the body on
its side, then rolling it over on the face, then on the o])posite side, and
on the back ; repeating the process twelve or fifteen times in a minute.
This plan has the advantage of not needing any assistant.
Si/lvester's method. — " Place the j)atient on his back, on the floor, with
a block or pillow under his shoulders, and rai.se the arms u])war(ls above
his head, by grasping them above the elbow, or better still, b}' seizing the
THE TREA TMENT OF ASPHYXIA 649
anterior folds of the axillae so as to raise also the clavicles ; the upward
pull must be continued firmly and steadily as long as there is any sound
of air entering the chest. The head must be permitted to fall back over
a block or cushion placed behind the neck, so as to open the larynx, or
failing this, the tongue may need to be pulled sharply forwards by
forceps or a noose of string, or by grasping it with a handkerchief.
" As soon as the sound produced by the entrance of air into the chest
ceases, the arms should be brought down a little towards the front of the
chest, and pressed down firmly and steadily against it for about one
second after air is heard escaping. This operation is usually repeated
every four seconds, but, in the case of poisonous vapours, such as those
of chloroform, carbonic oxide or acid, it may need to be done more
rapidly for a few minutes so as to quickly empty the lungs of the
vapour."
HuwanVs method. — This method, in cases of drowning, has the ad-
vantages of facilitating at first the trickling away of watery Huids and the
dislodgment of foreign bodies. Dr. Howard gives the following directions
in the first instance : — " Position of the body : face downwards. A hard
roll of clothing beneath the epigastrium, making that the highest point,
the mouth the lowest. Forehead resting on fore-arm or wrist, keeping
the mouth from the ground.
Position and action of operator : Place the left hand, well spread,
upon the base of the thorax to the left of the spine ; the right hand upon
the spine, a little below the left, and over the lower part of the stomach.
Throw upon them, with a forward motion, all the weight and force the
age and sex of the patient will justify, ending this pressure of two or
three seconds by a sharp push, which helps you back again into the
upright position. Eepeat this two or three times, according to the
duration of the immersion, and then proceed to artificial respiration as
follows : —
Position of patient : face upwards. A hard roll of clothing beneath
the thorax, with the shoulders slightly declining over it. Head
and neck bent back to the utmost. Hands on the top of the head.
Strip clothing from waist and neck. Position of operator : kneel
astride patient's hips ; place your hands upon his chest, so that the ball of
each thumb and little finger rest upon the inner margin of the free
border of the costal cartilages, the tip of each thumb near or upon the
xiphoid cartilage, the fingers dipping into the corresponding intercostal
spaces. Fix your elbows firmly, making them one with your hips.
Action of operator : pressing upwards and inwards towards the diaphragm,
use your knees as a pivot, and throw your weight slowly forwards for
two or three seconds, until your face almost touches that of your patient,
ending with a sharp push which helps to jerk you back to your erect
kneeling position. Rest three seconds ; then repeat this movement as
before, continuing it at the rate of seven to ten times a minute ; taking
the utmost care, on the occurrence of a natural gasp, gently to aid and
deepen it into a longer breath until resjoiration becomes natural."
650 SVSTE.V OF MEDICINE
This method is said to keep open the passage through the larynx
Avithout the aid of an assisUmt, or any contrivance for the purpose.
During the use of any of these methods the temperature of the body
must be kept up by hot blankets and hot bottles ; and if the means are
at hand it may be well to tr}' galvanising the phrenic nerve or the heart ;
but the attempt should only be a short one. An injection into the
rectum of warm beef tea, Avith a little brandy, may also be administered.
Th(j extremities should lie constantly rubbed with warm hands, but
without exposing the patient.
The Koyal Humane Society has published some excellent rules,
embodying in the main Dr. Sylvester's method.
Mr. Francis method. — The body having Ijccii laid on the back, with
clothes loosened, and the mouth and nose M'iped, two bystanders pass a
narrow lever of any kind under the body at the level of the waist, and
raise it until the tips of the fingers and the toes of the subject alone
touch the ground ; count fifteen rapidly ; then lower the body flat to the
ground, and press the elboAvs to the sides hard ; count fifteen again ; then
raise the body again for the same length of time, and so on, alternately
raising and lowering ; the head, arms, and legs are to he allowed to dangle
down quite freely when the body is raised.
Of course other aids for restoring the circulation are not to be
neglected.
Mr. Francis thinks that the position of the body, when raised as
described, mechanically puts upon the stretch all the muscles of insi)ira-
tion, except the external intercostals ; and that the ])ositi()n of the ribs,
sternum, and clavicles allows their weight to aid considerably in the
expansion of the thoracic cavity. The intestines and abdominal viscera
also gravitate towards the pelvis, and must draw down the diaphragm.
Laborde's method of inducing respiration, by making i-hythmical
traction upon the tongue, is well worthy of trial, especially when the
operator is alone. The method is fully discussed, and experiments
quoted, by Dr. Edward Martin {Amer. Journ. Med. Sci. March 1 896). The
tongue is drawn forward during attempts at inspiration, and icleased
for expiration, twelve to fifteen times in a minute. When more than
one helper is present, the Sylvester movements must also be made,
accompjinied by the above-mentioned traction and relaxation of the
tongue in inspiratory and expiratory movements respectively.
When the causes of asphyxia are more deeply seated, and arise from
profound aflections either of the lungs or heart, there is usually less need
of that immediate action Avhich I have just described. Yet there are
cases, even in this class, in which life has been saved by the early recog-
nition of the tendency to death, and ])y the prompt a))plication of means
for thi; restoration of the balance ])Ctwecn circulation and i-es])iration.
Thus in cases in which, owing to a failure in the natural functions of
either heart or lungs, the right heart has become over-distended with
blood, and cannot properly expel its contents, means of relieving this
engorgement may be instantly called for. Even in these days of popular
THE TREATMENT OF ASPHYXIA 651
prejudice against blood-letting I have several times seen immediate relief
given by prompt venesection, and life thus saved for considerable periods.
In less serious cases it may be possible to afford the necessary relief
by other means directed towards the removal of the venous stasis ; such
measures are free dry, or even wet, cupping of the chest, back and front ;
the application of Junod's boot ; the use of stimulating, hot fomentations ;
or, better still, of the hot-air bath ; or the envelopment of the body in
blankets wrung out of hot mustard and water, covered by a dry blanket
and by waterproof sheeting — the " blanket bath."
Acain, after some relaxation of the immediate distress has l^een
obtained by such measures as these, there are few means that give such
comfort as the regular use of a mercurial pill, on alternate nights, and the
occasional administration of some hydragogue purgative, such as pulv.
jalapoe co. or Carlsbad salts.
In some cases it will be necessary to tap the abdomen for ascitic fluid,
in others to insert Southey's tubes into the feet or legs. To remove fluid
eff"usions from one or both pleural cavities often gives striking relief. Again,
in all cases of great diflSculty of breathing much relief may be conferred by
administering pure oxygen, such as may now always be obtained from
Erin's Oxygen Company. It may be given, without danger, undiluted,
by means of a Clover's inhaler, or of a simple rubber tube and mouth-
piece ; but in many instances it suffices to deliver a stream of the gas
close to the mouth.
I have also found great benefit, when the lips and finger-tips are
becoming cyanotic, in giving by the mouth from twenty to thirty drops
of Richardson's ozonic ether. It should be given in pure Avater, and
should not come in contact with any organic matter, as the ozone it con-
tains is soon destroyed. It often brings back the ruddy hue to the face
and hands, and has been a source of much comfort even to the dying.
It is scarcely necessary to add that, when occasion offers, all other
means in our power should be brought into play to give increased power
to the heart to expel its contents ; such drugs, for instance, as digitalis,
nux vomica, and C[uinine, strophanthus, Virginian cherry, and so forth.
In all such cases diet and stimulants must be carefully regulated so as to
spare the labour of the vital processes to the utmost.
A. Eansome.
652 SYS TEM OF MEDICINE
PHYSICAL SIGNS OF THE DISEASES OF THE LUNGS
AND HEART
Physical signs may be regarded as embracing every impression, made on
our organs of sense, capable of giving information concerning the physical
condition of the human body and its organs. It is only as the result of
observation and experience that the value of the impression can be esti-
mated and the conclusion rightly drawn ; the inference must, however,
always be clearly distinguished from the sign itself. It is chiefly by the
correct observation of physical signs that it is in our power to obtain
trustworthy knowledge of the state of the several organs of the body in
respect of health or disease.
The impressions which the patient himself receives are in a certain
sense to him physical signs. These, however, although valuable, for the
most part, do not aflbrd exact information, and when resulting from
disease are generally called symptoms. AVithout physical signs, symptoms
frequently tell us nothing of the nature or seat of a malad^^ Various
instruments have been invented or employed Avhich, like the thermometer
or sphygmograph, add to the precision of our ol)servations, like the
ophthalmoscojje or laryngoscope extend their range, or like the stethoscope
or microscope increase their power. Sight, touch, smell, and hearing may
each separately receive impressions from external objects, and from these
impressions Ave are accustomed to draw conclusions as to the physical
conditions of the objects concerned.
In' the case of the internal organs of the body, unaided vision, so far
as ordinary light is concerned, is limited to the observation of the effects
produced by the internal movements on the surface of the body, or of
the alterations of shape, movement, or appearance which may take place
at the surface from altered internal conditions. The ophthalmoscope, the
laryngoscope, and a variety of specula enable us to bring vision to bear
on parts otherwise out of sight.
Touch may be employed to estimate the force and determine the
position of the heart's beats, or to observe the frequency, regularity, and
strength of the pulse, or to detect the presence of tumours in the abdomen
or elsewhere, or the enlargement of any of the organs which are accessil)le
to palpation. Sight, and even more certainly touch, will reveal the existence
of pulsation in an abnormal phice. The sense of tOTich is of great value
also in determining whether a tumour is fluid or solid. Smell may assist
in the recognition of such conditions as ozaena, gangrene of lung, bronchi-
ectasis, diabetes mellitus or other diseases which are attended with a
characteristic odour ; but its uses are narrowly limited, beciiuse there are
but few of the organs of the body and few diseased conditions which have
a distinctive odour. Taste is the only sense which, for obvious reasons,
cannot well be applied to practical use.
PHYSICAL SIGNS OF DISEASES OF THE LUNGS AND HEART 653
The physical signs, however, which specially concern us here are
those which have to do with the vibrations of sound and the impressions
made by them principally on the organs of hearing ; altliough to a minor
degree they aftect the sense of touch also. The two great means of
physical examination which we possess are kno-vra as auscultation and
percussion. Auscultation simply means the listening to the sounds
Avhich are produced Avithin the body. Percussion consists in striking a
part of the body in a special way and listening to the sound thus pro-
duced.
The sounds observed in auscultation produced from Avithin and the
sounds of percussion produced from Avithout are of the highest importance
as physical signs.
In order to have a clear conception of the meaning of these physical
signs Avhich Ave are noAV about to consider, it is absolutely essential that
certain acoustical principles should be enunciated and borne in mind.
These principles are the laAvs Avhich govern (I.) the production, and (II.)
the conduction of sound ; Avithout these it is impossible to understand
or properly to interj^ret the phenomena connected Avith auscultation and
percussion.
I. The production of sound. — All sound depends upon vibrations,
AA'hich vibrations must be conducted to the organ of hearing. Vibrations
may occur primarily in solids, liquids, or gases ; and they may be con-
ducted from one to the other l^efore ultimately reachins; the ear.
Sounds in general may be roughly divided into two classes according
as the vibrations which produce them are regular, continuous and periodic,
or the reverse. The sounds produced by vibrations of the first class are
called musical, those pi'oduced by the second class of vibrations non-
musical sounds or noises. Noises are irregular, confused, and interrupted,
and as a rule sound harsh to the ear, Avhile. musical sounds are more or
less agreeable to it. In practice, hoAvever, it is difficult to draw a sharp
distinction between a musical sound and a noise. Fcav musical sounds
are entirely free from noise, and many noises have some musical quality.
The special (juality of a musical sound is Avhat is known &■& [ntch, Avhich is
determined Ijy tlie frequency of the predominant Aabrations per second.
Very slight difterences in pitch can be accurately distinguished by the
trained ear. No sound Avhich has pitch can be Avholly unmusical. "We
refer to pitch Avhen Ave say a sound is acute or grave, shrill or Ioav, high
or deep, sharp or flat. In addition to pitch, musical sounds possess
three further properties : namely, (a) loudness or intensity, (h) duration,
and (c) character, quality, or timbre. Of loudness and duration no
explanation is required; Ave speak of sounds as being loud or feeble,
short or prolonged. It is otherAvise, hoAvever, Avith the property of
character, quality, or timbre, Avhich enables us to distinguish notes of the
same pitch Avhen sounded on different instruments, and causes us to
characterise them on the one hand as rich, SAveet, melloAv, or full, or on
the other hand as poor, harsh, nasal, or thin.
Some confusion has been introduced into medical literature by the
654 SYSTEM OF MEDICINE
use of the word tone in a sense different from the strictly scientific one it
possesses in acoustics. It has been stated, for instance, tliat musical
sounds possess loudness, duration, pitch, and tone, and that what dis-
tinguishes one percussion sound from another is the possession of tone.
This is clearly making tone the equivalent of timbre. Now a tone in
acoustics is a sound of a definite pitch and incapable of analysis into
simpler sounds. All ordinary musical sounds are harmonious combina-
tions of tones. ^Vhere the periods of vibration are as 1, 2, 3, 4, etc., the
corresponding sounds combine agreeably. No pure tone can be said to
have timbre. Timbre depends on the mode in which higher tones, -which
are called harmonics, are combined with the lowest or fundamental tone
in a musical sound. A trained ear can recognise the individual tones
Avhich go to make up a note, as sounded by such instruments as the piano
or violin.
The subject of musical tones is closely connected with the theory of
what is known as resonance, another term which in medicine lias un-
fortunately been used in (juite an inaccurate sense. The acoustical theory
of resonance has an important connection with some of the sounds met
with in percussion and auscultation, and it is therefore necessary to enter
into some little detail concerning it.
We have referred to the fact that sounds may be produced by the
■Nnbrations of circumscribed portions of a gas as well as by the vibrations
of licpiids or solids. An iMiclosed column or other mass of air can be
made to vibrate with a definite period and jn-oduce a musical sound
possessed of definite pitch. It will also possess the property of giving
out such a sound when a sound of its own pitch reaches it from the
external air. The term resonance is used to denote the reinforcement
of sound, by an enclosed volimie of air communicating with the external
air, due to the synchronism which exists ])otAveen the vibrating jtcriod of
one of the tones wliich compose the sound and that of the V(jlumc of air.
The instrument possessing the air-containing cavity is called a resonator.
The disturbance of the air produced by a mere noise in the neighbourhood
of a resonator may throw the air in its interior into vil)rations and cause
it to give out its own note.
Tlie resonators devised by Helmholtz are hollow globes possessed of an
ear-piece fitting into the external meatus at one pole, Avhile at the oj)posite
pole is a larger opening commuuicatitig with the external air. When thr
note which corresponds to tliis resonator is sounded it Ijccomcs enormously
intensified. With a series of such resonators an ordinary'- musical sound
can be analysed into its component parts, and the presence of a variety of
simple tones may be discovered in what might itself be regarded as a
simple sound.
A simple tone unaccompanied by harmonics is dull and uninteresting,
and if of low j)itch is destitute of penetrating quality.
AVhen a body capable of vibrating is struck it will emit a sound :
and conversely if it emit a sound it is able to vibrate. Capability of vibra-
tion shows that it is to some degree elastic. The sounds emitted by
PHYSICAL SIGNS OF DISEASES OF THE LUNGS AND HEART 655
different bodies vary immensely, depending, as they do, on the nature
of the substances, as well ns on their size, shape, elasticity, and so forth.
In the case of membranes and strings a certain degree of tension is
required before vibration, in such a way as to produce a musical sound, is
possible.
Bodies with slight elasticity will vibrate little ; they will produce but
feeble sound, and that of 'a dull damped character without much of the
musical element.
Bodies possessed of a fair amount of elasticity, on the other hand, will
vibi^ate freely ; they will produce a considerable volume of sound, and this
with a good deal of the musical character. Lead has very little elasticity,
and emits when struck a characteristic dull sound without any ring in it.
Fleshy organs, like the liver, spleen, kidneys, heart,, or consolidated or
collapsed lung, are possessed of little elasticity and produce a dull dead
sound when percussed. The air-containing lung is highly elastic, and when
distended will vibrate freely when struck, producing a full rotund sound.
Similarly, the membrane of the stomach or intestines, when distended bj^ the
gases in its interior, can vibrate freely. When the pleural cavity is filled
with ail- the thoracic wall, which is highly elastic, can vibrate freely, and
a full-toned sound is produced. When, on the other hand, the pleural
cavity is filled with fluid, vibrations of the thoracic wall are damped
at once, and a dull dead sound is the result.
Percussion. — Long use has rendered classical the terms resonance and
diilness as applied to the soiuids elicited on the one hand by percussion
of a part of the body which can vibrate freely, as the chest Avail over the
lungs or a pneumothorax ; and on the other by percussion of a part where
the vibrations are damped, as the chest wall over a pleuritic effusion or
consolidated lung.
The acoustical theory of resonance has led some authors to seek a
similar explanation for the resonance just mentioned. Thus an attempt
has been made to account for the kind of note obtained by jiercussion
over the lungs, by supposing it to be due to the occurrence of resonance
in the larger bronchial tubes. This theory is easily disproved by the facts
that the lungs remain resonant when the larger bronchial tubes are filled
with gelatine ; and that when the alveoli are filled with coagulum,
although the bronchi still contain air, the resonance is completely lost.
The resonance of the lungs indeed, as Flint has maintained, is very similar
to that of a loaf of l)read, and depends on the physical properties of the
tissue and on the character of the vibrations set up in it by percussion.
When percussion was first practised, the part of the body to be
examined was struck directly by the fingers, or by a small hammer. This
method was soon superseded by that now in vogue, known as mediate
percussion, in which the stroke is made by the finger or fingers of one
hand upon a plate of bone or other material, or more commonly upon one
of the fingers of the other hand applied to the part of the body under
examination.
In the analysis of the percussion sound as usually produced, then,
6s6 SYSTEM OF MEDICI. YE
there are thice elements which have to be taken into consideration : (u)
the sound produced by the impact of the ])ercussing finger on the one
percussed ; (/i) the sound prothiced by the vibration of the chest wall or
of the abdominal Avails or the wall of the stomach or intestines if the
latter be tense ; (y) the sound produced by the vibration of the lung, or
of the air in a cavity, such as a tubercular vomica, the pleura, stomach,
or intestine, as the case may be.
The first sound AviU be clearly distinguished if one finger be percussed
in the free air. It is a noise of feeble intensity and indefinite pitch. If
now, instead of percussing the finger in free air, we do so holding it a
a little distance above an open-mouthed jar it will at once become
evident that the sound, though still of no great intensity, has become
possessed of a definite pitch. If the experiment be tried with difierent
jars the pitch will be found to vary with the jar ; or if water be poured
into a jar, the pitch of the note produced by percussion of the finger over
its mouth will ])e found grailually to rise with the level of the water.
When the jar is filled the percussion note is as dead as it is in free air.
Again, if one percusses over one's own mouth slightly opened it will be
found that a note of a definite pitch is produced, Avhich can be altered by
altering the size of the buccal caA-itv.
The character Avhich the percussion note acquires, Avhen thus elicited
over the entrance to a cavity, is due to Avhat Ave have referred to as
resonance properly so called. It results from the vibration of the air in
a limited space in a definite manner, and the percussion throAvs the air
into a certain mode of vibration fixed by the form of the vessel, and
produces a note of definite pitch.
If the jar l)e held near the ear, and the corresponding note be sounded
on an instrument, the note Avill be greatly intensified. The note to Avhich
the jar speaks Avill differ slightly fi-oin that of percussion, owing to
circumstances Avhich it is unnecessary to go into here.
The point on Avhich I wish to insist is that the sound produced arises
primarily from the vibration of the air in the cavity, and not from that
of the Avails of the cavity ; although the latter by their vibration are
capable of increasing and modifying the sound.
When the slightl}' distended stomach or a loop of intestine is
percussed, a definite note is produced Avhich similarly arises from the
vibration of the contained air. The membrane, indeed, being slack, is not
in the physical condition to produce a musical sound.
In the case of a superficially situated cavity in tlie lung the same
result Avill be obtained, a clear note of definite pitch being produced.
In the ease of a pneumothorax the air in the cavity Avill have a
definite period of A'il>ration and produce a definite note, and AA'ill combine
Avith the sound produced by the vibration of the thoracic Avall.
If the lung be percussed outside the body a sound is produced Avhicli
closely resembles that of the ordinary thoracic sound. The resonant
character of the note depends, as I have already said, on the spongy and
elastic physical character of the lung-tissue.
PHYSICAL SIGNS OF DISEASES OF THE LUNGS AND HEART 657
The drum-like sound which occurs when the pleura is filled with air
is modified, and becomes somewhat muffled, when the thoracic cavity
contains the fully expanded lung.
The alteration which takes place when the ] 'leura is partly filled with
fluid is a very interesting one, and shows clearly the part taken by the
vibration of the lung in the production of the percussion note. In such
a case, if the upper part of the cavity were occupied by air instead of by
lung, th-e note which would be elicited on percussion would be of much
higher pitch than if the whole cavity were filled with air, and would
be distinctly musical. Where the upper level is occupied by lung, the
same is true ; the lung is slack, there is no tension of the lung-tissue,
and the air it contains vibi'ates almost as freely as if no lung-tissue
were present. The note consequently is high-pitched although less
pure, and less distinctly musical than it would be in the case of a
cavity of corresponding size. This peculiarity in the percussion note
above a pleuritic effusion is associated with the name of Skoda,
Avho specially drew attention to it ; the note is sometimes spoken of
as Skodaic.
A variety of the percussion note which is frequently referred to is
the tiimpanitk. This should proi)erly denote the low-pitched full note
which is obtained on percussion of the abdomen when the intestines are
distended. The term, however, has been l)y some transferred to the
rather high-pitched note elicited over a loop of gut which is not distended.
This latter note closely resembles the Skodaic note, or that met with over
a moderate-sized superficial pulmonary cavity.
In the case of a cavity in the lung where there is a free com-
munication with a bronchus, the percussion sound not infrequently
acquires a character spoken of as pot fele or " cracked pot." This is
generally noticeable only when the percussion stroke is sudden and
forcible and the patient holds his mouth open. The usual explanation
given for this modification of note is that it is due to the sudden
expulsion of the air in the cavity thiough the bronchus, which thus
gives rise to a hissing or chinking sound superadded to the ordinary
percussion sound. It may be produced when there is no cavity if the
walls be yielding, as in the case of children, if the air be suddenly
expelled from part of the lung by a sharp stroke.
The great value of the percussion note as a physical sign depends on
the definite information Avhich, as a rule, it gives about the structures
underlying the spot percussed. We know that the only structures of the
body capable of producing a resonant note are such as contain air.
Normally the lungs, the air-tubes, the stomach and intestines only can
give rise to a resonant note. Under abnormal conditions, air in the
pleura, peritoneum, or in a cavity will pi-oduce altered resonant notes.
When the note becomes dull we know there is little or no air present
beneath the part jiercussed. In this way by percussion we are able to
map out the superficial boundaries of tumours, of fluid effusions, or of
solid organs surrounded by air-containing viscera. When there is a
VOL. IV 2 U
658 SYSTEM OF MEDICINE
cavity, the peculiar quality already described which the percussion note
assumes, helps in the recognition of its existence.
In the })ractical enii)loyinent of percussion it must be l)orne in mind
that there is no standard of resonance which can be ai)plied to all cases.
The percussion note on one side of the chest must be carefully compared
with that on the other, and also the percussion notes at various points
of the same side must l)e contrasted.
Auscultation. — Thus far we have been dealing with the sounds which
are met with in percussion. We must now consider the sounds which
are connected with auscultation.
A large proportion of these owe their origin to the movements of
fluids through tul)cs and cavities. Such are the bruits met with in dis-
eased conditions either of the valves of the heart or of the lai'ge vessels.
Such are the normal respiratory murmurs and the abnormal sounds,
crepitations, or rhonchi audible in disease ; such, again, are the sounds to
be heard on listening over the stomach and intestines.
Other sounds depend on the movements of one surface on another, as
the friction sounds of pleurisy or of pericarditis.
We must therefore spend a little time in the consideration of the
mode of production of these sounds. To M. ChauAcau we are indebted
for an elaborate experimental study of the conditions under which sounds
are produced by fluid moving through tubes. His conclusions may be
summarised as follows : —
{a) No sound is produced by a fluid flowing through a uniform tube
or passing from a wider to a narrower one, Avhatever be the velocity of
flow or Avhatever be the condition of the Avail of the tube as regards
smoothness or roughness.
(h) A sound may be produced when a fluid flows from a narrower to
a wider space, and this soiuid will depend upon the velocit}' of flow and
the relative size of the tubes.
These results are the outcome of observation and experiment. The
statement that no murmur is produced in passing from a wider to a
narrower tube has been shown by Bergoon to be too general. If the
narrower tube have a lip projecting into the larger one it is capable, mider
certain conditions as to rate of flow, of producing a bruit.
With this exception the laws of Chauveau may be accepted as true
and capable of general ap])lication.
The cause of the sound produced by a flow from a narrow to a dilated
part is the formation of Avhat is called a fluid rein, that is, a small poition
of the fluid is set into vibration by the physical conditions under Avhich
it is placed. If now we apply these laws to the flow of blood in the
vascular system we can state under what circumstances bruits will arise.
The flow of l>lood through the arteries will ordinarily be unattended
with sound. If, however, pressure be exerted on the Avail of an artery,
so as to flatten it, a nnirnnir Avill be produced at once by the blood
flowing through the artificially narrowed portion to the Avider part be-
yond.
PHYSICAL SIGNS OF DISEASES OF THE LUNGS AND HEART 659
In aneurysmal dilatation, a bruit may be produced by the passage of
the blood through the dilated portion.
Similarly in the case of the veins no sound will ordinarily accompany
the flow of the blood. Pressure on one of the larger veins, however,
diminishing the lumen without stopping the flow, will produce the
physical condition retpiisite for the production of a murmur. The exist-
ence of a communication between an artery and a vein Avill also be capable
of producing a murmur.
As regards the heart and its valves, the relation of the orifices, the
cavities, and the great vessels is such that ordinarily no bruit is produced
by the motion of the blood itself. When the aortic valve is narrowed, or
the aorta dilated just beyond the valve, then the passage of blood through
the valve will be accompanied by a murmur Avhenever the velocity is
great enough. The same will be true in the case of narrowing of the
mitral or tricuspid valves.
When a chink is left in a valve, through imperfect closing, so that a
stream of blood trickles back in the contrary direction, the physical con-
dition for the production of a murmur is again satisfied.
Communications l»etween the aiu'icles or between the ventricles will
also obviously admit of the generation of murmurs.
Next let us consider how and where bruits can be produced by the
movements of air in the respiratory passages.
(i.) In inspiration a bruit may be produced at the external nares or
. naso-phary ngeal openings; at the mouth; at the glottis, and, as some
think, also at the termination of the bronchiole in the alveolus. It is
only Avith regard to the production of sound by the influx of air into the
alveolus that any question can arise. On this point there is some differ-
ence of opinion, most authors believing firmly in the existence of an
alveolar sound, while others hold that no sound can be produced in this way.
When we consider the small, almost microscopic, size of the alveolus and
of the bronchiole leading to it, the slightness of the current of air and the
small velocity with which it can enter the alveolus, theoretical reasons
appear very strongly to negative the possibility of any sound being pro-
duced in this way. The experiments of Chauveau and others, however,
seem clearly to have established the fact that experimental obliteration of
the glottic sounds does not annul the inspiratory sound heard by auscul-
tation over the lungs. AVe are therefore forced to side with the majority
in admitting the existence of an alveolar inspiratory sound resulting from
the formation of iimumerable small fluid veins.
(ii.) In expiration a bruit can be produced in the same situations as
in inspiration except at the last-mentioned — the alveoli.
Further consideration of these bruits must be reserved until we come
to deal with the subject of the conduction of sound.
We must next discuss what effects pathological conditions, such as
consolidation of a portion of limg, can have in the production of sound in
resjjiration.
In the case of consolidation, where the alveoli of a portion of the lung
66o SYSTEAf OF MEDICIXE
are completely filled with exudation, it is obvious no air can enter or
leave the atlected part. Whatever sounds, then, are audible over such a
consolidated area must be conducted from other parts. That portion of
the inspiratory bruit due to entrance of the air into the alveoli will be
abolished. Is it possible that the passage of the air to and fro over the
end of the tube leading to the consolidated part might produce a murmur ?
Theoretically this is possible ; but it has been shown exi)erimentally that
if it occur at all it is to so slight an extent that in practice it may be
neglected. Probably the volume of air and the velocity with which it
moves are so small that ordinarily no murmur is produced.
In what way will the existence of a cavity in the lung influence the
production of sound ?
Here an important secondary question arises — the theory of resonance
which has already been considered in part Avhen dealing with percussion.
The resonating property of a cavity will materially modify not only the
sounds produced in the cavity but also those reaching it. There may or
may not be entrance of air into the cavity and issue from it. Air may
be drawn into the cavity during inspiration by the expansion of its walls,
and expelled during expiration by their retraction ; or the walls may be
perfectly I'igid and ineapaV)le of mo^■ement. The entrance of air into the
cavity will be attended with the formation of a fluid vein and the pro-
duction of a murmur, but its issue will not.
In the case where air is forcibly expelled fi'om a cavity, as sometimes
happens during coughing, the succeeding inspiration may be accompanied
by a distinct suction-sound jiroduced by the sudden inrush of air into the
cavity.
The discussion of the modification both in conducted sounds and in
sounds locally produced in the cavity will be more appropriate after we
have fully considered the subject of conduction.
"We have next to consider what sounds owe their origin to the pre-
sence of secretions in the respiratory tubes : (i.) what will be the effect of the
presence of a mass of mucus or thick secretion in one of the larger tubes.
' This condition will produce a local narrowing in the calil)re of the
tube, and therefore a murmur may occur both with inspiration and ex-
piration. If the secretion be viscid, a projecting tongue may be formed
capable of moving backwards and forwards and of giving rise to a snoring
soiuid. It is ol)viously in the laiger tuV)es only that such sounds can l)e
produced ; they are generally described as rhonchi, and are often dis-
tinctly musical.
(ii.) The presence of thin secretion through which air can bubble will
produce (piite a different sound. This will nearly always occur in the
medium-sized tubes ; in the smaller tubes a })lug of mucus W'ould be
sufficient to prevent the entrance of air altogether. From its mode of
production such a sotuid will generally be of a crackling character, in
which case it goes by the name of crepitation. The diff'ei'cnt kinds of
crepitations depend j)iiiici])ally on resonance, and also on the nature of
the tissues through which the sounds are conducted.
PHYSICAL SIGNS OF DISEASES OF THE LUNGS AND HEART 66 1
The production of sounds by the passage of liquid and air along the
alimentary canal need not detain us long. Such sounds are similar to
those we have been considering ; but from the size of the tubes and the
relative proportions of air and liquid they will be of a very different
quality, and are more properly described as gurgling sounds. Sometimes
they are so loud that they are audible at some distance from the patient.
Mention must be made of the splashing sounds which may be pro-
duced by shaking the patient, when air and liquid are simultaneously
present in the pleura. This succussion sound, the origin of which is
sufficiently obvious, is specially interesting as having been observed by
Hippocrates.
The rul)bing of two roughened surfaces together produces what is
appropriately called a friction sound. It is generally met with in the case
of pleurisy or pericarditis ; but it may also occur over any of the larger
viscera when the peritoneum is roughened.
It is said that in the case of the smaller bronchi or alveoli crepitation
sounds may be produced by the separation of surfaces previously in con-
tact, and it is quite conceivable that this may sometimes occur.
II. The conduction of sound. — The following may be stated as the
laws which govern the conduction of somid so far as our subject is
concerned.
(a) Sound emanating from a single source in a uniform medium
diminishes in intensity according to the law of the inverse square of the
distance. The same amount of energy acts on surfaces whose areas
increase as the square of the distance. Thus if I be the intensity of
the sound, d the distance of the source,- E the amount of energy it gives
out, we have
M^ocE,
or
E
(&) Sounds are conducted by liquid and solid media as well as by air.
The same law is followed as regards intensity as long as the media remain
uniform. The velocity with which sound travels varies with the medium
in which it is propagated.
(c) When sound travelling in one medium meets the boundary of
another medium it is partly reflected and partly transmitted. Sound
propagated in a medium such as air is very badly transmitted to another
of a very different character, such as a liquid or a solid.
(f/) AYhen sounds are produced by the movements of fluids through
orifices they are best conducted in the direction in which the currents
flow.
(e) Sounds may be conducted to great distances by tubes, rods, or
wires, by means of which dissipation of energy is prevented. The
sectional area remaining practically the same, the law of the inverse
square does not come into operation. In the case of the tube, the sound
662 SYSTEM OF MEDICINE
is conducted hy the air in its interior aiul not as a nile by its walls.
The vails of the tube must be of sufficient thickness to prevent energy
leaving it transversely. In the case of the rod and wire the sound is
conveyed directly along the wood or metal of which they are composed.
A tube is specially adapted for the conduction of sounds of low in-
tensity, such as whispered voice sounds, breath sounds and vascular
murmurs. As is well known, the speaking-tube will conduct the whispered
voice a long distance.
Stethoscopes are either solid rods, or tubes, with end-pieces for appli-
cation to the surface of the body, and ear-pieces for apposition to
the ear.
The tubular form is nearly always used at the present time. The
tube may be made of some rigid material such as wood or metal, or of
some soft material such as india-rubber. The ear-piece may be single,
adapted for one car only ; or double, so that both ears may be employed
simultaneously, the sound being conducted by a tube to each ear.
We are now in a position to inquire how sounds produced in the in-
terior of the body are conducted to the surface.
First, let us consider the sounds which are to be heard on auscultat-
ing the trachea. From what has alread}' been said as to the production
of sound it is clear that in this case, under ordinary circumstances, the
glottic breath sounds only will be audil:)le. The sounds produced at the
glottis will be modified by resonance in the tracheal cavity. Their in-
tensity is thereby increased, and they will acquire a character peculiar to
the resonating cavity into which they are conducted. Expiration and in-
spiration Avill be about equally loud, and possessed of a harsh blowing
character. To the glottic breath sounds, as audible over the trachea or
one of the larger tubes, the name of " tubular breathing " has been given.
Next let us consider the conduction of the breath sounds to the lungs
and thence to the surface of the body. The sounds are of such feeble
intensity that they are inaudible unless the ear be applied close to the
chest wall, or diffusion be prevented by the interposition of a stethoscope
between the latter and the ear.
We shall take it for granted that the sounds ordinarily heard over
the lungs are the sounds produced at the glottis modified by conduction,
and supplemented by the sounds produced at inspiration by the entrance
of air into the alveoli. With the lungs in the ordinary condition the
law of the inverse square will be very appi'oximately true. The smaller
tubes, thin-walled themselves and surrounded on every side bv thin-
walled air-cells with which they freely communicate, do not answer the
purpose of preventing the general diffusion of sound. The consequence
is that if we take the main bronchus as a centre, and describe a series of
spheres round it, we shall have a series of surfaces over which the in-
tensity of the glottic sounds will, approximately, vaiy inversely as the
radius. The glottic sounds should, therefore, be better audible when the
chest walls are thin, when the pleura is not thickened, and the nearer the
point of auscultation to the main bronchi.
PHYSICAL SIGNS OF DISEASES OF THE LUNGS AND HEART 663
The sounds produced by the entrance of air into the alveoli should
everywhere be of about the same intensity. The result of these two
sources of sound is to make the inspiratory sound considerably longer
and louder than is the expiratory.
Consolidation of the lung acts in two ways —
(i.) As no air enters the alveoli of the affected part the alveolar part
of the respiratory murmur ■^^'ill be abolished.
(ii.) The alveoli l^eing filled with exudation, the glottic sounds will
be much more perfectly conducted along the tubes, the dissipation of
sound which occurred through the free communication of the tubes "with
the air-spaces being prevented. The result is that the glottic sounds are
distinctly conducted to the surface, and are unmingled with any sounds
of local origin.
The explanation we have given assumes the continued patency of the
tubes, the alveoli alone being blocked. If the tubes also are 1)locked, not
only will the consolidated lung not prove a better conductor than normal
lung, but indeed it will not conduct quite so well, as has been shown ex-
perimentally. In this case the breath sounds will be either very faintly
tubular or entirely absent.
When the lung is collapsed, the tubes are flattened and partially
obstructed. Collapse ^^^ll, however, bring about a result which con-
solidation does not ; and that is the approximation of the larger bronchi
and the surface, as the result of which tubular breathing may be more or
less clearly audible. In some cases the breath sounds may be entirely
suppressed.
Emphysema is a condition in which, ■ through dilatation of the alveoli
and impairment of their elasticity, a lessened amount of air enters and
leaves the lungs. The alveolar part of the respiratory sound is there-
fore diminished, while there is increased dissipation of the glottic
part.
When a large bronchus is blocked by a foreign body, or is completely
obstructed by external pressure, the only sounds which can reach the ear
must come from the tubeS on the laryngeal side of the obstruction.
These, from the nature of the case, will be very badly conducted, and will
be almost, if not quite, inaudible.
The presence of a cavity in the lung, communicating freely with a
lironchus, will make an important modification in the sounds.
(a) Suppose air neither enters nor leaves the cavity during respiration.
The dense walls of the cavity will prevent the diffusion of the sounds
conducted from the bronchus ; they can therefore reach the ear Avith in-
creased distinctness.
(/3) Practically in most cases air Avill enter and leave the cavity dur-
ing respiration. We already have considered what effect this Avill have
on the production of sounds.
Sometimes the amount of air entering vnW be so small that the sound
so produced may be neglected. The glottic inspiratory sound may thus
be augmented by the whiff, if any, produced by the entrance of air into
664 SYSTEM OF MEDICINE
the cavity, while no alteration will take pLicc in the expiratory sound,
which will be purely conducted glottic.
Frequently it will l)e quite inipnssihle to say from the character of
the breath sounds whether we are dealing with consolidated lung per-
meated by patent or dilated Ijronchi, or with a cavity. The breath sounds
audible over a cavity may, however, have a certain distinctive character,
in which case they are fre(|uently sjjoken of as cavernous or aiiiphnric.
This quality is like that resulting fi-om blowing over a Ijottle or jar.
It has been explained as due to resonance or to reflection of the sounds
at the walls of the cavity.
In discussing the percussion note we pointed out that in the case of a
cavity the air contained by it is capable of vilirating so as to produce a
note possessed of a definite musical pitch, although of no great intensity
unless the vibration setting it in motion be correspondingly great. In
the same way any sounds conducted to the cavity or produced in the
cavity will, when it is of sufficient size and of definite shape, take on the
note quality peculiar to the cavity. The breath sounds will then acquire
that pecidiar resonance quality which gives pitch and lim])re to them, and
makes them cavernous or amphoric.
In the same way this property of resonating will give the definite
cavity quality to sounds otherwise essentially unnuxsical, such as crepita-
tions. In the case of a large cavity, such as a pneumothorax, or one
involving the greater part of a lung, the corresponding sounds will be
proportionally loud and will have definite musical jDitch. In this way
crepitations frequently acquire a metallic character.
Of the same nature is the bell sound or bruit cVairain. This is
observed when percussion is employed over a large cavity, or a pneumo-
thorax, by means of two coins, one of which is held in contact with the
chest and is percussed with the other. The sound so produced excites
resonance in the cavity, and a peculiar metallic clink may be heard on
auscultation with the stethoscope.
What is the eficct of fiuid in the pleura on the conduction of the
breath sounds ?
1st. Fluid in the pleura is necessarily attended with collapse of the
part of the lung subjected to the pressure of the fluid, and consequently
the only sounds which can be audible ynW be conducted glottic.
2nd. The interposition of a layer of fiuid between the lung and the
surface will undoubtedly cut ofi" a considerable portion of the sound, and
may succeed in cutting it off altogether.
In ordinary cases, at the upper margin of the fluid the breath sounds
will be faintly tubular; at the lower pait they Avill be almost, if not
quite, annulled.
In the case of air in tlic pleura, the problem will difler according as
there is or is not a fairly free communication with a bronchus. In the
absence of adhesions the lung becomes collapsed. AVhatever sounds are
heard will be purely conducted glottic. If the communication of the bronchi
with the pleural cavity be free, then tubular breath sounds, augmented
PHYSICAL SIGNS OF DISEASES OF THE LUNGS AND HEART 665
by resonance and probably thereby invested Avith metallic quality, will
be audible. If, on the other hand, communication Avith the bronchi have
ceased, then such breath sounds as may be audible Avill be extremely
feeble.
We may now consider very briefly what laws govern the conduction
of the spoken and whispered voice sounds to the surface of the chest.
The spoken voice sounds are produced at the larynx, and are modified
and augmented by resonance in the cavities of the mouth and nose. The
whispered sounds are produced by the lips, tongue, etc., and not at the
larynx. We have already observed that whispered sounds are exceed-
ingly well conducted by means of tubes. It therefore happens that
whatsoever promotes the conduction of the laryngeal breath sounds will
similarly assist the conduction of the whispered sound. Ordinarily the
whisper will be very little audible over the chest wall. It will be well
conducted, however, wherever there is underlying consolidation with
patent bronchial tubes or a cavity opening into a bronchus : in the latter
case it may acquire the cavernous quality. It may be audible over the
upper part of an effusion, but will be absent at the lower part.
The spoken voice sounds will be conducted well or badly under
similar circumstances. As they are of considerable intensity they have
the power of throwing into vibration the tissue through which they are
conducted. In the case of consolidation of the lung-tissue with patent
bronchi, in consequence of the increased conduction of the voice sounds
there will be increased viljration, which can be distinctly felt on the
sui-face on application of the hand. The opposite is the case where there
is effusion of fluid. The voice sounds, are then badly transmitted, and
the vocal fremitus to be felt hj the hand is greatly diminished, or may
be absent altogether.
Here I must refer very briefly to a modification of the voice sounds
which is sometimes observed in cases of pleural effusion. When auscul-
tation of the voice is practised about the upper level of the fluid it is
found that it has acquired a peculiar bleating quality ; a modification
usually spoken of as cegophony. No completely satisfactory explanation
of this phenomenon has yet been given. The explanation most generally
received is that of the late Dr. Stone, who found that when a pure tone
was produced by the patient by means of a pitch-pipe there was no
segophony. The ordinary spoken voice is a compound sound composed
of fundamental tones and their harmonics. Low tones are known to
travel from air to liquid with greater diflSculty than higher tones. A
sound composed of a tone and harmonics will be altered on passing
through the fluid by the deadening of the fundamental, the higher har-
monics in consequence becoming relatively louder.
On the conduction of the adventitious sounds, such as rJionchus and
crepitation, only a few words are necessary. Rhonchi, being produced in
the larger tubes, usually in the trachea, will be audible all over the chest
wall. Crepitations, on the other hand, arising in the smaller tubes will,
as a rule, be audible only over the limited portion which is supplied by
666 SYSTEM OF MEDICINE
these tubes. As crepitations usually arise under conditions which are
associated with consolidation, the former are gener'ally conducted clearly
to the surface, for the same reason that the breath and ■\oice sounds are
so distinctly conducted. When a cavity exists, crepitations excite reso-
nance, and then frequently acquire a metallic character.
In the consideration of the heart sounds, normal and otherwise, the
question of conduction is not of so much importance, and the laws which
govern their conduction need not detain us long. Murmurs produced by
the formation of fluid veins are conducted in the direction of the current.
Hence the murmur due to mitral incompetence is conducted towards the
left aiiricle, and is therefore generally audible towards the axilla as well
as at the apex of the heart. The nuu-nnxr due to aortic stenosis will be
audible not only at the base of the heart but also in the direction of the
great vessels. The murmur due to aortic incompetence will be con-
ducted down the left ventricle, and often be well heard along the left
border of the sternum.
The heart sounds will often be well heard over a pulmonary cavity or
consolidation, in the case of the cavity being augmented by resonance.
In such cases the cavity or consolidated lung must be closely connected
with the heart or great vessels.
Friction sounds, such as those of pleurisy and pericarditis, are already
superficial, and their conduction is a very simple matter. They are
usually audible at and near the place of production.
The recent discovery of the Bnntijcn rai/s has greatly extended the
possible range of A'ision as regards the interior of the body. If we cannot
actually see internal structures, their shadows may sometimes be made
visible. This depends upon the fact that when the rays pass through a
body of varying density, the denser pnrts offer more obstruction to the
passage of the rays than the rarer, and thus cast shadows which may be
made visible on a sensitive screen or be permanently recorded on a
photographic plate.
In the case of the hands and feet, where the parts are thin, the bones
Cixst well-defined shadows, and thus are clearly shown on the screen or in
a photograph. Foreign bodies in such parts may also be readily made
manifest.
Where the parts are thick, as in the case of the thorax and abdomen,
the shadows are much less well defined, but broad effects may be obtained.
Thus the healtliy lung is very transparent to the rays as compared with
a consolidated lung, a new growth, a pleural eff'usion, or a hydatid cyst.
The latter, therefore, may give evidence of their presence by casting
relatively darker shadows on the screen. The ])resence of an aneurysm
with its pulsations may similarly be revealed by the shadow it casts.
The application to the investigation of abdominal diseases presents great
difficulties which have not yet been surmounted.
It may be pointed out, in connection with what has been said relating
to percussion, that dulness on pei'cussion goes along with bad transmission
of the Kontgen ray.s, while resonance is accompanied by good transmission.
PHYSICAL SIGNS OF DISEASES OF THE LUNGS AND HEART 667
Thus it is found that, as a rule, wherever there is dulness to percussion
there is shadow as compared with areas in which there is resonance ; the
intensity of the shadow being proportional to the degree of dulness.
Hector AV. G. Mackenzie.
REFERENCES
1. AuENBRrGGER. Iiiventum novum ex percussione thoracis humani ut signo
ahstrusos interni jjedoris morhos deteyendi. Vindobonse, 1761. (Translation by
Corvisart, Paris, 1808.) — 2. BariS, E. Bruits de souffle et bruits de galop. Paris,
1894. — 3. Bekgeon. Des causes et du, mdca7iisme du bruit de souffle. Paris, 1868. —
4. Besnier. "Matite," Diet, encycl. d. sc. vi^d. Paris, 1872, v. 212-227. — 5.
BuLLAR, J. F. "On the Percussion of tlie Lungs and Chest," St. Ba.Hh. Hosp. Rep.
Lond. 1883, xix. 211-220.— 6. Gary, C. "The Production of Tubular Breathing in
Consolidation and other Conditions of the Lungs," Tr. Ass. Am. Physicians, Pliila.
1892, vii. 313-323. — 7. Casten, E. "Kote sur une loi fondanientale dans la theorie
de I'auscultation," Conipt. rend. Soc. de hiol. Paris, 1894, 10 s. i. 805-807 ; Arch, de
physiol. norm, et path. Paris, 1895, 5 s. vii. 225-238.-8. Chauveau, A. " fitudes
pratiques sur les murmures vasculaires ou bruits de souffle et sur leur valeur semeio-
logique," Gaz. mid. de Far. 1858, 247, etc. — 9. Coiffier. Frdcis d' auscultation,
2nd ed. Paris, 1890.— 10. Flint, A. "The Analytical Study of Auscultation and
Percussion with Reference to the Distinctive Characters of Pulmonary Signs," I'r.
Internat. M. Cong. 7 sess. Lond. 1881, ii. 130-141. — 11. Galliard, L. " Le bruit
de pot fele," Mid. mod. Paris, 1895, vi. 597-601. — 12. Gee, Samvel. Auscultation
and Percussion, 4th ed. Lond. 1893. — 13. Idem. "The Theory of the Breathing
Sounds heard by Auscultation," St. Barth, Hosp. Pep. Lond. 1890, xxvi. 103-105.—
14. GuTTMANN, P. "' Fercwshion," Ecal-Encycl. d. ges. Hcilk. AVien u. Leipz. 1882,
zehnter Band, 442-465. — 15. Idem. A Handbook of Physical Diagnosis. Translated
by A. Napier, M.D., London. The New Sydenham Soc. 1879.— 16. Laexnec,
R. T. H. Traite de V auscidtation midiate et des maladies des poumons etducceur, 2nd
ed. Paris, 1826. (Translation by Sir John Forbes, 4th ed. Lond. 1834.)— 17. Leke-
BOULLET, L. "Percussion," Diet, encycl. d. sc. mid. Paris, 1886, xxii. 733-760. —
18. Lyon, T. Glover. The Thoracic Percussion Note. Thesis for M.D. Cantab. 1885.
— 19. NooRDEX, C. V. " Anscnltation," Pcal-Encycl. d. ges. Heilk. Wien u. Leipz.
1894, drit. Aufi. zweiter Bd. 536-559. — 20. SiMOX, P. Manuel de percussion et
d' auscultation. Paris, 1895. — 21. Skoda, Joseph. Abhandlung iiber Perkussion und
Auscultation. "Wien, 1839. (Translation by W. 0. Markham. Lond. 1853.) — 22.
Steinthal, C. F. Experimentelle und klinische Untcrsuchung ubcr die Ursachen
des vesiculdren Athmungsgerdusches. Heidelberg, 1885. — 23. Stone, W. H. St.
Thomas's Hospital Reports, 1871, ii. 187.— 24. Taylor, F. "On the Causation of
.ffigophony," Mcd.-Chir. Trans. Lond. 1895. — 25. Vierordt, H. Kurzer Abriss
der Percussion und Auscultation, 4. Aufl. Tiibingen, 1895.
H. W. G. M.
DISEASES OF THE NOSE, PHAEYNX, AND
LARYNX
I— DISEASES OF THE NOSE
Rhinoscopy :
Acute Rhinitis :
Chronic Hypehtrophic Rhinitis :
Chronic Atrophic Rhinitis :
Purulent Rhinitis :
Membranous, etc., Rhinitis :
Epistaxis :
Tuberculosis :
Lupus :
Syphilis : — Y. de Havilland Hall.
NE^v Growths :
Bone Affections : — Greville MacDonald.
Rhinoscler6ma :
Glanders : — F. de Havilland Hall.
Neuroses. Felix Semon and Watson
Williams.
Foreign Bodies :
Rhinoliths :
Maggots : — F. de Havilland Hall.
Diseases of Accessory Sinuses.
Greville MacDonald.
Naso-pharyngeal Catarrh :
Tuberculosis \
Syphilis /
F. de Havilland Hall.
Adenoid Vegetations. Felix Semon
and Watson Williams.
OF Naso-pharynx :—
Rhinoscopy. — Anterior rhinoscopy is the name applied to the examina-
tion of the anterior nares, and posterior rhinoscopy to the examination
of the naso-pharynx and posterior nares.
For rhinoscopy the same reflector and source of illumination are
emploj'ed as for laryngoscopy. In examining the anterior nares various
kinds of specula are used for dilating the nostril ; the most convenient is
Duplay's bivalve speculum. The examination of the nose is much
facilitated hy a]>plying a 20 per cent solution of cocaine to the interior of
the nostril, as in consequence of the astringent action of the drug on
the mucous membrane a much better view is obtained of the posterior
part of the nasal passages. The addition of resorcin to cocaine — in the
proportion of 1 to 2 — diminishes the toxic and increases the anaesthetic
effect. In the methodical examination of the nose the condition of the
mucous membrane and the presence and ai)parent source of any discharge
should first be noted ; then attention should be directed to the bony and
cartilaginous framework of the nose, to deviations of the septum, and to
any spurs and crests on it : finally, the presence of new growths and
their points of origin should be recognised.
For the examination of the nasopharynx and posterior nares a
tongue depressor and a rhinoscope are necessary. Michel's instrument
is the most cojivenient form of the latter. A cone of light should be
thrown on the posterior wall of the pharynx by means of the laryngeal
672 SYSTEM OF MEDICINE
reflecfor, the totigue should then be depressed by a suitable depressor
and the rhinoscope, the mirror having been first warmed, introduced
behind the soft palate. When in position the ti'igger should be pressed
so as to elevate the mirror. Three main difficulties are met with in
posterior rhinoscopy : (i.) A hard i)alate which extends so far back that
there is no room for the introduction of the mirror ; (ii.) A broad and deep
soft palate with a long uvula ; (iii.) The instinctive drawing backwards and
upwards of the soft palate on the introduction of the mirror. The
first condition, which is fortunatel}' rare, presents an insuperable obstacle
to rhinoscopy ; the second and third may be overcome by the use of a
cocaine spray, and a little practice. Various hooks and snares have been
devised for pulling the soft palate forward, but more will be accomplished
by patience th;ui by means of this kind.
The first thing to be recognised in posterior rhinoscopy is the septum;
having identified this, the lower turbinals and sometimes the su])erior
turbiiial can be seen on either side, together with the choaiue or posterior
openings of the nasal passages ; then the mirror should l)e turned to the
right and left in order to see the openings of the Eustachian tubes ;
finally, the mirror should l^e directed upwards so as to examine the
vault of the pharynx. The appearances met with here vary very much.
In children, a red irregular mass, constituting the so-called adenoid vege-
tations, is frequently to be seen ; in adults, Avithout an enlargement of
the pharyngeal tonsil, the vaulted condition of the nasopharynx may be
distinguished.
In making a rhinoscopic examination it must be remembered that it
is impossible to get a com{)letc view of the whole of the posterior nares
at the same time ; segments only of the picture can be obtained, as the
position of the mirror is shifted.
Acute Rhinitis. — Nasal catarrh and coryza are some of the names
applied to an ortlinai-y cold in the head. Here we have to do with an
acute catarrhal inflammation of the nasal mucous membrane.
That the disease is of bacterial origin seems highly i)roliable, but at
present no proof to this effect is forthcoming. If acute rhinitis be due to
bacteria, then exposure to cold and damp is a remoter cause, and
the contagious nature of the disease is explical)le. The symptoms
associated with a cold in the head are so well known tliat it is quite
unnecessarj'^ to mention them here.
In children, especially infants at the breast, acute rhinitis may be
a serious affection. The infant, Ix'ing unable to breathe through the
nose, cannot take the breast ; and if it be placed on its back the nasal
obstruction may cause cyanosis and other symptoms of suflbcation.
Trmlnu'nt. — Pei'sons who are subject to attacks of corv/.a may do much
to prevent their i-ecuricnce by attention to the rules of hj'gicne. The
clothing should be suitjible to the season of the 3'ear, and never too thick.
Exercise in the fresh air is most important, and a cold bath in the
moi'tiing, followed l)y vigorous friction, is useful for all, except very
young, old, or delicate persons. The diet should be simple, and over-
DISEASES OF THE NOSE 673
eating io to be avoided. If the patient be anaemic, iron, arsenic, and cod-
liver oil are the appropriate remedies. Attempts may be made to cut
short an attack by taking ten grains of Dover's powder at night, full
doses of the solution of acetate of ammonia, and hot drinks. The
sulphate of atropine in doses of y ^-g- to -^-^ of a grain has been found
useful in many cases. After the more acute symjjtoms have subsided,
quinine will usually be found of service.
Locally A'ai'ious antiseptic and sedative preparations have been recom-
mended. Spraying the nostrils with menthol and eucalyptol dissolved
in liquid paraffin is useful. A snuff composed of seventy-two parts of
boric acid, twenty-five of salol, two of cocaine, and one of menthol, may be
employed about every half-hour. The carbolised smelling-salts often
give great relief. In cases of coryza in infants the nostrils may be kept
clear by passing a small roll of blotting-paper into them. Liquid
paraffin containing 2 per cent of cocaine can be applied to the nostrils
with a paint brush, and will do much to promote the comfort of the
infant.
Early treatment of nasal catarrh in children is most important.
Any obstruction to free nasal respiration should be removed, and parts
normally separate should not be allowed to touch one another.
Chronic Hypertrophic Rhinitis. — As a result of repeated attacks
of acute rhinitis the nasal mucous membrane becomes thickened, and to
this condition the term of chronic hypertrophic rhinitis is applied. Any
obstruction to free nasal respiration, such as that offered by outgrowths
from the septum, or deflections of it, increases the tendency to hypertrophic
changes in the nasal mucous membrane. The irritation caused by the
inhalation of dust, flour, and other substances suspended in the air also
leads to similar changes. Various cardiac, pulmonary, and hepatic
affections produce engorgement of the mucous membranes in general,
including the nasal mucous membrane. Hypertrophic rhinitis is not
infrequently found associated with adenoid vegetations and enlarged
tonsils, and the tendency to these conditions seems to be hereditary. In
addition to the changes usually met with in mucous membranes as the
result of a chronic intlammatory process — namely, increase of the fibrous
and lympiioid elements of the part, with more or less atrophy of the
glandular structures — attention has of late been strongly directed to a
permanent distension of the venous sinuses. This form of hypertrophy
is especially marked at the posterior extremity of the inferior turbinated
bodies, and has received the name of turbinal varix.
The symptoms of chronic hypertrophic rhinitis are almost entirely
dependent on the nasal stenosis which it causes. The amount of visible
obstruction affords no measure of the amount of discomfort to the patient.
In neurotic patients a slight degree of stenosis produces symptoms out of
all proportion to the obstruction.
The difficulty in breathing through the nose leads to mouth-breathing,
and consequently to pharyngeal and laryngeal catarrh. The patient is
constantly coughing and hawking to get rid of the viscid mucus which
VOL. IV 2 X
674 SYSTEAf OF MEDICINE
adheres to the naso- pharyngeal, phar3'ngeal, and huyngcal mucous
membrane. In some cases sneezing and a continual flow of mucus from
the anterior nares are the chief troubles ; in- other instances headache,
giddiness, and deafness due to implication of the accessory sinuses and
Eustachian tubes. Mental depression, amounting even to melancholia,
may result from hypertrophic rhinitis. At night for some obscure
reason all the symptoms of stenosis are aggravated.
Chronic hypertrophic rhinitis can be distinguished from vaso-motor
rhinitis by the application of a solution of cocaine, Avhich in the latter
aflfcction causes the mucous membrane to contract, whereas in the former
it has but little effect. New growths are usually more or less pedunculated ;
and, in any case, the growth is generally circumscribed. Bony and car-
tilaginous tumours may be excluded by their hardness. Tiie appearance
of a pale ashy gray or pink growth blocking up one or both choanfe, as
seen by the aid of the rhinoscope, is very characteristic of eidargement
of the posterior extremity of the inferior turbinal.
'Treatment. — The line of treatment to be adopted depends to a
certain extent upon the nature of the sj^mptoms. If the patient is most
troubled by the secretion of viscid mucus, which he has difficulty in
getting rid of, various alkaline or mildly astringent sprays will be foimd
uscfid. In some cases great relief is obtained' by the use, night and
morning, of one of the fluid paraffins in an oil atomiser. Menthol,
eucalyptol, resorcin, or carbolic acid may be added to the paraffin.
Usually, however, some more radical treatment is requisite in order to
reduce the bulk of the hypertrophied mucous membrane. Antciiorly
this may be done by the use of the galvano-cautcry, by incisions with a
Icnife down to the bone, or by forming an eschar Avith chromic, nitric, or
trichloracetic acid. If the tissue be of a polj-poidal nature the anterior
extremity of the inferior turbinal should be transfixed with a curved
needle, and the galvano-caustic loop passed over the handle and
point of the needle, and gradually tightened. Electrol3'sis has given
excellent results in some cases. For hypertrophy of the posterior
extremity of the turbinal it is advisable to use a Avire-snare ecraseur, on
account of the tendency to haemorrhage from the dilated sinuses. The
cold wire is also better in this Itjcality on account of the proximity of the
Eustachian tube, and of the risk of setting up otitis media by the use of
the galvano-caustic loop. Dr. Greville MacDonald's nasal snare is a
very convenient instrument. The operation shoidd l»e performed slowly,
a turn being given to the screw from time to time ; if so done, there is
hardly any bleeding. Should hamiorrhage occur, the injection of hot
water will generally check it ; if not, the nose may be plugged posteriorly.
Some operators prefer the ring or draw-knife. In all operative procedures
about the nose the greatest care should be taken to carry out strict
antiseptic precautions. Some operators advise that the nose should
be carefully sprayed with some disinfectant before it is treated. The
application of cocaine is now universal, as it al)olishes pain, and by
constringing the mucous membrane allows a better view of the interior
DISEASES OF THE NOSE 675
of the nose. After cauterisation or other operative interference in the
nose, a pledget of cotton avooI smeared with some antiseptic ointment
should be introduced into the nostrils, and the patient warned against
the risk of exposing himself to any septic influence.
The general treatment of cases of hypertrophic rhinitis requires a
little consideration. A high, dry, and bracing locality has usually a
beneficial effect, especially after the patient has had a course of treatment
at a place like Ems. I have seen good results from a stay at Strath-
peffer. Visceral engorgement must be treated with tonic aperients,
such as the combination of the sulphates of iron and magnesium. The
patient should be advised to take but little alcohol and to have regular
exercise in the open air.
Chronic Atrophic Rhinitis. — Many authorities use the term ozaena as a
synonym for chronic atrophic rhinitis ; but this is incorrect, as oza^na (that
is, a foetid discharge from the nose) may occur independently of atrophic
rhinitis, and there are cases of atrophic rhinitis without ozsena.
Etiology . — Chronic atrophic rhinitis begins in early life, and some
authorities regard it as due to a congenital defect. The disease is not
often recognised under the age of four or five years ; it increases in
severity towai'ds puberty, and the majority of cases arise before the age
of sixteen. Females are more frequently attacked than males, in the
proportion of about seven to two.
It appears to be more common in an?emic patients and in those of
phthisical parentage ; but there is no general consensus of opinion on this
point : some authors state that it usually occurs in persons who are
otherwise perfectly healthy. Yet atrophic rhinitis frec^uently affects
more than one member of the same family.
M(.rhiil anatomy and pathology. — In some cases atrophic rhinitis is
preceded by a hypertrophic stage, in which there are dilatation of the
blood-vessels and emigration of leucocytes. Very soon the blood-vessels
lose their tonicity, supply of blood to the part fails, and atrophic changes
are the conse({uence. Many authors, however, hold the opinion that
chronic atrophic rhinitis represents an atrophic process from the beginning,
■with sclerosis of the tissues and metamorphosis of the epithelium.
Bosworth is of opinion that atrophic rhinitis is almost invariably the
result of the purulent rhinitis of children, and there is much to be said
m its favour. By Zaufal the disease is regarded as due to a con-
genital defect, or to an arrest in the development of the turbinated
bones. In atrophic rhinitis the turbinated bones are undoubtedly small ;
but this change is rather a part of the general atrojihy of the structures
of the nostrils than the cause of the disease.
Atrophic rhinitis is indeed the most common cause of ozsena,
although cases of chronic atrophic rhinitis do occur in which ozaena is not
present. Any condition which leads to a permanent dilatation of the
cavity, as for instance the presence and removal of a nasal growth,
may be the cause of ozsena. Michel regards chronic catarrh of the
accessory sinuses as essential to the existence of ozaena ; and Tissier lays
676 SYSTEM OF MEDICINE
especial stress upon a diseased process in the ethmoidal cells, oi" in one of
the accessory sinuses, with necrosing osteitis, as the primary cause of
ozoena.
The relation of micro-organisms to the production of oza?na is still un-
determined. Loewenberg has dcscril)ed a micrococcus, resembling the
pnoumococcus, "which he discovered in the mucous membrane, and ho
regards it as the cause of the condition. Hajek has detected in ozaena
a short bacillus, occurring in the form of a diplococcus or in chains, which
possesses the i)roperty of decomposing organic substances with the forma-
tion of a penetratijig stink. Hajek has applied the name of bacillus
feeUdns to this organism. When we have decided whether these micro-
orjjcanisms are to l)e reijarded as the cause or effect of the disease, the
further difficulty will still remain of settling to which micro-organism the
production of ozajna is to be assigned ; for no one of them is found in all
cases.
At the post-mortem examination of cases of atrophic rhinitis extreme
atrophy of the nuicous membrane and bony structures is found, and a
fibroid degeneration of the soft parts : the ciliated epithelium is replaced
by the non-ciliated A'ariety. Krause regards fatty degeneration in the
ghmd epithelium as an essential feature in the disease, and he attributes
the sickening and rancid smell, so characteristic of it, to the decomposition
of the fat and liberation of fatty acids.
Symptoms. — The patient usually complains of a sense of discomfort,
and of obstruction in the nostrils ; on blowing the nose violently
masses of dry crust are expelled, together with a more or less fluid
secretion.
Attempts have been made to divide atrophic rhinitis into two varieties
— the dry and the moist ; but there is no advantage in this, as in the
same patient at one time crusts are found, and at another time the
secretion is more liquid. The state of the atmos])hcre influences the
nature of the discharge ; in dry weather with east winds the discharge is
dry, whereas in damp weather it is muco-pundent. A characteristic
feature of the disease is the extreme foetor of the discharge, which has a
sickening, penetrating character : this when once perceived is readily re-
cognised. Fortunately for the patient his sense of smell is usually
destroyed early in the progress of the disease, so that he is unconscious of
the horrible stench proceeding from his nostrils. As already mentioned,
however, there may be no foetid discharge.
Though the disease is not painful the nose is often very irritable, so
that the patient jncks or scratches the interioi', and may thus cause
excoriation of the mucous membrane and slight haemorrhage. Such
picking at the septum may lead to a perforation of the tissues already
thinned by the disease.
Owing to the condition of the nasal mucous membrane, the air which
passes over it in insj)iration is not pro{)erly warmed, moistened, or filtered ;
thus pharyngeal and laryngeal catarrh are frequently met with in
patients suffering from ati'oj)hic rhinitis ; in some cases crusts form in the
DISEASES OF THE NOSE 677
larynx and trachea — " tracheal ozsena "—and cause foetor of the breath,
even after the nostrils have been thoroughly disinfected.
By extension of the disease to the Eustachian tube, acute and chronic
catarrh of the middle ear and tinnitus sometimes arise. Ulcer of the
cornea with hypopyon and conjunctival catarrh and various reflex
symptoms are observed occasionally.
The aspect of the patient suffering from chronic atrophic rhinitis is
characteristic ; the nose is broad and depressed at the bridge, giving rise
to the condition called saddle-back, and the tip is turned up, showing the
dilated nostrils. On anterior rhinoscojDy the nostrils will be found full of
dry crusts composed of inspissated muco-pus and micro-organisms, and
having an al)ominable stench. On removal of these the nasal passages will
be found unusually capacious, so that it may be possible to see the posterior
wall of the pharynx. The mucous membrane of the nose is generally
pale, but it may sometimes be slightly reddened. Ulceration is rare, but
a little bleeding may follow the detachment of the crusts. Should there
be necrosis of bone or cartilage the case is not one of atrophic rhinitis.
Atrophy of the turbinated bodies, however, is a marked feature of the
disease.
On posterior rhinoscopy, after the removal of the crusts, a similar con-
dition of atrophy will be found in the naso-pharynx. The pharynx is
dry or glistening, or covered with mucus blackened by soot and other
impurities of the air. Crusts may also be seen in the larynx.
Diagnosis. — The characteristic stench issuing from the nostrils, the
crusts which block them, and the dilated state of the nostrils seen after
the removal of the crusts render the recognition of the disease easy.
Moreover, the disease affects both nostrils, whereas the presence of foreign
bodies causes a unilateral discharge ; and in these cases a careful
rhinoscopic examination ought to clear up any doubt. Syphilitic disease
of the nose leads to ulceration and necrosis of the subjacent bone, but
neither of these conditions is present in atrophic rhinitis. Suppuration of
one antrum should be readily distinguished ; but if both antrums were
affected, causing a discharge from both nostrils, there might be some
difficulty in diagnosis. In affections of the antrum the patient complains
of the smell more than his friends do, the discharge is purulent, and its
amount is increased by lowering the head ; moreover, the test of trans-
illumination with the electric light will aid in the diagnosis.
Prognosis. — Chronic atrophic rhinitis is not a disease attended M'ith
any danger to life, but the amount of annoyance it causes is at times
sufficient to make life hardly endurable, and it may render the patient
unfit to earn his livelihood. Though the cure of a marked case of
atrophic rhinitis is not to be expected, by careful and prolonged treat-
ment the disease can be deprived of its worst features. The disease
reaches its climax about the age of twenty, is less troublesome in middle
life, and is hardly noticed in old age. The symptoms, especially the stench,
are always worst at the catamenial period.
Treatment. — Such is the difficulty of curing cases of atrophic rhinitis,
678 SYSTEM OF MEDIChXE
that it is extremely important that any conditions which seem to stand in a
causal relation to this disease should be promptly met. Hence the puru-
lent rhinitis of children should receive early and a2)propriate treatment;
adenoid vegetations and enlarged tonsils, which so frc(|uently lead to per-
sistent nasal catarrh, should be removed, and attention should be directed
to the condition of the accessory siiuises. At the same time the general
health of the patient should be improved as nnich as possil)le ; anaemia,
debility, or a tuberculous tendenc}' must be comljated by fresh air, good
food, and the administration of iron, arsenic, and cod-liver oil.
Whatever plan of local treatment be adopted, the essential part of it
is the thorough cleansing and disinfecting of the nasal cavities. This is
most conveniently efl'ected by s})raying the nostrils with a wai-m alkaline
solution ; 5 grains of borax and the same amount of bicarbonate of sodium
in an ounce of water answers well. A 10 per cent solution of hydrogen
is highly recommended for the same purpose, and it has the additional
advantage of acting as a disinfectant. If the crusts are very hard, it
may be necessary to remove them with the nasal forceps. When
the nostrils have once been thoroughlv cleansed the patient should be
instructed to use the spray two or three times a day, or as often as is
necessary to keep the nose sweet. After a time various astringents and
antiseptics may be tried ; for instance, 2 to 5 grains of resorcin, sul])hatc
of zinc, or alum respectively, in an ounce of water ; or G minims of the
liquor potassii permanganatis in an ounce of water : or the nose may be
swabbed out with a solution of nitrate of silver — 5 to 10 grains to the
ounce — dissolved in a 20 per cent solution of nitrate of cocaine. In
some cases, after the nose has been sprayed, the insufflation of iodoform,
iodol, ariotol, or boric acid will give good results. An excellent jjlan of
treatment is, after thorough cleansing, to spray the nose Avith one of
the liquid j^araffins, for instance, jjaroleine containing in solution some
antiseptic such as menthol, thymol, or eucalyptol. The application of
a solution of trichloracetic acid (5 to 20 parts in 1000) by means of cotton
wool on a suitable holder, quickly and safely removes the smell of oza'ua.
In intractable cases Gottstein's tampon is very serviceable. To obtain
the best effect the plug of cotton wool should be in contact with the
whole of the interior of the nostril. In some cases the plug acts more
powerfully if moistened with glvcerine. The action of the plug is to stimu-
late the nasal mucous meml^rane, and, by causing an increased secretion,
to prevent the formation of the crusts. IVIassage, vibration -massage,
electrolysis, and the constant current are said to give excellent results in
suitable cases.
Purulent Rhinitis. — A purulent discharge fiom the nostrils occurs as
the result of many <litrerent causes. In the first i)lace, it may be due to
empyema of one of the accessory sinuses ; this of course must be distin-
gui.shed from purulent ihinitis. The presence of adenoid vegetations, again,
is a very common cause of nasal .sup])uration ; restriction of pus to the floor
of the nose and to the posterior wall of the phai yiix is pathognomonic of
this variety. In the acute specific infectious diseases — scarlet fever,
DISEASES OF THE NOSE 679
measles, small-pox — a purulent nasal secretion is frequently observed ; as
also in cases of glanders, tuberculosis, and syphilis of the nose. In addi-
tion to these causes there is also a condition to which the name purulent
rhinitis is more correctly applied. A purulent rhinitis is occasionally
seen in the newly-born infant, analogous to the purulent ophthalmia of
infants and dependent on gonococci of maternal origin. This variety
is seen immediately after birth, is purulent from the outset, and soon leads
to excoriation of the upper lip as well as to painful swelling of the whole
nose. Adults suffering from gonorrhoea may infect themselves or others.
Children of a strumous diathesis, or otherwise in delicate health, are apt
to sufl'cr from nasal catarrh which frequently becomes purulent. Bos-
worth lays great stress on the purulent rhinitis of children, as he main-
tains that it may be the starting-point of atrophic rhinitis.
In addition to the causes already enumerated a purulent discharge
from the nose may be due to the presence of I'hinoliths, foreign bodies,
I^olypi, and other new growths. The change seen in purulent rhinitis is
that met with in suppurative inflammation of other mucous surfaces ;
namely, hyperaemia, at first with a mucous secretion which soon becomes
mucopurulent : then, as rapid cell-proliferation takes place, the discharge
becomes puriform, and no longer yields mucin. In infants the swelling
of the mucous membrane may lead to nasal stenosis, and interfere Avith
breathing and sucking. In children and adults the yellowish purulent
discharge is the characteristic symptom.
The diagnosis must depend upon a careful examination of the nose
and its accessory sinuses, with attention to any collateral symptoms.
The treatment must depend upon removal of the cause if possible.
Hence the necessity for a careful examination of the nose and the treat-
ment of polypi, rhinoliths, foreign bodies, and other causes of irritation.
When this has been effected, various sprays — alkaline, antiseptic, or
slightly astringent — may be employed. In children of a " strumous " tend-
ency attention to the general health is most importiint.
Bearing in mind the possil^ility that purulent rhinitis may represent
the first stage of atrophic rhinitis, every endeavour should be made to
arrest the disease when it is still in a curable form.
Membranous, Fibrinous, or Croupous Rhinitis. — Under this head are
included cases in which a membranous exudation forms on the surface of
the nasal mucous membrane. In the majority of cases the disease is the
result of diphtheritic infection, and in some the general symptoms are so
slight that the true nature of the disease is likely to be overlooked. It
is, therefore, only after a careful bacteriological investigation has been
made, with a negative result, that the possibility of any cause other than
diphtheria should be admitted. Until such examination has been made
the patient should be isolated. In the non-diphtheritic cases various
micro-organisms have been detected in the exudations ; such as a coccus
resembling the staphylococcus pyogenes aureus, but differing from it by
its extraordinarily quick growth, and by the duration of its power of
infection : the streptococcus aureus and the pneumococcus are also found.
6So SYS'J'EM OF MEDICINE
Membiatious rhinitis occasionally occurs in the new - born infant,
usually in connection with septicemia in the mother.
The application of the galvano-cautery to the nasal mucous membrane
is sometimes followed by the formation of a false membrane, Avhich, how-
ever, is limited to the cauterised suiface. The exudation in simple mem-
branous rhinitis resembles that of diphtheria ; it has a grayish white
colour, it is more or less firmly adheient to the subjacent mucous mem-
brane, and on attempts to remove it a bleeding surface is left. In the
non-diphtheritic cases the attack begins like an ordinary cold, the nose
becomes blocked, and frontal headache may be a prominent symptom.
The nature of the disease is only recognised by the detection of shreds of
membrane in the secretion from the nostrils, or by making a rhinoscopic
examination. A case has been recorded in which several recurrences
took place. The slight and transient disturbance of the general system,
the absence of glandular swelling, of membrane on the jjharynx and naso-
pharynx, and of allnmiiiuuia and of secondary paralysis, together with the
absence of contagious properties, distinguish simple membranous rhinitis
from nasal diphtheria. The result of a bacteriological examination, and
the fact that meml)ranous rhinitis occurs sporadically, are of diagnostic
importance. Attempts may be made to keep the nasal passage patent by
the use of alkaline and antiseptic sprays. Painting the aflected surface
with a mixture of 5 grains of papain and 5 minims of lactic acid in a
drachm of water Avill facilitate the separation of the membrane. The
insufflation of iodoform, after the nasal passages have been sprayed with
an antiseptic solution, has given good results. It is not advisable to
remove the membrane forcibly, as under these circumstances it is apt to
recur.
Epistaxis. — In cases of bleeding from the nose it is necessary to re-
member that the source of the blood may be at a distance, tlu' nostrils
merely serving as channels ; or the blood may come from the nose itself.
It is with the latter form of hiemorrhage that we have to do. The causes
of epistaxis may be ai'ranged according as the local or constitutional ele-
ment plays the most important part in the haemorrhage. The chief local
causes are the various foi-ms of rhinitis, tuberculosis, and syphilis of the
nose ; and the presence of new giowths, es])ecially those of a malignant
nature. Leeches, worms, and maggots sometimes give rise to epistaxis.
The most common local cause, however, is mechanical violence. In con-
nection Avith the liical origin of epistaxis, it should be borne in mind that
in a large niuiiber of cases the blood comes from a s])f>t on the anterior
part of the se])tuni ; and from the frequency with wliicli this connection
is found to exist, this spot has come to be designated as the site of pre-
dilection of nasal hremorrhage. In some cases the spot on the septum
from which the bleeding comes can be recognised by varicose condition
of the vessels, or there may Ije a small patch of erosion or idceration ; in
other cases the mucous membrane is soft and spongy. The characteristic
feature, however, is that on gently rubbing the part with a smooth sound
bleeding occurs.
DISEASES OF THE NOSE 68 1
Among the constitutional causes which give rise to epistaxis are
changes in the vascular system, as in Bright's disease, atheroma, and
valvular disease of the heart. In lung affections (especially in emphysema
and bronchitis) and in whooping-cough there is a tendency to nose-
bleeding. Cirrhosis of the liver is frequently accompanied by the same
symptom. In diseases attended with alterations in the composition of
the blood — such as purpura, scurvy, chlorosis, ansemia, pernicious anaemia,
leukaemia, and haemophilia — epistaxis is a common symptom. Epistaxis
is met with in all the acute infective diseases, especially in enteric fever.
It may occur in the prodromal stage of measles, varicella, typhus fever,
erysipelas, and, less frequently, in scarlet fever ; but when it occurs at
the end of the latter disease, it is to be referred rather to the kidney
affection than to the fever. Epistaxis is not infrequent in diphtheria,
even when the diphtheritic process is not localised in the nose.
In the recent influenza epidemic many cases of epistaxis have been
noted, in most instances due to the catarrh accompanying this disease ;
but in some cases a special haemorrhagic tendency seems to have arisen
during the attack. Epistaxis occasionally follows the administration of
drugs, such as phosphorus, salicylate of sodium, and chloralamide.
Earefied air, as in l)allooning and mountaineering, and extremes of heat
and cold sometimes cause nose-bleeding. Finally, epistaxis has been
descril^ed as vicarious to the menstrual flow.
Epistaxis is rare in the newly-born, and occurs extremely seldom in
the suckling ; from the second year of life it begins to increase in
frequency, and attains its maximum about the period of puberty ; in
adult life it is somewhat rare, but the tendency may again manifest
itself in old age, as degenerative changes take place in the vessels.
Epistaxis is more common in the male than in the'female sex.
The amount of haemorrhage in cases of epistaxis varies from a few
drops up to several pints. The attacks may recur daily for many weeks,
and then cease entirely for a considerable time ; or there may be
frequent attacks of slight haemorrhage persisting for years ; or, lastly,
the attacks may be infrequent, but very severe. Epistaxis is sometimes
preceded by headache, and relief folloAvs loss of blood ; in other cases,
especially when the haemorrhage has been large, headache may follow
the attack. AVhen the epistaxis depends on a lesion of the septum the
blood usually comes from one nostril only. In haemorrhage from the
posterior part of the nares the blood, trickling down the pharynx, may
excite cough and give rise to the suspicion of haemoptysis. On the
other hand, as I have said, blood may pour from the nostrils though its
source may be quite remote, as in fracture of the base of the skull.
In the majority of cases epistaxis ceases spontaneously, and the
individual is often the better for the loss of blood ; occasionally, however,
the loss may be excessive, and death has been recorded as the result of
it. In haemorrhage due to nasal diseases, with the exception of malignant
new formations, a good piognosis may be given. In old people with
degenerated vessels, and in cases of granular kidney, the occurrence of
6S2 SYSTEM OF MEDICINE
epist:ixis requires a guarded prognosis, as one of the cerebral vessels
may be the next to give way. In the presence of head symptoms the
history of epistiixis is in favour of cerebral haimorrhage. In diseases due
to altered blood states epistaxis is always a grave symptom, and not
infrequently the cause of death. In diphtheria the occurreilce of
epistaxis is an unfavourable sign, indicating probably that the meml)rane
has spread to the nasal fossne ; in enteric fever, on the contrary, it often
seems to give relief.
Treatment. — In a considerable number of cases, especially in young
people, nose-bleeding seems to be an effort of nature to relieve plethora :
no active treatment is required. It will suffice to keep the patient quiet,
sitting up with the head somewhat forward, so that the blood may
trickle down the anterior iiares ; anything which constricts the neck
should l)e removed, the head should be kept cool and the feet Avarm. If
the bleeding continue, and it is considered advisa])le to stop it, the
patient should be told to raise his arms above his head ; an ice-bag may
be applied to the cervical spine, or the feet and legs placed in water as
hot as can be borne. Should these measures fail, plugging the nose
anteriorly will usually arrest the flow.
The most convenient plan is first to insufflate the nose with iodoform
by means of Kabierski's insufflator ; then to introduce a Duplay's
speculum, and pass a long strip of iodoform gauze up through the
sjieculum. In cases in which it is known from previous cxj^erience that
the hannorrhage comes from the septum, a small plug of iodoform gauze
introduced within the nostril, and compression of the nose externally
between the thumb and forefinger, is generally sufficient.
Instead of plugging the nose with lint or gauze the instrument
designed by Dr. Cooper Rose may l)e em])loyed. This consists of an
india-rubber bag, connected wnth a tube, which is provided with a stop-
cock. The bag is introduced into the nose in a flaccid state, and is then
inflated by the tube.
In cases of recurrent haemorrhage from the septum, the most efTective
cure is to apply the galvano-cautery at a dull red heat to the source of
h:emorrhage, after the previous application of a 20 per cent solution of
cocaine. After cauterisation a small pledget of cotton wool smeared
over with carbolised vaseline or boric acid ointment should be placed in
the nostril. If plugging the nose anteriorly fail to stop the bleeding,
the method of posterior plugging must be employed. Inasmuch, however,
as otitis media and other dangers have resulted from its employment,
it is desirable not to have recourse to it unnecessarily. The best instru-
ment for carrying out the posterior tamponage is Bellocq's canula. The
canula, which contains a watch-spring fixed to a stylet, is passed into
the nostril. By turning a screw the watch-spring runs down the caiuda,
and jirotrudes into the mouth. The piece of stiing which is tied to the
end of the spring can then be seized and attached to a pledget of lint of
sufficient size to occlude the posterior naris. The canula is now with-
drawn through the nostril, carrying with it one enil of the piece of string,
DISEASES OF THE NOSE 683
and this is tied to the other end which protrudes from the mouth. After
the nostril has been phigged posteriorly it may 1)C necessary also to
plug the nose anteriorly. This should be done in the manner already
indicated. It is not advisable to leave the plug in the nostril more
than thirty-six or forty-eight hours. The posterior plug may be
removed by making traction on the string coming through the mouth.
If there be any difficulty in withdrawing the plug the nostril must be
irrigated with a warm alkaline solution.
In the aljsence of Belloc({'s canula a gum-elastic catheter, or a piece
of silver wire, doubled so as to form a loop sixteen inches long, may
be employed for drawing the string through the nose.
Instead of plugging, various styptic solutions have been used for
spraying the nose ; among these may be mentioned vinegar, lemon juice,
and tincture of hamamelis.
Water at a temperature of 110'^ to 120° F., or even higher, has been
found extremely useful in arresting hasmorrhage from the nose.
Lastly, in cases of epistaxis due to liver disease speedy cure has
been effected by the application of blisters to the right hypochondrium.
Tuberculosis of the Nose. — Tuberculous disease of the nose is almost
invariably secondary to tuberculosis of other organs, especially of the
lungs and larynx ; but cases have been recorded in Avhich tumours
containing tubercle l)acilli have been discovered in the nose when the
lungs and other organs seemed healthy. This may well be so, as tubercle
bacilli are to be found in the nostrils of healthy persons who are
associated with consumptives, as in a hospital. It is possible, also, that
tuberculosis of the nose may be set up by the introduction of infectious
material by the finger, or by using the pocket-handkerchief of a phthisical
patient. In the majority of cases the onset of the ulceration is to be
attributed to local infection.
Chronic catarrh, the formation of crusts with a dry condition of the
mucous membrane, fissures and abrasions of the epithelium produced by
picking the nose, o?iev a footing to the tubercle bacilli, which, if the
soil be suitable, multiply and give rise to the characteristic lesions.
Tuberculosis of the nose occurs in the form of either a tumour or an
ulcer. No strict line of demarcation can be drawn between tumour and
ulcer, since the former may become ulcerated ; or the two may coexist ;
or nodules may arise on the margin of an ulcer in process of healing.
In forty-eight cases out of ninety, collected by Heryng, ulcers were
present ; and in forty-two tumours were seen. In the majority of cases
the tumours are chronic and local, interfering with the general health
little, if at all; on the other hand, ulcers occur for the most part secondarily.
Bosworth describes tuberculous tumours as springing from one of the
turbinals, and resembling a small papillomatous growth, but flatter, more
regular, and of a reddish gray colour. Usually, however, the tumours
occur as irregular red growths on the septum, which readily bleed when
touched. They may attain the size of a hazel nut. The cartilaginous
septum is the favourite seat of the ulcer, more rarely it is seated on the
684 SYSTEM OF MEDICINE
membnuious part ; tlie ulceration may extend to the al;e nasi, and even
to the upper lip, and may lead to perforation of the septum. The edges
are sometimes thickened and everted, but in other cases they are clean
cut. The surface of the ulcer is of a grayish colour, and is covered
either by a muco-purulent secretion or by a crust. Tubercle bacilli may
be absent from the superficial layer ■whilst they are abundantly present
deeper down.
Sijmptums. — Pain, ha?morrhage, and nasal obstruction are the most
prominent symptoms. In some cases the nose is swollen. There is
usually an increase of the nasal secretion, which is sometimes ofl'ensive
and may contain blood. Tuberculous disease of the nose usually nuis a
much more chronic course than a similar condition of the tongue or
larynx, as the nose is not subject to the constant movement and
irritation of the two latter organs.
D'uKjnosis. — Tu])erculosis of the nose must be distinguished from lupus,
syphilis, glanders, and the chronic eczema of the introitus nasi met with in
strumous children. If the affection is confined to the nose it is almost
impossible in some cases to exclude lupus ; usually, however, to aid in
diagnosis, there are the characteristic growths on the skin and mucous
surfaces, and the tendency of lupus to improve and then to relapse. The
absence of tubercle bacilli and the success of an anti-syphilitic treatment
speedily clear up any doubt as to syphilis. Eczema is moi-e superficial
and usually involves the up])er lip also. Tul)erculous tumours of the
nose must be distinguished from other tumours found in this region,
such as sarcoma, fibroma, and the like.
Treatment. — As in all tuberculous affections, the general health of the
patient must be maintained by good food, fresh aii", and tonics. The
most successful local treatment is to curette, after previous cocainisation,
and to rub in lactic acid. Even though the treatment be vigorously carried
out, relapses are frequently observed. For small ulcers the galvano-
cautery may be employed, but the results are not so satisfactory as those
of the lactic acid treatment. If operative treatment be deemed un-
advisable, the nose should be cleaned with an alkaline sohition, and then
insufflated with iodoform, or sprayed with a 5 per cent solution of menthol
in fluid jiaraffin.
Lupus of the Nose. — In the majority of cases lupus aflecting the
nasal passages is an extension of the disease from the face. If the nose
were systematically examined in all cases of facial lu])us many more
cases of intra-nasal lupus would l)e reported. In rare instances the
nasal mucous membrane is the primary seat of the disease \_vidc art.
" Lupus " in a later volume].
Si/mptoms. — The patient's attention is usually first attracted by the
formation of crusts and a feeling of irritation in the nostril ; occasionally
complaint is made of pain. The thickening of the mucous membrane
and the crusting cause more or less nasal stenosis. There is but little
discharge, and this is usually free from odour, unless the crusts have l)een
retained in the nose sufficiently long to decompose. After sjiraying
DISEASES OF THE NOSE 6S5
the nostrils in order to remove the crusts, the damage wrought by hipus
may be recognised. In some cases ulceration is the most marked
feature of the disease ; in others the formation of nodules is the chief
feature. Ulceration as a rule begins at the orifice of the nose, and the
septum is attacked early. Perforation of the septum is accelerated
by picking the nose. The ulceration may heal, or it may extend up
to the edge of the vomer ; the bone itself is attacked in exceptional
cases only. The nodules seen in the nostrils resemble those met Avith
on other mucous surfaces.
Diagnosis. — It is almost impossible to distinguish between some cases
of chronic tuberculosis of the nostrils and lupus ; indeed, if the view be
correct that the latter is due to an attenuated tuberculosis, it can be
readily understood that there is no line of demarcation between the two.
Lupus of the nose is most likely to be confounded with syphilis ; the
latter runs a more rapid course, and attacks bone, whereas lupus usually
spares bone. The absence of response to an anti-syphilitic treatment is
a strong point in excluding syphilis. The soft, granular, irregular
surface and opaque pale colour of the lupus nodules distinguish them
from polypi. The recognition of lupus nodules on the external skin, and
the microscopical examination of a portion of the growth, will confirm
the diagnosis.
Prognosis. — Lupus usually runs a chronic course, and does not lead
to a fatal termination. In one case, however, the septum was destroyed,
and the sphenoid bone eroded ; death took place from basic meningitis.
Treatment.— Ijocal treatment must be carried out actively. Any out-
growths must be removed by the cold or galvano-caustic loop, and the
cautery applied to the base. Some operators prefer the sharp spoon,
followed by the application of chromic acid. Lactic acid answers well
in the less severe forms. The local application of cold in the shape of
an ice-bag to the nose has been successfully employed, the bag being
placed on the nose for three hours, night and morning.
Should the case be too far advanced for any radical treatment, the
nose should be sprayed with a simple alkaline solution to remove the
crusts, and then a 5 per cent solution of menthol should be sprayed up
the nostril with an oil atomiser.
Cod-liver oil, syrup of the iodide of iron, and arsenic are the internal
remedies that promise the best results. Some of the lupus patients
treated by tuberculin were permanently benefited ; and it is possible that
in properly selected cases there may still be a future for this remedy.
Syphilis of the Nasal Mucous Membrane. — Syphilis in all its forms
— primary, secondary, tertiary, and inherited — may attack the nose.
Primary chancre of the nose is comparatively rare, nevertheless
thirty-seven cases have been put on record up to the year 1894. Between
3 and 4 per cent of the cases of extra-genital syphilis belong to
this category. The virus is usually conveyed to the nose accidentally ;
but cases of direct transference by the genital organ have been reported.
The site of the chancre is most frequently at the orifice of the nose, and
686 SYSTEM OF MEDICINE
the surrounding parts have an erysipelatous appearance. The sub-
nuixillary glands are enlarged and tender. Primary syphilis of the naso-
pharynx has been met with in fourteen patients. In every case infection
was conve\'ed by the Eustachian catheter.
In the absence of history a chancre in the nose Avould give rise
to much difficulty in diagnosis before the supervention of secondary
symptoms. It would most probably be mistaken for a sarcoma, but from
this it may b<3 distinguished by i;s tendency to bleed, by the small amount
of swelling compared with the ulceration, and by the eaily enlargement
of the submaxillary glands on the corresponding side. The orifice of the
nose is the part usually attacked in the secondary stage, and, as on other
mucous surfaces, the affection ma}' assume a catarrhal, erythematous, or
superficial ulcerative form. Condylomas have also been seen in the nose.
In the tertiary stage the nose is frequently and often severely aff'ected.
The disease usually begins as a gumma, though this stage may be
overlooked, and the patient may not present himself until ulceration has
occurred. In some cases ulceration takes })lace Avithout the previous
formation of a gumma. The damage wrought by tertiary syphilis in the
nose is at times very great ; there may be complete destruction of the
contents of the nasal cavities, the antrum being thrown open on 1)0th
sides. Perforation of the septum is a very common result of syphilis ;
the syphilitic aff"ection difll'ers from simple joerforation in that the bone is
attacked in the former, consequently a much greater destruction may
occur ; the ulcers are longitudinal, and the margins of the ulcer are
thickened. As a result of cicatricial conti-action of the connective tissue
which binds the cutaneous and cartilaginous structures to the nasal bones,
the so-called " saddle-back " nose may be formed. It is important to
bear in mind that a similar condition may be brought about by phleg-
monous inflammation of the nose without syphilis. In inherited syphilis
it is very connuou to meet with a catarrhal condition of the nares giving
rise to " snuffles." Inasmuch as ulceration at the angle of the mouth, a
rash about the body, and condylomas usually occur at the same time, the
diagnosis is easy. Later, especialh' about the period of i)ubert3', the
manifestations of inherited syphilis are such as are seen in the tertiary
form of acquired syphilis.
I'realm.enl. — Under the usual treatment for syphilis the swelling
caused by the primary sore in the nose rapidly disaj^pears, and leaves no
traces except some scairing.
For secondary syphilis of the nose the usual constitutional treatment
is required, with some simple alkaline solution to spray the nose,
followeil by insufflation of iodoform, or the application of dilate citrine
ointment.
In tertiary syphilitic disease of the nose large doses of iodide of
potassium are needed ; and in some cases the inunction of mercurial
ointment will accelerate the cure. The nostrils should be kept clean
by spraying them with warm antiseptic solutions. If necrosis takes
place, and the necrosed bone do not separate spontaneously, it may be
DISEASES OF THE NOSE 687
necessary to remove it by forceps. "When sequestra are seated above
the middle D:eatu3 great care is needed in attempts at removal. The
instifflation of iodoform will check the oftensive odour and promote
healing. In infants suffering from the coryza of inherited syphilis it
is most important, in addition to constitutional treatment, to keep the
nostrils open ; this can be effected by spraying them with an antiseptic
solution, and then applj'ing dilute citrine ointment, or a 10 per cent
solution of menthol in fluid paraffin. — F. DE H. H.
The new growths of the nasal cavities. — Mucous Foli/jms. — The
production of polypus is either dependent upon, or actually consists in
a more or less circumscribed inflammation of the mucous surface from
which it springs. Where the growth is attended by suppuration the
initial factor is probably an epithelial necrosis. As an immediate con-
sequence of such an accident we find grantdation tissue covering the
ulcerating surface. The longer cicatrisation is delayed the larger these
granulations become ; and, being perpetually bathed in mucus, they
absorb moisture, become cedematous in fact, and thus acquire an increas-
ing tendency to fungate. This process is precisely that of an ordinary
ulcerated surface where granulations are proliferating freely. If such an
ulcer be b.ithecl constantly in water the granidations become watery,
pale, and flabby, and are scarcely to be distinguished histologically from
many a specimen of simple mucous polypus.
As this incipient polypus grows older its strttctux'e becomes modified,
owing to the production of a fibrous element. The growth becomes more
prominent and the blood-vessels more developed, especially towards the
base, where the fibrous element grows firmer and contracts the surround-
ing tissue ; thus gradually a pedicle is produced containing fully-developed
vessels which ramify in the peripheral and more cedematous tissue.
Usually the structure ultimately becomes quite distinct from the sur-
rounding surface from which it springs, although very often the mucous
membrane in the immediate neighbourhood is in a condition of pro-
nounced hyperplasia. As this granulation jjolypus increases in size we
find, curiously enough, that the epithelium tends to creep over it from
the base ; and it is in this way that these growths are often fotmd com-
pletely covered with ciliated epithelimn. Precisely the same thing occurs
in the ear Avhere the similar so-called "polypus" admittedly consists
originally of granulation tissue. In the tympanimr such formations in-
variably are or have been associated with carious bone, a fact con-
clusively proving their inflammatory origin ; yet even the epithelium of
the tympanum creeps over these granulations, and covers them more or
less completely with columnar ciliated cells.
Rindfleisch has described a fine reticular formation in the ordinary
f ungating granulation ; and in the polypus we may find, associated with
such reticulum, round cells which become larger and fusiform in various
places, and are gradually converted into fibrous tissue. At an equal rate
with the increase of reticulum the tendency to absorb water becomes more
6S8 SYSTEM OF MEDICINE
pronounced. Amid this increasingly coarse reticulum we find, in different
parts, various quantities of cells of diverse shape and size; varying, that is
to say, from the small granulation to the long fusiform cell, which prol)ably
produces the fihrous clement. Such I believe to be the essential structure
of mucous polypus.
While admitting that pathologists commonly describe polypus of the
nose as either myxoma or adenoma, yet for my part, although I have
examined some hundreds of specimens, I have never succeeded in finding
a true myxoma cell. In the younger growths we may find a cell appar-
ently branched at the points where the fine reticidar fibres cross one
another ; yet an unmistakable myxoma cell I have never seen.
But although, clinically speaking, the initial inflannnatory attack
which results in polypus is often accompanied hy su])[)uration, yet
probably there is another method, possibly more frecjuent, in which these
growths originate. A succession of acute attacks of cold in the head
may gradually induce a chronic infiltration, weakening and thickening of
a certain area of mucous membrane ; the fibrous elements, becoming
softened and granular, gradually disappear into mucous fluid which
steadily increases in the interspaces. New cells are produced which,
accumulating into clusters, ultimately produce <1, definite projection above
the surface ; and this granuloma may gradually pass through all the
changes of fungating granulation ti-sue till a structure recognised as
polypus is produced. In such case there need have been no loss of
continuity in the epithelial surface.
Clinically, as I have said, we are perfectly familiar with the two
different modes of formation ; and, even if true myxomatous tissue
occur occasionally in polypi, the fact does not militate in any way
against my view of the inflammatory origin of such growths. For, as I
have pointed out upon the authority of liindfleisch, ordinary fungous
granulations may contain a quantity of Avell-fornied mucous tissue, pre-
senting a pale pink, watery appearance, sometimes even j^ellow and jelly-
like. Virchow, moreover, teaches us that mucin is a common product
in irritated connective tissue, and that thus it must be admitted as a
product of inflammation.
In cases where the initial inflammatory attack is of suflicient intensity
to produce molecidar necrosis of the mucous membrane, where, moreover,
the tendency to heal is not strong enough even to produce a polypus, the
ulceration may extend to the muco-periosteum and expose the subjacent
bone. In such a way we may have masses of granulation tissue, avcU-
formed poly]:)i, and carious bone coexisting side by side ; and where such
a process takes place within any of the accessory cavities we then find
abscess and other conscqueiices attendant upon the retention of pus. But
these points will be considered in a subsequent section.
Very frequently a portion of mucous membrane, especially Avhen
depenrling from the free border of the middle turbinal, presents such an
appearance as makes one doubtful whether it should be considered as a
diffuse polypus or rather as a mass of hyperjilasia ; nor will the microscope
DISEASES OF THE NOSE 689
materially assist us in drawing the distinction. And if sucli a fragment do
not appear sufficiently translucent to justify its being considered as
polypus, we may, by soalcing for a few minutes in water, so increase its
size as to give it microscopically every characteristic of ordinary polypus
tissue.
The description of the oi'dinary mucous polypus just mentioned does
not account for the classification generally given by surgeons. We arc
told that the benign mucous polypus consists, as I have already remarked,
either of myxoma or adenoma. The former misapprehension I have
attempted to explain ; but the other is less easy to comprehend, seeing
that the growths for which the name polypus is now reserved by rhinolo-
gists never present any glandular structure, except, indeed, in cases in
which the neoplasm consists rather of an oedematous hypertrophy of a
widely-attached piece of mucous membrane. The fact is that the surgeon
has habitually confounded with polypus those curious lobulated or cauli-
flower-like growths which consist entirely in a hyperplasia of the mucous
membrane covering the erectile tissue more especially developed over the
inferior turbinals. In such growths the normal mucous glands are often
largely increased in size and number, and one readily realises how the
name adenoma was applied to them. But, according to usual observance,
the discussion of these growths belongs rather to the domain of chronic
hypertrophic rhinitis, although there is no good reason for discussing
polypi as new growths if the former are not to be similarly considered.
Clinical aspects. — On several occasions I have actually watched the
inception of a polypus in an attack of acute inflammation ; that is to say
in cases where I knew that no suspicion of such growths had previously
existed. The patient is seized with more or less severe pain, generally
referred to the supraorbital region ; while the intensity of the swelling and
the obstruction to breathing are altogether out of proportion to the degree
of inflammation on the opposite side. The acuteness of the pain probably
points to inflammatory tension deeper than the mucous surface, that is
to say in the muco-periosteum, or perhaps in an ethmoidal cell. After
two or three days of such pain I have seen a polypus appear in the
middle meatus, perfectly translucent, pale pink in colour, and sharply
defined. But the more ordinary course is for the patient, after complain-
ing of a constant succession of colds in the head, to find that his nose is
becoming persistently obstructed. He tells us he is always worse in
damp weather, he walks and sleeps with his mouth open, his eyes become
watery and bloodshot, and his nose frequently widens across the bridge ;
unable to obtain any satisfaction from blowing his nose, he is perpetually
wiping it ; he loses his senses of smell and taste, and becomes a Avoe-
begone object. In the earlier stages sneezing is often a prominent
and very distressing symptom ; but as the obstruction increases the
mucous membrane becomes less sensitive to tactile stimulation, and the
sneezing may disappear altogether.
With his nose troubles the patient may show symptoms of an extensive
catarrh of the larynx, trachea, and bronchial tubes ; and not infrequently
VOL. IV 2 Y
690 SYSTEM OF MEDICINE
the asthmatic and bronchitic troubles mask the nasal altogether. By some
authorities, especially in the German and American schools (Hack,
Bosworth, and others), such symptoms are supposed to result from reflex
action originating in the nasal mucous membrane ; but, so rare is it to
find the asthma cured b}' removing polypi, it is proba])ly more correct
to consider the bronchitic and nasal conditions as several local manifesta-
tions of a chionic inflammatory process pervading the whole tiact of
respirator}' mucous mem])rane. And I am prepared to emphasise this
view, knowinif full avoII that the rectification of nasal abnormalities other
than polypus often results in a most romai'kable cure of the bronchial
symptoms.
Treatment. — Various remedies have from time to time been suggested
for the absorption of nuicous ])oly|)Us, but as a matter of fact they nearly
all result in failure. Astringents sometimes appear to have a temporary
effect in contracting the size of the smaller growths ; and where these
consist chiefly in masses of fungating gianulation tissue, doubtless the
stronccer astringents and caustics may bo of material benefit. I have found,
for instance, zinc chloride (gr. xx. or xxx. ad 5J.) of considerable service,
and chromic acid (gr. x. ad 5]'.) or silver nitrate (gr. xxx. ad. 5J.) may
be equally efficacious ; but every such case is infinitely better treated upon
ordinary surgical principles. Masses of graiuilation are best eradicated
with the curette, Avhile the larger growths, which we distinguish as ])olypi,
are best removed by the cold snare. Many advocate the use of the incan-
descent snare, but I fail to see the advantage of it ; while risks of scalding
from the generation of steam are obvious.
Beni(jn growths of the nose other than mucous poI>/pL — Besides raucoiis
polypi there are other growths which must at least be eiuunerated
in this place. Those curious cauliflower developments so common in
hypertrophic rhinitis, especially as it affects the erectile tissue and the
infei'ior turbinals, actually belong to the section of rhinitis. They con-
sist of erectile tissue infiltrated Anth large masses of granulation tissue,
maintained by some authors to be lymphoid. In old-standing cases they
grow more fibrous, and under certain conditions lose their ruddy hue,
becoming onlematous and colourless ; in this case the fibro-cellular
elements become infiltrated with mucin and water, and the growths very
closely resemble many instances of ordinary polypus. When finely
lobulated and very substantial they have frequently been mistaken for
papilloma, and recorded as such.
Papilloma is actually very rare in the Schneiderian membrane ; though
occasionally small specimens are found, attached to the septum or in the
vestibule, which have all the appearance of such growths as found on
other distributions of mucous membiane. I have seen a few examples of
well-developed ])a])illoma covering the surface of a long-standing mucous
jxjlypus, when projecting between the alai and constantly exposed to the
friction of the handkerchief. Such a development has no connection
whatever with any tendency in the parent growth to originate malignant
disease.
1
DISEASES OF THE NOSE 691
Malignant disease of the nasal cavities. — Malignant disease of the nose
falls rather within the domain of the surgeon, and needs but little notice in
these pages. According to Erichsen, the transmutation of mucous polypus
into epithelioma is by no means a rare occurrence. That this is an error
is an opinion which I believe every author will now accept. After having
treated more than a thousand cases of polypus, I have never seen these
benign growths degenerate into malignant, although I have seen sarcoma
and mucous polypus associated in the same nasal fossa. Sarcoma is decidedly
commoner in the nose than epithelioma ; and I may add, as a charac-
teristic of the former in this region, that its malignancy is probably more
difficult to estimate on microscopical examination than in other regions.
Cases have been recorded of complete ciu-e of sarcoma by intra-nasal
operation alone. I am w^atching a patient of my own who presented every
symptom of malignancy, both clinical and microscopical, in whose case
the surgeons declined to interfere, yet for over four years now he has
presented no indications of recurrence. The treatment Avas entirely intra-
nasal, and extended over three years ; the tendency to recurrence, at first
extraordinarily rapid, gradually diminished until it has ceased now, I
believe, altogether. Probably all the cases of so-called fibrous tumour
found in adolescents, which moke such frightful local ravciges, separat-
ing and protruding the eyes, flattening the nose, and producing " frog-
face," are actually sarcoma. Enchondroma has also been described as a
cause of like symptoms.
Affections of the nasal bones. — The pathological conditions en-
countered in certain conditions of inflammation, as it involves the osseous
structures of the nose, are inseparably associated with the subject of
polypus. That simple inflammation, unsupported by any constitutional
clyscrasia, may result in exposure of bone is a fact which can no longer
be disputed. As I have said, Avherever we find granulations or polypi
filling the middle meatus, and attended by suppuration, careful insertion of
a blunt probe into the diseased region will readily reveal patches of
carious bone. But the cases are extremely rare in which the inflammation
is sufficiently intense to set up more than a superficial molecular necrosis.
Undoubtedly at times a sequestrum may be produced, although, so far as
I am aware, never of any more important part than a fragment of the free
border of one or other turbinated bone. Whenever large sequestra are
discovered there can be little doubt as to the syphilitic origin of the
disease. So far we are unacquainted with any essential difterences from
similar processes in other bones : the same inflammatory mischief which,
in one spot, led to the substitution of a layer of granulation tissue for the
normal periosteum, may in adjacent spots produce an accumulation of
osteoclasts, causing extensive absorption of bone ; or yet again may lead
to a more chronic process which has been called by Billroth osteophytic
periostitis. So far as I am aware, the majority of cases of caries in the
nose have not been attributable to tubercle.
But there is yet another condition of bone disease observed, so far
as I know, only in the nose, the pathology of which has not yet been
692 SYSTEM OF MEDICINE
satisfactorily studied. Wc may occasionally detect by the jirobe an
extensive surface of bare bone, uncovered even by graniUations, not
presenting the roughness of an ordinary sequestrum, and, so far from
being frial)le, of an ivory hardness. Suj^puration occurs from the
neighbourhood of these exposed surfaces, if not actually from them ;
and there are always granulations in the vicinity. Such conditions I
have watched for many months at a time Avithout the formation of a
sequestrum. Probably the phenomenon is due to a grailual interstitial
condensation of bone with encroachment upon the Haversian canals, and
even obliteration of them ; thus depriving any rudimentary granulation of
its necessary blood-supply, and reducing suppuration to a minimum. But
the process of condensation is so gradual that no attempt at repair is
made by throwing off the necrosing surface : and possil»ly the veiy con-
densation minimises the risks of local infective processes, and lessens the
danger of extension. In some such manner we may i)erhaps account for the
rarity with which these diseases extend into the cranial cavity. Osteojihjiic
periostitis may lead to the most extraordinary OA'ergrowths of the bone
itself, more especially when it aftects the middle tuiljinal. The hvpor-
trophy of the free border of this bone is indeed sometimes so exaggerated
as to bring it in contact with some portion of the under surface, where
such extensive adhesion may take place as to enclose a jiei-fcctly sealed
space lined, of course, Avith mucous membrane continually poiu'ing out its
secretion. This is one of the methods in Avhich the rare and curious
osseous cyst is formed, whicli sometimes assumes such a magnitude as to
fill the fossa completely, and even to Aviden the bridge of the nose, separate
the orbits, and induce so much deviation of the septum as to block the
other nasal fossa also. Such cysts necessarily have Avails the thickness of
Avhich is in inverse ratio to the volume ; Avhile the contents A^ary from a
thin mucus to a dense atheromatous matter. Occasional] j' small polypi
are found studding Ijoth inner and outer surfaces. — G. MacD.
Rhinoseleroma. — This disease, Avhicli is exceedingly rare, Avas first
described by Hebra in 1870.
Etinloiji/. — Very little is known of the conditions under Avhicli
rhinoseleroma originates. The majority of cases have occurred in the
south-east of Europe. A few cases haAC been reported in Central
America, Egypt, and India. The first case shoAvn in tliis countr}' AA-as that
of a Guatemalan, aged 18, Avho was brought Ix'fore the Pathological
Society by Dr. Payne and Sir F. Semon in 188-1. The somcAvhat narrow
geographical distribution of the disease Avould seem to point to some
endemic condition as its cause. An instance of the tran.sference of the
disease by contagion has been reported.
MorJAd anntomii and pitlholor/f/. — The sites of ])i'cdilection of the
scleroma are the cartilaginous part of the nose, the connnenccment of the
bony part of the nasal cavity, the choanse and the larynx beloAv the glottis.
Each of these places may be affected independently, and not by extension
from one part to the other. In exceptional cases the neoplasm has
DISEASES OF THE NOSE 693
started in the pharji^x or hard palate. The disease may be considered as
a chronic infective granuloma ; that is to say, a round-celled infiltration
and a large amount of fibrous tissue are present ; there are also numerous
larger cells and spaces, "vacuoles," formed by hyaline degeneration of
the larger cells. Micro-organisms, first observed by Frisch, resembling in
many respects Friedltinders pneumococcus, are found in larger cells, the
vacuoles, blood-vessels and lymphatics of the affected part. They can
be stained by Gram's method. Inoculation experiments on animals have
given no very definite results.
Sijnrptoms. — Necessarily the symptoms vary accniding to the part
affected. Out of eiarhtv-five cases the mucous membrane of the nose was
attacked in eighty-one, the cutaneous covering of the -nose in seventy-four,
the pharynx in fifty-seven, the larynx in nineteen, the trachea in five, the
upper lip in forty-six, the upper jaw in sixteen, the hard palate in seven-
teen, the tongue in four, the lower lip in two, the lachrymal tract in five,
and the ear in one case. When the nose is affected, obstruction, which may
be complete, is the symptom chiefly complained of ; there may be some
discharge and even a little bleeding. Pain is usually absent, but there
may be some tenderness. The neoplasm occurs in slightly elevated plates
or nodules of a red colour, smooth on the surface, and as hard as cartilage.
In very exceptional cases the growth has been somewhat soft and of a
polypoidal appearance. In the larynx scleroma may cause urgent dys-
pnoea, and Bandler has shown that chorditis vocalis inferior hypertrophica
is simply a variety of the same disease. Evidence is strongly in favour of
the view that Stoerk's blenorrhoea is scleroma of the upper air-passages.
Diagnosis. — Rhirioscleroma may be distinguished from lupus, tuber-
culosis, malignant disease, and syphilis by its slow progress and by the
absence of ulceration and off"ensive discharge. The want of response to
an antisyphilitic treatment Avill confirm the diagnosis as against syphilis.
There may be some difficulty in distinguishing keloid from rhinoscleroma ;
but the former is rarely met with in the nose. The crucial point, however,
in the diagnosis of rhinoscleroma is the detection of the characteristic
bacilli in portions of the growth removed for the purpose.
Prognosis. — The disease is a very chronic one, and cases are on record
in which it has existed f<jr upwards of twenty years. The only dangerous
variety is that which attacks the larynx. Cases have been reported in
which a complete involution of the growth, A^erified by microscopic
examination, has taken place after an attack of fever ; in one instance the
fever was tj'phus, in another possibly of malarial origin.
Treatment. — Attempts have been made, but with very partial success,
to maintain the patency of the nose by means of the galvano-cautery and
knife. Good results have been reported from injections of 1 to 12 per
cent solutions of arsenic into the aifected part ; a 2 per cent solution of
carbolic acid has been used in the same way. The two latter methods are
Avorthy of trial. If stenosis of the larynx be threatened, tracheotomy
must be performed.
Glanders. — The nose may be aff"ected in the acute form, to which
694 SYSTEM OF MEDICINE
the name ghmders was at one time restricted ; or it may be attacked
iluriiig the course of the chronic form (the farcy of horses).
The disease is frequently contracted hy the secretion of the nasal
mucous membi'ane of the diseased animal coming in contact with the
nasal mucous membrane of the patient. In these cases the earliest
syni])toms are met with in the nose. At first a thin mucus is secreted,
and the nose becomes swollen, red, and painful ; the SAvelling may extend
to the face. After a time the discharge liecomes thicker, nuico-i)urulent,
stained with blood and very offensive, and the nostrils may be blocked
with crusts. The nasal mucous membrane is greatly swollen, and the
lining membrane of the accessory sinuses is similarly affected. In some
of the chronic cases tubercle-like nodules form and lead to ulceration of
the mucous membrane and necrosis of the septum. The nose is not so
generally affected in man as in the horse ; the disease may run its course
without imjilication of the nose, or the nasal mucous membrane may not
be involved until the later stages of the disease in the second or third
week.
Diagnosis. — If the nose be early affected and the disease run a rapid
course the diagnosis is easy, especially if the patient's occupation be con-
nected with horses. In the more chronic forms the nasal affection may
be confounded \v\t\\. tuberculosis or syphilis ; but the cutaneous affections
of glanders are not seen in tuberculosis, and the disease does not yield to
anti-sj'^philitic treatment. Moreover, the characteristic bacilli of glanders
should be sought for in the morbid secretions. For further information
the reader is referred to the article " Glanders " in this Avork (vol. ii.
p. 513).
Treatment. — All that can be done locally is to keep the nostrils clean
by frequently spraying them Avith such antiseptic solutions as weak
solutions of creasote, carbolic acid, or permanganate of potassium. The
occasional application of solution of nitrate of silver or tincture of iodine
may be tried. — F. DE H. H.
Nasal Neuroses. — Olfactory Neuroses. — The olfactory nerve is the
nerve of the special sense of smell. Numerous nervous filaments deriA'cd
from the olfactory bulb pass through the foramina in the cribriform plate
to the mucous membrane of the upper part of the septum and of the
outer Avails as far doAvn as the middle turbinated body, and to the olfactory
cells of Max Schultze from Avhich the fine terminal filaments pass through
the external limiting membrane of v. Brunn, to lie betAveen the columnar
epithelial cells. The mucous membi'ane here is peculiarly soft, thick,
delicate, pulpy and highly vascular. For the normal ])orocption of odours
it is essential that the odoriferous particles should icaeh the nnicous
membrane of the upper part of the nasal passages, and that these should
be in a moist condition ; thus any local abnormality ]ireventing inspiration
through the nasal j)assage.s, or the presence of i)()lypi or collections of
nnicus and secretions, or a permanently dry condition of the mucous
membrane, Avill interfere Avith the sense of smell or completely destroy it.
DISEASES OF THE NOSE 695
The terminal filaments of the olfactory nerve may be impaired in
various chronic conditions of the mucous membrane, inflammatory and
degenerative ; thus in chronic rhinitis, or as the result of irritating in-
jections or sprays, or douches, there may be more or less defect of smell.
In testing the sense of smell it is imperative to exclude substances,
such as ammonia, which act on the nerve of common sensation ; lest we
confuse olfactory and purely sensory impressions. Musk or some such
scent should be used as the test.
Anosmia, or complete loss of the sense of smell, is frequently observed
in-polypus cases, as a consequence of disease of the fifth nerve ; or in the
dry atrophic condition of the mucosa in atrophic rhinitis. It may be either
lanilateral or bilateral ; and may result from congenital defects, l>lows
or falls on the head producing fracture of the cribriform plate, basilar
meningitis, intracranial tumours, syphilitic disease, embolism or haemor-
rhage of the middle cerebral artery, or from the less gross central lesions
associated with epilepsy, locomotor ataxia, general paralysis, hysteria
and insanity. A few cases of unilateral destruction of the olfactory bulb
with anosmia are recorded, and in these the left bulb has always been the
one affected. Anosmia is very rarely detected in intracranial haemorrhages
or tumours, as in the few cases in which the sense of olfaction is inter-
fered with their effect is almost always unilatei'al. Anosmia has been
observed to follow the removal of both ovaries.
Parosmia, or perversion of the sense of smell, in which imaginary or
subjective perceptions of odours are present, is usually central. It occurs
in hysteria, hypochondiiasis, epilepsy, influenza, and lesions of the
anterior temporal lobes ; it is important to know that it may be the
first, or one of the first, signs of mental derangement. Olfactory hallucina-
tions have been known to occur in cases of sexual neurasthenia.
Hyperosmia, or hyperesthesia of the olfactory nerve, Avith increased
sensitiveness to smell, may arise in neurasthenic conditions with exaggera-
tion of all nervous impressions, in hyster'ia and hypochondriasis, or as the
result of irritative lesions affecting the olfactory bulbs.
The prognosis in anosmia will depend very much on the special cause
of the loss of the sense of smell. If it be due to nasal ])olypi, or other
removable causes, the prognosis is favourable, provided the loss of function
have not persisted for a long time ; after two years the sense is seldom
regained. But when associated with degeneration of the mucous mem-
brane, as in syphilitic disease or atrophic rhinitis, the olfactory end organs
soon become atrophied and the prognosis hopeless. Loss of smell due to
organic central nerve lesions will rarely be restored ; on the other hand,
the prognosis in functional anosmia and parosmia, except in cases when
this symptom precedes insanity, is generally favourable.
Treatment. — If the neurosis of olfaction be due to local disease this
should be treated, and, with the removal of the cause, the functions of
the olfactory nerve may possiljly l)e restored ; but very little more can
be done. Local galvanisation and faradisation may prove useful, and
strychnine and arsenic may be given internally.
696 SYSTEAf OF MEDICINE
The treatment of anosmia and parosmia due to central nervous affec-
tions resolves itself into the treatment of the various causes of the disease.
The purely functional cases should be treated by nervine tonics, change
of air and rest; while in women any irregularity in menstruation, or other-
wise, should receive attention.
Sensory and Reflex Neuroses of the Nose. — A great deal has been
recently said and written in reference to the sensory neuroses of the nose.
That these neuroses occur, and that their effect may be far-reaching, there
is now no room for doubt. But Avhile, on the one hand, there has been a
tendency on the part of some clinicians to ignore the obvious existence of
these diseases, there has been an unfortunate proclivity of late to refer all
and sundry obscure neuroses to the nose, and to explain their occurrence as
nasal reflex phenomena. "We Avould emphasise the importance of being
on our guard against this prevalent error, while giving due regard to the
large class of cases that may legitimately be included under the term
nasal neuroses.
M'hen we remember the intimate anatomical correlation between the
nerves supplying the nose and other regions around or more distantly
situated, it is easy to conceive that centripetal impulses from the nerves
in the nasal passages may have far-reachiug reHex effects. The nasal
mucous membrane is supplied with ordinary sensation by the ethmoidal
branch of the nasal nerve and l)ranches from Meckel's ganglion. This is
connected with the Gasserian ganglion, which, in turn, is in relation with
the carotid })lexus of the sympathetic and perhaps with the pneumogastric.
The arterial supply to the mucous membrane and to the erectile tissue of
the turbinated l)odies is controlled by vaso-motor nerves from Meckel's
ganglion, and is under the control of the vaso-motor centres in the medulla.
The phy.siologieal nasal reflexes are sneezing, coughing, laclnymation,
and vasomotor changes producing increased secretion. Their intimate
relationshij) with other reflex areas is seen in the effect of bright suidight on
the eye producing lachrymation, coughing, and rhinorrha\a; in the fact that
particles of food in the laryn.x give rise to lachr\ niation as well as to cough,
and again in the reflex cough due to irritation in the ear. In some sus-
ceptible persons, if certain portions of the nasal mucous membrane arc
irritated by a ])robo, sneezing and lachrymation ensue; and if the turltinals
arc irritated po.steriorly, especially if the Eustachian orifices are touched,
cough is often excited. Dust and particles of foreign matter and irritating
vapours produce similar effects. The specially sensitive spots — called hyper-
a'sthetic areas — are situated on the posterior extremity of the inferior tur-
binal and the corresponding portion of the septum, at the anterior extremity
of the superior turbinated body, at the anterior extremity of the middle
turbinated and the corresponding portion of the septum ; to these must be
ailded the lips of the Eustachian tubes. Further, it has been shown that
irritation of the nose may produce arrest of respiration and syncope from
temporary arrest of the heart's action ; similar effects are sometimes
observed as the result of strong odours. Unilateral exophthalmos and
increased pulse frequency have been observed (Semon) to follow an ojiiera-
DISEASES OF THE NOSE 697
tion for nasal polypi ; it is questionable, however, Avhether these events
stood in the relation of cause and effect.
Hypertesthesia is generally associated with a more or less definitely
abnormal condition of the nasal mucous membrane ; often, however, no
abnormality can bo detected. It is usually associated Avith sneezing and
rhinorrhoea, and is generally the immediate local factor in " hay fever,"
nasal cough, and so forth. It may be due to any irritation or catarrhal
inflammation in nsurotic subjects ; or it may result from central or from
reflex causes in the eye, the ear, or the digestive or genital organs.
Incomplete, anaesthesia results from various chronic degenerative
diseases of the mucous membrane, and in many cases of polypus. Total
anaesthesia may be due to degeneration or destruction of the sensory
nerves, as in cerebral tumour or in intracranial sjqohilis ; or it may be
functional, as in hysteria.
Nasal cough. — Occasionally cases arise in which there is a hard, per-
sistent, dry cough, which ceases during sleep, due to an exaggeration of
the normal nasal reflex cough. It may sometimes be excited by touching
the sensitive parts of the nasal mucous membrane with a probe. If there
be no pulmonary disease, and no other cause for such a cough can be
detected, the possiljility of its nasal origin should be borne in mind.
Post-nasal gi-owths will also excite it sometimes ; but in cases of this
class it may l)e due to irritation in the ear.
Vaso-motop Neuroses. — Vascular engorgement of the nasal mucosa
and distension of the erectile tissues, especially of the turbinated bodies,
occur in two forms : {a) Periodic vascular swelling ; {h) Vascular
engorgement with coryza (vaso-motor coryza), and various reflex neuroses,
as in paroxysmal sneezing.
Periodic vascular engorgement and swelling of the erectile tissues is
generally associated with nervous prostration or imperfect digestion.
The fulness of the nasal mucosa produces more or less obstruction in one
or both nasal passages ; it comes and goes, and is usually worse at night
on going to bed. Very often an examination is made just at the
time when the swelling has subsided and nothing abnormal can be de-
tected. If the patient be seen while the nose is obstructed by the
turgidity of the tissues the real nature of the affection is readily dis-
tinguished from hypertrophic rhinitis on applying a cocaine spray ; Avhen
vaso-motor swelling entirely disappears. In some cases, particularly in
gouty and dyspeptic patients, the engorgement of the mucous mem-
brane is accompanied by redness and swelling of the nose externally
and flushing of the face.
These changes are prone to occur — (i.) in persons of the neurotic
temperament who have run down from hard brain work ; (ii.) in gouty
patients; (iii.) from abuse of alcohol; (iv.) in neurotic women, especially
at the menstrual period.
The treatment must be mainly directed towards improvement of the
general health by nerve tonics, massage, cold baths, and out-of-door
exercises. It is sometimes necessary to use the galvano-cautery, linear
698 SYSTEM OF MEDICINE
cauterisations being made over the turbinated bodies ; and if chronic
rhinitis exist, suitable local treatment "vvill l)e required.
Paroxysmal sneezing may be due ('?) to rcHex jieripheral irritation ;
{}>) to a central neurosis. The physiological mechanism of sneezing may be
briefly desci'ibed as a reflex act brought about by irritation of the tri-
geminal nerve, cither in the nasal passages or in other regions Avhich it
sii])plies.
We have met "with cases in neurotic women in which it occurred in
paroxysuis of thirty or forty sneezes, especially on rising in the morning,
and when the face was plunged into cold water; and sinn'lar cases have
been frequently recorded. In a few cases there is no rhinorrhiea ; but
as a rule there is lachrymation and stuffiness of the nose followed by
watery discharge, and a pain in the bridge of the nose. Prolonged
attacks are very exhausting.
Paroxysmal sneezing is generally due to a hj'perajsthetic condition
of the nasal mucous membrane, and it is set up by the irritation of
l^articles of dust.
"Hay fever" is a form of paroxj^smal sneezing usually brought about
by the irritation of certain kinds of pollen. Some patients are peculiarly
susceptible to the ettiuvia of certain animals — for instance, the cat, horse,
or dog, and invariably suffer from sneezing or asthma when in proximity
to these animals ; others are similarly affected by peaches, violets,
music, peppermint, ipecacuanha, lycopodium, and so on. The exciting
causes of paroxysmal sneezing are such that although every one is
continually exposed to their influence, yet comjtaratively few persons
suffer ; thus it is obvious that individual j)redisposition is necessary for
the occurrence of the affection. Patients are almost invariably of the
neurotic temperament, especially dwellers in cities ; and there can be no
doubt that, to some extent, the predisposition is hereditary. The causes
being so general and yet paroxysmal sneezing being relatively so rare, a
third factor must 1)6 necessary for its occurrence ; and in most cases
some local abnormalities Avill be found in the nasal passages, the most
frequent being («) hypertrophic rhinitis; {h) spurs and bony projections
of the turbinated bones or of the septum ; (c) deviations of the septum ;
{(l) polypi; (e) old post- nasal vegetations; (/) areas of hyperaisthesia
in the nasal mucous membrane.
Thus it ap^iears that paroxysmal sneezing is the conjoint residt of
three factors : — (i.) The predisposing neurasthenic constitutional state ;
(ii.) an external irritant; (iii.) a pathological state of the nasal passages.
Asthma. — By the law of irradiation of reflex action — by the exten-
sion, that is, of reflex action fi-om nerves in which it first appears to
neighbouring ones, by means of the communications between the different
systems or groups of ganglionic cells — persistent irritation in the nose may
result in spasmodic asthma. It has long been knoAvn that asthma is
sometimes associated Avith intra-nasal disease, but it is only since Yoltolini's
classical case of asthma, which he cured by the removal of nasal polypi,
that attention has been directed to the causal connection between nasal
DISEASES OF THE NOSE 699
disease and asthma. "Whilst this connection, in our experience, is un-
deniable, we must again state that at present there is perhaps too strong
a tendency to attribute asthma to any slight departure from the normal
anatomical configuration of the intra-nasal structures.
No doubt, in a good many cases, it is extremely difficult to determine
how far the asthma and the associated nasal phenomena are but ditierent
concomitant expressions of a common central neurosis ; namely, a peculiar
condition of the nerve-centres in which paroxysms may be excited by
various peripheral irritations ; for paroxysmal sneezing and coryza often
precede, accompany, or alternate with attacks of spasmodic asthma.
And just as we observe that attacks of asthma by frequent recur-
rence may eventually lead to chronic bronchitis and emphysema, so we
likewise find that paroxysmal sneezing and coryza may result in a form
of chronic rhinitis, which is then the consequence but not the cause of
the asthma.
Further, we have to consider that when nasal coiyza results from the
action of some irritant conveyed by the inspired air, it is probable that
the lower air-passages, though in a less degree, are simultaneously ex-
posed to its influence ; thus the asthma may be due to the latter
influence. When the nose is partially or completely obstructed, and
respiration oral, the defective filtration and warming of the inspired air
will injure the lower respiratory tract. In these cases restoration of the
nasal functions by appropriate loc<d treatment will save the bronchial
mucous membrane from much of the irritation to which it was previously
subjected.
Treatment. — In paroxysmal sneezing and asthma, as in all sensory and
reflex neuroses of the nose, treatment should be mainly directed to over-
coming the underlying neurasthenia by appropriate nervine tonics — such
as phosphorus, iron, arsenic, valerianate of zinc — and by general hygienic
measures. The nasal conditions should, of course, be carefully investi-
gated ; and if positively morbid changes be detected, such as are
reasonably likely to cause the reflex neurosis, these must receive appro-
priate treatment ; but the discovery of a small spur on the septum or of
a small amount of erectile swelling on the middle or lower turbinated
bones should not be proclaimed at once as the undoubted cause of the
malady. Caution is the more necessary in these cases as it is very
difficult, and often impossible, to distinguish between the cases in which
intra-nasal treatment is likely to prove beneficial and those in which
but a temporary effect will be obtained, or none. On the other hand,
we may say that a good many cases of paroxysmal sneezing will probably
be improved by local treatment ; and, in a considerably smaller propor-
tion, that asthmatic paroxysms may be cut short or considerably relieved
by spraying a solution of cocaine into the nasal passages. If chronic
hypertrophic rhinitis, or polypi, or any other manifest nasal disease be
found, it should certainly be treated in the hope that the neuroses may
be relieved thereby ; but assurance of cure by nasal treatment cannot
be given to patients even if the concomitant nasal affection be well
700 SVSTE.1/ OF MEDICINE
marked, for we cannot remove a hereditary or an acquired instability of
the nerve-centres. Nevertheless, by nasal treatment we sometimes o1»tain
most brilliant results and perfect relief from all symptoms, particularly in
cases in which nasal polypi and bronchial asthma coexist.
In paroxysmal sneezing, when the only abnormality is erectile swelling
and vascular injection of the mucous membrane, we may cauterise the
swollen parts superficially. The l)est jDlan is to ascertain, before applving
cocaine, if there are any sensitive s^jots, and then to cauterise these after
the cocaine has been applied.
A method followed In' one of us (W. W.), with most gratifying
results, is to sj)ray the nasal passages cautiously with an aqueous solu-
tion of " iodic hydrarg " (a comliination of the iodides of mercury and
potassium) of the strength of 1 part in 100. A cocaine spray should
be used lieforehand, but, as the cocaine is destroyed by the mercuiial salt,
it is necessary to relieve the pain which very rapidly ensues by a hypo-
dermic injection of morphine. The solution is intensely irritating, and
care is necessary lest it get into the eyes or into the throat. The mucous
membrane of the nose becomes much congested and swollen. In about
three hours the pain and swelling subside, and are followed by a simple nasal
catarrh lasting two or three days. In suitable cases, if this be efficiently
done at the onset of the symptoms of that form of paroxysmal sneezing
distinguished by the name of " hay fever," the patient will remain free
from symptoms throughout the season ; and there are very few persons
who have sull'ered from the affection who will not readily undergo this
or any treatment that offers a fair prospect of relief. This method has
the advantage of leaving the sense of smell unimpaired, and involves no
destruction of tissue. It may have to be repeated the following year,
but in some cases the relief has extended over sevei-al' years.
Cocaine should never be recommended as a routine method for the
relief of paroxysmal sneezing. It tends to aggravate the condition after
its transient effects have passed off. Moreover, serious symptoms of acute
cocaine i)oisoning may suddenly declare themselves, even after the patient
has to all appearances become quite accustomed to the use of the drug.
\Vide art. "Cocaine," vol. ii. p. 904.]
Idiopathic rhinorrhcea is a name applied to an affection in which
the prominent symptom consists in a profuse watery discharge from the
nasal mucous meml)rane. While the group of cases comprised under this
heading are probably due to a variety of etiological factors, they are all
essentially vaso-motor neuroses. In some cases the copious discharge is
the only symptom ; in others it is accompanied In' sneezing and lachr}^-
mation, and is in fact a form of paroxysmal coryza and sneezing in which
the coryza is the prominent feature. In most cases the patients are of
neurotic temperament ; physical shock, hard brain work, exposure to cold,
are the chief exciting causes to which it has been attributed ; but in other
cases it comes on suddenly without api)arent cause. In a case recorded
by Dr. Althaus it was associated with anesthesia of the regions supplied
by the fifth cranial nerve. In a case recently rejjorted it was associated
DISEASES OF THE NOSE 701
with disease of the pituitary body ; usually, however, its cause has re-
mained in obscurity. Sometimes this rhiiiorrho?a is an escape of cerebro-
spinal fluid through the nose. In such cases, which appear to be more
frequent than hitherto supposed, the discharge is usually unilateral, and
its quantity sometimes very considerable.
The symptoms may begin with some itching or pricking sensations in
the nose. When the discharge has continued for some hours the mucous
membrane becomes swollen and oedematous. The copious clear colour-
less or slightly yellow discharge consists of Avater with traces of chloride
of sodium and mucus. The amount varies very much ; in some cases as
much as two or three quarts have come away in the twenty-four hours.
In the intervals between the periodic attacks the mucous membrane
resumes its normal aspect ; but when the affection has -existed for a con-
siderable time the mucosa becomes sodden and there is a tendency to
mucous polypi. The disease may recur for months or years, but eventu-
ally it nearly always ceases spontaneously.
Copyza cedematosa is very closely allied to idiopathic rhinorrhoea.
It consists of a serous infiltration into the connective tissue of the inferior
and middle turbinated bodies, which is sometimes migratory and
suddenly appears in other regions supplied by the trigemiiuis as it leaves
the nasal passages. It is apparently connected with some irregularity of
digestion in neui'otic subjects.
No treatment appears to have any lasting results. Galvano-cauterisa-
tion of the turbinated bodies may give relief, but local tieatment is
generally Avithout any lasting effect. General hygienic measures and con-
stitutional treatment should be adopted. -
Epilepsy is said to have been due in some instances to intra-nasal
disease, the treatment of which relieved the patient of this grave neurosis.
Many other neuroses — such as tinnitus, vertigo, headache, choi'ea,
asthenopia. Graves' disease, facial erythema — have been attributed in like
manner to intra-nasal disease. The possiliility of their occurrence must
be admitted, but such cases are at mo'^t extremely rare. — F. S. and W. W.
Foreign bodies in the nose. — Foreign bodies may find their way
into the nasal passages luider various circumstances. Children frequently
put foreign Ijodies up their noses ; hysterical women and lunatics may do
the same. Bullets and portions of knives and other sharp instruments,
penetrating the skin, have thus entered the nasal fossa?. Plugs introduced
to control epistaxis have occasionally been forgotten. In some cases a
foreign body has been forced into the naso-pharyngeal cavity in the act
of vomiting. Among the most common articles met with in the nose are
fruit stones, beans, buttons, beads, pieces of wood or slate pencil, shells
or pebbles. A supernumerary tooth sometimes erupts into the nasal
cavity.
Symptoms.- — The symptoms depend in great measure upon the nature,
size, and shape of the foreign body. As a rule, the presence of a foreign
body in the nose sets up a discharge which at first is muco-purulent ; but
702 SYSTE.V OF MEDICINE
it may become fa?tid and tinged with blood. In most cases pain is com-
plained of, and the pain may radiate over the side of the face. AVhere
the foreign body is large, or has caused much swelling, there is obstruc-
tion of the affected nostril. There is often sympathetic disturbance of
the eye and ear, as shown bj' increased secretion of tears, earache, tin-
nitus, and even otitis media. The voice may have a nasal twang, and
attacks of sneezing, giddiness, and vomiting have been described.
Delirium has occurred in a child. In process of time toleration may be
established, and instances have been recorded of foreign bodies lying in
the nose for many years without giving rise to any marked sym})toms.
Duignosis. — The existence of a unilateral purulent, foetid, or bloody
discharge from the nose, especially in a child, should always lead us to
suspect a foreign Ijody. If there be any doubt in the matter, careful
spraying of the nose, and the use of the probe after cocainisation of
the nasal mucous membrane, will usually clear up the diagnosis. If the
patient be a child it may be necessary to give a general anaesthetic in
order to make a satisfactory examination without injury to the soft parts.
Treatment. — In most cases the foreign body can l)e removed most
readily by means of the forceps or the snare. A modification of Leroy
d'EtioUe's instrument used in aural cases, or a strabismus hook, may be
employed for the same purpose. Gross' nasal spud or probe, with cork-
screw point, will be found useful for the removal of jieas and other soft
substances. Should it not be possible to remove the foreign body
anteriorly, it may be necessary to pnsh it backwards into the pharynx ;
while doing so the operator should introduce his finger into the patient's
throat, so as to prevent the body passing into the larynx.
For all these procedures the nasal mucous membrane should be
anaesthetised with a 20 per cent solution of cocaine. If the patient
be a child, his arms should be secured by a shawl wrapped round them ;
or a general anaesthetic should be given. The pneumatic method some-
times answers ; this is best effected by introducing the nozzle of a
Politzer's bag into the patient's nostril, and then suddenly compressing
the bag as the patient swallows some water, as in inflation of the Eus-
tachian tube.
The attempt to expel the foreign body by a stream of water passed
into the unobstructed nostril is attended with serious risk of setting up
otitis media by the entrance of water into the Eustachian tul)e. The
administration of sternutatories is another plan which had better be
avoidc(l.
Rhinoliths. — This name has been applied to the deposition of calcare-
ous matter within the nose, forming a stone or nasal calculus.
Etiolofjij. — Women are much more su1)ject to this affection than men.
Of 110 cases collected by Seeligmann, 62 occurred in women, 29 in men;
in 9 the sex was not recorded. No obvious explanation of this prefer-
ence is forthcoming ; it has been suggested that women l)low their noses
less than men, and that consequently there is a greater liability in them
to retention of secretion.
DISEASES OF THE NOSE 703
Rhinoliths gradually increase in frequency above the age of ten ;
but they are occasionally met with under this age. Concretions of a
characteristic form are frequently found in the nostrils of cement-workers ;
chiefly in those who are engaged in raking out cement-ovens, and who
consequently inhale hot cement dust.
In the great majority of cases the concretion takes place round some
foreign body, which may have been introduced into the nostrils, or may
have entered through the choana3 in the act of vomiting or sneezing.
The nucleus may consist of a bead, button, or other foreign body. In
some cases it is represented by a piece of inspissated mucus, or a blood-
clot.
Three conditions seem to promote the formation of these concretions
— (i.) An abnormal condition of the nasal and lachrymal secretion ; (ii.)
Any condition, such as nasal stenosis, which leads to retention of the
secretion ; (iii.) The presence of micro-organisms : this last condition may
depend upon the two former. Micro-organisms attract the lime salts of
the nasal mucus iind favour their deposition on the foreign body.
Usually one stone only is found ; and the exceptions to this rule are
more apparent than real, the second stone being probably a small mass
detached from the first in the process of extraction. Cases, however,
have been recorded in Avhich two stones were found ; and in one or more
cases a stone has been found in each nostril. The average weight of
rhinoliths is from 7 to 90 grains : a case of a stone weighing 720 grains
has been recorded. In colour, rhinoliths vary from a dirty white to
gray, brown, or black. They may be soft and crumbling, or as hard as
ivory. Chemically, rhinoliths are composed chiefl}^ of the phosphates
and carbonates of calcium and magnesium, with traces of the chloride and
carbonate of sodium, and a certain proportion of organic matter. Traces
of iron have been detected occasionally, probably in cases in which the
nucleus was composed of that metal.
Symptoms. — The symptoms due to the presence of a rhinolith are
similar to those caused by a foreign body in the nostril. Inasmuch,
however, as the rhinolith grows slowly the symptoms come on slowly.
The most usual symjitom is a unilateral discharge, generally muco-
purulent, but occasionally foetid. In exceptional cases, where the septum
has become perforated, there may be discharge from both nostrils.
Diagnosis. — For the detection of a rhinolith the nose must be
examined as directed under the heading " Foreign Bodies in the Nose."
In some cases the rhinolith becomes so embedded in the mucous membrane
that it may be mistaken for a polypus, or even a cancer. The purulent
discharge may excite fear of necrosis, or it may be put down to oza?na.
Prognosis. — The removal of the rhinolith is almost invariably followed
by an immediate cessation of the symptoms it had produced.
Treatment. — The removal of a rhinolith is effected in the same manner
as that of any other foreign V)ody in the nose.
In cases in which the rhinolith is hard, and very large, it may be
impossible to remove it without separating the nose from its attachment
704 SYSTEM OF MEDIC I. YE
to the cheek ; attempts to lessen its bulk may be made by the applica-
tion of hydrochloric acid.
Mag-gots in the nose. — This disease is almost entirely confined to
the tropins ; a vuiy small numljer of oases have occurred in Europe.
In India, where the disease is called " Pecnash," it is fairly common j
but this name is used rather loosely to include several afi'cctions of the
nose not necessarily indicative of the presence of magt^ots.
The fly is the Lucilia hominivora, or the Sarcophaga Georgina ; to
the larva of the latter the term " screw-worm " has Ijeeu applied. In
rare insbmces the larva? of other flies have been met with in the nose.
The fly commonly enters the nostril during sleep. As a rule, patients
suffering from oziena are attacked. The flies are prol)al)ly attracted by
the smell, and they find a ready entrance into the capacious nostril of
patients with atrophic rhinitis. It would appear that the larvie are
deposited in healthy nostrils accidentcdly.
The larvae develop very quickly and in enormous numbers. In one
case 388 maggots were counted. The sjMuptoms which first appear are
excessive irritability of the i)ituitary membrane, sneezing, and a sanious
discharge from the nostrils. In some cases epistaxis occurs. In severe
cases intense frontal headache, anorexia, and fever with delirium are met
with. The nose and face are swollen, and the larva? may be seeii esciiping
from the nostrils. Not only the nuicous memljrane of the nose, but even
the cartilages and bones of the nose may be destroyed, so that death may
occur from the meningitis of septic poisoning, or of direct extension from
the sphenoidal and ethmoidal sinuses invaded liy the larvce.
The prognosis is always a grave one ; for instance, out of seven cases
occurring at Fort Clarke, in Dakota, all were fatal except one. This is,
however, an exceptionally high mortality.
Treatment. — The only effectual method of treatment is the use of
chloroform. At the very beginning of the disease, and in slight cases,
the inhalation of chloroform may suffice. In more severe cases the
patient must be anaesthetised, and the nostrils syringed out Avith a mix-
ture of equal parts of chloroform and water, or with pure chloroform.
Spraying the nose with a one in forty solution of carl)olic acid in oil will
relieve the pain produced l)y the injection of pure chloroform.
Centipedes, caterpillars, earwigs, leeches, and ascarides have occasion-
ally been known to take up their abode in the nose. The symptoms
produced are those conmion to the presence of any foreign body, with
the addition that the movements of the visitor give rise to excessive
formication in the part. In the case of the leech epistaxis has been
noticed as a symptom, — F. DE H. H.
Diseases of the accessory sinuses of the nose. — Practically
speaking, we may disregard in this i)lace all affections of the accessory
cavities other than suppuration ; it is sufficient to bear in mind that
polypus, cystoma, fil)r()ina, osteoma and malignant disease — sarcoma more
especially, may originate in any of these regions.
DISEASES OF THE NOSE 705
Suppuration in the accessory sinuses cf the nose. — The large
majority of these cases is intimately associated with, if not actuallj^
secondary to one or other of the affections considered in the previous
sections ; and as, with such an association, two or more of these cavities
are often simultaneously involved, it is neither desirable nor expedient
to dissociate altogether the etiology and symptoms of the different
localities. Yet for clinical reasons the conventional classification must
be followed to a certain extent, although we may briefly mention here
certain points of causation common to all these sinuses. The only
predisposing factors are such as have been enumerated in speaking of
polypus and bone disease ; and any conditions favouring a development
of the catarrhal state may lead, if unchecked, to the implication of one
or more accessory cavities in the simple catarrhal process, and, secondarily
from retention or increasing intensity of the inflammation, to suppuration,
abscess, granulation, and polypus. Probably any local peculiarities inter-
fering with free drainage, such as extreme narrowness of the fossse, or
distortions of the septum, may be quoted as predisposing factors.
Empyema of the Antrum. — A small war has long been raging among
rhinolocrists as to whether disease of the nose or of the teeth is the
O
commoner source of suppuration in the antrum ; the dentists, I need
hardly add, hold to the latter view. But those specialists who
have worked most conspicuously at the subject appear to support the
opinion, strongly maintained by myself, that the immense majority of
such cases originates in suppurative conditions of the nasal mucosa, or is
associated with it. Among our supporters Ave may count Zuckerkandl,
Ziem, Hartmann, Krause, Gouguenheim, Baratoux, and others ; while
the alternative opinion is supported by the surgeons and dentists, and,
among specialists, by Semon, M'Bride, Fraenkel, Moritz Schmidt, Schecb,
and others. I believe the discrepancy of opinion is easily accounted for
when we remember that, only a few years ago, empyema of the maxillary
sinus without swelling of the face Avas overlooked unless there were an
obviously carious tooth to account for the foetid discharge from the nose ;
whereas in all cases associated Avith polyjDus, the latter, together Avith the
general catarrhal state of the mucous membrane, Avas supposed sufficient
to account for the discharge, MoreoA'er, Avith certain observers, I am
convinced it has become a custom to accuse any coexisting carious tooth
of being the prime source of the mischief ; and most people either have,
or have had, carious molars or bicuspids in the upper jaAv.
But apart from these tAvo methods of causation, there undoubtedly
exists a considerable number of cases Avhere abscess originates in the
antrum, primarily as the result of catching cold ; such cases are not
necessarily attended by the symptoms of pain, SAvelling of the face and
fever, first described, I believe, by John Hunter, and quoted in the text-
books of surgery.
Finally, to our humiliation, it must be admitted that occasionally
suppuration in the antTimi has folloAved removal of the middle turbinated
bone, injudicious cauterisations, and probably other operations.
VOL. IV 2 2
7o6 SYSTEM OF AfEDTCINE
The usuiil symptoms for which the patient seeks relief arc unilateral
and frequently fietid discharge from the nose, and occasionally more or
less severe supraorbital neuralgia. This pain generally assumes a curious
periodicity, appearing regularly at the same time each day, and persisting
for the same number of hours ; it is not obviously associated with
increasing accumulation in the cavity, nor does augmented discharge
seem to account for its cessation : nevertheless it ceases altogether on the
surgical evacuation of the abscess. In exce})tional cases the pain is
referred to the cheek ; and "we may sometimes elicit it by percussion
over the malar bone, the side of the nose, or the frontal region. liarely
the discharge finds exit only into the post-nasal space, a fact which has
occasionall}'' (in two cases in my experience) led to an erroneous diagnosis.
A point worthy of note is that, the patient's olfactory sense being intact,
he is perpetually haunted by the evil o<lour himself ; although it is
often not sufficiently pronounced to be perceptible by his friends. On
the other hand, in oza?na, or atrophic rhinitis, the unpleasant smell gives
no trouble to the patient himself, M'hose olfactory sense is seriously im-
paired, although it often makes him intolerable to his friends. Beyond the
local symptoms there is frequently some general disturbance of health,
especially if the discharge has continued for many years ; the patient
grows anamitc ; partly, no doubt, from mental distress at the perpetual
stench which he cannot forget and cannot be persuaded to believe is
imperceptible to others. The discharge is occasionally intermittent
and small in quantity ; at other times continuous and extraordinary in
amount. Generally it flows out more readily on lowering the head, a
point of some service in diagnosis. Rarely the disease is bilateral, and
then is generally symptomatic of bilateral etlmioidal disease.
In passing to the objective symptoms, it is wise to bear in mind the
fact that there may be considerable difficulty in making a positive
diagnosis. Some cases are fairly clear, yet in none are the conditions
aljsolutely pathognomonic, for the main jooint in diagnosis is the situation
of the discharge as it is seen lying in the nose. Whenever, in fact, we
perceive an opaque canary-coloured purulent discharge (which must be
carefully distinguished from the transparent muco-pus of simple rhinitis)
lying in the concavity of the middle turbinal, Avhich discharge, after
being wiped away, is immediately reproduced, and esp«cially on lowering
the head between the knees, we need have but little hesitation in opening
the antrum with the tolerable certainty of evacuating pus. Yet it must
be remembered that the frontal sinus and the anterior ethmoidal cells
also open into this region, and almost at the .same point — an inch or so
back from the anterior extremity of the middle turbinal — and that con-
sequently suppuration in any of these cavities would yield a similar
ap;ieai-ance. As a matter of fact, it is even possible that, in the event of
pus originating in the anterior ethmoidal cells or infundil»\ilum, the
antrum will prove to be a receptacle of pus, even if not directly involved
in the disease.
A means of objective investigation recently added to our list by
DISEASES OF THE NOSE 707
Voltolini consists' in a method of transillumination first employed by
that observe!" for diagnosing thickening of the al?e of the thyroid cartilage
in perichondritis of the larynx. The method now usually employed,
which has been elaborated, by Heryng, and later by Davidson, is as
follows : — A five-A'olt lamp is attached to the extremity of a tongue
depressor, the lingual portion of which is constructed of some non-
conducting material such as vulcanite ; this is inserted into the mouth
and the tongue depressed, while tlie patient closes the lips firndy round
the instrument. The room is now totally darkened and the circuit of
the current is completed. Immediately a rosy red light suffuses the face,
the cheeks and lips being the most brilliant, though often brightest
immediately under the eyes. It is essential to the success of the
procedure that the room should be absolutely dark. According to
Heryng's observations, whenever there is pus or a solid tumour in the
antrum, that side of the face, especially above the malar prominence and
beneath the lower eyelid, is less bright than the other ; while in cystic
disease, on the contrary, the side afl['ected will be the more brilliantly
illuminated. This latter point had been discovered by Voltolini, who
was thus enabled to diagnose a cyst in a case supposed to be a sarcoma ;
the patient having been doomed to the removal of the superior maxilla.
I believe the general opinion in regard to transillumination of the
antrum now is that it gives no more positive evidence of the presence of
pus than do other objective signs. Nevertheless in a disease in which no
one point can be relied upon, any additional evidence must be of consider-
able value. Such being the case, it may be justly admitted that many
cases cannot be satisfactorily investigated without this method. Besides,
it is so simple, and needs so little special experience, that it may often
be of value to surgeons of little skill in the examination of the nasal
fossse. Yet it must be acknowledged that probably its most .striking
service is in the diagnosis of cystic from solid tumours of the antrum.
In syphilis of the nose a unilateral fretid discharge is generally due
to a sequestrum, which can usually be detected in the neighbourhood of
the vomer or turbinated bodies by the help of a probe ; there is often
perforation of the hard palate also. Rhinolith may give rise to identical
symptoms. Simple caries, with the exposure of small portions of bone,
leads to no foetor, provided the exit of the pus be not interfered with.
In empyema of the sphenoidal sinus, as well as in disease of the posterior
ethmoidal cells, the pus makes its exit into the post-nasal space, and
is accidentally, as it were, blown into the nose. In the case of malig-
nant disease of the antrum there may be a purulent discharge from the
nose ; but the usual signs of distension of the cavity will be present,
and this, together with the history of the case, will prevent any error in
diagnosis. In case of difficulty it may be remembered that in abscess
the swelling, if any be present, subsides as soon as the pus is evacuated.
Finally, it must be admitted that a positive diagnosis can be made
only by adopting one of the different procedures for opening the
cavity.
7o8 SYSTEM OF MEDICINE
The trciitment of emj)yema of the maxillary sinus has of late j^eara
given rise to as mnch divergence of opinion as the etiology ; though,
before the nose was made a region of special study, no one attempted to
improve upon Hunter's method of tapping the antrum. This consisted
in removing one of the molars, and breaking down, with a gimlet or drill,
the thin layer of bone between the alveolus and the cavity above.
Hunter, too, refers to the alternative of making an opening from the nose
into the antrum, though he does not dwell upon it even for the sake of
indicating its disadvantages ; these are, chiefly, the difficulty in the
subs(>quent drainage — the opening not being in the most dependent
portion of the cavity, and in the irrigation of the cavity.
Suppuration in the frontal sinus and ethmoidal cells. — I have already
said that a few 3'ears ago I considered empyema of the frontal sinus
so rare that we were unable to give an}' satisfactory rules for its
diagnosis ; apart, of course, from those cases where complete retention of
secretion led to external swelling and pain : but more extended observa-
tion has convinced me that many cases which I used to consider as
ethmoidal suppuration are actually due to mischief in the frontal sinus.
I must admit, however, that the association of the two conditions is
common enough, while it is by no means rare for the frontal sinus,
anterior ethmoidal cells, and antrum to be involved simultaneously.
A brief reference to the anatomy of the parts will make the etiology
and diajcnosis more intellisiible. The frontal sinus is continued ddwn-
wards and backwards into the passage known as the infundiljuluni Mhich,
having one or more accessory cells communicating with it, passes exter-
nally to the anterior extremity of the middle spongy bone's attachment,
on its outer side traversing the inner Avail of the antrum till it o})ens in the
middle meatus at the semilunar hiatus. I believe that many a case of sup-
puration in the frontal sinus begins in an inflammatory occlusion, more or
less complete, of this opening ; whence we have the one essential factor for
the production of abscess. The iiifundilnxlum is probal)ly often involved,
before the mischief extends into the middle meatus, to siich an extent as
to occlude and distend it, giving rise to the appearance of a duplicated
middle turbinal. Indeed this appearance has been erroneously-described as
a cleavage of the middle s])ongy l)one, and as symptomatic of the somewhat
hypothetical "necrosing ethmoiditis" (Woakes). Retention of simple
mucus in the infundibulum possibly gives rise to some cases of osseous cysts ;
and I have seen three or four instances of abscess confined to the infundibu-
lum : occa.sionally these abscesses, instead of rupturing externally, make an
exit into the antrum and thus convert the case into abscess of the latter
sinus. Or the mischief may gradually extend upwards, Avhen the mucous
membrane of the infundil)ulum disappears and is replaced by granulation
tissue, which further obstructs free drainage ; the accessory cells of this
region partake in the process, and in time the cavity of the frontal siiuis
IjC^Dmes similai-ly involved. But during the whole history of such a
case, although the flow of the discharge is sufficiently obstructed to cause
distension of the thin-walled infundibulum, yet retention may at no time
DISEASES OF THE NOSE 709
be so complete as to attenuate the denser parietes of the frontal sinus ;
so that it is only in the rarest cases that slowly progressing disease would
give rise to the generally accepted symptoms of acute frontal abscess.
The etiology of disease beginning in the ethmoidal cells is not
materially dift'erent. A small abscess may arise during an attack of
acute rhinitis, which abscess, if the patient be constantly suft'ering from
attacks of the initial mischief, becomes chronic ; and thus is initiated the
whole train of symptoms which may end in such extensive disease as I have
described. Besides simple inflammation, a rhinolith may be the starting-
point of abscess in the frontal sinus or in an ethmoidal cell ; or phos-
phorus poisoning, tuberculosis, or syphilis may be concerned in the case.
Rarely such suppuration is observed in conjunction with erysipelas
(Zuckerkandl, Weichselbaum).
I have latterly become convinced of the fact that the point in
diagnosis upon Avhich formerly we chiefly relied for diagnosing suppura-
tion of the antrum, namely, the reproduction of pus in the middle
meatus by hanging the head forwards and rotating it, is actually quite
as often indicative of suppuration in the frontal sinus. While many
rhinologists will admit that the symptom is by no means pathognomonic
of antral disease, yet I believe most would doubt its frequent occurrence
in the frontal disorder ; yet I am prepared to aflirm that such is the
case. It is not altogether easy to account for the phenomenon, seeing
that in the upright position of the head the opening is at the lowest
point. When we remember the narrow passage of the infundibulum,
more or less obstructed as it generally is in these cases by granulations,
we may liken the condition to that of a beer-bajTel with the tap turned
on but the vent-peg tight in the bung ; unless we remove this peg
the only way to ensure entrance of air will be to invert the whole
barrel from time to time. In the case of the frontal sinus, I have again and
again elicited this symptom after washing the antrum free of all suspicion
of pus ; and the large quantity poured out of the frontal sinus on such
occasions, by tilting the head forwards or between the patient's knees,
has been sufficient to preclude a possibility of its flowing from any of the
smaller ethmoidal cells.
As a matter of fact, in most of these cases, when more than one
cavity is simultaneously and similarly affected, I doubt if it be ever
possible, except in the case to be immediately considered, to be convinced
of the fact of frontal suppuration before we have shown by surgical
measures that the antrum is sound ; and it may even be necessary to
eliminate ethmoidal suppuration also before Ave are certain as to the
frontal.
The one sign which may make a diagnosis quite clear in frontal
abscess is that when the inner walls of the infundibulum have undergone
absorption, the point at which the pus makes its exit is brought so
much forwards that a probe with a slight anterior curve may be passed
up into the cavity ; or a long, fine Eustachian catheter may Ije passed
up and the abscess irrigated : the diagnosis will then be positive. In
7IO SYSTEM OF MEDICINE
other more doubtful cases some liel]i may be gained by transillumination,
A small tive-volt lamp with condenser is enclosed in a cylindrical chamber,
the open extremity of which can be firmly })ressed under an overhanging
brow. This in a perfectly dark room will illuminate the region under
which lies the frontal sinus, provided the siiuxs be of tolei-able size and
the walls correspondingly thin. If one sinus be full of pus and granu-
lations it will appear less translucent than the other. But of course the
method is of no value in the many cases in Avhich both frontal sinuses
are involved simultaneously.
The anterior ethmoidal cells sometimes open dii-ectly into the roof of
the middle meatus, that is to say, into the concavity of the middle
turbinal ; at other times they may open into the lower part of tlie
infundibulum. In the former case we are often able to pass a probe — and
it should always be a blunt one — directly into the region in question ;
but in the latter case it is extremely ditlicult to detect the source of the
discharge. Occasionally also these cells open directly into the antrum,
and, it is said, into the orbit. After the persistence of the disease for
any length of time, the Hoor and party walls of these little chandlers
become absorbed and break down, and granulation tissue fills up the cavities,
into which the probe freely passes, discovering here and there spots of
carious bone ; and, as I have said before, ethmoidal mischief is frequently
associated with like trouble in the antrum, infundiltulum, and fi'ontal
sinus. The pus may even make its way directly into the maxillary
sinus, into which the disease may also extend. Indeed, I have a suspicion
that many cases of such extensive nose disease begin in a small abscess
affecting an ethmoidal cell.
I have purposely said nothing about symptoms in frontal disease,
seeing that, so far as I am aware, they are only with great dithculty to be
distinguished from those of disease of the antrum. Probably supraorbital
pain is even a commoner symptom ; and I am inclined to think that
periodicity in the flow of pus may be more frequent in the case of the
frontal sinus. Thus cases occur where the patient, after taking cold, has
attacks of " brow-ague " at variable intervals, such as one, two, or more
days, Avhich pain, after persisting with increasing intensity for some hours,
is suddenly relieved by a copious flow of purulent seci'etion ; and uidess
the patient present himself for examination during such a discharge, we
may find no objective indication Avhatevcr of the nature of his ailment.
Such symptoms are probal)ly indicative of small spots of acute sup])ura-
tion ; and the very fact of their undergoing spontaneous recovery makes
it impossible to determine Avhethcr an ethmoidal cell or the frontal sinus
I)e concerned. We are altogether de])endent on the patient's subjective
experience. In either case one would assume that spontaneous recovery
is more likely to occur than in antral disease.
Formerly, when a correct diagnosis was barely attempted, the treat-
ment of such cases consisted in the removal of the larger masses of poly-
pus and granulations ; the patient was then dismissed Avith the consola-
tory advice that he was sufliering from a chi'onic catarrh which would
DISEASES OF THE NOSE 711
persist in spite of all treatment ; or he was sent to Egypt or South Africa,
the chief recommendation of such places being their distance. But now,
Avith improved methods of diagnosis, practice has so far changed that, as
regards ethmoidal disease at any rate, no difference of opinion will be
found among specialists as to the importance and the success of treat-
ment. Whether we are dealing with ethmoidal or frontal disease, the
principle of treatment consists in securing free drainage ; if this can be
seciu'ed, we may entertain every hope that the supj^urating cavities will
gradually become obliterated by organising granulation tissue. In the
case of ethmoidal cells the process can be greatly facilitated by cautiously
breaking down the very friable dissepiments with a curette, which instru-
ment is also most usefully employed in removing such granulation masses
as are interfering with free di'ainage. The curette is prcferal)le in every
way to caustics, though doubtless these have their use when carefully
applied and to small areas at a time. The electric cautery has only
to be mentioned in words of condemnation ; and we may lay it down
as a rule that whenever the limitation of a polypus or granulation mass
is indefinite, whenever Ave are unable to determine the actual distance
from the cribriform plate at which we are Avorking, the galvano-cautery
ought never to be used. And it is this imperative necessity for caution
in such operation, as it appears to me, that makes the treatment of these
cases A'ery tedious : yet after a fcAV sittings the j)atient becomes so far
convinced of the improvement in his symptoms that he is ready enough
to undergo a prolongation of the treatment. In the case of the frontal
sinus it is not easy to secure free drainage ; but as, perhaps, the majority
of such cases (and as far as my experience goes, I should say all of such
cases) are complicated with suppuration in the infundibulum and its con-
tributory cells, it is obvious that to open the sinus from the outside Avill
not be altogether successful. This, of course, Avas formerly the routine pro-
cedure for acute abscess, and U]) to a certain point must still be admitted as
correct ; but in chronic cases, unless accompanied by intra-nasal treatment,
it is far less satisfactory than drilling the antrum. Of late I have sought
to abandon the external opening altogether, seeing that to the patient it
is a serious operation, entailing a certain amount of disfigurement, and
considerable distress in the after-treatment. My object has been to break
down the inner Avails of the infundibulum, often attenuated or partly de-
stroyed by the disease, after removing the anterior extremity of the middle
turbinal. The channel generally corresponds Avith a distinct Inilging into
the middle meatus; and into it a fine chisel or indeed a blunt raspatory
can be ea-sily thrust, and the inner Avail broken away piecemeal. In this
manner the passage can be laid open as far upA\^ards and forwards as the
anterior extremity of the attachment of the middle spongy bone, and an
opening thus made sufficiently large to admit of easy irrigation, Avhich,
indeed, the patient can sometimes be taught to practise for himself. Once
free drainage is secured, the natural tendency is to spontaneous cure by
cicatrisation, and more or less to the obliteration of the cavity.
Posterior ethmoidal cells. — Every remark that has already been made
712 SYSTEM OF MEDICINE
concerning the etiology and pathology of snjipuration in the anterior
ethmoidal cells applies to the same all'ection of the posterior. The only
dilference is in diagnosis. But this' is actually an easier matter ■with the
posterior than the anterior, seeing that stippuration in the former is not so
frequently associated and confounded with disease in the antrum and frontal
sinus. The one point in diagnosis is that, in the case of the posterior cells,
while the discharge flows by preference into the post-nasal space, it may
occasionally i)ass through the anterior nares, when, on examination, it Aviil
he found occupying the space between the free border of the middle turbinal
a:id the septum ; for, as will be n-membercd, the posterior ethmoidal cells
open into the superior meatus, Avhich is fully developed only in the pos-
terior portion of the nasal cavity. On examining the posterior nares ^nth
the post-rhinoscope, the pus will l)e seen occupying the region of the
superior turbinal, which may be wholly or partly obscured l)y j)olypus or
by masses of less transparent and redder granulation tisstie. I']xamination
of this region with a probe is by no means easy owing to the obstructing
middle turbinal ; nor is the removal of the posterior extremity of this
structure an altogether comraendal)le operation. And even when this
difficulty is surmounted, it may prove impossible to clear out the largest
of the posterior ethmoidal cells, seeing that this cavity, extending out-
wards and backwards, is often of considerable size. And for similar
reasons irrigation of the upper and back regions of the nose is extremely
difficult to carry out satisfactorily.
Suppuration in the sphenoidal sinus. — Abscess of the sphenoidal sinus
is, according to my experience, extremely rare ; and in most of the re-
corded cases of so-called sphenoidal suppuration the clinical points, as
related, have failed to convince me of the observer's sagacity in dia-
gnosis. For my part, I have oidy been al)le to diagnose three cases posi-
tively. Acute abscess, like suppuration in the other cavities, is said to
occur as the result of syphilis, tuberculous meningitis, erysipelas, and
acute rhinitis. In acute abscess the s^-mptoms described arc intense
deep-seated pain referred to the centre of the head ; as the pain increases
in severity, symptoms of pressure on surrounding parts supervene, the
optic nerve is compressed, and sudden blindness follows. Exophthalmos
and strabismus should be accompaniments ; and where necrosis occurs,
orbital abscess and meningitis ma\' follow.
The only diffictdty in diagnosis arises from the similarity in the
symptoms of posterior ethmoidal and sphenoidal supptiration, seeing that
in each case the discharge finds its way more readily into the posteiior
nares than from the anterior. In every tuiciiui vocal case of suppiu-ation
of the posterior ethmoidal cells which I have seen, the pus did not con-
spicuously flow over the posterior walls of the nas()-j)haryngeal cavity,
which indeed could happen only when the patient was lying on his back.
On the contrary, in a supposed case of empyema of the sphcnciidal sinus,
the pus would obviotisly How over the posterior wall whether the head
were held upright or supine ; while the only position in wliich it cotdd
gain access to the nasal fossa; would l»c when the patient was lying prone :
DISEASES OF THE NOSE 713
yet an occasional bend of the head forwards might account for some of it
finding its way on to the superior turbinal. Such points will be per-
fectly clear if the anatomical arrangement of these cavities is remembered :
the posterior ethmoidal cells open immediately into the superior meatus,
and the sphenoidal immediately behind the posterior nares, although
approximately on the same level. Briefly, the tendency in sphenoidal
suppuration is for the pus to flow downAvards over the posterior wall of the
naso-pharynx, keeping to the affected side of the middle line ; while in
jDOsterior ethmoidal suppimition the pus, though flowing also backwards
and downwards, finds its exit from both anterior and posterior nares,
favouring the latter ; the examination does not indicate that it is con-
fined to the posterior naso-pharyngeal wall, unless the patient has been
lying for some time ujDon his back.
The treatment, Avhen the diagnosis is clear, consists in cautiously
breaking down the anterior wall of the sinus, which, looking directly for-
Avards and sometimes slightly downwards, is readily reached by passing
the instrument upwards and backwards through the anterior nares, and
following the line of junction of the perpendicular plate of the ethmoid
with the vomer. But it must always be remembered that the size of
this sinus varies greatly. — G. MacD.
Naso- pharyngeal or post- nasal catarrh. — Acute catarrh of the
naso-pharynx is usually associated with a similar condition of the nose
and pharynx. It is accordingly seen in cases of measles and scarlet
fever, typhoid fever, and other infectious diseases which attack the nose
and throat. The symptoms and treatment are the same as for acute
nasal and pharyngeal catarrh.
Chronic catarrh of the naso-pharynx is most commonly due to some
obstruction t(j free nasal respiration, as for example deflection of the sep-
tum, or crests on it, hypertrophic rhinitis, and especially enlargement of
the posterior extremity of the inferior ttirbinals, or the presence of
polypi. In some cases chronic enlargement of the pharyngeal tonsil
seems to be the direct cause ; and Tornwaldt laid great stress on the
so-called jDharyngeal bursa as the seat of the processes leading to catari-h
of the naso-pharjmx. Recent researches, however, have shown that this
bursa is only the remains of the noi-mal median cleft in the pharyngeal
tonsil. Naso-pharyngeal catarrh is often accompanied by gastro-intestinal
disturbance, and treatment of the latter will relieve the former.
The symptoms of naso-pharyngeal catarrh are those due to obstructed
nasal respiration with increased secretion. The patient usually Avakes in
the morning with the mouth dry ; he feels a sense of discomfort in the
back of the nose, which is relieved by haAvking and clearing the throat.
There is frequently some laryngeal catarrh as revealed by hoarseness.
Owing to the Eustachian tubes becoming blocked by catarrhal SAvelling of
their mucous lining, complaint is made of deafness and of tiimitus aurium ;
otitis media sometimes occurs. Headache, pains in the nape of the
neck, and giddiness are not uncommon symptoms. On examination of
•14 SYSTEM OF MEDICINE
the naso-pharvnx by means of the rhiiioscope the mucous memhiane will
be found swollen and usually more or less covered with sticky mucus
or dry crusts. Occasionally enlargement of the pharyngeal tonsil may
be detected. In the more chronic cases atrophic changes, similar to those
seen in atrophic rhinitis, may be recognised. The nose should be care-
fully examined in order to detect any obstructive lesion.
Treatmeid. — In the milder cases tonics, change of air, and attention to
the state of digestion will usually have a good effect. If the symptoms
contiinie in spite of this method of treatment, the use of mild alkaline
solutions to the nose and naso-pharynx by means of the anterior or pos-
terior spray will yield beneficial results, especially if followed by spraying
the parts "\vith a solution of twenty grains of menthol and fifteen minims
of eucalyptol in an ounce of fluid paraffin. In cases in which the pharyn-
geal tonsil seems to be the seat of the mischief, the application of a solu-
tion of ten grains of iodine and twenty of iodide of potassium and five
minims of oil of iDcppermint in an ounce of glycerine by the post-nasal
brush, night and morning, will have an excellent effect. If the pharyngeal
tonsil is much enlarged it may be necessary to remove it by means of
the curette or forceps.
Should the catarrh be dependent on nasal obstruction, free nasal
respiration must be secured hy surgical treatment adapted to the special
necessities of the individual case.
Tuberculosis may attack the naso-pharynx, giving rise in some cases
to ulceration, and in others to a diff'use infiltration of the posterior aspect
of the soft palate. Tubercle bacilli have been detected in adenoid vegeta-
tions.
Syphilis in all its forms has been observed in the naso-pharynx.
Primary syphilis of the naso-pharynx is almost exclusively due to infec-
tion by means of the Eustachian catheter.
Secondary syphilis occurs in connection with a similar affection of the
pharynx.
It is not at all uncommon for tertiary ulceration of the naso-pharynx
to occur quite independently of any mischief in the pharynx, hence the
importance of a rhinoscopic examination in these cases. — F. I?E II. II.
Hypertrophy of the pharyngeal tonsil. — Adenoid vegetations ;
Post-nasal growths. — The aggregation of lymphoid tissue on the roof and
posterior wall of the naso-pharynx, known as the phaiyngcal or Luschka's
tonsil, is very similar in structure and formation to the faucial tonsils,
and is liable to the same morbid changes. In fact, in altout 50 per cent
of the cases hypertrophy of the faucial tonsils and post-nasal adenoids co-
exist ; but the latter disease gives rise to a distincti\e group of symptoms,
the clinical importance of which, first recognised and described by ^^'ilholm
Meyer of Copenhagen in 1SG8, is becoming very generally appreciatt'<l.
Etiology. — Post-nasal adenoid hypertrophy is a disease of eai-ly chiUl-
hood, a period when all the lymphatic structures are especially active.
It has been observed as early as the tenth month ; the symptoms generally
DISEASES OF THE NOSE 715
date from birth or early infancy, becoming Avell marked, as the hyper-
trophy increases, by the fourth or fifth year, if not before. Thus there
is little room for doubt that the affection is often congenital in origin.
The majority of cases come under our notice 1)etween the ages of five and
fifteen ; and the adenoids, though sometimes persisting and still more
rarely extending after the age of twenty, in nearly all cases participate
in the retrogressive changes and atrophy common to many lymphatic
structures after the age of puberty. By this time, however, the health
and development of the patient are often permanently impaired.
The considerable influence of heredity in their occuiTence is shown by
the frequency with which several members of a family sufter from
adenoids. This influence is probably indirect, and is due to the trans-
mission of the strumous diathesis in which we observe so marked a
tendency to hypertrophy and degeneration of the lymphatic glands and
a decided proclivity to tuberculous afi'ections. Further, we often find,
associated with the rhino-pharyngeal affection, various inherited defects
in development, such as a high-arched or V-shaped palate, contraction of
the superior maxilla and consequent encroachment on the nasal fossse and
cleft palate. The importance of nasal stenosis as an etiological factor in
producing the adenoid hypertrophy has been over-estimated : nasal
stenosis and chronic nasal catarrh are almost always the results of post-
nasal growths and concomitant defects in development.
A cold and damp climate disposes to the disease by increasing the
tendency to catarrhal affections ; and in warm and dry climates the disease
is less common : thus Massei remarks that in Italy the disease is very
rarely observed in any marked degree. Measles, scarlatina, and influenza
are apparently very frequent exciting causes of the disease. On the other
hand, it is equally certain that the presence of adenoids very greatly
increases the risk of infection in various exanthems, and the lialtility to
colds and bronchitis ; thus it is often very difficult here to distinguish
between cause and effect. Finally, in many patients who are otherwise
healthy and strong we find no obvious cause for the glandular hyper-
trophy.
We have no certain knowledge of the physiological functions of the
lymphoid tissue in the upper air-passages ; but it is probable that they
furnish leucocytes which are protective against the inspired micro-organisms
that always exist in these parts. This question is more fully discussed
in the chapter on the diseases of the tonsils. But it is quite certain that
the pharyngeal tonsil, when in a condition of chronic hypertrophy and
degeneration, like all tissues of low vitality, has lost its power of resisting
the invasion of pathogenetic microbes, and is a ready poi-tal of entrance
for tubercle bacilli. Thus the pharyngeal and particularly the cervical
lymphatic glands are frequently affected and become enlarged in cases of
adenoid vegetations, and one of us (F. S.) has twice of late seen retro-
pharyngeal abscess associated Avith adenoids.
Pafliolugy. — The growths occupy the vault and posterior wall of the
rhino-pharynx, forming either a large cushion-like mass or an aggregation of
7 1 6 S YSTEM OF MEDICINE
nunioi'ous large and irrcgulur projections. They are covei-ed ■\vitli ciliated
epithelium and the surface is coarsely lobular or mammillar. The sub-
stance of the growths consists of a connective-tissue reticulum filled Avith
lymph corpuscles, the trabeculte being formed of ramified corpuscles which
have generally lost their nui'lei. The tissue is, as already mentioned, very
similar to that of the faucial tonsils, differing only in the aljsence gf the
crypts, the relativel}'' small amount of connective tissue, the high
vascularity, and the ciliated epithelium. Tuberculous tissue hcis been
observed in the vegetations, and, very rarely, small cvsts also. In adult
patients we generally find the growths more or less atrophied, and
firmer in texture from the preponderance of connective tissue.
Tlie symjjtoms vary very much in kind and in severity : thus Avhile in
some cases there is little to observe but nasal obstruction or deafness, in
the vast majority the symptoms are so characteristic that the general
aspect alone is sufficient for the practised eye to make a diagnosis of post-
nasal growths. The nose becomes pinched, the alse nasi fall in from long-
continued disuse of the dilator muscles, and a dimple forms in the angle
between tlie superior and inferior lateral cartilages. The upper lip is
retracted, the upper incisors show, the naso-labial fold is more or less
obliterated, and, the inner canthus of the eye being drawn down, the eyelids
droop and the whole face lengthens ; moreover, the necessity of breathing
through the mouth gives an expression of dulness and vacuity which is
still fiu'ther increased by deafness. The child is generally pale and
unhealthy-looking, and the cervical lymjDhatic glands are often enlarged.
Defective gi-owth and all the evils due to mechanical obstruction to
respiration in the young are often observed ; as, for instance, chronic
pharyngitis, colds in the head, laryngitis, and bronchitis. Dr. Eustace
Smith, whose experience of diseases of children is exceptionally wide,
observes that in childhood symmetrical retraction of the infra-mammary
region and depression of the ensiform appendix (pigeon-breast) owe their
origin with few exceptions to rhino-pharj'ngeal olistruction, the retraction
of the chest wall being directly due to pulmonary collapse. If this
collapse be extensive, the lower part of the sternum becomes prominent
from retraction of the cartilages of the ribs, whilst the recession of the
infra-mammary and epigastric regions with each inspiration, noticed in
vory young children suffering from rhino-pharyngeal ol)struction, results,
if long continued, in permanent retraction of these parts. Moreover, in
infants and young children with adenoids it is common to find collapse
of the upper parts' of the lungs ; and there may be deficient resonance
with weak, harsh l)reathing in the supras})inous fossa?, extending down to
a short distance below the scapular spine : this may be accompanied by a
dusky tint of the lips with other signs of imperfect aeration of the
blood. Dr. Smith reminds us that, at this period of life, a high-pitched
percussion note in the supraspinous fossa^, without notable alteration in
the breath sounds, is coinmoidy due to a patch of pulmonary coUajise ; and
that when the ihino-pharynx is obstructed by amass of adenoid growths,
very hollow breathing, conducted from tlie pharynx, is heard over the
DISEASES OF THE NOSE 717
upper part of the chest on either side — a combination of physical signs
which often leads to an erroneous diagnosis of serious disease.
The breathing of children suffering from advanced adenoid vegetations
is peculiarly noisy and snuffling ; this is very noticeable during eating and
drinking, and especially in sleep. While in the daytime respiration is
mainly by the mouth, the physiological habit of nasal respiration reasserts
itself during sleep ; moreover, the tongue tends to fall back against the
soft palate, by which respiration is still further embarrassed, and snoring
is set uji. Suffocative "night-terrors" often occur; the little jDatients
are always restless in bed and their sleep much disturbed : for as the
embarrassed respiration through the nose creates an excess of carbonic
acid gas in the blood, the hcsnin de resjnrer arouses the child so far as to
take a few breaths by the mouth.
Speech is affected as the nasal obstruction interferes with the pro-
nunciation of certain consonants : thus B is substituted for M, D for N,
G for NG and K, F for TH, and so forth. The voice is also remarkably
toneless and flat, since the rhino-pharynx, being occupied by the growths,
loses its resonant functions. Apart from these effects of nasal obstruction
the children are usually backward in learning to speak and read ; and
articulation is very often defective, partly from want of tone in the palate
muscles, and partly from deafness. To the deficient aeration of the blood
must further bea,scribed the lassitude, the "ready flagging," the headaches
and giddiness of the little patients, and their inability to fix their attention
(Guye's " aprosexia ").
A peculiar harsh, dry, barking, reflex cough, independent of any
bronchi tic affection, is a very frequent complaint ; it is usually worse at
night. Cough is further induced by the accumulation of mucus in the
back of the throat trickling down to the larynx, or by catarrhal affections
of the upper respiratory tract. The soft vascular adenoids bleed so
readil}- that the secretion is often blood-stained ; and blood, even in con-
siderable quantities, may be coughed up or, passing into the stomach, may
be vomited. Whilst a history of inveterate cold-taking with constant
running from the nose is usual, yet, on the contrary, the complaint may
be that the child has a particularly dry nose, and that he never uses a
pocket-handkerchief ; although his speech sounds as though he has a cold
in his head. Asthma, stuttering and stammering, laryngismus stridulus,
chorea, nocturnal enuresis, and even convulsions and epilepsy, are among
the neuroses that have been attributed to the presence of adenoids.
Though we should guard against the tendency to refer every conceivable
reflex neurosis to a rhinal or rhino-pharyngeal irritation, it is conceivable
that adenoids may cause any of these symptoms ; and we have strong
evidence of the intimate association between the upper and lower respira-
tory tract in the fact that respiration may be completely arrested by the
presence of the forefinger in the rhino-pharynx. Probably the intensely
disagreeable sensation of choking produced by digital exploration of the
rhino-pharynx for diagnostic purposes, arises largely from the same cause.
Deafness in greater or less degree — sometimes periodical and
7i8 SYSl^EM OF MEDICINE
coincident with colil in the head, sometimes constant — is one of the
most frequent complications of adenoids ; although very often treated
lightly by the parents, who trust that the child will grow out of it ; or
they regard it as mere " inattentiveness."' From the gradual absorption
of the air in the middle car which cannot 1)e renewed — either in
consequence of the Eustachian tubes becoming obstructed ])y catarrh in
the naso-pharynx, or from paresis and interference with the action of the
levator palati and salpingo-pharyngeus muscles — the tympanic membi"incs
become so much depressed that on examination we see extreme fore-
shortening of the handle of the malleus, prominence of the short process
and posterior fold, and an ill-deiined or al)sent Itright spot. The membrane
is often thickened and somewhat opaque and congested. From retention
of the catarrhal secretions otitis media purulenta may arise with
subsequent perforation, otorrhcea, and granulations. The extreme degrees
of depression of the drum-heads are practically never seen in children
except in connection with adenoid vegetations. Should a child suffering
from adenoids lie attacked by scai-let fever or diphtheria, ear-complications,
often severe and even incvu'able, are almost the rule.
In adults, the growths having usually become more or less atrophied
while the rhino-pharyngeal space has increased, nasal obstruction and
mouth -breathing generally disappear; though many of the evil effects
persist.
On examining the fauces the soft palate is seen to be relaxed, and its
distance from the posterior wall of the pharynx unusually great. If
the tonsils are not greatly hypertrophied, as in these cases they often
are, numerous enlarged follicles on the posterior wall of the pharynx may
be seen, unless they are obscured by the muco-ijurulent secretion descend-
ing from the rhino-phaiynx. The growths themselves may be examined
by rhinoscopic inspection and by palpation. Even in -very young
children it is occasionally possible to obtain a view of the rhino-phaiynx
with the rhinoscope. The growths appear either as a grayish pink
gelatinous cushion-like mass with vertical ridges and furrows, or as an
aggregation of stalactite-like projections crowded together and presenting
an irregular mammillated surface growing from the vault and posterior
wall. They often extend laterally to the foss;e of Ivosenmiiller, or occlude
the orifices of the Eustachian tubes more or less, sometimes forming
adhesions with the posterior lips. The Roman arch formed l)y the
upper insertion of the vomer into the roof of the naso-pharyngcal cavity
and the choanae are ])artially shut off from view ; or the whole rhino-
pharyngeal sjiace may be filled with masses of growth. The surface of
the mass is often more or less covered by viscid muco-purulent secretion.
In adult patients it is not difficult to make the rhinoscopic examination.
Digital exploration of the rhino-pharynx should be employed in all
doubtful cases. With the cliild seated in a chair, the physician standing
on the right side and holding the head firmly with the left hand, the
right forefinger, protected cither by a finger-guard, or l)y a napkin, or l)y
a cork between the patient's teeth, is rapidly passed behind the posterior
DISEASES OF THE NOSE 719
pillar of the fauces, and thence upwaids to the roof of the rhino-pharynx,
and swept i-apidly over the whole of the post-nasal space so as to
determine the size, consistency, and location of the vegetations. As the
forefinger impinges on the soft adenoids, the sensation reminds one of a
bag of worms. However gently and carefully the examination be made,
there is almost always some bleeding, and on withdrawing the finger it is
stained with blood. Disagreea])le though the digital exploration l>e, avc
must not be deterred from employing it, unless the posterior rhinoscopic
examination yields absolutely satisfactory results ; indeed, palpation is
superior to the latter method in enabling us to form a definite notion of
the quantity of the growths present.
Diagnmis. — It is only in infants or very young children, whose
undeveloi)ed featui-es do not show the characteristic facial aspect
described above, that a difficulty in diagnosis should be possible. iN'asal
discharge and snuffling respiration, which as we have seen are marked
symptoms in adenoid cases, are also frequently associated with congenital
syphilis. But in syphilitic infants the nostrils ax'e dry and show radiating
linear fissures ; and, nasal obstruction being more complete, they are
unable to take the breast. Moreover, other signs of the constitutional
disease are usually present. Other kinds of growth in this region are
extremely rare in children. In adults a ditFerential diagnosis may have
to be made between persistent adenoids, fibroma, nasal polypi extending
backwards from the nose, and moriform hypertrophy of the inferior
turbinals ; all of which, Avith the exception of nasal polypus, are extremely
rare conditions, and may readily be distinguished by the seat of origin,
colour, or consistency.
Prognosis. — The prognosis is always favourable on the whole, provided
no serious complication have arisen ; broadly speaking, it stands in direct
proportion to the patient's age and to the length of time the obstruction
has existed. The most brilliant results are obtained by timely operation
in young children ; but the prospect, of course, is less favourable \i
organic changes have once taken place in the middle ear, or thoracic
deformities are definitely established, or the time has passed when, by
relief of the obstruction, an advantageous change could be expected in
the configuration of the face. Although the adenoid growths, as a rule,
atrophy spontaneously after puberty, and, with the increasing size of the
rhino-pharyngeal space, the symptoms usually disappear, yet, before that
age is attained, not only does a child run great risks of permanent deafness
and impaired health and development, but it is also constantly exposed
to attacks of catarrh and bronchitis, and is increasingly liable to contract
the various exanthems. Moreover, in a certain number of cases the
spontaneous atrophy is very partial ; in others the symptoms do not
vanish with the disappearance of the growths : whereas by skilful and
timely treatment the whole disease can be completely and permanently
ei^adicated and all these risks to health removed. Children almost
invariably show a most remarkable improvement in general health and
intellectual development within a short time of the operation ; the pale
720 SYSTEM OF MEDICINE
and dusky comjilexion and dull woe-ltegone exi)iessic)u are replaced by
brightness and intelligence, healthy respiration dilates the lungs, the chest
develops, and the patient increases in stature, "weight and activity. In
short, removal of adenoids in really suitable cases is one of the greatest
medical blessings of our era, and must have a far-reaching effect upon the
health of future generations !
Our advice should be as follows : — If the patient be under twelve,
while certainly admitting that the child may escape all the dangers in-
volved in the disease, 3'et all the disadvantages of postponement niav be
removed by an operation Avhich, if properly and skilfully performed, is
practically devoid of danger. Of course no unnecessary operations
should be performed, but in doubtful cases it is better to operate. AVe
must not definitely promise that the growths will not recur, for even
after very thorough and complete extirpation recurrence takes place in a
small percentage (in our experience amounting to 1 per cent), especially
after influenza. Moreover, some of the symptoms, especially speech
defects, may persist for a considerable time after treatment.
Treatment. — Unless the vegetations be very small, and not pro-
ductive of any of the more serious symptoms above eimmerated, no time
should be lost in internal medication or change of air. Whilst again
deprecating unnecessary operative interference, one of us (F. S.) must
confess that more than once in the light of stxbsequent events he has
regretted that, guided by the wish to spare the patient an operation
which at the time did not seem to be urgently required, he had not
laid more emphasis on the risks of delay. Moreover, there cannot be the
least doul)t that the operation itself acts indirectly as a powerful tonic,
and promotes the desired restoration to health more effectually than any
amount of cod-liver oil, extract of malt and iodide of iron.
Operative treatment is called for in the great majority of cases present-
ing definite sym[itoms, and the younger the child the greater the reason
for removing the growths without delav. For their complete extirpa-
tion a general anaesthetic ought to be employed, at any rate in children ;
and though in adults removal may be done under cocaine, a general
anresthetic is desirable. We give chloroform only for this operation.
There is practically no risk with this anaesthetic, provided it be given
slowly and cautiously, and not pushed to the abolition of the cough-
reflcx, Avhich protects the larynx against the entry of blood. Fortunately
it has been shown, by Semon and Horsle\', that this reflex is the last to
go : and the administration of the anaesthetic should therefore cease as
soon as the conjunctiva is insensitive. If possible, no further anaesthetic
should be given after the operation is once begun. The advantage of
chloroform over gas and ether is that the latter combination gives a very
short time for operating, while ether alojie increases the vascidarity of the
parts, induces a copious secretion of frothy mucus, and is not so well borne
by young children disposed to bronchitis. We quite admit that it is
possible to remove both tonsils and adenoid growths under nitrous oxide
gas alone ; but in our opinion there is less opportunity for a complete
DISEASES OF THE NOSE 721
removal of the growths, and a greater likelihood of recurrence, than when
the operation is somewhat more deliberately performed under chloroform ;
and whenever operative interference is undertaken, the imjDortance of a
thoi'ough and radical removal cannot be over-estimated.
As regards the pai'ticular method of removing the growths there is
wide choice. Some operate by scraping with the finger-nail, others by
curetting with post-nasal cutting curettes introduced through the
mouth ; or with a straight curette as employed by Meyer through the
anterior nares ; or by the use of cutting forceps, such as Loewenberg's ; or
by snaring with the cold or galvano-caustic wire, and destruction by
caustics or the galvano-cautery. Each of these methods has its advocates,
nor can the surgeon confine his practice to any one method.
Our own practice is to have the patient lying on his back with the
head Avell extended and low down, a small pillow being placed under
the neck. The mouth being kept open by a gag on the left side, held
by an assistant, the operator, standing on the patient's right, passes a
Gottstein's curette behind the soft palate to the vault of the pharynx,
and then while gently but firmly pressed against the posterior wall it is
drawn down so as to cut away the whole mass of growth, which, ap-
pearing below the soft palate, is readily removed by aseptic sponges
attached to long straight holders. If vegetations are situated laterally
in Rosenmiiller's fossae, these are removed in a similar manner with
Hartmann's curette. The right forefinger is then introduced, and
rapidly swept over the vault into the fossae of Rosenmiiller and over the
Eustachian orifices, ascertaining whether anything has been left behind,
and scraping away, if necessary, any remnants of growth Avith the finger-
nail. The curette has often to be introduced several times. Haemor-
rhage is always very free for a few minutes, but soon ceases spontaneously.
Secondary haemorrhage is exceedingly rare ; in our experience it has
never happened : cases, however, have been reported in which it Avas
necessary to plug the rhino-pharynx. If the tonsils are hypertrophied
and demand removal, this is done by us after the adenoids have been
operated on ; except in cases where the tonsils are enormous and impede
the administration of the anaesthetic or the removal of the adenoids, in
which case they should be removed before the adenoids.
For tough growths we find it necessary in very rare cases to use
cutting forceps, such as Loewenberg's. "With the left forefinger in the
rhino-pharynx the forceps are guided to the portions of gi'owth to be
remoA'ed, care being taken not to include mucous membrane or any of
the normal structures.
The after-treatment is very simple ; the patient is kept in bed for
twenty-four hours, and fed on cold bland food, such as milk, custard
jDudding, beaten-up eggs, and jelly. The temperature is sometimes
slightly febrile the first night, and the throat rather sore ; but this
is very transitory and slight, and is relieved by sucking ice. The bowels
should be well moved. The next two days the patient is confined to his
bedroom, and for two days more to the house. No cleansing of the
VOL. IV 3 a
SYSTEM OF MEDICINE
parts is necessary or advisable. A nasal or postnasal douche should
never be emiilo3'ed, as there is great risk of setting up otitis media by
their use. Since giving up cleansing of the parts, and all after-treatment
of the rhino-pliarynx, we have hardly ever seen otitis media. For the first
two or three days, owing to the irritation and iiiflainmation set \\\> by the
operation, the nasal ol)sti'UCtion and deafness may be 1)ut little improved.
As regards the ears, if the membrane be simply depressed, it may
suifice to inflate the middle ear by means of Politzer's bag ; or, that
failing, by the Eustachian catheter, for a varia])lc pci'iod. This should
not be undertaken till nearly a week after the removal of the growths,
lest any blood, muco-pus, or disintegrating tissue be driven into the
Eustachian tubes. But with middle ear disease the pi-ognosis must be
guarded, especially if perfoi-ation of the drum-head and chronic otorrhoia
be present — serious complications which reciuire their appropriate treat-
ment. The nasal catarrh usually subsides in the course of a week or ten
days.— F. S. and W. W.
REFERENCES
1. Ball, J. B. Diseases of the Xose and Pharynx. London, 1S94. — 2. Beioee
and Tykman. Die Krankheitcn dcr Kcilhcini- Holder und dcs Sichein-Lahyrinthes.
"Wiesbaden, 1886. — 3. Billuoth. Ucber den Bmi der Schleimjjolypeii. Berlin, 1855. —
4. Blackley, C. H. Hay Fever: its Causes, Treatment, and Effeetive Prevention.
London, 1880. — 5. Blake. "Relation of Adenoid Growtlis in tlie Kaso-iiliaryn.\ to
tlie I'roduetion of Middle-Ear Disease in Children," JJoslon Hied, and Sury. Jour.
March 15, 1888. — 6. Boswouth. Diseases of the I'hroat and Ahise. New York, 1897.
— 7. Bresgex. " Der Circulationsapparat in der Nasenclileiinhaut voni klinischen
Standpimkt betrachtet," Deut. med. fFoeh. 1885, No.s. 34, 35. — 8. "Discussion on
Atrophic Rliinitis," I'rans. Internal. Med. Conyress, 1881, vol. iii. — 9. Fii.'vxkel, B.
"Ueber adenoide Vegetationen," Deut. med. U'och. 1884, No. 41. — 10. Fueuden-
THAL, W. " Rliino-.seleroma," iVcit; York Med. Jour. Feb. 1, 1896.— 11. GkCnwald.
Die Lelire V071 den Naseneiterunyen. Mliuchen, 1896. — 12. Gi'YE, Lie, ZuckeFvK.xndl,
M'BiiiDE, and others. "Discussion on the Etiology of Mucous Polypi of the Nose,"
Brit. Med. Jour. 1895, vol. ii. p. 474 et seq. — 13. Hall, F. de Havilland.
" Epistaxis," Jl'estininster Hospital Peports, vol. viii. — 14. Idem. Lettsomian Lectures,
1897. — \5. Ide)n. Diseases of the Xose and Throat. London, 1894. — \ba. Idem. "On
Diagnosis and Treatment of Emityenui of the Na.sal Accessory Sinuses," Brit. Med. Journ.
15th December 1894, p. 1358. — 16. Heath, Chulstupher. "On certain Di.scases
of the .laws," Hu7iterian Lectures, 1887. — 17. Idem. Injuries and Diseases of the Jaws.
London, 1894. — 18. He.wen, J. C. " Fibrinous Rhinitis or Diplitheria,"/'wWic Health,
vol. viii. No. 7. — 18a. Heryng. " Die electrische Durchleuchtung der Highmorshohle
bei Emiiyem," Berlin, klin. JFoch. 1889, Nos. 35, 36, j). 798 et st^.— 19. IIvlke, J. W.
"Five Cases of Disorders of tiie Frontal Sinuses,'/ X««(r/, 1891, vol. i. p. 589.— 20.
K.iELLMANN. " Epileptiform Convulsions diq)endent on intra-nasal Changes," Hyyeiu.
Stockholm, Feb. 1893.-21. Knight, C. H. "Nasal Secpiehe of Syj-hilis and their
Tr.'atment," Trans. Amcr. Laryng. Assoc. 1896. — 22. Loewenherg. Tumeurs
ndenoides da pharynx nasal. Paris, 1879. — 23. Idem. "Les vegetations adenoides
dans la vaute du pharynx," Trans. Internal. Med. Conyress, London, 1887. — 24.
.M'BiUDK, P. Diseases of the Throat, JVose, and Ear. Edinburgli, 2nd edition. — 25.
M'IjKIKE and Logan TriiNEi;. "Na.so-Pharyngeal Adenoids : a Clinical and Patho-
logical Study," Elin. Med. Jour, new series, vol. i. 1897. — 26. Macdonald, Gkeville.
Diseases of the Nose. London, 1892. — 27. Mackenzie, Morell. Diseases of the Throat
and Nose, vol. ii. London, 1884. — 28. Idem. Hay Fever and Paroxysnuil Sneezing.
London, 1887. — 29. Mackenzie, J. N. "The Pathological Anatomy of Stnimoid
Disease," Trans. Amer. Laryny. Assoc. 1896. — 30. Ma.ior. " Lu]tus, Tuberculosis,
Syphilis, Glanders, and Diplitliiria of the Nose and Naso-i)iiarynx," B.irnette's System,
1893. — 31. Mayg-Collier. " Dellcctions of the Nasal Septum," Jom;-. of Laryng.
DISEASES OF THE PHARYNX
723
1891, vol. V. — 32. Meyer, Wilhelm. "Adenoid Vegetations in the Naso-pliaryngeal
Cavity," Med.-Chir. Trans, vol. liii. — 33. Nasal Obstruction, Discussion on, o[)ened
by Dundas Grant, Brit. Med. Jour. 1888, vol. ii. p. 602. — 34. Newman, David.
Malignant Disease of tlte Throat and Nose. Edinburgh, 1892. — 35. Onodi. An Atlas
of tlie Anatomy of the Nasal Camty and its Accessory Sinuses. Translated by St. Clair
Thomson. London, 1894. — 36. Pierce, Nouval. " Syphilis of the Xose," i\'ew 17/?-^
Med. Jour. Nov.'30, 1895. — 37. Roe, J. 0. " Jitiology of Deviations, Spurs, and
Ridges of the Nasal Sej^tuni," Trans. Amer. Laryng. Assoc. 1896. — 38. Thomson,
St. Clair, and Hewlett, R. T. "The Fate of Micro-organisms in Inspired Air,"
Lancet, Jan. 11, 1896. — 38a. Voltoltni. Die Kranklieiteii der Nasc Nachtrag.
p. 465 et seq. 1888. — 39. Walsham, W. J. "On Nasal Obstruction and its Treat-
ment," St. Bartholomeiv s Hospital Reports, vol. xxiii. — 40.
Diseases of the Nose. London, 1890. — 41. Watson Williams,
Upjyer Respiratory Tract, the Nose, Pharynx, and Lafynx.
ZucKERKANDL. Anatomie der Nasenhohlen. Wien, 1882. — 43.
pathologische Anatomie der Nasenhohlen. Wien, 1882. — 44. Rlem. "Schvvellgewebe
der Nasenschleimhaut und dessen Beziehungen zum Respirationsspalt," JFicn. med,
Woch. 1884, vol. xx.\iv. No. 38.
Watson, Spencer.
P. Diseases of the
Bristol, 1897. —42.
Idem. Normal und
II.— DISEASES OF THE PHARYNX
Pharyngitis
Phakyngoscopy :
Acute "1
Chronic j
H.EMORRHAGE :
Diseases of the Uvula :— Felix Semon
and Watson Williams.
Throat Affections of the specific
FEBRILE Diseases. F. de Havilland
Hall.
Acute septic Inflammations of
Pharynx and Larynx :
Retropharyngeal Abscess :
Pharyngomycosis Leptothricia :
TUBEIiCULOSIS :
Syphilis :
Gout :
Rheumatism :
New Growths :
Neuroses :
Foreign Bodies in the Air and upper
Food Passages :
Diseases of the Tonsils -. — Felix Semon
and Watson Williams.
Phapyngoseopy. — The pharynx and fauces may be examined by
direct inspection in bright daylight, or by the aid of artificial light
reflected and concentrated by a forehead mirror, which should be the
same as that used in laryngoscoj)y. The remarks on the form of the
forehead mirror and the best kind of light will be found on page 780.
In examining the pharynx, we sit facing the patient with the
forehead reflecting mirror over the right eye, so adjusted that the eye
looks through the aperture in the centre. The lamp, if one be used,
should be placed on the patient's left, on a level with his ear, and so
that the light is directed towards the forehead mirror and thence into
the patient's mouth.
The patient should then open his mouth and go on l^reathing quietly,
Avhen in many cases a good view of the fauces will be obtained ; generally,
however, it is necessary to depress the tongue with a spatula or some
form of depressor, such as Tiirck's or Frankel's. In introducing the
depressor it should be placed just beyond the dorsum of the tongue, and
then gently and steadily depressed. If not far enough back, the dorsum
of the tongue bulges up and impedes the view ; on the other hand, if it
724 SYSTEM OF MEDICINE
is placed too far back, retching and nausea arc induced. If the tongue is
forcibly arched up, gentle pressure should he continued for a moment;
if we attempt to depress the organ forcil»ly, it will arch up the more.
In the first place, the condition of the parts during quiet respiration
should be noted. The tonsils are seen Ij'ing between the anterior and
posterior ])illars of the fauces ; they should not project beyond the faucial
pillars. Behind the faucial opening the posterior wall of the pharynx
comes into view. The colour and surface of this part and of the soft
palate should be noted. The patient should then be instructed to sound
" ^Ui ! ah ! " and the power of retraction of the velum palati observed.
A laryngeal mirror ought then to be introduced as in laryngoscopy ;
but the mirror should be held less obliquely, so as to reflect the ])ack of
the tongue and the upj)or surface of the epiglottis ; by this means we
observe the condition of the lingual tonsil. Simple enlargement and
tortuosity of the superficial veins at the back of the tongue are very
common, and are devoid of clinical importance. The lower portion
of the pharynx and the begiiuiing of the oesophagus are seen by
placing the mirror in the position for laryngoscopy, while the patient's
tongue is protruded and held by a cloth in the examiner's left hand.
Finally, the back of the uvula and soft palate, and the rhino-pharynx
should be examined with the rhinoscope, as in posterior rhinoscopy.
The rhino-pharynx is continuous with the anterior nasal cavities, and
extends from the base of the occiput and sphenoid downwards as fur as
the isthmus, the narrow space corresponding to a line drawn from the
posterior margin of the soft palate to the posterior pharyngeal wall.
Into it open the Eustachian tubes by trumpet-shaped orifices, from the
posterior margins of which may be seen the salpingo-pharyngeal folds
extending downwards, and forming on each side a fossa between them-
selves and the posterior wall of the pharynx — the fossa of Rosenmiiller.
The orifices of the Eustachian tubes are just behind the posterior
extremities of the inferior turl)inated bodies.
The mucous membrane is covered Avith ciliated columnar epithelium,
and is more abundantly supplied Avith mucous glands than the anterior
nasal cavities. Numerous lymphoid follicles exist throughout the
pharynx ; and a collection of these in the roof and posterior wall of the
rhino-pharynx forms a mass, similar to the faucial tonsils, named
Luschka's, or the })haryngeal, tonsil. The pharyngeal tonsil presents
an uneven surface Avith longitudinal ridges. At the loAver extremity is
the elevated bursa pharyngea, Avith its central depression — the "foramen."
The colour and condition of the A'arious structiu'cs must be carefully
noted. Some departure from the usual smooth, pinkish red character
of the mucous membrane of the pharynx must be regarded as Avithin
the limits of the normal ; for, as in the nose, it is important not to
diagnose every variation from the ideal pharynx as disease. Isolated
an*mia of the pharynx and larynx, however, in patients otherAvise not
particularly anaemic, may j)ossibly be a jireinonitory sign of tuberculous
disease. Further, Ave must guard against ovei'looking any diseased
DISEASES OF THE PHARYXX 725
condition on the posterior surface of the soft pahate ; for, particularly in
syphilis, extensive infiltration and ulceration may affect its posterior
surface only, without there being anything strikingly abnormal anteriorly,
beyond some hyperaemia or defective mobility.
In cases of nerve disease it is necessary to use a probe to test the
tactile sensibility and reflex irritability of the soft palate.
Finally, it is sometimes desirable to make the patient "gag," by
introducing the tongue depressor rather farther back than usual, as in
this way we cause the pharyngeal muscles to contract and to bring the
tonsils well into view ; thus sometimes considerable hypertrophy of these
structures may be revealed, or such thickening of the lateral pharyngeal
walls as we find in pharyngitis lateralis and in gouty, pharyngitis.
Congenital malformations are occasionally met with ; the most
common being a more or less completely bifid uvula, or complete absence
of the uvula in association with cleft palate. The anterior pillars of the
soft palate may have a separate and complete fold of mucous membrane
covering the palato-glossus muscle, with a perforation of the mucoiis
membrane of the anterior pillars of the fauces which may be mistaken
for perforation resulting from former disease.
An accessory thyroid gland has also been recorded, which formed a
small tumour in the region of the lingual tonsil.
In conclusion, we cannot too strongly insist on the importance of
paying attention to the general condition of every patient who consults
his medical adviser for a throat affection. A chronic pharyngitis may
arise from cardiac vahtilar disease, while gout, rheumatism, anaemia, and
dyspepsia are prolific causes of acute and chronic pharyngitis ; again,
congestion of the jjharyngeal mucous membrane and haemorrhage from
rupture of small vessels may be due to chronic renal disease, mitral
stenosis, or portal obstruction.
Acute Catarrhal Pharyngitis. — The causes may be classified as
follows : — (i.) Idiopatltk, due to sudden exposure to cold and damp,
especially after being in heated rooms ; (ii.) Diathetic, especially gouty and
rheumatic — many of the cases of so-called simple catarrhal pharyngitis,
following exposure to damp, belong to this class ; (iii.) Toxic, due to the
action of various drugs, as, for example, antimony, mercury, belladonna ;
or to the virus of infectious diseases ; (iv.) Traumatic, from burns, scalds,
external violence, and the like.
Pathnlogi/. — How cold and damp may cause acute angina is uncertain ;
but acute catarrhal pharyngitis is frequently epidemic and often con-
tagious, especially in the spring and autumn ; this prevalence points to a
microbial origin of many forms of acute catarrhal angina hitherto
regarded as idiopathic and due directly to cold, and recent bacteriological
researches corroborate this ^dew. The very intimate connection between
pharyngitis, acute tonsillitis, and the rheumatic diathesis, the fact that
all these affections are prone to occur under similar climatic and telluric
conditions, and also that acute tonsillitis and rheumatism are probably
due to infection by micro-organisms, favour the view that the idiopathic
726 SYSTEM OF MEDICINE
juui rheumatic forms of pharyngitis and acute rheumatism stand in much
the same rehition to one another as does tlie sore throat which prevails
during epidemics of scarlet fever to scarlet fever itself.
On the other hand, there is no reason to believe that the toxic forms
of acute pharyngitis are in any Avay associated with micro-organisms ; they
are more probably due to l)io-chemical alterations in the tissues, similar to
those resulting from the action of belladonna in acute j^oisoning by this
drug.
^Vhatsoeve^ the exciting cause of the inflammatory condition, the
pathological changes in the pharynx are identical, and consist at first in
general hyperemia and round-celled infiltration of the afl'ected region,
with diminished secretion from the mucous glands, giving place in the
course of twelve to twenty-four hours to increased secretion of grayish,
viscid mucus which soon becomes muco-purulent. The implicated
mucous membrane appears red, velvety, and thickened, and the uvula
especially is prone to be thickened, elongated and oedematous. As the
inflammatorj^ condition subsides, the mucous membrane generally regains
its normal colour and functions ; but, on the other hand, a subacute
catarrhal inflammation may persist for a consideral)le time, and in the
absence of appropriate treatment may eventually pass into the chronic
form.
The S!/m2)foms vary in degree according to the severity of the attack ;
in many cases they are slight and the patients do not seek advice. In
the earlier stages a dry soreness in the throat is felt, especially during
speaking or swallowing, with a sensation of stiffness in the parts, rendering
speech uncomfortable. AVhen resulting from a chill there may be some
aching in the liml)s and back, general malaise, and slight feverishness.
The dryness and harshness of the throat are due to the ai-rest of the
secretions ; after a day or two a small quantity of tenacious purulent
mucus is secreted ; but this is rarely so exccssi^'e in amount as in chronic
pharyngitis. The tonsils and uvula are generally more or less implicated,
and are red and swollen, or in the severer cases dusky pnrple in colour ;
the catarrhal inflammation often spreads up to the rhino-pharynx, perhaps
to the Eustachian tubes, giving rise to temporary deafness ; or it passes
downwards to the larynx and trachea.
Diagnodii. — It is necessary to bear in mind that diphtheria, scarlet
fever, measles, and septic inflammations may begin with symptoms of
acute pharyngitis, and therefore all cases of acute pharj'ngitis, especially
in children, shoidd be Avatched. It is very important, fi'om a therapeutic
standpoint, to recognise the cases in Avhich the afl'ection is due to
rheumatism and gout.
Treatment. — In milder forms very simple treatment is generally
sufficient, such as a hot mustard and water foot-bath and a Dover's
powder at bedtime. A menthol spray (R Menthol 3ss. 01. adepsin
pur. 5J.), sprayed several times a day by means of an oil atomisoi', and
sucking ice will greatly relieve the local inflammation. When the larynx
and trachea are involved, the inhalation of tincture of benzoin, or a
DISEASES OF THE PHARYNX 727
mustard poultice applied to the chest, is serviceable. The bowels should
always be freely moved by saline aperients. For the rheumatic cases
salicin, and for the gouty colchicum and alkalies are required. As the local
inflammation subsides we may prescribe the compound krameria pastil,
but local astringent ap])lications are rarely necessary.
Chronic Pharyng-itis.— The causes of chronic pharyngitis are many
and diverse, and often enough they are remote and obscure. The char-
acteristic objective conditions in the pharynx are commonly seen in very
young children, while the subjective symptoms ai-e generally observed
from the age of eighteen onwards. In children the lymphoid tissues are
especially active ; and not only are the palatine and rhino-pharjmgeal
tonsils well developed, but the sam.e excess is found in a much less degree
in the smaller aggregations of Ij^mphoid tissue aroiind the muciparous
glands. Thus, when from various causes a pathological condition Qt?
hypertrophy arises in the post-nasal and palatine lymphoid structures,
constituting post-nasal adenoids and chronic enlargement of the tonsils,
we very frequently observe a concomitant hypertrophy of the pharyngeal S
lymphoid tissue which, like the tonsils, participates in the tendency to
atrophy in later life.
Thus in some cases the disease is congenital in origin ; in others,
catarrhal attacks, measles, or scarlatina leave behind them a similar
hypertrophy, or increase that which may already be in existence. At
puberty chlorosis and general anaemia, dyspepsia and constipation are
fruitful causes of granular pharyngitis — the former two perhaps the most
fruitful ; later in life dyspepsia, gout, rheumatism, the irritation of
tobacco smoke, alcoholic drinks, and so forth, operate in a like manner :
but the pharyngitis in these cases is accompanied by ^general irritation
and congestion of the whole pharyngeal mucous membrane ; consequently,
while on the one hand we may meet with enlarged lymphoid nodules
only, as in granular pharyngitis, in these latter conditions there is also
general thickening of the mucosa, with enlargement of the vessels and
secretion of tenacious mucus in the rhino-pharynx and pharynx. If
the patient suffered in childhood from post-nasal adenoids which have
not completely atrophied, and if chronic nasal catarrh has persisted,
there is a copious secretion of unhealthy sticky mucus in the rhino-pharynx,
and the condition is known as post-nasal catarrh.
Thus it is impossible altogether to separate the simple catarrhal and
chronic hypertrophic forms ; they generally coexist, though the character-
istics of the one or the other may predominate.
Many cases, especially those due to constipation and dyspepsia, or to
portal congestion, are regarded by one of us (W. W.) as toxic in origin,
and due to a failure on the part of the liver to arrest and destroy toxines
resulting from imperfect digestion or decomposition in the intestinal
tract ; these toxines, like belladonna, have a specific effect on the
pharyngeal mucous membrane. The soreness, stiffness and hypersemia,
the dryness of the throat and pain in deglutition, which are characteristic
of belladonna or muscarin poisoning, are simulated very closely by the
728 SYSTEM OF MEDICINE
sore throat of dj-spepsia following a late and heavy meal ; and these con-
ditions by frequent recurrence, even in a mild degree, eventually bring
about permanent structural alterations of the mucous membrane. We
ma}' explain the occurrence of gouty pharyngitis in much the same way.
The pain often complained of is generally attributed to the implica-
tion of the nerve-endings in the degenerated graiuiles ; it is, howcAer,
more probable that the nerve filaments are irritated by the same causes
which produce such very obvious hypera?mia and thickening of the
mucous membrane ; but the factor of teni])erament is clearly seen in the
painful character of the chronic 2:)haryngitis in chlorotic girls and in those
of the neurotic temperament.
In later life the pharyngeal mucous membrane may become more or
less atrophied, and the secretion of mucus very deficient — a condition
sometimes distinguished by the term atroj/hic pharyngitis or j^/u/ryw^^i^ts
sicca.
Thus it will be seen that chronic pharyngitis is generally due to
several factors acting conjointly, which may be classified as follows : —
(i.) One of the most important is general anremia. Graiuilar pharyn-
gitis is most frequently met with in anaemic girls, in whom also other
signs of chlorosis exist.
(ii.) The strumous, rheumatic, and gouty diatheses. . Gouty pharyn-
gitis is usually characterised either by general or, more frequently, by
lateral thickening, which often gives the appearance of thickened liands
of tissue extending down the lateral walls of th» pharynx behind the
posterior palatine pillars.
(iii.) Dyspepsia and constipation, especially if associated with con-
stipation or portal congestion, whether due to gastro-intestiual catarrh
or heart disease, are prolific causes.
(iv.) Constant exposure to dust or irritating vapours, as in mattress-
making, stone-dressing, tobacco-manufacturing.
(v.) Abuse of alcoholic drinks; it is also said to result from the use
of irritating condiments.
(vi.) Recurrent acute attacks of catarrhal pharyngitis, or measles,
scarlatina, and other exanthems.
(vii.) Improper methods of voice production, residting in congestion
of the mucous membrane of the fauces ; and excessive use of the voice
during an attack of acute or subacute pharyngitis.
Sjimptums. — In making a diagnosis of chronic pharyngitis, it is very
important to remember that every departure from the ideal normal
j>harynx does not constitute disease ; that in fact nearly all the objective
conditions observed in this aftection may be present without producing
symptoms, and in this disease there is no constant relation between the
physical signs and the sul)jective symptoms. The ])aticnts are apt to
complain of a constant irritating cough, and a sensation as of a hair or
foreign body in the throat which they cainiot get rid of ; or of soreness and
aching often amounting to sharp pain, especially in swallowing : often
also there is a sense of weakness and discomfort in the fauces. The
DISEASES OF THE PHARYNX 729
symptom for which advice is most usually sought, however, is impairment
of vocal i)Ower. Hence professional and amateur singers, clergymen,
public speakers, lawyers, and schoolmasters form by far the largest con-
tingent of those , who seek advice on account of chronic pharyngitis.
Their complaints are various. Most frccpiently it is stated that the
voice is readily tired and deficient in resonance and timbre ; singers
usually complain of deficiency or even of loss of the higher notes.
These alterations in the voice are even more marked in those younger
patients in whom post - nasal growths occupy the rhino - phai-ynx.
Prolonged speaking, or singing, in the presence of marked chronic
pharyngitis, often results in aching in the throat and back of the neck,
whilst the voice gets weaker and Aveaker. After this has continued for a
time the larynx becomes more or less congested, and then the voice, for
public speaking, often goes altogether.
In patients Avho are suffering from simple catarrhal pharyngitis the
chief features are the constant accumulation of mucus in the throat, the
necessity for perpetual hawking, and the tendency to gagging and
retching.
On examining the pharynx the mucous membrane is found to be
diffusely congested. In the simple catarrhal forms it is bluish pink, with
enlarged venules coursing over the posterior wall, which is often more or
less covered by collections of mucus. The mucous membrane of the
uvula and soft palate is sometimes considerably congested, thickened and
granular, and some eidarged mucous glands are seen. The tonsils are
often somewhat enlarged, with gaping crypts, and the larynx, especially the
inter-arytienoid fold, is injected ; some hypertrophied lymph follicles are
always observable, in granular pharyngitis there is often little else to be
seen. There is seldom any excessive accumulation of mucus ; in fact the
complaint very often is that the throat is too dry.> In some cases, and
particularly in the gouty, the lateral bands of hypertrophic tissue stand
out prominently.
Treatment. — Before entering on the question of treatment it is desir-
able to lay stress on the necessity for attending to any primary dyscrasia,
instead of relying solely on local treatment. Thus, in the great
majority of cases, the general treatment of chronic pharyngitis is of far
greater importance than the local. Ansemia and chlorosis must be com-
bated with Blaud's pills and aperients ; gout and rheumatism, constipa-
tion, dyspepsia, and portal congestion require each its appropriate
treatment ; while in other cases, as in many clergymen and schoolmasters
suffering from granular pharyngitis, the health is more or less impaired
and general nervine tonics are indicated ; though, as a rule, the relief is
unfortunately only temporary. Many patients Avill be greatly benefited
by a course of alkaline or aperient waters, such as those of Aix-les-Bains,
Ems, Mont Dore, La Boiu'boule ; and, for gouty patients, Kissingen,
Marienbad, or a gentle Carlsbad course is advisable.
Local treatment, however, is often required. The usual astringent
lozenges, sprays, pigments, and gargles are- most disappointing and
730 SYSTEM OF MEDICINE
inefficient. A very useful spray for fjoneral use in relaxed throat is a
pinch of salt dissolved in a wineglassful of cold Avater. If the mucus
tend to collect in the pharynx and rhino-pharynx, a solvent coarse spray,
composed of bicarbonate of soda (1 to 2 per cent) with a few grains of
l>oracic acid, may l)e used once or twice daih'. A pastil containing
2 grs. of guaiac resin, I gr. powdered cul)el)s, -.}^ gr. of emetine, and -} gr.
of menthol, slowly dissolved in the mouth four or five times daily, will
often relieve rheumatic forms of pharyngitis, while \ qi a grain of
codeine in the form of a pastil, and repeated if necessary, is useful in
relieving the constant cough which in some cases of irritable pharyngitis
interferes with sleep.
Enlarged granular lymphoid follicles should be destroyed by the
galvano-cautery. Having previously cocainised the part (with a 10 per
cent solution of cocaine), a small flat platinum or porcelain burner is
placed on the centre of a granule when cold ; the current is then turned
on to a cherry red h-eat and immediateh^ withdrawn. If there are any
enlarged veins on the posterior pharyngeal wall they may be divided
in places in a similar manner, so as to obliterate them ; if left, they tend
to maintain the vascular engorgement and general congestion. After
using the galvano-cautery the patient should oidy take bland or cold food
for a day or two ; sucking ice may be grateful to him for a few
hours after the operation, or a spray of cocaine (2 per cent dissoh'ed in
ol. adepsin pur.) may be used with an atomiser to relieve pain and
soreness.
A pellicle forms on each cauterised spot, Avhich separates in a day or
two, leaving a clean surface. The cauterisation may be resumed, after an
interval of three days to a week, till all the granules have been destro3'ed
in turn.
Thickened bands of mucous membrane, when present, should likewise
be destroyed by the galvano-cautery. If, as is sometimes the case in
gouty pharyngitis, the lateral bands are very much thickened, they may
be more quickly removed by the knife. Other methods of destroying
the granules can only be recommended when the galvano-cautery is not
available. The best alternative is to touch the centre of each with
chromic acid fused on a silver probe, or curettement.
Great stress must be laid, of course, upon the future avoidance of
those causes of irritation to which the malady was due ; such as improper
use of the voice, insufficient exercise, abuse of alcohol, or excessive
smoking.
Haemorrhage from the pharynx. — Ha>morrhage from the pharynx
is deserving of special )iote, not so much on account of the actual causes
of lileeding in this region, but of the frequency with which patients
complain of " bleeding from the throat," and of the gravity of the
pulmonary disease which is only too often the actual source of the loss of
blood attributed to the throat.
Causes. — The chief causes of bleeding from the mouth and throat are —
(a) Alterations in the condition of the blood in various pathological states,
DISEASES OF THE PHARYNX 73 1
such as purpui'a, pernicious anaemia, lcuka3mia, mercurial stomatitis,
hcemophilia, renal affections, and various acute fevers, especially typhoid
fever and yellow fever, (i) Suppuration and ulceration, as in malignant
disease, lupus, or syphilis, {(i) The oozing of blood from spongy gums.
(/) Post-nasal adenoids. (//) So-called vicarious haemorrhage in women
at the menstrual period. (A) Rupture of enlarged veins in the pharynx,
especially in gout, and atrophic cirrhosis of the liver, (i) Laryngeal
haemorrhage in so-called hemorrhagic laryngitis ; in laryngitis sicca with
bleeding after separation of crusts, traumatism, abrasions caused by
swallowing hard angular bodies in food, surgical operations, and so on.
ie) Epistaxis with escape of blood into the pharynx.
Yet with all these possil:)le sources of haemorrhage from mouth and
throat, patients who seek advice for bleeding from the mouth generally are
subjects of pulmonary haemoptysis. Doubtless the mistake is owing in part
to the very prevalent misconception that, unless the blood is coughed up
or vomited with food, it cannot come from the lungs or stomach ; while,
on the other hand, bleeding from the gums or streaks of blood from a
congested pharynx after violent coughing and haAvking do not, as a rule,
attract mi;ch attention : moreover, haemoirhage from the throat from alJ
other causes is either very rare or only secondary to graver general
affections.
Symptoms. — A capillary oozing from the gums, or from any part of
the pharynx, simply gives rise to a taste of blood, and is spat out mixed
with saliva. If the oozing of blood occurs during sleep in the recumbent
position, the blood may be hawked up with a small c^uantity of frothy
mucus, and so give the impression that it is coughed iip from the lungs.
On examination, the real source of the haemorrhage may be discovered ;
but very often this is impossible. If the bleeding be more copious, it
may still be possible to examine every part of the upper respiratory and
food passages for the bleeding point ; but if the blood be poured out
too rapidly for any such examination, the head should be held low, so
that the blood can run out of the mouth. If it does so without coughing
or retching, the source of hgeraorrhage is almost certainly from the
mouth, nose, or throat.
It is more diihcult to determine the source of haemorrhage Avhen a
patient, without any signs of lung disease, states that a tickling sensation
arises in the larynx, and on coughing slightly blood comes in consider-
able quantity. Of course, if there be evidence of pulmonary disease, or
if the blood when coughed up is frothy and bright red, there can be
little doubt that it has come from the lungs ; but blood which has come
from the throat may be bright red, frothy, and mixed with saliva, and
on the other hand a pulmonary haemorrhage may l)e unmixed with air.
One point of distinction lies in the fact that in pulmonary haemorrhage
the blood continues to be coughed up with frothy mucus for an hour or
two, and that the expectoration generally shows evidence of altered
haemoglobin for some days ; whereas when blood comes from the mouth
or larynx it is soon got rid of completely by coughing and spitting, and, if
732 SVSTEJ/ OF MEDICINE
none is poured out subsequently, all trace of the hamiorrhage will disappear
in an hour or two. Still, with all these differential signs, it is some-
times extremely difficult to make out the true source of the hasmorrhage
with certainty.
It is important to remember that tuberculous disease of the lungs often
manifests itself by hiemoptysis, and that the initial hiemorrhage may be
consideral)le withotit the presence of any physical signs. If, therefore, a
patient present himself with a statement that he has had a ha.'morihage
from the throat, if the pulse rate is persistently increased in frequency,
and especially if the temperature is raised at night, then, even though
there mav be no other evidence of tuberculous disease of the lunsj,
and even if no tubercle bacilli be detected in the expectoration, he
should be treated as though tlie ha3morrhage were pulmonary ; unless
of course there be direct evidence that the blood actually came from the
throat.
Treatnunt. — The treatment must be guided by the cause of the
haemorrhage. If it be clue to injury, the patient may suck ice, and sprays
or local applications of some astringent solution, such as tannic or gallic
acid, catechu, matico, or calcium chloride, may be employed ; or if the
bleeding point can be seen it may be touched with the galvano-caustic
point. It is sometimes possible to secure and twist the ruptured vessel with
torsion forceps. These sim{)le methods, together with the other general
measvu'es which are usually adopted in haemorrhage, generally suffice to
check bleeding from the rupture of small vessels in the mucous membrane
of the pharynx or larynx from all causes, if indeed it do not cease
spontaneously ; but it has sometimes been necessary to ligature the
common carotid artery on account of the haemorrhage arising from a
suppurating tonsillitis or a malignant growth.
The bleeding having been checked, attention should be directed
to the treatment of the underlying cause of the haemorrhage, whether it
be a local condition of the throat, or disease of the liver, heart, or kidneys,
or a general systemic affection.
Diseases of the uvula. — The uvula being practically a part of the
soft palate, it is very frequently implicated in diseases affecting that
region, while its affections present some special features.
Congenital absence of the uvula occurs especially in association with
cleft palate ; or the uvula may be more or less completely bifid, repre-
senting an incomplete cleft palate.
Inflammatory/ ajfecfions. — In acute inflammatory diseases of the pharynx,
from whatever cause, the uvula generally becomes inflamed ; and in
septic inflammations it is especially liable to become so enormously
swollen and elongated that it may even ajiproach the size of the little
finger. Sometimes it is long enough to be gras{)ed between the teeth
when coughed forward to the front of the mouth, or to fall into the
larynx when drawn backwards and downwards.
An oedematous uvula may be freely scarified, and, when the inflam-
mation is acute, sucking of ice may be grateful to the patient. In other
DISEASES OF THE PHARYNX 733
respects the treatment does not differ from that of the pharyngeal affec-
tion with which it is associated.
Chronic uvulitis is usually associated with chronic pharyngitis, the
velum palati and uvula being relaxed and congested, and the latter
frequently elongated ; Avhile enlarged venules and mucous glands are
found scattered over the surface.
Elongated uvula. — An exaggerated importance is only too frequently
attached to the uvula as a source of many and various symptoms in the
region of the throat ; we must therefore express at once our decided
opinion that it is in very rare cases only that the condition of the uvula
can properly be regarded as the cause of any notable symptoms ; in
the vast majority of patients whose symptoms are attributed to the
uvula, these are really due to morbid conditions in other parts of the
upper respiratory tract.
We may conveniently classify cases of elongated uvula into two sub-
divisions, viz. ((() those in which the uvula is merely relaxed, the mucous
membrane extending some distance below the muscular structures but
without congestion or hypertrophy ; and {h) those in which hypertrophy
and chronic congestion are present, often associated with degeneration of
the glandular structures of the naso-pharyngeal mucous membrane.
Sijmptoms. — In a great many cases, unless the elongation be very
marked indeed, there are no symptoms whatever. In the milder cases,
where there is merely relaxation of the soft palate and uvula without
hypertrophy or congestion, the symptoms complained of are mainly
impairment of the quality and strength of the voice, and are mostly ob-
served in professional singers. But the alteration and impairment of
voice are often due rather to the relaxation of the soft palate, interfering
with the proper movements of the uvula in singing high notes, than to
the elongation of the uvula in itself. In well-marked cases patients
usually complain of continual hawking, with a sense of some foreign body
in the throat. The cough is sometimes very severe and persistent, par-
ticularly on lying doAvn at night. The constant titillation at the back of
the tongue not infrequently results in vomiting ; this is especially in the
morning or after meals, and, if the elongation be so considerable that the
uvula reaches down to the larynx, laryngeal spasms may occur. In
men much addicted to abuse of tobacco and alcohol the last-named
symptoms are particularly frequent. In a fcAV and very rare cases the
constant pain and irritation in the throat, persistent cough and frequent
vomiting, may result in emaciation and Aveakness ; while the recurrent
haemorrhage from rupture of enlarged vessels in the pharynx may, in
conjunction with the other symptoms, give rise to the suspicion of serious
lung mischief.
Treatment. — When really necessary, and when all other sources of the
symptoms presented have been excluded, ablation of the uvula should be
performed ; but here again we would emphatically state that in our opinion
the operation is very rarely necessary.
The cases in which uvulotomy are required are — (i.) In professional
734 SYSTEM OF MEDICINE
singers suil'ering from loss of vucul tone without appreciable affection of
the larynx, and in whom the uvula is elongated, thickened, and relaxed ;
(ii.) in cases where the elongation is so considerable that it becomes
sucked into the larynx and produces attacks of suffocation, especially
during sleep ; (iii.) when a long and thickened uvula is associated with a
persistent tickling cough, and Avhcn, after careful examination of the
pharynx and lar\^nx, all other possible causes for the symptoms have been
excluded ; (iv.) in malignaiit disease of the uvula ; (v.) and, final!}', in cases
where a much elongated uvula is an obstacle to the j)erformance of
delicate intra-laryngeal operations. When cases are properly and judici-
ously selected the result is most gratifying, sometimes altogether out of
proportion to the relatively trinal operation. The great amount of
benefit that may be derived from such a simple pi'occdure as removal of
the uvula was well illustrated in a case observed by one of us (W. W.).
The patient presented the wan and wasted appearance of advanced con-
sumption, and had in fact been treated for pulmonary tuberculosis. He
was certainly very feeble and emaciated, and crepitation could be heard
over both lungs. After his UA'ula was partly removed the improvement
and final recovery were rapid ; three pounds in weight Avere gained
during the first fortnight.
In performing uvulotomy, the parts having been well cocainised, the
tip of the u\'ula — unless the uvulotome be used — should be seized with
forceps and gently draAvn forward. The redundant portion is then
removed by one cut with a pair of curved blunt-pointed scissors. By
;perating in this manner the cut surface comes to be posterior, and
irritation by food on deglutition is avoided.
The whole uvula should not be removed, but the redundant part only.
If too much has been taken away, patients often complain of " want of
power " in the throat, and sometimes of difficulty in speaking or reading
aloud.
For a few days after the operation the patient should avoid talking,
and the food should be soft, bland and cold. A spray may be used con-
taining cocaine and phenazonum dissolved in glycerine and water ; or a
mild morphine and cocaine pastil should be sucked at intervals, especially
before meals. The pain antl irritation resulting from the operation are
generally considerable, and last from two to five days, being altogether
disproportionate to the smallness of the cut surface. Secondary hti^mor-
rhage may occur two or three days after the ojx'ration, hence the import-
ance of the patient avoiding all hard or even solid food.
Chronic infective diseases. — Syi)hilis or tuberculosis, for instance, may
attjick the uvula, the symptoms and treatment being the same as in
these diseases when affecting the fauces.
Growths of the unila comprise papilloma, mucous polypus, and car-
cinoma. [See "New Growths of the Pharynx," p. 752.]
Paralysis of the uvula occurs in association with paralysis of the velum
palati. Paralysis of the uvula alone may occur as a consequence of diph-
theria.—F. S. and W. W.
DISEASES OF THE PHARYNX 735
The throat affections of the speeifle febrile diseases. — These
affections will be described under the heads of the respective diseases, but
it has been thought, well to make some reference to them in this place.
Small-pox. — A certain amount of catarrh of the phaiynx and larynx
is met with in most cases of small-pox. In some cases pocks are seen on
the pharyngeal and laryngeal mucous membrane, but, owing to the pre-
sence of moisture, well-marked pustules are seldom seen. The pustules
give rise to the symptoms of laryngitis about the sixth day ; but it is not
until the ninth to the twelfth day that grave symptoms, due to an
oedematous condition of the larynx or to the formation of a false mem-
brane, occur. With either of these complications the disease may run a
rapid and fatal course ; occasionally deep ulceration followed by necrosis
of the cartilages occurs ; if not immediately fatal, the resulting cicatrisa-
tion and contraction lead to stenosis of the larynx. In the malignant
form of small -pox hfemorrhagic extravasations may be seen in the
laryngeal mucous membrane.
Treatment. — If the eruption is limited to the mouth and pharynx anti-
septic or slightly astringent gargles may be employed. The laryngeal
complications must be treated after the manner described for idiopathic
affections of the larynx.
Varicella. — The vesicles of chicken-pox have been noticed in the
mouth.
Measles.— Preceding the cutaneous rash is seen an eruption of small
red points or patches on the roof of the mouth and palate, to which the
tei-m endanthem has been applied. Pharyngeal and laryngeal catarrh is an
invariable accompaniment of measles. In young children a certain amount
of spasm is present, which gives rise to croupy attacks. In severe cases
the inflammation may go on to ulceration and even to the formation of
an abscess. Membranous laryjigitis is a rare but very dangerous com-
plication of measles.
The treatment of the laryngeal affections of measles differs in no respect
from the treatment of similar affections due to other causes.
Rotheln (German measles).— There is almost invariably a certain
amount of soreness of the throat, and the soft palate and fauces will be
found injected and swollen.
Scarlet fever. — For a full account of the throat affection of scarlet
fever the reader is referred to the article on the disease (vol. ii. p. 122).
In this place it will only be necessary to refer to the formation of a false
membrane over the palate and fauces, which sometimes accompanies the
sore throat of scarlet fever. The exudation Avhich is often seen on the
fauces during the acute stage of scarlet fever is not caused by the Lofiier
bacillus, and is therefore not true diphtheria. It is possible, however,
that diphtheria may accompany the acute stage of scarlet fever, but this
is very uncommon. On the other hand, the membranous exudation
occurring on the fauces during the convalescent stage of scarlet fever,
being caused by the diphtheria bacillus, is true diphtheria. Post-
scai"latinal diphtheria usually occurs at a late period of convalescence.
736 SYSTEM OF MEDICINE
Influenza. — A catarrluil condition of the pharynx and larynx exists
in ahnost all cases of influenza. Implication of the pharyngeal tonsil is
not at all uncommon, and follicular inflammation occasionally occurs.
Acute pharyngeal catarrh and follicular tonsillitis with or -without
peritonsillar iuHammation are frequently seen. In the larynx all conditions
of inflammation are met with, from slight catarrh up to oedema or the
formation of an abscess. The expectoration is occasionally tinged with
blood, and cases of hcTmorrhagic laryngitis have been seen as a result of
inHuenza. Superficial ulceration of the vocal cords not infrequently
occurs. A notable feature of iiiHuenzal laryngitis is the protracted course
which it runs. Laryngeal paralysis is a not infrequent sequel of the
disease.
Enteric fever. — Erythema of the pharynx m;iy occur at the com-
mencement of enteric fever, but it presents no characteristic features. In
some severe cases of enteric fever a few small shallow ulcers, not larger
than a linseed, have been noticed on the soft palate. Their borders are
well defined and have an inflammatory zone, and the surface of the ulcers
is covered with a grayish film. The ulcers are not jminful, there is no
glandular enlargement, and typhoid bacilli are not present in them.
A secondary diphtheritic deposit may occur on the fauces of patients
with enteric fever ; this is a grave complication.
The most important of the throat afl'ections of enteric fever is laryn-
gitis, which may occur at the very beginning of the attack, or be one of
its later manifestations. Bacteriological investigation confirms the clinical
view that these larj'ugeal affections are directly due to localisation of the
t3'phoid \nrus and are not complications.^ The presence of the bacilli
of typhoid prepares the ground for the settlement of other micro-
organisms, including the pus exciters ; and these are responsible for the
secondary processes which are sometimes observed.
In those cases in which laryngitis occurs at the outset the symptoms
of the local malady may so completely obscure the general condition that
it is not until the appearance of an eruption, and of abdominal symptoms,
that a definite diagnosis can be made. Usually, however, the symptoms
of laryngitis show themselves in the third week, and the local disease
runs an acute course ; ulceration may occur, and this may be the first
stage of the severe affection to which the term of " laryngo-typhus " has
been applied by German writers. Hoarseness, dyspnoea (chiefly aflfecting
inspiration), difficulty and pain in swallowing, arc generally })resent.
Tracheotomy is frequently necessary on account of oedema of the larynx or
purulent infiltration of the mucosa. The occurrence of these acute cases
of laryngitis, with iilceration and the presence of the Ebcrth-Gaffky bacilli
in the part, points to the possibility of enteric fever being communicated
by the breath and expectoration. In some cases the laryngeal aHcction
is not recogni-sed until convalescence has begun, or even after complete
recovery. In such cases the signs of stenosis of the larynx are the most
' According to Kantliack and Drysdale, tlie.se laryngeal ulcer.s are usually due to
pyogeuetic organisms and not to the typhoid bacillus.
DISEASES OF THE PHARYNX 737
characteristic ; and death may occur from oedema of the larynx or impac-
tion of a piece of necrosed cartilage in the glottis. On account of the
extensive ulceration and necrosis which occur, tracheotomy is often
required ; and if recovery take place, it is seldom possible to dispense
■with the canula on account of collapse of the larynx and cicatricial con-
traction.
It is not uncommon to find an affection of the larynx on post-mortem
examination, although during life there were no symptoms indicative of
an}^ laryngeal trouble.
Typhus fever. — Changes similar to those seen in enteric fever are
also met with in typhus.
Whooping" -cough. — In this disease there is slight catarrh of the
larynx in the first stage, Avhich becomes intense during the spasmodic
stage ; and the hyperaemia extends into the trachea. — F. DE H. H.
Aeute septic inflammations of the pharynx and larynx (including
phlegmon of the cellular tissue of the neck — Angina Ludovici).- — Under
this heading we include a number of forms of acute septic inflammations
of the pharynx and larynx which hitherto have been usually considered
as pathologically diff"erent ; such as acute inflammatory oedema of the
pharynx and larynx, phlegmon of the pharynx and larynx, and erj'^sipelas
of these parts. In our opinion phlegmonous cellulitis of the neck
(angina Ludovici) also comes under this head.
. In a recent communication to the Koyal Medico-Chirurgical Society,^
one of us (F. S.) argued, on clinical and bacteriological evidence, that
these various forms of acute septic inflammation of the throat should be
considered as varying degrees of virulence of one and the same patho-
logical process. The primary seat and subsequent development depend
in all probability upon accidental breaches of the protecting surface
through which the pathogenetic micro-organism, which causes the sub-
sequent events, finds an entrance ; and it is absolutely impossible to draw
any definite line of demarcation between the purely local and the more
complicated cases, or between the oedematous and the supp^^rative forms.
That each and all of these septic processes may be produced by several
pathogenetic organisms docs not, in our opinion, in the least speak against
their pathological identity. These micro-organisms are " interchangeable "
in the sense that each and all of them, when penetrating into the tissues,
pi'oduce one and the same eftect ; namely, an acute septic inflammation —
oedematous, })urnlent, or gangrenous. Likewise we believe that erysipelas
etiologically considered is not a specific disease ; usually it is caused by the
streptococcus pyogenes, but it may also be produced by the staphylococcus
pyogenes aureus, as Max Jordan's researches have definitely proved.
The micro-organisms causing erysipelas most probably enter into the
^ We miist refer readers iiitere^terl in this subject to this paper [Trans. Roy. Mcd.-Chir.
Soc, vol. Ixxviii. p. 161) and to its discussion (Proc. Roy. Med.-Chir. Soc. 3rd series,
vol. vii.) for the particulars which cousiderations of space will not allow us to discuss at
length in this chapter.
VOL. IV 3 B
738 SYSTEAf OF MEDICINE
circulation in every case ; p_vfipmia following erysipelas is therefore primary,
and not due to a mixed infection.
"When we attempt to draw definite distinctions between the inflam-
mations associated with different micro-organisms we fall inevitably
into a confusion of terms. In the discussion on Semon's paper Dr.
Kanthack gave most valuable support to our views by quoting in detail
four cases of his own in which various pyogenetic micro-organisms had
been found pi-oducing various stages of the same process. Thus these
cases bacteriologicaliy distinct were pathologically identical (see also vol. i.
pp. 533, 53G).
Etiolngy. — The affections here discussed are due to the invasion of the
system by pathogenetic organisms, of Avhich, so far, the streptococcus
pyogenes appears to be the most frequent. No doubt, however, any
one of the other pyogenetic microl^es, such as the staphylococcus
aureus or citreus, the micrococcus tenuis, the bacillus coli communis,
the bacillus pyocyaneus, and so on, if by chance it multiply suffi-
ciently, may alone produce an acute septic inflammation indistinguishable,
except fi'om a bacteriological point of view, fiom the streptococcous
inflammation.
Pathology. — Pathologicall}?' these inflammations are characterised by a
violent exudation into the tissues affected. This exudation may be
serous, sero-purulent, purulent, and in the worst cases may even lead to
gangrene. All these various forms, however, merely represent various
degrees of intensity of inflammation, not differences in kind.
Si/mpfoms. — For clinical purposes we may recognise four degrees of
inflammation : — (a) Superficial septic inflammation, as in the so-called
" hosj)ital sore throat"; (b) (Edematous inflammation, as acute a^dematous
tonsillitis, uvulitis, pharyngitis, epiglottiditis, aryttenoiditis, cellulitis of the
tissues of the neck, and so forth ; (c) Suppiu'ative inflammation or
phlegmon ; ('/) Gangrenous inflammation.
Septic inilammations of the throat attack persons of all ages and both
sexes, very frequently even those apparently in perfect health ; though in
those who are run down in health from any cause, or are suftering from
some debilitating affection such as diabetes, the disease is especially prone
to occur and to run a severe course.
We know nothing definitely about the length or even the existence of
an incubation stage. Prodromal symptoms, such as headache, feverish-
ness, sore throat, nnd general malaise, may pi'ccede the onset of more
acute symptoms for a few days. In the slighter forms, as in hospital
sore throat, there may be only localised soreness and stiflness in the throat,
with headache and general malaise, without fever or marked constitutional
disturbance. These nn'ld cases, however, may ])ass into the more sevei'e
forms. In the grave forms often enough the disease manifests itself
quite aliruptly. It may be ushered in by a rigor and rapid rise of
temperature. The course of the fever is very variable, as it proliably
depends on the virulence of the septic infection in the individual case ;
and, while usually ranging high, it may never rise above 100° F.,
DISEASES OF THE PHARYNX 739
especially in asthenic cases ; or it may present a remittent or I'elapsing
type : but the temperature as a rule reaches its highest point at the very
onset. Rigors occurring later in the course of the disease generally
indicate further complications or the onset of suppuration. The urine is
febrile ; the frequency of albuminuria has yet to be determined ; sugar
is found comparatively often. The pulse during the acute stage is usually
frequent, full, and bounding, but soon becomes weak and compressible.
When suppuration has occurred and the strength is greatly reduced, the
pulse is small and thready, and perspiration profuse.
In those rare cases in which the nervous centres are involved early,
the pulse and respiiation become irregular, and the patients are generally
delirious by the second or third day.
Whether the part attacked be the fauces, pharynx, larynx, or cellular
tissue of the neck, the first symptom usually complained of is sudden
pain in the throat and difficulty in swallowing, which within a few hours
may amount to complete aphagia. If the larynx be involved, hoarseness
of voice and, soon after, laryngeal stridor are observed. Often the
aphonia is complete. The aphagia and dyspnoea last for a few hours
to a few days ; but in the cases of recovery, these and all other
symptoms rapidly subside.
01)jectively the symptoms vary, of course, with the seat of the
inflammatory process. In the great majority of cases the pharynx is
first affected, and more especially the tonsils — the latter, with their
anatomical configuration, forming a natural portal for the entry of
infecting micro-organisms into the body. This process was fully considered
in F. Semon's paper, to Avhich we have referred. On the other hand,
the microbes may pass on farther to find a point of invasion in the tissues
lower down, in the larynx — and here especially in the epiglottis, or in
the cellular tissue of the neck.
When the tonsils are primarily aff'ected, the inflammation — clinically
speaking — hardly differs from ordinary acute follicular tonsillitis. In the
case of the pharynx rapid oedematous swelling occurs, and the uvula may
be greatly elongated and thickened to the size of the little finger. The
swelling is often distinguished by a peculiar bluish discoloration. After
a few days, if suppuration do not occur, the swelling sul^sides, leaving the
mucous membrane more or less wrinkled in appearance ; or the inflamma-
tion may spread down to the larynx.
Some of the worst and most fatal cases begin in the pharynx and
suppurate in the course of a few days, the septic inflammation remaining
limited to that part (Senator's acute infectious phlegmon of the pharynx).
More frequently it extends to the regions around, or spreads downwards,
much more rarely upwards, to the naso-pharynx, the nasal passages, and
even to the membranes of the brain. In the great majority of cases of
septic pharyngitis the inflammatory process leaves this part in a few hours
or days and extends downwards to the larynx. Here it appears that the
epiglottis is generally most markedly affected, becoming enormously
swollen and turban-shaped, so that by simply depressing the tongue it
740 SYSTEM OF MEDICINE
may often 1)0 solmi as a semi-transparent scarlet or bluish-red roll. Next
in point of frequency the aryU^noids and the arj'tieno-epiglottidean folds
suffer, and lose their characteristic shape in the enormous red or j^urple
swelling which takes place ; a swelling very often so great as completely
to hide the ventricular bands and vocal cords. In such cases, as already
mentioned, the voice at first is weak and hoarse ; in a day or two, or even
in a few hours, complete aphonia and dyspno?a supervene, and the glottic
chink is often so narrowed that at any moment there is great ri-sk of an
asphyxia so acute as to require the immediate performance of tracheo-
tomy. In other cases the submaxillary or cervical cellular tissues become
primarily infected, the pathogenetic micro-organisms gaining entrance
from the mouth by a carious tooth or fissure in the mucous membrane,
by the tonsil or phaiyiix, and causing a hard swelling under the
tongue and a localised hard, brawny infiltration beneath the jaw — hitherto
commonly named angina Ludovici — but in its eventual course spreading
to the pharynx or larynx, or to other regions of the neck, and ending in
resolution, or more usually in suppuration ; whilst in the worst cases
gangrene may ensue. In some cases dift'use purulent infiltration is met
with, or abscesses arise in the cedematous cellular tissue or between the
muscles of the neck. In the very worst cases metastatic abscesses occur
either in the superficial parts or in joints. Except in its primary seat it
i.5 in onset, course, and event precisely similar to the disease as seen in
the pharynx or larynx.
Whilst the purulent variety of the septic inflammation usually leads
to speedy death, cases of serous inflammation of the larynx and its
neighbourhood may get well within a few days, however considerable the
inflammation. Here, again, it is characteristic that the maximum inflam-
mation is i^sually attained within a few hours from its very onset ; and
that in the cases in which recovery takes place even considerable diminu-
tion of the swelling is the rule ^vithin a day or two from the beginning.
Often, however, the disease is not confined to the neck, but spreads,
sometimes with incredible rapidity, to other parts. In addition to the
lungs, in which patchy or general pneumonia may appear, the serous
membranes are particularly liable to suffer ; and pleurisy (single or double),
pericarditis, peritonitis, or meningitis may appear A\nthin a few days
or even hours from the initial rigor. As in the original seat of the dis-
ease, the exudation of the serous membranes may be either of a serous
or of a purulent character; sometimes it is fibrinous. Even in
cases complicated with pneumonia, pericarditis, and pleui'isy, recovery is
possible ; and if it docs occur, is remarkable for its quickness and com-
pleteness. In more severe cases, however, death ensues with signs of
increasing coma and heart failure ; and in the Avorst of them the whole
process from beginning to end may not occupy more than ten to twelv
hours.
In very rare cases it appears as if the whole brunt of the septic
infection, apart from the parts first attacked, fell upon the central nervous
system. In such cases epileptiform convulsions, delirium, irregularity of
DISEASES OF THE PHARYNX 741
the heart and pulse, are amongst the earliest symptoms ; and death may
occur with signs of severe septic infection of the nervous system, without
any complications ' in the chest, and after the local inflammation of the
pharynx and larynx has completely subsided.
Diagnosis. — Unless the patient be suffering from facial erysipelas the
earlier symptoms and physical signs may give little indication of the
grave nature of the disease, and it may easily be mistaken for acute
tonsillitis or pharyngitis ; but the rapidly progressing constitutional
disturbance, the early onset of delirium, and especially the supervention
of oedema of the larynx, should serve to put us on our guard. Early
implication of the lymphatic vessels, and brawny induration of the neck,
taken in conjunction with the other manifestations of a grave affection,
should leave no manner of doubt that the case is one of septic inflamma-
tion. The bacteriological examination of the affected parts will reveal
the species of microbe which in the individual case has caused the
disease.
Treatment. — The necessity for prompt and energetic treatment in all
"forms of septic inflammation is but too obvious. Our aim must be
directed towards controlling the local inflammation, to support the patient
with light nourishment, and to watch for any symptoms of heart failure.
Ice should lie administered internally, and also externally by means of
Leiter's tubes, or the ice-bag applied to the front of the neck. If there
be oedema of the larynx, careful watch must be kept lest at any moment
intubation or tracheotomy become necessary ; and on no account should
the patient be left if dyspnoea have arisen : in fact dyspnoea, if at all
marked, is an indication for immediate intubation or tracheotomy, unless
the laryngeal obstruction can be relieved by freely scarifying the parts
affected.
Four or five grains of quinine should be ordered every four hours ;
and if the pulse be weak and there be any indication of heart failure, this
may be combined with the tincture of perchloride of iron and digitalis.
In such cases, or where pneumonia has supervened, one of us (F. S.) has
found frequent inhalation of oxygen very useful. Light nourishing food
must be given, and probably alcohol in the form of brandy or whisky.
In suppuration, particularly in cases of phlegmonous cellulitis of the neck,
the affected tissues should be incised, and the resulting wound treated
antiseptically.
Retpopharyng'eal abscess. — Causes. — Retropharyngeal abscess is a
— usually circumscribed — suppuration occurring in the tissues between
the mucous membrane of the posterior wall of the pharynx and the spine ;
it is mainly a disease of early childhood, though occasionally it may occur
in an adult.
The vast majority of cases must be called idiopathic, and due to
inflammation of the lymphoid tissue of the pharynx arising, from no
definitely assignable cause, in young children up to the age of four. The
strumous diathesis and rickets dispose to its occurrence ; or it may
follow measles, scarlet fever, or injury. It is sometimes due to caries of
742 SYSTEM OF MEDICINE
the cenncal A'ertebr.T, or, in rare cases, to burrowing of pus from other
regions ; it is probiihle that not a few cases are septic in origin, es})ecially
in older patients. The aftection may follow injury from blows or foreign
bodies. One of us (F. S.) has twice seen it occur in association with
adenoid vegetations.
rathologi/. — In children there is an aggregation of lymphoid tissue in
the posterior wall of the pharynx opposite the second and third cervical
vertebrae; and the suppuration is usually due to inflammation and breaking
down in this tissue on one or other side : the abscess is rarely central.
In adult patients the suppuration occurs in the cellular tissue which
remains after the involution of the lymphatic tissues of the pharynx.
The abscess is generally confined to the oro-pharyngeal region, and, though
it may burrow down towards the oesophagus, it very rarely extends
upwards much above the level of the soft palate.
The glands below and behind the angle of the lower jaw on the side
of the abscess usually become enlarged, indurated and inflamed.
The abscess may rupttire spontaneously into the pharynx, or burrow in
various directions ; the inflammation very often extending to the larynx
with resulting acute laryngitis or cedema.
Sijmploms. — The onset may be acute or chronic. If acute, there is
general pyrexia, sometimes preceded by a rigor with local heat and
painful tumefaction which, on inspection or digital exploration, is seen as a
fluctuating bidging of the posterior pharj-ngeal wall. As a I'ule, the voice
is husky or aphonic ; and cough resembling croup is usually present,
accompanied by more or less acute dyspnoea. The child's cry has a
peculiar throaty tone. Fixation of the head is usually a marked feature.
In the more chronic cases the symptoms are much the same, luit the
temperature is not raised. In adults difficulty and pain in deglutition
are the chief subjective symptoms. In children it is more dithcult to
detect the bulging abscess.
Diagnosis. — The symptoms in young children are easily mistaken for
croupous laryngitis ; but in retropharyngeal abscess deglutition as well as
respiration is difficult : moreover, the fixation of the head and the uni-
lateral swelling below the jaw point to retropharyngeal abscess. The
chronic forai has to l)e distinguished from sarcoma, which grows rapidly,
does not fluctuate, often has an irregulai' or nodular surface, and is rarely
attended by actual rigidity of the head.
The prognosis in very young children should be guarded, especially
when the symptoms of laryngitis are decided ; in older children and in
adults the prognosis, under appropriate treatment, is always favoural)le.
Untreated, the rupture of the abscess in the pharynx is liable to cause
suffocation from the pus entering the larj'nx ; while the danger of oedema
of the larynx causing acute asphyxia is very considerable. Needless to
say that any underlying afFection, such as caries of the cervical vertebrae,
would greatly modify the prognosis as regards complete recovery.
In the acute cases of adults there is even more need for a cautious
prognosis, as they sometimes take the peculiarly fatal course and character
DISEASES OF THE PHARYNX 743
of acute septic pharyngitis — the so-called acute infectious phlegmon of
Senator.
Treatment. — In all acute cases young children should be placed in a
steam bed, while adults should frequently use medicated steam inhalations.
The treatment consists in evacuating the pus as soon as fluctuation is
detected, either thi-ough the mouth by the knife, or, especially if the case
is complicated by cervical caries, by an incision behind the sterno-mastoid
muscle under strict antiseptic precautions. The operation through the
mouth should always be done Avith the patient's head hanging low down,
to avoid the danger of pus escaping into the larynx. Of course if the
pus be actually pointing behind the sterno-mastoid, or elsewhere, this will
determine the seat of evacuation. Aspiration is often recommended, but
refilling of the abscess cavity is more likely to occur.
The great danger lies in the occurrence of oedema of the glottis. Ice
should be sucked if the patient be old enough, and hot applications made
to the neck and submaxillary region. Young children should be kept in
the steam bed, and any symptoms of ol)structive dyspnoea carefully watched
for ; as intulmtion or tracheotomy may at any moment be urgently
required, even for some little time after the evacuation of the abscess.
Pharyngomyeosis leptothrieia. — The leptothrix fungus and spores are
almost invariably present in the concretions of tartar that gather round
the teeth, and on the papilke of a coated tongue ; and very frequently
they may be found in the crypts of the tonsils. Under certain conditions
they take root in the tissue and germinate, forming characteristic milky-
white chalk-like out-growths. The fungus grows from the bottom of the
crypts and acinous glands, and is most frequently seen on the palatine
and lingual tonsils ; though the soft palate and uvula and posterior
pharyngeal Avail also are often the seat of the growth. Under the
microscope the elongated cylindrical or thread-like cells of the cryptogam
will be found, together with a certain amount of amorphous granular
matter. The mucous memljrane around t^he growths of fungus is healthy,
but the masses are remarkably adherent and often cannot be torn away
without some of the epithelium of the matrix ; though sometimes they
are soft and break off short when i-emoval is attempted.
The affection generally occurs in patients who are run down in health
from one cause or another, and is especially apt to follow digestive
disorders.
The symptoms are generally very slight or altogether absent, and often
enough the patches are accidentally discovered by the patients. A certain
degree of discomfort, stifihess, and dryness may occasionally be felt in the
throat ; Avhilst in some cases there is an irritating cough, and the voice
may l)e impaired. It is very doubtful, lioAvever, how much even of these
slight symptoms is directly due to the growths, and how much to the
dyspej^tic troubles and impaired health with Avhich the affection is gener-
ally associated.
The only affection that may be confused Avith this mycosis is chronic
lacunar tonsillitis Avith yellow caseous exudation in the crypts. The
744 SYSTEM OF MEDICINE
yellow masses, however, arc readily extruded ; whereas the leptothrix
masses are very adlierent and are chalk-white in colour. The leptothrix
spores have been found in the cheesy masses of follicular tonsillitis ; but
it is only when they have taken root in the tissues that they constitute a
real mycosis.
The absence of pain, febrile temperature, and constitutional dis-
turbance at once distinguish the affection from acute tonsillitis or
diphtheria.
The treatment should be directed to improvement of the general health.
Many forms of local treatment have been advocated, but even when most
vigorously and perseveringly carried out they are all very tedious, and fail
to prevent the return of the fungus ; whereas we have often found that with
improved health the growth disappears spontaneously. Thus, in our
opinion, in most cases at any rate, no local treatment is required.
Calcareous concretions in the tonsils are originated by the leptothrix
buccalis in the tonsillar crypts, just as tartar is deposited on the neglected
teeth ; and around this nucleus altered mucus, pus, and epithelium cells
collect and become calcareous. In this manner several such accumulations
of calcareous matter may come to occupy the crypts ; or one or more
large calculi, varying in size up to more than an inch in diameter, may
be formed. The symptoms are often very slight, and are simply those
common to enlarged tonsils : sometimes they maintain a certain degree of
chronic inflammation.
The diagnosis may be made by means of a probe or, iu the case of
larger deposits, by palpation.
The calculus should be removed, and if the tonsil be hypertrophied,
or multiple small concretions be present, it is better to remove the gland
at the same time.
Diseases of the lingual tonsil. — The fourth tonsil situated at the
base of the dorsum of the tonsjue is liable to the same diseases as the
palatine tonsils. Thus it may be the seat of acute lacunar or paren-
chymatous inflammation, which may suppurate. Treatment is the same
as in acute tonsillitis.
Chronic hypertrophy is frequently found in a mild degree in chronic
pharyngitis, and more marked — often without adequate explanation — in
otherwise healthy persons, particularly in women. In the last-named
class of cases, by direct contact of the hypertrophic glandular tissue with
the dorsum of the epiglottis, it often gives rise to a constant irritating
cough, sensations of fulness, choking, " lump in the throat," and so forth.
Many cases of so-called "globus" are of this kind. The hypertrophied
tissue is sometimes seen quite to overlap the epiglottis, often, indeed,
almost to conceal it.
The hypertrophy should be reduced by applications of Lugol's solution
(iodine grs. xx., iodide of potassium grs. xxx., to an ounce of water) ; or
by the lingual tonsillotome, curette, or snare according to the shape and
size of the mass. The employment of the galvano-cautcry, which is often
recommended, is not free from the risk of causing violent parotitis.
DISEASES OF THE PHARYXX 745
Tuberculosis of the pharynx. — Etiology. — The immediate and remote
causes of tuberculous disease of the fauces and pharynx are the same as in
pulmonary tuberculous disease, to which the pharyngeal affection, which
is one of the rarer manifestations of tubercvdosis, is almost invariably
secondary. Occasionally the pharyngeal aftection appears to precede or to
appear simultaneously with pulmonary tuberculosis ; but if we except the
tonsils, primary pharyngeal tuberculosis is very rare. Chronic enlargement
of the faucial or pharyngeal tonsils disposes these structures to tuberculous
infection ; but no definite reason can be assigned for the occurrence of the
disease in the soft palate.
Pathology. — Pharyngeal tuberculosis may be either acute or chronic.
Only two or three cases are recorded Avhere the acute form was believed
to be primary ; the chronic variety is more frequently unaccompanied by
evidence of pulmonary infection. The route by Avhich the bacilli gain
access to the infected tissues is not at present known. The old view that
the pharyngeal tissue is directly infected by the sputum does not account
for the fact that tlie deeper tissues are affected first ; and that the
superficial ulcei^ation arises by the extension and breaking down of deeper-
lying miliary tubercles. On the other hand, the tendency for tuberculous
disease in this region to attack either the anterior surface of the soft
palate, the posterior pharyngeal wall, or the laryngo-pharynx opposite
the cricoid ring, suggests that slight or superficial abrasions produced in
swallowing food provide the portal for the entrance of infection, which in
the case of the tonsils is always present in the crypts.
The tonsils are much more frequently affected than hitherto believed ;
and we are of opinion that these glands are in many cases to be held
responsible for the entrance of tubercle bacilli, as indeed of other
microbes also into the system. Krueckmann has shown that tuber-
culosis of the cervical lymphatic glands almost always depends upon the
invasion of the glands by way of the tonsils ; and in no less than 60 per
cent of cases of tuberculosis of the lungs examined on the post-mortem
table by this observer, tubercles were detected in the tonsils : similar
results had previously been obtained by Strassmann and Dmochowski.
Many cases of pharyngeal adenoids have been proved to be tuberculous ;
in some giant cells have been demonstrated, while a very large proportion
contain tubercle bacilli. Masked tuberculous disease of the tonsils
undoubtedly occurs in the course of pulmonary tuberculosis ; but it is
probable that a similar condition of the tonsils often precedes the
establishment of the lung affection.
The subsequent course of the tuberculous deposit differs in no respect
from tuberculous disease in other regions ; caseation and breaking down
soon result in characteristic ulceration.
The si/mptoms of tuberculosis of the pharyngeal mucous membrane and
of the tonsils differ in several respects ; though many of the symptoms
are common to all tuberculous processes.
The acute form of the pharyngeal affection usually begins with pain
in the faucial region, which on examination is found to be hyperaemic
746 . SYSTEM OF MEDICINE
and slightly swollen. The soft palate, if the seat of deposit, becomes
stitt" and paretic ; and in the course of a day or two several discrete,
muddy-gray miliary tubercles are visible, slightly elevated, but obviously
below the translucent mucous membrane. The initial hypera-mia gives
place to a more or less general amtmia of the soft palate, as the tubercles
increase in number and coalesce. Very soon discrete or contluent
ulceration of the tubercle occvu's, and by superficial extension the
originally small solitaiy ulcers coalesce and form a larger superficial ulcer
covered with grayish white, diffluent, breaking down, caseating matter, and
with irregular " worm-eaten " or " mouse-nil>blcd " margins which are flush
with the surrounding mucous membrane. Fresh tubercles meanwhile
appear, only to pass through similarly rajiid phases of (levelo])ment.
Ere this the infiltration of the soft palate has resulted in failure of
its functions ; consequently the voice is nasal, and fluids escape by the
nose on drinking. Deglutition becomes very painful, and coughing
almost impossible ; consequently the patient is unable to get rid of the
copious, sticky, stringy, nuieo-purulent discharges covering the paits,
which accumulate and dril)l)le from the ojjen mouth, or are expelled
by feeble attemjjts at hawking. As in acute miliary tuberculosis of
the lungs, the temperature ranges high, without presenting the hectic
character ; but the emaciation and general pi-ostration are moi'e rapid.
In the more common chronic form the formation of tubercles is less
obvious, the ulceration is indolent, while granulations and nodular
thickening may cause it to resemble lupus. Pain, wasting and febrile
symptoms are well marked ; though, of course, concomitant pvilmonary
disease will be attended by the usual clinical phenomena.
Tuberculous disease of the tonsils occurs alone or in association with
the palatine deposit. It manifests itself by congestion and enlargement
of the glands, and superficial ulceration soon occurs, the ulcers being
multiple and with irregular ill-defined margins ; they are covered Avith
grayish white muco-purulent matter Avhich contains the specific bacillus.
The, diagnosis of the acute form has to be made from diphtheria,
follicular tonsillitis, syphilis, herpes, and small-pox ; while the chronic
variety must be distinguished from lupus and sy})hilis.
The presence of [)uluionary lesions will, of course, at once suggest the
probable nature of the throat affection, and the characteristic miliary
tubercles and superficial " worm-eaten " ulceration will serAc to exclude
diphtheria, syphilis, and small-pox : the general symptoms will likewise
difl'cr from small-pox and diphtheria. In herpes of the fauces, the clear
vesicles and absence of severe constitutional disturbance should jJi'event
any mistake in diagnosis. In lupus, apart from the rarit}' of the primary
faucial cases, the occui'i-ence of slowly forming, clear, ajiple-jelly-like,
painless tuT)ercles and the tendency to cicatrisation of the clean ulcers
should serve to distinguish it from the irregular ulcers of tubercle,
which are covered with detritus and never cicatrise.
Treatment. — In all cases the affected tissues, having been cocainised,
should be thoroughly scraped with a sharp curette, and lactic acid applied
DISEASES OF THE PHARYNX 747
daily (20 to 80 per cent solution). In many cases the disease may be
arrested, at least temporarily, by this method. In the acute form ice
should be sucked and the throat frequently sprayed with a solution of
cocaine (4 per cent) and menthol (20 per cent) in adepsine oil.
The general treatment should be the same as in pulmonary
tuberculosis.
Syphilis of the pharynx. — Syphilitic disease may affect any part of
the fauces and pharynx, and in. the more exposed regions occurs in all
stages— namely, i. Primary chancre ; ii. Erythema ; iii. Mucous patch
(condyloma) ; iv. Superficial ulceration ; v. Gumma ; vi. Deep ulceration ;
vii. Cicatrix. Though it is generally possible to assign pharyngeal
syphilis to the so-called secondary or 'tertiary periods, the statements
made on this point in reference to laryngeal syphilis (see p. 806) apply,
though to a less extent, here.
i. The primary sore, though decidedly rare in this region, has been
observed in a good many cases, chiefly on the tonsils, very occasionally
on the faucial pillars ; for whereas the irregular surface and crypts of
the tonsil form a ready means of entrance for the infection, the smooth
unbroken surface of the fauces and soft palate affords but slight oppor-
tunity for inoculation ; consequently, with very few exceptions, the
essentially localised initial sore is encountered on the tonsils only,
and generally in cases where the tonsils are already chronically enlarged.
The affected tonsil is red, and the sore is generally eroded, without
marked ulceration, presenting a sharply-cut, well-defined margin, with a
small amount of sticky, grayish white secretion covei'ing the floor of the
ulcer. There is very marked induration on palpation, often stony hard-
ness. The sore often extends over the whole surface of the tonsil,
and the submaxillary glands are very much enlarged and tender to
pressure ; but they do not suppurate. Pain is seldom well marked
and is often absent ; yet in some instances it is severe and lancinating
in character.
ii. Erythema usually occurs between six weeks and four months after
the initial sore, and is generally coincident with cutaneous erythema or
the papular syphilide. It presents a peculiar, almost characteristic bright
bluish red, symmetrical hyperoemia, generally confined to the soft palate
and pillars of the fauces, rarely implicating the tonsils, with a somewhat
sharply -defined border, so that the line of demarcation bet\veen the
hypersemia and normal mucous membrane is almost abrupt. This appear-
ance should always lead to the suspicion of syphilis.
There are generally no symptoms sufficiently notable to attract the
attention of the patient ; some stiffness of the parts may be observed.
iii. Mucous patches usually appear about the fourth month after
inoculation, but, as they are remarkably persistent, they may be
observed some years after. While ordinarily coexisting Avith a papular
cutaneous syphilide, they often appear when there is no general mani-
festation of the disease. Mucous patches are usually more or less
bilaterally symmetrical, slightly elevated, bluish Avhite patches on the
748 SYSTEM OF MEDICINE
fauces, tonsils, or posterior wall of the pharynx ; they are attended with
slight congestion and superficial abrasion.
iv. Superficial ulceration is especially prone to occur on both tonsils,
forming remarkable symmetrical kidney-shaped ulcers, with a grayish
white, ill-defined border. But the ulceration may be limited to the
postei'ior surface of the soft palate and the rhino-pharyngeal space. It is
one of the earliest manifestations of secondary syphilis, often preceding
or accompanying the cutaneous erythema, and, like the latter, usually
disappears very soon, without sore throat. On the other hand, it may
persist and be followed by a more painful inflammatory sore throat.
V. Gumma is generally unilateral and single, and in the soft palate,
pillars of the fauces, tonsils, and particularly in the posterior pharyngeal
wall may appear as a smooth, uneven, red or angry-looking swelling,
covered and surrounded by congested mucous membrane. It rarely gives
rise to much pain, and frequently to none whatever ; but a sense of fulness
and discomfort in the part or a difficulty in deglutition attracts the first
notice of the patient. Very soon its centre becomes yellowish and soft,
and, pain being absent, the gumma often breaks down before the patient
consults a medical man, when a typical deep crateriform ulcer, with steep
margins and a base covered Avith sticky muco-pus and debris, is already
formed.
vi. Tertiary syphilitic ulceration is always due to the disintegration
of gummatous deposit. In the earlier cases these ulcers are most found
in the soft palate, faucial pillars, or uvula ; but tertiary ulceration
occurring many years after the initial lesion more frequently affects the
tonsils and posterior pharyngeal Avail. A gumma may form on the
posterior wall of the soft palate or in the naso-pharynx. In the former
case very rapid perforation of the palate or dropping off" of the uvula may
occur if the actual condition has not been diagnosed and treated. In
view of the frequently painless character of the affection it is therefore
essential that the posterior surface of the soft palate should be inspected
by the rhinoscope, especially Avhen the anterior surface appears red
and infiltrated. Not only may the soft palate and uvula completely
disappear, but the destructive process may involve the hard palate and
open into the nasal passages.
vii. Cicatrix. — Deep syphilitic ulceration is generally followed by
contraction, distortion, and adhesion of the tissues involved : thus the soft
palate may ho. bound down to the posterior pharyngeal Avail, more or less
completely shutting off the rhino-pharyngeal space; or the uvula may
become adherent to the faucial ])illars. Syphilitic scars may often be
recognised by their stellate or radiating appearance due to the contraction
and dragging of neighbouring tissues toAvards the former site of the ulcer
as a centre. A similar process occurring in the loAvcr pharynx or
cesophagus may lead to obstruction to the passage of food.
Inherited syphilis. — Inherited syphilis affecting the pharynx gener-
ally manifests itself in eaily infancy or at the age of puberty. It may
assume the form either of secondary or of tertiary lesions, of syphilitic
DISEASES OF THE PHARYNX 749
catarrh, eiythema and superficial ulceration, or gummatous deposit with
deep ulceration. Syphilitic catarrh and superficial ulceration are generally
associated with a similar condition in the nasal passages, giving rise to
what is commonly called " snufties." Deep ulceration of the fauces or
pharynx is very frequently combined Avith destructive ulceration of the
nasal bones, as has already been described as a consequence of tertiary
manifestations in acquired syphilis.
Diagnosis. — A tonsillar chancre is liable to be mistaken for tertiary
ulceration, epithelioma, or tuberculous disease. From tertiary ulceration
it is distinguished by its superficial character, the stony hardness of the
tonsil, and the large cervical bubo ; while the early appearance (in from
two to four weeks) of secondary cutaneous manifestations will always
settle the question. It is less easy to distinguish between a chancre and
epithelioma, and very often it is impossible to do so till other syphilitic
phenomena arise ; but the duration of the aflfection, and the fact that the
margins of the ulcers are flush with the surrounding tissues, which in turn
are congested, will favour the diagnosis of chancre. The patient's age
must also be taken into consideration. Malignant disease of the pharynx
hardly ever appears before the age of thirty -five. The effects of mercurial
treatment, and, finally, the microscopic examination of a fragment of the
ulcerating tumefaction, will assist us in arriving at a definite diagnosis.
Tuberculous iilcers are more irregular, they present a mouse-nibbled
appearance, they are covered with copious sticky muco-pus, and are
usually multiple. The enlargement of the cervical glands is less rapidly
developed, and the evening rise of temperature and increased frequency of
the pulse, even in the absence of concomitant pulmonary lesion, should
lead to an examination of the debris for the specific bacilli.
Mucous patches and condylomata may be taken for diphtheria, from
which the absence of constitutional symptoms and the presence of
coexistent syphilitic skin disease should distinguish them. As a rule, the
bluish white, symmetrical, opalescent appearance of the mucous patches
surrounded by apparently healthy mucous membrane is in itself suffi-
ciently characteristic, for the tertiary syphilitic ulcer seldom causes
difficulty in diagnosis; yet the deep ulcer with foul-smelling disintegrated
d(§bris sometimes closely simulates a breaking -down epithelioma, from
which it is distinguished by the red areola surrounding the margin, by the
edge of the ulcer not being raised, and by the absence of the fungating
base. In doubtful cases a microscopical examination of a fragment, and
rapid diminution in size of the " growth " under iodide of potassium,
would probably reveal the true nature of the case.
A gumma is sometimes diagnosed as quinsy, especially when its
formation is attended with pain and febrile symptoms ; or it may be
mistaken for a fibroma, sarcoma, or carcinoma. In the former case the
facts that it is unilateral, little tender to pressure, not painful, and
not inflamed on the mucous surface, favour the diagnosis of gumma.
Fibroma is very rare, but in doubtful cases antisyphilitic treatment
must be relied upon to distinguish both this and malignant growths from
750 SYSTEM OF MEDICINE
gumma. Surcoma is less rapid in growth, and presents a more highly
coloured and succulent aspect.
Treatment. — Mucous patches which do not disappear Avith anti-
syphilitic remedies ma}'- be painted at intervals with a solution of
nitrate of silver (20 grains to the ounce). This, however, will be very
rarely required. Suijerficial ulcers may be painted ■with solution of
chromic acid (grs. x. to the ounce) ; the ulcerated surface must pre-
viously be wiped dry.
Deep ulcers should be cleaned by a simple alkaline gargle or spray,
and a mei'curial antiseptic gargle used afterwards.
Cicatricial stenosis of the rhino-pharynx may require division with
subsequent dilatation persistently repeated for a long time ; as all
syphilitic scars tend to contract afresh.
The general treatment of syphilitic disease of the pharynx does not
differ from the treatment of similar manifestations in the larynx, to which
the reader is referred (p. 811). The remarks there made on the necessity
of avoiding too rigid an adherence to any routine method of treating
secondary lesion with mercury, and tertiary lesions with iodine of
potassium, apply with ecjual force to syphilitic disease of the pharynx.
Local treatment is usually unnecessary ; but in all syphilitic affections
of the 2)harvnx an antiseptic gargle, such as a solution of perchloride of
mercury (1 in lO'iO), may be used with advantage.
Gouty aflTections of the throat. — The so-called " lithaemic diathesis "
is a much more frequent cause of throat disease than is generally believed.
This is probably largely owing to the fact that the throat is often affected
in patients who present no definite evidence of gout, or who have never
had any acute joint inflammation.
Symptoms. — The throat manifestations of gout may assume the acute
or chronic form.
Acute gouty pharyngitis, tonsillitis, or laryngitis may result from
exposure to cold, or may occur without any obvious local cause in predis-
posed persons. The affection may run the usual course of acute inllani-
mation of these regions, or may yield abruptly to an ordinary attack of
acute gout. One of us (AY. W.) observed a case of a medical man, who
had had many definite attacks of gout, in which nocturnal laiy'ngeal
spasms were prone to occur whenever an error in diet rendered the
patient gouty. A similar case was observed by the editor of this work ;
in this case, in a fine and vigorous but gouty man of middle age, the
spasms, which recurred at intervals for some years, would compel the
sufferer to spring from his bed in an agony : the local signs were never
very notable. The chief distinguishing subjective sj'mptom is that the
pain, or spasm, is out of proportion to the degree of inflammation.
Objectively the fauces or larynx, as the case may be, are acutely
inflamed and bi'ight red, the inflammation, as a rule, being strikingly
patchy in appearance ; the inflammation is particularly noticeable on the
lateral pharyngeal walls, while the uvula may be oedematous.
The more chronic form may be indistinguishable from ordinary
DISEASES OF THE PHARYNX 75^
pharyngitis and laryngitis ; but in most cases there is -well-marked
thickening of the lateral walls of the pharynx. As indicative of gout we
lay particular stress on lateral pharyngitis with a sense of uneasiness or
pain on swallowing ; the pain may be of a darting character and shoot up
to the ears. tSniall tophi may form under the mucous membrane and
may be expelled ; or urate of soda may be discharged from accumulations
in the mucous membrane. These gouty concretions, in exceedinglj^ rare
instances, may form on a vocal cord (as in a case recorded by Yirchow),
or within the crico-arytsenoid joint, causing anchylosis. A gouty in-
flammation of such character may produce symptoms and physical signs
indistinguishable from those of laryngeal cancer. In a case seen by one
of us (F. S.) in consultation, thyrotomy was performed by a distinguished
surgeon on suspicion of malignant disease of the larynx ; but the supposed
new growth turned out to be a gouty concretion embedded in a vocal
cord. A similar instance came before Krishaber and Morell Mackenzie ;
in this case the laryngeal disease disappeared while the patient was
undergoing treatment for gout.
The diagiiosis of gouty affections of the throat is often simple enough
if the peculiar patchy aspect of the inflammation and the lateral pharyn-
gitis are noted. Such appearances, especially when attended with
unusual sensitiveness and pain in the throat, should lead to incjuiry into
the family and personal history of the patient, and to careful investiga-
tion into any constitutional or other local manifestations of the gouty
habit ; in many instances, however, the diagnosis must largely depend on
the response to suitable treatment. On the other hand, it does not by
any means necessarily follow that every' inflammatory aftection of the
throat in a gouty patient is itself of gouty nature.
The treatment is simply that suited for systemic gout, the only local
treatment necessary being some sedative spray or pastil containing
menthol and cocaine. Tincture or wine of colchicum (TTI^x. to rn^xxx.),
with or without bicarbonate of potash or salicylate of soda, may be added
to a tumbler of Yichy water and taken twice daily after meals ; in the
more chronic cases a visit to some appropriate spa is highly to be recom-
mended to patients of sufficient means and leisure. The more acute
cases should be treated as acute attacks of gout, and in the usual manner,
the patients being confined to the house.
Under any circumstances the larynx, if inflamed,- should be rested as
much as possible, and all sources of irritation removed ; and, after the
gouty condition has been combated by appropriate treatment, the treat-
ment suited to subacute or chronic inflammation of the pharynx or larynx
may be necessary.
Needless to say, the usual dietetic rules for gout must be strictly
carried out.
Rheumatic affections of the throat. — The causes of rheumatic
aflfections of the throat differ in no respect from those of rheumatic
affections occurring in other parts of the body ; nor can it be said that
there are any distinguishing characteristics of rheumatic pharyngitis,
752 ^ SYSTEM OF MEDICINE
tonsillitis, or laryngitis. The very intiiDcate pathological connection
between acute lacunar tonsillitis, jDeritonsillitis, and acute rheumatism is
now Avidely recognised ; but it is important to remember that a large
])roportiou both of acute and chronic ]»haiTngitis and laryngitis is of
rheumatic origin, for success in their treatment will very much de])end on
a correct diagnosis. Pain, stiffness, and inHanimatiou of the fauces very
frequently precede an attack of acute rheumatism, and either subside or
are disregarded when the acute joint symptoms are manifested. In other
cases the throat symptoms persist for days or weeks Avithout further
development, and not seldom recur regularly whenever the patient is
exposed to cold or damp. Rheumatic inflammation may arise in and
around the crico-arytaenoid joints, or directly attack the intrinsic muscles
and peripheral nerves, causing diffuse neui'itis, impairment of mobility of
one or l)oth vocal cords, and in some cases marked tenderness to pressure.
The diagnosis of " rheumatic " paralysis of the vocal cords, however,
ought not to be made until after exclusion of all other possible organic
causes of the palsy.
Treatment. — It is unnecessary to suggest the general treatment to be
adopted in rheumatic affections of the throat, for it is simply that suited
to rheumatic diseases of the joints. Locally a sedative spray, such as
menthol and cocaine in colourless oil of vaseline, and other local treatment
referred to in the chapters on acute and chronic inflammation of the
pharynx, tonsil, and larynx, should be carried out.
New growths of the pharynx and tonsils. — A. Benign Neoplasms.
— It is as little possible in the present state of knowledge to assign
any definite cause for the appearance of benign neoplasms in the fauces
as elsewhere, with the sole exception of dermoid tumours, which very
rare growths are abnormalities of development.
Benign growths are not of frequent occurrence in the fauces.
Papilloma is by far the most common form ; the small, warty, sessile or
pedunculated, light pink growths, Avith cauliflower or granular surface,
being usually attached to the margin of the soft palate, the pillars of the
fauces, or the uvula. Next in point of frequency comes the adenoma, a
hard, rounded, sessile growth of slow development, covered Avith smooth,
irregidarly rounded mucous membrane of normal appearance, arising in
the mucous membrane of the anterior or posterior surface of the palate or
in the tonsil, and often attaining a considerable size. Fibroma is very
rarely met Avith in the fauces, though it is more common in the rhino-
pharynx, Avhere as a rule it is attached to the A'ault of the pharynx.
These tumours are somcAvhat rapid in their growth, and may become as
large as a hen's egg or a small orange. They are hard, rounded, smooth
and red on the surface, and sometimes highly Avascular.
Anijioma may occur as pui-ple, nodular, soft, A-ascular growths, com-
posed of enlarged tortuous blood-vessels held together by a small amount
of connective tissue. Calcareous concretions occur in the tonsil and
rarely in the soft palate, and, being covered by mucous membrane, the
SAvelling may simulate a groAvlh.
DISEASES OF THE PHARYNX 753
Diagnosis. — Papilloma often bears a very strong resemblance to a
warty epithelioma. There is generally no infiltration of the neighbouring
tissues, and no zone of hyper£emia around the benign neoplasm ; but a
microscopical examination of the removed growth should always be
made.
Fibroma and adenoma are very similar in aspect and consistence, but
the former are much rarer than the latter, and develop more rapidly.
Prognosis. — The prognosis as regards life is ahvays favourable ; and
the same may be said of the results of operative interference, as they do
not tend to recur after radical removal.
The symptoms manifested by all these benign growths are mainly due
to mechanical interference with the action of the soft palate, with
deglutition and phonation, or, if very large, with respiration ; and the
severity of the sym])toms depends chiefly on the size of the growth. A
papilloma on the tip of the uvula may give rise to the usual symptoms of
elongated uvula. Fibromas are sometimes rather painful, especially if
large ; and, like any large growth in this region, may give rise to a sense
of fulness and discomfort.
Treatment. — A papilloma should be* cut off, and the tissues immediately
around the seat of attachment included in the excised portion. An angioma
may be removed by the galvano-cautery snare ; but haemorrhage is apt to
be considerable if precautions are not taken to prevent it. The other
forms of growth should not be removed unless their presence occasion
inconvenience or pain. Fibroma, especially of the rhino-pharynx, may
give considerable trouble in removal. A description of the many surgical
methods employed to overcome this difficulty is outside the scope of this
work.
B. Malignant Neoplasms. — Both carcinoma and sarcoma occur with
tolerable frecpiency in the fauces and pharynx.
The causes of malignant growths in this region are as obscure and ill-
defined as are the causes of similar growths occurring in other parts of
the body ; heredity and local irritation seem to exercise some influence in
their occurrence. Almost invariably the pharyngeal growth is primary,
or due to extension from neighbouring structures ; malignant disease in
this j-egion is very rarely secondary or "metastatic."
The male sex is more frequently attacked than the female ; especially
is this the case with carcinomatous growths. It is rare for carcinoma to
appear before the age of forty, and the great majority of all forms of
malignant disease of the pharynx do not begin till after the fifth decade ;
sarcoma, however, may occur at any age.
Pathology. — The morbid anatomy of growths occurring in the pharynx
does not differ in any way from the usual structure of similar growths in
other regions. Primary carcinoma either occurs in the soft palate or
pillars of the fauces, the tonsil, rhino-pharynx, or the lower pharynx at
its junction with the oesophagus.
If arising in the soft palate it generally soon spreads to the tonsil, or
from the pillars of the fauces to the tongue ; Avhile carcinoma of the lower
VOL. IV 3 0
754 SYSTEM OF MEDICINE
pharynx tends to involve the larynx, so that it is often impossible to
dcrino the seat of origin. The growth presents an nncven suiface and
soon ulcerates. In its earlier stages epithelioma usually appears as a
wart-like growth surrounded by hyperajniic, infiltrated tissue. At first it
grows rather slowly, but, as it attains a considerable size, it rapidly spreads,
involvinii surionndin^ structures in all dii'cctions. The growth sometimes
forms a large tumour ; bnt in other cases it soon begins to break down in
the centre, the ulceration extending laterally as well as in depth, fresh
nodules fo;'ming in the immediate neighbourhood of the hard, elevated
margin, soon to be included in the ever-advancing ulcei-ation. The base
of the ulcer is covered with muco-pus and breaking-down tissue, in the
midst of which uneven ridges of the growth and ulcerating nodules are
seen; but no granulation tissue is formed and scarring never takes place.
The glands of the neck, and particularly those under the angle of the
jaw, are soon extensively involved, whether the growth arise in the fauces
or rhino -pharj^nx ; when the laryngo -pharynx and (esophagus are the
primary seat, the cervical glands are not so rapidly implicated.
The varieties of sarcoma met with in the fauces and pharynx
comprise lympho-sarcoma, round-celled sarcoma, mixed round and spindle-
celled, spindle-celled, alveolar, melanotic, and myxo-sarcoma. Lympho-
sarcoma is probably the most common variety, and ]\Ir. Butlin has
suggested that a connection probably exists between this form of
growth in the fauces and Hodgkin's disease ; and that in some cases
the primary lymphoid deposit occurred in the faucial lymi)hatic tissues.
While it is beyond dispute that many cases of sarcoma of the fauces
and tonsil display a mild malignancy, and that instances occur in which
the faucial lymphoid tissue becomes involved in the course of Hodgkin's
disease [lide p. 579], it is most unusual to see the latter aflection following
the ai)pearance of sarcomatous growths in the fauces. Kundrat has
observed lymj)ho-sarcoma in two cases of pseudo-levd\temia ; Chiari states
that leukiemia and pseudo-leukamiia are distinguished from lympho-
sarcoma of the throat by the infection of the lymphatic glands of the
whole body as well as of the spleen and liver. Sarcoma grows some-
what rapidly ; and when the growth has attained any size, the nuicous
membrane covering it is succulent and bright red in aspect, and it
infiltrates and displaces the neighboiu'ing structiu'cs. It ])egins in the
tonsil, or in a lymphoid follicle of the mucous membrane of tlie soft
palate, ])illars of the fauces, or rhino-pharynx. It is less hard than
e]nthelioma, and sometimes is soft and gives the sensation of a cyst or
abscess. The rate of growth varies a good deal ; in some cases it
remains localised for a considerable period, or for a time may diminish
in size. It spreads by extension to the neighboiu'ing regions, and very
generally involves the deeper tissues behind the angle of the jaw, so as
to cause large swellings in the neck ; sarcomas in the fauces or tonsil, on
the contrary, not infrerjuently remain distinctly localised and more or less
encapsuled for a long time, and tlieii it is diily wlien they extend beyond
the limiting capsule that they increase rapidly and involve neighbouring
DISEASES OF THE PHARYNX 755
structures and glands. Ulceration does not occur very early, and when
it does it is usually superficial, and haemorrhage very slight.
Lympho-sarcoma of the throat is a rare affection, and generally occurs
in middle-aged men. 0. Chiai^i, who has made a special study of this
variety of pharyngeal growth, states that it arises either on one of the
tonsils or in the lymphoid follicles of the soft palate or rhino-pharynx ;
or the lymphatic glands of the throat, mostly on one side, may be
attacked, and from them conical tumours may grow towards the throat,
causing more or less narrowing of the space. Lympho-sarcoma appears
either as a definite tumour on the tonsil or as an infiltrating growth ; in
either case ulceration and breaking down of the surface soon occur.
Thus the larger tumours or the flat complex of smaller growths break
down or suppurate. The resulting ulcers may heal partly or entirely,
and even deep scars may be formed ; yet soon fresh points of infiltration
appear on the edge of the old ulcer, either as yellowish mari'ow-like
nodules or simply as diffuse thickening. In this way the process spreads
superficially. Sometimes the degeneration and the breaking-down pro-
cess are accompanied by febrile disturbance. Like other forms of
sarcoma, the lymph o-sarcomatous tumour may, temjDorarily, diminish
in size.
Symptoms. — Carcinoma of the fauces is usually accompanied by pain
of gradual onset, increased but not induced by deglutition, and lancinating
in character, darting up to the ears. Salivation is often present. The
voice becomes throaty or nasal in quality. A large growth may produce
considerable dysphagia. Difficulty in swallowing, indeed, is often the
earliest and most marked symptom in growths occupying the laryngo-
pharynx ; obstruction to nasal respiration and a sanious muco-purulent
discharge occur rather when the rhino-pharynx is the seat of the disease.
The breath becomes foetid when the tumour breaks ' down, and cachectic
symptoms are. seldom long delayed. In sarcoma and lympho-sarcoma the
symptoms generally consist chiefly of mechanical obstruction to respiration
and deglutition, and alteration in the equality of the voice. Pain is not
usually a marked symptom, though generally noticeable when superficial
ulceration has occurred. With the further progress of the growth deep
ulceration with foul muco-purulent discharge, cpiickly-increasing extension
of the disease, pain, loss of appetite and general weakness become manifest,
and the patient then rapidly sinks.
Diagnosis. — The differential diagnosis of these forms of malignant
growths often presents many difliculties : first, in distinguishing between
the different varieties of malignant growths, a point of importance as re-
gards prognosis and the advisability of operative interference ; and,
secondly, in distinguishing them from benign growths and various infective
diseases.
Carcinoma differs from sarcoma in the early onset of pain, its irregular
surface and infiltrating character, and the rapid secondary infection of the
neighbouring glands ; early fixation of the lower jaw and the early
appearance of cachectic symptoms being in favour of carcinoma. The
756 SYSTEM OF MEDICINE
growths are usually harder on palpation, jiale pink or even l)luish pink in
colour, and are surrounded with a Avell-marked areola. Ulceration and
hemorrhage occur early ; the margin of the ulcer is ulcerated, raised, and
irregular, and the floor is co\-ered with characteristic cauliflower vegeta-
tions. A sarcoma is softer, smoother, and more succulent in aspect, covered
with light pink or yellowish pink mucous memlmme, and ulceration is
often delayed. The ulceration tends to remain superficial, but Avhen the
growth does break down there is a copious seci'etion of ichorous muco-pus.
Lympho-sarcoma differs from sarcoma and carcinoma in that these
arise as more or less globular tumours, the ulceration of which shows less
tendency to spread on the surface. The lympho-sarcomatous ulcer is
thickly covered with ichorous pus, but the floor shows no cauliflower
excrescences. Moreover, the lympho-sarcomas show greater tendency to
diminution ; and the ulceration often heals, at an}' rate for a time.
In all forms a microscopical examination of removed fragments of the
growth will generally decide the question of diagnosis ; but it is necessary
to proceed in this research with great caution : first, we must obtain a
piece which includes the deeper tissues of the tumour, for superficial
portions may only show normal or inflammatory tissue without evidence
of malignancy ; and, secondly, we must distinguish between the varieties
of cai'cinoma which closely resemble sarcoma.
The diseases most likely to be mistaken for malignant growths, and
convei'sely, are chronic hypertrophy of the tonsils, tonsillitis, benign
growths, syphilis, tuberculosis, lupus, diphtheria, and chronic retropharyn-
geal abscess. Chronic hypertrophy of the tonsils is almost invariably
bilateral, and is essentially a disease of early childhood and adolescence ;
and although enlarged tonsils dating from childhood may persist through-
out life, yet an enlargement beginning in an adult, especially if unilateral,
must always be regarded wath grave suspicion.
A sarcoma may be mistaken for gumma, and especially for a gumma
which looks yellowish and marrow-like just before breaking down ; the only
trustworthy distinction, indeed, consists in the failure of syphilitic medi-
cation. An ulcerating sarcoma, especially if ulceration be attended with
febrile distiu'bance, may resemble acute tonsillitis, or peritonsillitis; but the
more gradual onset, slight constitutional disturbance, and al)scnce of acute
pain or tenderness, would serve to distinguish these aftections apart from
the aspect of the growth. Sometimes an ulcerating sarcoma, and more
especially a lympho-sarcoma, is covered with a thick layer of muco-pus
which may simulate diphtheria or syphilitic ulceration. The ])rescnce of
fresh nodules of growth around the margin, the shape of the ulcer, and
the fact that it is always single, together with the general condition and
freedom from albiuninuria and from characteristic bacilli in a culture,
woulfl point to a maliL^nant growth.
Syphilis is more likely to be diagnosed when a malignant growth has
undergone extensive breaking down with deep ulcei'ation. Very often
only a microscopical examination of a removed fragment and the adminis-
tration of iodide of potassium will settle the question. Yet it is always
DISEASES OF THE PHARYNX 757
important to remember that a temporary subjective amelioration, and
even a transient diminution in the size of a malignant growth, may be
produced by the exhibition of iodide of potassium. Too much stress
ought not to be laid on the history of a syphilitic aftection, or evidence of
old syphilitic scars, and the like ; for, on the one hand, in syjjhilis a history
of infection is often unobtainable, and on the other hand malignant disease
not infrequently occurs in syphilitic subjects.
The jDeculiar apple- jelly dike nodules of infiltration around lupus ulcers
should prevent an error in diagnosis as regards this disease.
Similarly ulcerating sarcoma may bear a strong resemblance to tuber-
culous ulceration ; more especially is this true of lympho-sarcoma.
Tuberculous ulcers are more superficial, have mouse-nibbled edges, and are
usually multiple. If no concomitant pi;lmonary symptoms are detected,
the examination of the muco-purulent secretion will reveal the tubercle
bacilli ; while the frequent pulse and nocturnal rise of temperature should
lead to a suspicion of this disease. Of course the presence of pulmonary
tuberculosis does not exclude the possibility of a malignant tumour in
the pharynx.
A warty epitheliomatous growth on the fauces may closely resemble
a benign papilloma ; yet it difters from it in growing from an indurated
base, and in l)eing surrounded by a zone of hyperaemia and infiltrated tissue.
Similar points of distinction serve to differentiate malignant growths and
fibroma ; but a sarc(5ma may appear so truly benign in aspect, in rate of
growth, and in the absence of any enlargement of neighbouring structures
a: id glands, that the only means of diagnostic distinction may be in a
microscopical examination of a removed fragment (the possible sources
of error will be fully discussed in the chapter on malignant disease of the
larynx, p. 839). The same difficulty may arise in the distinction of the
rarer forms of benign growth, such as adenoma, and malignant growths.
Chronic retropharyngeal abscess occurs in an unusual site for sarcoma,
and presents a smooth swelling which fluctuates on digital exploration,
and is sometimes associated with cervical caries. Aspiration of the
tumour would, of coiu-se, reveal its true character at once.
Prognosis. — The prognosis of carcinomatous growths in the pharynx is
very grave. To this statement an exception may be made in the case
of small warty growths which appear on the soft palate or uvula, and
which may be radically extirpated in an early stage.
A sarcoma occurring in the fauces is a more hopeful affair, especially
the less rapidly-growing spindle-celled variety and the lympho-sarcoma.
These growths may remain encapsuled for a long time, so that a relatively
favourable prognosis is justified when secondary extension is slow to
appear, inasmuch as a radical operation is often completely successful. It
is hardly necessary to say that any form of malignant growth, especially
in a region so difficult of access as the tonsils or fauces, not to mention
the rhino-pharynx, is peculiarly grave ; but on the other hand there is
too great a tendency to overlook the fact that many recorded cases prove
that a radical operation has been completely successful, especially of late
758 SYSTEM OF MEDICINE
years ; and from personal experience Ave would emphasise the importance
of not regarding malignant disease in this region as invariably hopeless.
Trcatiiu'tit. — From a therapeutic standpoint the importance of early
diagnosis and early I'adical removal of malignant growths cannot be too
strongly emphusised ; for once the growth has extended beyond the
structures which permit of complete removal, or has affected the neigh-
bouring lymphatics, it is hardly possil>le to hope for lasting cure ;
whereas, as has already been stated, early and complete extirpation —
especially of late yeai-s — has jDroduced most brilliant and permanent
results. In considering the advisability of attempting a radical operation,
the surgeon will be guided not only by the situation and limitations of
the gi'OAvth, but also by the particular variety of malignant tumour to be
dealt with ; for an encapsuled or well-defined sarcoma, especially if it be a
lymplio-sarcoma or a spindle-celled sarcoma, may be permanently removed,
although a similar procedure in the case of encephaloid cancer would
probaljly l)e tmsuccessful.
The choice lies between removal through the mouth by the knife,
snare, or ecraseitr, and lateral pharyngotomy. One of us (F. S.) has
seen several very successful cases of early operation from the outside.
It is impossible, hoAvever, to lay down rules for guidance in Q\ery
case ; each has to be judged on its own conditions.
On the other hand, growths may require partial removal Avhen there
is danger of suffocation or difficulty in swallowing ; and pharyngeal
or oesophageal constriction may necessitate gastrostomy or lateral oeso-
phagotomy.
AVhen a radical operation is impossible, or has been folloAved by
recurrence of the growth, all that can be done is to maintain the patient's
strength by nourishing diet and suitable tonics, and to alleviate pain by
opium. Ulcerating growths should be cleansed with antiseptic sprays
and gargles.
DISEASES OF THE PHARYNX
759
The following tul)le, compiled by one of us (W. A^'^.), summarises the
main })oints of distinction between several of the diseases of the pharynx
and fauces : —
Carcinoma.
Sakcoma.
Chancre.
Symptoms. — Dysphasia is
always an early syniptoiii,
and pain is considerable and
persistent, but of gradual
onset. Increased pain on
swallowing becomes so great
as to prevent the patient tak-
ing food.
Saliva accumulates in the
mouth.
Early and vv-ell - marked
cachexia, and rapid loss of
flesh.
Physical Signs. — Carcinoma
always presents an enlarge-
ment with superficial irregu-
larity of surface, which is light
pink or bluish, and soon
ulcerates with granular lis-
sured surface, haitl elevated
margin, general cartilaginous
hardness and fixedness. Ul-
ceration not very <leprrssed,
covered with fuetid nmco-
pus.
Early infiltration of neigh-
bouring glands.
Hiemorrhage frequent and
often profuse, sometimes
fatal.
Generally unilateral.
Symptoms. — Difficulty and
pain in deglutition, some-
times very slight, and, until
ulceration occui's, is chiefly
mechanical.
Saliva accumulates and
dribbles from the mouth.
Loss of flesh generally
rapid.
Physical Signs. — Sarcoma
attains considerable dimen-
sions before ulceration com-
mences. The growth is led,
fleshy-looking, and soft, sur-
rounded by a well-marked
bright red areola.
Spreads to neighbouring
regions and externally to tlie
neck, — especially lajiid is the
extension of round-celled sar-
comata.
Hiemorrhage is frequent
and sometimes fatal.
Generally unilateral.
Fiinct io n a I Sy7nptoms. — The
first symjjtom is a stinging
jiain in the tonsil, but with
little ]iain on swallowing,
whichisneversodiftlcultasin
cancer or in tertiary syphilis.
Cancer occurs in late
nuddle life, but sarcoma may
also occur in the young;
chancre generally in young
adults.
Physical Signs. — The sur-
face is very red, but there is
always a well-defined erosion,
with .sharply - cut margin
from the cominencenient. In-
duration or even stony luird-
ness. The submaxillary
glands early enlarged.
Like cancer and tertiary
syphilis, and unlike second-
aiy, it is unilateral.
No hfeniorrhage, only
streaks of blood.
No emaciation, early ap-
pearance of secondary rash,
etc.
Responds well to treat-
ipent.
Syphilis,
Secondary and Tertiary.
Tuberculous Ulceration.
Acute Tonsillitis.
Si/mptoms. — Often no pain
whatever, and swallowing
often difficult, never impos-
sible. Wasting and cachexia
in proportion to the difficulty
in taking nourishment, and
not very pronounced. No
salivation.
In secondary syphilis of
the tonsils and fauces there
is generally bilateral deposit
of mucous patches and super-
ficial ulceration, with well-
marked purplish areola.
In tertiary syphilis the ton-
sils are unilateially affected
by a deep perforating ulcer.
The margins of the ulcer
are often undermined, and
overhang the deep-lying ulcer,
the floor of which is covered
with necrotic tissue.
The sympathet'c glandular
enlargement is slight, and
not painful as in cancer.
Hsemorrhage slight or ab-
sent.
The rapid improvenipnt
under antisyphilitic remedies
is always a valuable sign.
Symptoms. — Swallowing is
always very painful, and loss
of flesh rapid, with nocturnal
rise of temperature, and a
general well-marked tuber-
culous cachexia is always pre-
sent. There is early and
rapid infiltration of the parts
around, with very early tend-
ency lor fluids to return
through the nose on swal-
lowing.
Physical Sfpus. — General
pallor, with diftuse infiltia-
lion of the affected region.
Early superficial, irregular,
mouse -niobled ulceration,
with gray debris. In the
earlier stages the deposits of
miliary tubercles are very
characteristic ; these ulcer.ite
and coalesce. No inflamma-
torv areola.
Hiemorrhage generally ab-
sent.
Usually concomitant dis-
ease of larynx and lungs.
Functional Symptovis. —
Pain very marked from the
commencement, great ten-
derness and difficulty in swal-
lowing. Generally some rise
in temperature. Usually
both tonsils affected, though
one after the other.
Physical Signs. — Character-
istic redness and inflamma-
tory infiltration. Lacunar
exudation, but no ulceration.
May proceed to suppuration.
Chronic abscess of the tonsil
may be diagnosed by incision
and discharge of pus.
Responds well to treat-
ment.
F. S. and W. W.
76o SYSTEM OF MEDICINE
Pharyngeal Neuroses. — {a) Motor Neuroses. — The motor neuroses of
the pharynx may be conveniently divided into spasmodic neuroses and
paralyses.
Spasm of the pharyngeal muscles is nearly always a functional
disorder. It is a rare ati'ectioji, interfering with deglutition, generally
met with in nervous and hysterical patients. It may occur in association
with various acute inflammatory processes, such as acute tonsillitis.
Spasm of the pharynx is a pi-oniincnt symptom in hydrophobia, and has
l)ecn oljserved in a case of cerebral tumour. Courmont records a case of
tonic spasm in tabes. Clonic spasm of the levator palati gives rise to a
peculiar clicking sound audible to the patient and those around. The
cause is obscure ; but by some observers it is regarded as a reflex neurosis,
and therefore any possible source of irritation should be removed.
In some cases local api)lication of the galvanic current has proved
useful in relieving spasm. When due to hysteria or associated with
neurasthenic constitutional states, nervine tonics, rest, and change of air
are indicated.
Paralysis. — The experimental results of Horsley and Eeevor show
that the soft palate and uvula, the levator palati and the pharyngeal
constrictors are innervated by the spinal accessory fibres in the pharyngeal
plexus, and not by the vagus. The tensor palati is supi)lied by the fifth
nerve. Thus paralysis of the soft palate may be caused by central nerve
lesions involving the spinal accessor}^ or by peripheral neuritis and
pressure on the nerves to this region, or the paralysis may be myopathic.
The paralysis is generally unilateral, but may be bilateral.
Paralysis of the palate from bulbar disease may Ijc due to acute or
chronic myelitis involving the spinal accessory nuclei, to bulbar apoplexy
or embolism, to tumours, or to basilar meningitis.
Acute bulbar paralysis is characterised by the sudden onset of giddi-
ness, headache, and sometimes vomiting, with unsteadiness of gait, but
with no loss of consciousness. The voice becomes nasal and thick, and,
the lips ami tongue being involved, articulation is difficult. The
dys[)hagia increases, and finally respiration becomes irregular, and the
pulse small and frecpient from the progressive implication of the various
bulbar nuclei.
Chronic bulbar or glosso-labio-laryngeal paralysis generally begins in
the tongue ; then the lips, velum palati, and pharyngeal constrictors are
involved ; and very often the abductors and internal tensors of the vocal
cords likewise. Speech liecomes nasal in tone, articulation very imperfect,
and swallowing very difficult, and liable to result in the food passing into
the larynx. The va go-accessory nuclei being concerned, the pulse is
often persistently frequent, respiration may become shallow and inrguhir,
and attacks of periodic dyspufca are not uncommon towards the end.
Unilateral paralysis of the tongue, palate, and larynx, first described by
\)i\ Hughlings Jackson, is of special interest from the light it throws on
the innervation of the soft palate ; inasmuch as it implies that the motor
innervation of the organ is supplied by the accessor}' in agreement
DISEASES OF THE PHARYNX 761
with the experiments to which we have referred above. Moreover, in
several cases the trapezius and sterno-mastoid Avere also paralysed, and
thus both branches of the accessory were aifected, whilst there was no
symptom pointing to an affection of the vagus.
Post-diphtheritic neuritis is the most common cause of palatal paralysis.
A similar condition may probably be caused hj membranous sore throat
not associated with the Klebs-Loffler bacillus, and from acute lacunar
tonsillitis.
Paresis of the palate and constrictors of the pharynx may be due to
hysteria, or to general weakness in the anajmic and debilitated.
The si/nyjtoms and signs of paralysis vary as it is unilateral or bilateral.
When the lesion is unilateral, the uvula is drawn towards the healthy
side, and the velum palati is drawn down by the palato-pharyngeus and
palato-glossus on that side ; if bilateral, the velum palati hangs loosely
and does not res2:)ond to local stimulation, the voice is nasal, and fluids
escape by the nose during deglutition. As the paralytic condition
of the pharyngeal constrictors becomes better marked, deglutition gets
more and more difficult, and the difficulty in swallowing fluids is always
greater than for solids, in contradistinction to the difficulty in swalloAving
due to obstruction, when, as we should expect, it is first noticed, and is
always more pronounced in the swallowing of solids.
It is necessary to distinguish from true pharyngeal paralysis the
very similar appearances which may result from inflammatory exuda-
tion and mechanical interference with the movements of the soft palate
resulting from syphilis and other forms of local disease.
The view that paralysis of the palate is due to and accompanies
paralysis of the facial nerve has nowadays lost most of its former
adherents.
The ireatinent of pharyngeal paralysis will, of course, depend on the
causes. In many cases local treatment is obviously of no use whatever.
Post-diphtheritic paralysis should be treated by hypodermic injections of
strychnine and local faradisation.
(b) Sensor// N'euroses. — Ancesthesia, partial or complete, may be uni-
lateral or bilateral, The commonest cause is diphtheria ; but it may
occur in hysteria, bulbar paralysis, and in insanity ; it is also produced
by pressure on a glosso-pharyngeal nerve by tumours near the exit of the
nerve from the skull, or by intracranial tumours, gummas, etc. It is
nearly always associated with neuroses of sensation and paralyses of the
velum and larynx.
Hyper cesthesia and parcesthesia of the pharynx are often met with,
apart from any organic disease, in ansemic and neurotic patients ; but in
many cases some slight affection of the tonsils or granular pharyngitis
is the source of a discomfort altogether out of proportion to the cause.
Very similar painful or uncomfortable sensations in the pharynx are
often found in gouty patients, in the early stages of pulmonary phthisis,
of cancer of the pharynx, and so forth. Both in men and women there
is a very intimate connection between the whole region of the upper
762 SYSTEM OF MEDICINE
respiratory tract, the nose, pharynx, and larynx, and the sexual organs ;
and many of the more obscure neuroses of these resjions have a sexual
basis. That sucli a special if somewhat mysterious connection exists,
has long been known. Its physiological con-elation in man is found in
the sudden development of the larynx during the time of puberty,
particularly in men, accomixanicd by characteristic changes in the voice,
known as the "break of the voice"; whilst in the woman a slight
huskiness of the voice and other indefinite phenomena are often notice-
able at the time of menstruation ; jn-actised singers often notice the
deteriorating influence of the menstrual period on the voice. The
effect of castration of boys in modifying these changes in tlie larynx is
well known. In the lower animals this physiological connection is seen,
again, in the "roaring" of the othcrAvise silent stag at the rutting time;
while numerous well-authenticated cases of vicarious bleeiling from the
nose or pharynx, replacing the menstrual flow more or less completely,
have been recorded.
While the influence of the sexual organs on the respiratory organs
is most ob\iously recognised in the larynx by the alterations in the
voice, many of the purely subjective neuroses are referred indefinitely to
the throat region generally. As Schadewaldt pointed out, the power of
localising sensations felt in the throat is very defective })hysiologically as
well as pathologically ; " the sensations in the most difi'erent parts of the
organs of the neck arc, as a rule, jointly referred to a region in which,
so to speak, the joint sphere of sensation (the sensorium commune,
according to analogy) of the entire throat is situated." This region is
the front part of the neck, the " laryngo-tracheal region" (Gottstein).
It is therefore of no use to attempt to distinguish the subjective sensory
neuroses of the pharynx from the rest of the upper respiratory tract, as
an attempt of this kind might easily lead to therapeutic mistakes.
Chlorotic and antemic girls, and Avomen at the climacteric period, very
frequently suffer from par;i?sthesia of the throat region ; but it is the
latter class who afford the great majority of instances and in the aggra-
vated forms. The "sensory throat neuroses of the climacteric period," as
they have been called by one of us (F. S.), may be classed under two
headings, " paraesthesia " and " neuralgia " cases, the former class being the
more frequent. We have never seen a case of ansesthesia of the throat
due to the climacteric period. The majority of cases of climacteric
throat neuroses occur in women who are by no means of a neurotic
or hysterical type. Most frequently patients complain of unpleasant
sensations which often enough cannot be described exactly ; in some
cases they are general, in others they shift from one part to the
other. In other cases, again, the patients speak of general or ])artial
" soreness," " dryness," " tickling," of a desire to be constantly " scraping,"
or "hawking" and "hemming," of sensations of "choking" or "strangu-
lation," or of a feeling as if the throat were " wooden " ; very frequently
there is a sensation as of a foreign body, variously compared to a crumb
of bread, a bone, a hair, or a needle, or a constant desire to " swallow
DISEASES OF THE PHARYNX 7^3
empty," or feelings of heat or cold. But in very many cases one sees
how the patients strive in vain to describe exactly what they feel, and to
define the seat of the sensation. Much less frecpiently there are " neur-
algic " sensations, described as a fixed pain on one side of the throat, some-
times radiating to the ear and temporarily diminished by swallowing.
The intensity of these neuroses varies most remarkably ; in some, the
sensations are merely felt as an inconvenience ; in others, the subjective
troubles are of a more severe kind. The patients not rarely even cry
whilst relating the histoiy of their ailment ; and the general depression
accompanying the affection is sometimes so great that in a good many
cases the patient dreads cancer, consumption, syphilis, or some other
organic disease of the throat.
The throat symptoms complained of may be the only sign of the
approaching change of life ; or sometimes may even precede the menstrual
irregularities ; in other cases they follow the usual uterine disturbances
of the climacteric period, or are associated with dyspepsia, insomnia, and
other complications commonly observed at the menopause.
Objectively there may be little or absolutely nothing to be seen in
the throat. In some cases a few small ])haryngeal granulations, or a slight
enlargement of the lingual tonsil, or some hardly noticeable thickening of
the lateral folds of the pharynx, are detected. It is important to guard
against two sources of error ; namely, of overlooking some actual and
tangible cause of the affection, or, on the other hand, of wrongfully attri-
buting the neuroses to any slight abnormality. The olijective symptoms
in the cases which belong to the domain of parsesthesia and hypertesthesia,
and of the sensory neuroses of the climacteric period, are either conspicu-
ous by their absence, or the changes found are so slight as to make it
extremely unlikely that they can be held responsible for the subjective
phenomena. On the other hand, it ought to be remembered that par-
sesthesia, hypersesthesia, or neuralgia of the throat may be the first sign of
malignant disease of the part or of its neighbourhood ; and that the age
at which the climacteric neuroses come under observation is identical with
that in which the beginning of malignant mischief is most frequently
observed. Before arriving at a diagnosis of sensory throat neuroses, we
must first, by careful examination, exclude chronic pharyngeal catarrh in
its definite forms, considerable nasal stenosis, a foreign body, considerable
enlargement of the lymphatic tissue at the base of the tongue, general
anjemia of the pharynx — particularly in cases of commencing tuberculous
disease of the lungs, ami general neurasthenia or hypochondriasis.
The treatment of sensory neuroses will of course depend on the cause.
In bulbar paralysis and other central organic nervous affections treatment
is practically useless ; while in post-diphtheritic ancesthesia the treatment
is the same as that indicated in the motor paralysis with which it is
almost invariably associated ; namely, gentle faradism or galvanism com-
bined with hypodermic injections of strychnine. As regards hyper-
aesthesia and aucesthesia, the treatment must be directed to improve the
general health and to remove any possible local cause ; and in cases in
764 SYSTEM OF MEDICINE
Avhich there is an}' reasonable doubt whether the neuroses be due to the
climacteric period or to some local mischief, tlie latter should always be
treated, while at the same time our suspicions that the affection depends
upon the " change of life " ought to lead us to feel that if the local therapy
fails to give relief the patient should not l)e discouraged, but should be
induced to look forward Avith confidence to its sjiontaneous disappearance
in course of time. In cases of neuralgia particularly the probe ought to
be used in oixler to ascertain whether there be any tender spot in the
painful part ; anaemia and chlorosis should be treated by the cautious
use of iron and arsenic. The usual local remedies — astringents and
caustics — are generally quite useless, or have but a very transitory effect;
and their indiscriminate use is to be strongly condemned, inasmuch as
this w;.ole period of a woman's life is in itself associated often enough
Avitli a state of mental depression : thus, after the failure of local means,
patients are prone to become still more depressed and more than ever
convinced that their ailment is really of a serious nature. This caution
applies particularly to the use of narcotics, such as opium, cocaine, bromide
of potassium, and the like, which, whether locally or constitutionally em-
ployed, after a very short time lose their effects, and the patients either
become enslaved by a pernicious habit, or by abstinence from the accus-
tomed drugs their general and local sufferings are consideraljly increased.
In severe cases of paresthesia, and more particularly in cases of neuralgia,
we should use those drugs only which cannot do any possible harm, such
as menthol in spray and general tonics. The best effects are certainly
obtained in those climacteric cases in which the throat neurosis is associ-
ated with considerable increase in bulk, digestive disturbances, and gouty
manifestations. In such cases, if the patients can be persuaded to go
through a mild course of the mineral waters of Carlsbad, Marienbad,
Kissingen, Aix-les-Bains, or Vichy, a disappearance of all the symptoms
complained of and a restoration of balance are often much sooner ol)tained
than in ordinar}' forms of climacteric neurosis. But in the great majority
of cases no treatment other than moral influence is either necessary or
desirable.
Foreign bodies in the air and upper food passages.^t is con-
venient that the suljject of foreign bodies in the fauces, pharynx, larynx,
and trachea should be considered together for two reasons : first, on
account of the very important fact that the power of localisation of
sensations felt in the throat is extremely defective, and sensations arising
in any part of this region are generally subjectively referred to one
common region, namely, to the front part of the neck corresponding to
the larynx and upper part of the trachea, the lari/ngo-tracheal region ; and,
secondly, because the invading body is obviously liable at any moment
to pass from one region to another, with or without modification in the
symptoms presented. These remarks do not apply to the same extent
to the nasal passages proper [vide p. 701].
It is unnecessary to enumerate the various foreign bodies that may
become impacted in the throat ; our purpose is mainly to consider the
DISEASES OF THE PHARYNX 765
chief difficulties that may be encountered in the diagnosis, and the prin-
ciples that should guide us in the treatment of these cases.
In a considerable proportion of the patients who present themselves
for the removal of foreign bodies in the throat, the foreign body has
already been dislodged, and it is the persistent sensation only which leads
the patient still to believe that it is actually there. These after-sensa-
tions of pain, pricking, and soreness, or of the actual presence of the
foreign body, are apparently far more lasting in this region than is
the case in other sensitive parts, such as the eye ; and it is important
to remember that in spite of the most positive assurances, even of educated
persons, that the foreign body is still present, it may long have passed
down, leaving behind, however, strangely vivid and persistent after-sensa-
tions : more especially is this the case Avhen foreign bodies have been im-
pacted in the pharynx, tonsils, and the upper part of the oesophagus. On
the other hand, we cannot too strongly insist on the necessity for a most
thorough and methodical examination of all the parts in cpiestion ; and
only after a positive exclusion of the possibility of the continued presence
of the foreign body are we warranted in arriving at a diagnosis of a per-
sistent after-sensation only, and in telling the patient that the foreign
body is no longer impacted.
In all cases except those of immediate urgency (see farther on under
the head of " Treatment ") the examination should be begun by inspection,
and not by digital exploration. Palpation may be desirable or necessary
when inspection has failed; but it is always attended with the risk of dis-
lodging the foreign body and driving it farther down, possibly into the
lower air-passages ; while in the case of small pointed bodies, such as fine
fish-bones, pins, and needles, which are already deeply buried in the
tissues, the still projecting portion may be pushed in still farther and
completely buried, whereby subsequent attempts at removal are made
more difficult if not altogether frustrated. For the same reason, if
cocaine is to be used to diminish the soreness and irritability of the parts,
it should be applied by means of a spray, and not by a brush, which is
open to the risk of producing the same undesirable result as digital ex-
ploration. For the inspection of the throat a good light is essential, and
the examination should extend to every region in turn, and not be limited
to an inspection of the one part which the patient indicates as being in
his opinion the place where the foreign body is lodged ; inasmuch as the
subjective sensation of localisation is very deceptive. This fact is well
illustrated by the personal experience of one of us (F. S.), in whom the
sensations caused by a piece of partridge bone impacted in the throat
were felt at a distance of at least two or three inches from the spot where
it was really impacted. A patient may positively state, as he did in his
own case, that he felt sure the foreign body was impacted in the region
of the larynx, whereas in reality it had stuck in the posterior wall of the
pharynx behind the uvula. This instance well exemplifies the necessity
for a really methodical examination ; and an observer who trusts the
patient's statements in these cases, and only examines the laryngeal region,
766 SYSTEM OF MEDICINE
neglecting a thorough inspection of the fauces and naso-pharvnx, may have
the mortification of liearing afterwards that anotlier physician had actually
removed the foreign body from a part unsuspected.
It is advisable, therefore, to begin the examination with inspection of
the fauces, particuhu-ly noting that the foreign body is not lying con-
cealed by the anterior pillars of the fauces or by the tonsils. Next we
should observe the glosso-epiglottic fossa? and lingual tonsils, before
thoroughly examining every part of the larynx and the upper end of the
oesophagus with the la)yngoscopc ; finally, the rhiiio-phai-ynx should be
explored. Particular care should be taken when the foreign body is a
fish-bone ; for, if so deejjly impacted in the tissues that only a small part
projects, it is sometimes extremely difficult to discover it; the more so
as strings of tenacious saliva extending from one part of the throat to
another often closely simulate it. In such cases examination Avith the
probe, under the guidance of a good light and, if necessary, of the
laryngoscope, ought to establish the actual existence of the supposed
body in the tissues before an attempt is made to introduce forceps or
other instruments for removal.
Quite recently our means of detecting foreign bodies in the upper air
and food passages, those at any rate Avhich are impenetrable to the
liontgen X rays, have been enriched by the introduction of that method
of examination ; and there can l)e no doubt that it will prove of the
highest value in cases in which coins, buttons, needles, bones, and similar
foreign bodies impenetrable to light have become impacted in these
parts and cannot be discovered by the ordinary methods.
It is impossible to form any definite classification of the foreign bodies
that may be encountered in the different regions ; but speaking gener-
ally, it may be said, as a rule, that only sharp-pointed bodies — such as
pins, needles, and small pointed pieces of meat or game bones and fish-
bones— become fixed in the fauces and rhino-pharynx, though they are
equally apt to bs caught in the larynx or oesophagus. Coins and small
rounded bodies usually pass down till they are impacted in the larynx,
oesophagus, or lower air-passages. In the larynx they are most apt to
lodge in the pyriform sinuses, or to lie across the glottic opening, upon
the venti'icular 1)ands, or between the ventricles of Morgagni.
Owing to the funnel-shaped narrowing of the lower end of the
pharynx, and to the fact that the narrowest part is at the level of the
cricoid cartilage, foreign bodies, if arrested on their passage downwards,
are particularly apt to lodge at this spot. Bodies which pass into the
bronchi most frequently lie on the bifurcation, or pass into the right
bronchus ; the right bronchus being the seat of lodgment about twice as
frequently as the left.
Sijmptomii. — While the primary symptoms of a foreign body in the
throat, and particularly in the larynx, are generally sutticicntly obvious
when the patient states the cause of his suffering, it is important to bear
in mind that some cases of aj^parentlj'^ sudden loss of consciousness may
be due to occlusion of the glottis by a foreign body ; and if summoned
DISEASES OF THE PHARYNX 767
to a case Avhere the patient is said to have had a fit or to have become
suddenly unconscious whilst eating, the possibility of such an accident
should not be forgotten.
In children especially, foreign bodies are liable to be swallowed or
drawn into the air-jDassages unconsciously, where they may set up more
or less acute dysj)noea or obstruction to deglutition. One of us (W. W.)
recently saw a case which presented all the symptoms of croupous
laryngitis, and, dyspnoea becoming urgent, tracheotomy had been per-
formed. The symptoms abruptly subsided when a jDiece of nut-shell was
coughed up and revealed the true character of the complaint, after it had
been arrested for six days. This case well illustrates the necessity of
thinking of foreign bodies when an obscure inflammatory affection or a
swelling is seen in the air or food passages, even though no history of
the impaction be obtainable. These remarks apply with no less force to
the cases of adult patients.
Haemorrhage may result from direct injury by a sharp body ; thus
Mr. Rivington records a case in which a fish-bone, which had lodged in
the pharynx, penetrated the common carotid and necessitated ligature of
the artery. The puncture was believed by Rivington to be due to the
use of a probang whereby the fish-bone was pushed through the wall
of the pharynx.
If a foreign body has lodged between the vocal cords, and, owing to
the small size or peculiar position or shape of the invading body, acute
asphyxia is not induced, aphonia may be the most notable symptom ;
and when it passes into the trachea or a bronchus, violent coughing and
dyspnoea will be experienced. On the other hand, especially after the
initial symptoms have passed off — such as pain, or coughing and dyspnoea,
if the body lodge in the larynx, or the sensation of the presence of a
foreign body if it lodge elsewhere, — there may be no indication whatever
of its presence ; nevertheless a careful exploration of the whole region
should be made, as secondary mischief may subsequently arise.
Very frequently foreign bodies, Avhich shortly after their impaction
cause slight symptoms or none at all, may later be the source of most
serious troubles. Secondary symptoms are generally of the nature of
inflammation or ulceration, in consequence of which an abscess may form
and the pus may burrow in the structures, or even set up suppuration in
the mediastinum. In the larynx a foreign body, after originally giving
but little trouble, may cause subsequent perichondritis and lasting dis-
ablement of the organ ; or, after having remained in the larynx for some
time, may become dislodged and fall into the lower air-passages, set-
ting up most serious disease there. If a bronchus have been invaded,
secondary pneumonia and pulmonary abscess or bronchiectasis are apt
to supervene. Sometimes penetration of the structures in the neck
causes extensive subcutaneous emphysema. In the resophagus after a
while it may either perforate the wall or lead to the formation of a
pouch. Copper coins may give rise to metallic poisoning; and foreign
bodies more or less occluding the oesophagus may produce such a
768 SYSTEM OF MEDICINE
degree of dj-sphagia as seriously to interfere with deglutition and
nutrition.
All these contingencies are so grave that we cannot contemplate the
impaction of a foreign body in these parts with indifference, even if at
first it be unattended l>y serious symjjtoms.
Treatment. — We have already s})oken of the necessity of methodical
investigation preceding any therapeutical eflfort in ordinary cases.
When, however, the lodgment of a foreign body in the air- passages
results in dyspna'a so urgent as to threaten immediate asphyxia, or has
actually caused loss of consciousness, there is ol>viously no time for a
careful examination of the throat ; the forefinger should be cautiously
passed at once down to the larynx, and, if the cause of the obstruction
can be felt, the liody may be dislodged ; but it is important to avoid
pushing the foreign l)ody into the trachea. If nothing can be felt in the
larynx, and the urgency of the case permit, the patient shoidd be in-
verted. In this position a sharp blow on the back may dislodge the
foreign body from the trachea or bronchus, and cause it to fall into the
larynx, whence, possibly by inducing coughing, it may be expelled without
tracheotomy. But should our eflForts prove futile, tracheotomy should
be performed promptly ; and if, nevertheless, dyspnoea be still urgent the
patient should again be inverted, and every effort made to cause the
foreign body to ])ass into the upper region of the trachea, whence it may
be extracted through the tracheotomy wound.
In the vast majority of patients who seek medical aid complaining of
a foreign body in the larynx, the symptoms are less urgent ; or, if at
first alarming, the acuter manifestations of the presence of the impacted
body have .subsided ; under these circumstances both the examination and
the treatment can be carefully and methodically conducted.
Two principles ought to guide the practitioner in treating these
cases :—
First, no foreign body, the presence of which has actually been
detected, should be permitted to remain impacted, even although at the
time it may not produce any active symptoms ; we have already pointed
out the very serious secondary symi)toms which may arise nevertheless. In
the face of these risks it is hardly necessary to eni])liasise the importance
of leaving no justifiable means of removing the foreign Ijody untried.
Secondly, no attempt should ever be made forcibly to ram down an
angular or pointed foreign body. The danger of passing bougies or pro-
bangs foi' this ])urpose is self-evident; yet this risk is very frequently
ignored, and consequently perfoiation of the carotid or the descending
aorta, tearing or perforation of the pharyngeal and a!sophageal walls, and
many other such serious results, have actually occurred.
Needless to say, no definite rules can be laid down for the best
method of removing the various foreign bodies that may become impacted
in the regions in question ; the practitioner must be guided in each case
by {a) the nature and size of the foreign body, and {h) the spot in which
it has become lodged. In cases of impaction of foreign bodies in the
DISEASES OF THE PHARYNX 769
pharynx and rhino-pharyngeal cavity, forceps with indented blades will
in most instances be the most suitable instrument, the curve of the
forceps being adapted to the locality of the impaction.
When the body has passed doAvn into the larynx, or into the lower
air-passages, and when its form is round or circular, as of coins, beans,
peas, and so forth, it is always worth while, before any instrumental
interference, to try inversion and forcible shaking of the patient ; the
plan may even be adojited when the foreign body is pointed or angular.
In a most remarkable case, seen by one of us (F. S.) and desciibed by
Mr. Pitts, an earring, which had first become impacted in the larynx
just below the vocal cord, and a few days afterwards had fallen into the
left bronchus, was spontaneously evacuated by coughing about an hour
after inversion and shaking had been tried, apparently without success.
Should the foreign liody be fixed in the larynx itself, and should its
nature be such as to allow of the hope of removing it by intra-laryngeal
operation without injury, this plan of treatment Avill, of course, be pre-
ferable to an external incision. Should it be too large, however, or too
irregular to justify such attempts, and should it moreover cause dyspnoea,
tracheotomy might first be performed, and an attempt be made to get
hold of it through the tracheotomy wound, or to dislodge it from the
larynx into the pharynx, Avhere it can, of course, be grasped more easily;
or, if this shoukl fail, tracheotomy may be carried forward to thyrotomy
and the foreign body thus removed.
A similar plan of treatment is called for when foreign bodies of large
size and angular shape have lodged 'n the trachea ; and in cases in which
the foreign body is situated in one of the bronchi, tracheotomy, followed
by an attempt at extraction by means of very long slender forceps, is
advisable. If the foreign body cannot be exti'acted at the time of the
operation itself, it will be desirable not to insert a tracheotomy tube, but
to keep the tracheal wound open by stitches in the trachea attached to
an elastic band carried from the two sides of the wound round the neck
posteriorly ; thus, in the event of the foreign body becoming sub-
sequently dislodged, it can easily be expectorated through the open
Avound during the act of coughing. "When bodies are impacted in the
oesophagus, a parasol probang may be cautiously passed down and with-
drawn opened, so as possibly to catch the body in its meshes. In some
cases the coin-catcher is required. Only when it is quite certain that
the offending substance is of a soft or rounded form can it be justifiable
to push it down into the stomach.
Of course extraordinary cases require special measures ; the necessity
of oesophagotomy or gastrotomy may even arise : but the problems of
dealing with these various cases and the mode of treatment to be adopted
are of a purely surgical kind, and beyond the scope of the present article.
Diseases of the Tonsils. — Introductwy remarh. — We have no cer-
tain knowledge of the physiological functions of the faucial, lingual, and
pharyngeal tonsils ; but Philip Stoehr has drawn attention to the fact
that in their epithelial covering are gaps large enough to allow the
VOL. IV 3d
770 SYSTEM OF ME DICTATE
passage of leucocytes ; an enormous transit of such cells undoubtedly
occurs into the tonsils -without actual destruction of the epithelial
straiuls. The leucocytes or phagocytes are i)rotective against the inva-
sion of the pathogenetic niicrohes •vvliich arc brought into the fauces and
naso-i)harynx l)y inspiration ; although it may avcU be that they have
other uiu-ecogniscd functions also to fulfil. However this may ])e, Avhilst
the fissures and crypts of the tonsil form convenient resting-places or
" traps " for microbes, the peculiar an;itomical arrangement of their
epithelial covering opens the gates to their invasion ; niul thus it is easy
to understand how the tonsils, especially if the vitality and resisting
power of the tissues be flagging, may form a jxiital foi' the invasion
of the system by pathogenetic organisms. Eecent researches furnish
abundant proof of the correctness of these surmises. In addition to the
demonstration of tubercle and other bacilli in the tonsils by Buschke,
Schlenker, Krueckmann, Strassm;uin and Dmochowski, Dietdafoy and
Cornil have foiuul that of seventy adenoid tumours examined micro-
scoiiically, four (that is, one in seventeen) showed iumiistakal)le evidence
of tuberculous "iant cells. As the residt of an investiiration into the
part of the tonsil in scarlatinal infection, "Walter Dowson was led to
the conclusion that the tonsilLir lesion and cervical bubo of scarlet fever
are the analogues of the chancre and bubo of syphilis. That diphtheria
preferentially makes its first ap[)eararicc on the tonsils is well known,
and in a series of cases of septic infiammation of the throat and neck
recently published by (»ne of us (F. S.), acute tonsillitis formed one of
the initial symptoms in a considerable proportion ; while the researches
of Sendziak and others have proved that acute lacunar tonsillitis is due
to direct infection by streptococci, staphylococci, and pseudo-diphtheritic
bacilli. Finally, Suchannek has recently summarised the ])revious
observations on the connection of rheumatism with tonsillar aficctions,
and has rendered it highly pro1)able that in many cases the s})ecific poison
of rheumatic fever also obtains its entrance into the organism through
the portal of the tonsils.
In view of such facts as these, it is obvious that the tonsils play a
very much more impoi'tant part in admitting the various infecting
microbes than has hitherto ])een conceded ; and we have no doubt that
their condition merits close attention when the question of the etiology of
infectious diseases is discussed.
Acute Tonsillitis. — We distinguish three clinical forms : — (i.) Super-
ficial 0/ lacunar idunUHis, with difi'use infiammation of the mucous mem-
brane of the tonsil and accunudation in the crypts of a great ninnber of
bacteria (small diplococci especiall}'), and of lymphoid corpuscles con-
tained in a fibrinous network and appearing in the mouths of the distended
crypts as discrete patches of yellowish exudation. While this exudation
is mainly lying on the surface of the epithelium, small necrotic points
have been observed where the process has extended into the superficial
layers of tissue (Sokolowski and Dmochowski). (ii.) Parenclifpnatous
tonsillitis, in which the deeper tissues of the body of the tonsil are mainly
DISEASES OF THE PHARYNX 771
inflamed, the amount of swelling being considerable, (iii.) PeritonsiUitis,
in which the connective tissues in front of the tonsil are chiefly
involved.
Suppuration is especially prone to follow peritonsillitis, but lacunar
and parenchymatous tonsillitis may also end in suppuration.
Acute lacunar tonsillitis is undoubtedly an infectious disease, which
is associated with various micro-organisms, and may be induced by a
variety of causes. It is especially prevalent in the late autumn and
early spring, and is frequently epidemic ; and numerous instances have
occurred in which the aft'ection has run throu'-h a household, afl'ectino; its
various members in turn. Overwork, anxiety, and all causes, whether
local or general, which lower the resisting power of the tissues, render
the individual more liable to infection. Thus chronic hypertrophy and
degeneration of the tonsils indirectly dispose to attacks. In many
cases attacks of arthritic rheumatism directly precede or follow the
tonsillitis ; and, indeed, the causes of rheumatism, such as exposure to
cold and damp, or to sudden changes in temperature, are likewise
important causes of tonsillitis. Tonsillitis is commonly one of the initial
symptoms in measles and scarlet fever, and is often met Avith in diphtheria
and secondary syphilis. In not a few cases tonsillitis is due to septic
poisoning ; and the frequent occui'rence of attacks of tonsillitis in a
h')Usehold, like all forms of recurrent sore throat, should lead us to
suspect bad drainage. Again, it may occur traumatically, as by injury by
a .spicule of bone in the food, or by mechanical injury ; and it is sometimes
set up by the presence of calcareous cheesy masses in the crypts.
Tonsillitis is essentially a disease of early adolescence, but may occur
at any time of life from earliest infancy to extreme old age.
The symptoms vary very much in degree in difTerent cases. The
attack generally begins with soreness and stiff"ness in the throat for one
day, with aching in the back and limits, headache and general feeling
of malaise, followed by a rigor with sudden rise of temperature which
soon reaches 104° to 105° F. ; the pulse is frequent, full, and bounding.
With the onset of swelling and inflammation of the tonsils, pain dart-
ing up to the ears, and dysphagia, are prominent symptoms, and are
often agonising. The constant desire to swallow is dreaded because
of the pain of it ; the accumulating saliva therefore dribbles from
the mouth. The tongue becomes thickly coated, and the bowels con-
stipated. The urine is scanty, high-coloured, rich in urea and urates,
and sometimes contains albumin. The spleen is often enlarged. The
mouth can scarcely be opened, partly on account of the SAvelling of the
tonsils, and often of the submaxillary tenderness and tumefaction also.
Catarrhal inflammation always extends more or less from the tonsils to
the fauces and pharynx. The rhino-pharyngeal tonsil is likewise involved
with much greater frequency than is generally believed ; and this must
very often be held to account for the deafness and tinnitus due to
stoppage of the Eustachian tubes. The lingual tonsil is also liable to
attack ; Sendziak observed this complication in twelve patients out of 133
772 SYSTEM OF MEDICINE
cases of lacunar tonsillitis. When suppuration has begun, the pain and
tenderness are greatly increased. In sujjpurative peritonsillitis, though
the pain is more pronounced than in the first two clinical varieties, the
general disturbance and febrile symptoms are often slighter. In the
lacunar and parenchymatous forms both tonsils generally become involved,
though as a rule one tonsil is allected earlier or to a greater degree than
the other : peritonsillitis is almost always unilateral.
The course of the affection is rapid, seldom lasting more than two
days or a week, and ending in resolution or suppuration ; but the sub-
sequent prostration may be exti'eme.
Diagnosis. — In peritonsillitis the tonsil is often slightly inflamed or not
at all — a redness and smooth forward bulging may be observed on one
side of the soft palate ; in parenchymatous and lacunar tonsillitis the tonsils
themselves are always red and swollen. In the latter form the discrete
patches of yellowish exudation from the crypts are ordinarily character-
istic enough to prevent confusion with diphtheria ; but in not a few cases
a differential diagnosis is impossible without resorting to bacterial cultures,
for the lacunar exudations may spread beyond the crypts, and, becoming
confluent, may form a sort of false membivine sometimes adherent to the
tissues and indistinguishable from a diphtheritic membrane. The points
in favour of diphtheria are (a) a false membrane of a grayish white colour,
thick and firmly adherent, and involving the pillars of the fauces, the
soft palate, or uvula ; (h) the early presence of albumin in the urine in
considerable amount, with a low or only slightly raised temperature,
little pain, and unilateral affection. Submaxillary swelling and enlarged
cervical lymphatic glands are common to diphtheria and tonsillitis.
"We must further remember that, instead of the usual tough, gray,
adherent false membrane, diphtheria may be associated with a soft,
pultaceous exudation which may be restricted to the crypts, or may occur
with no visible false membrane. In tliese doubtful cases it will always
be advisable to leave the diagnosis in suspense for twenty-four hours until
cultures have been made.
Prognosis. — In simple tonsillitis the prognosis is nearly always
favourable; but we must be on our guard lest we overlook, the earlier
manifestation of the more virulent septic forms, which may result in
cedematous, erysipelatous, or phlegmonous laryngitis, or in purulent
cervical cellulitis (angina Ludovici), spreading to the mediastinal
glands; or in general infection with resulting endocarditis or pericarditis,
infective phlebitis, orchitis, or ovaritis. Further, tonsillitis may be the
])recursor of an attack of acute rheumatism, or less frequently of acute gout.
Very rarely paralytic sequels have occurred ; and though no doubt palsies
of the S'^ft palate, ocular muscles, or other parts are strong presumptive
evidence of the diphtheritic nature of the case, yet in a few of these
careful investigation has failed to reveal the Klel)S-Luliler bacillus.
Cases of death from suffocation in young children by excessively
swollen tonsils are recorded ; and it has been necessary to perform
tracheotomy to prevent asphyxia from laryngitis consequent on the
DISEASES OF THE PHARYNX 773
tonsillitis. Death has occurred from rupture of tonsillar abscess and
escape of pus into the larynx.
Treatment. — From the outset the bowels should be kept freely moved,
preferably by saline aperients. If the temperature be much above the
normal, six grains of sulphate of quinine should be given every four
hours till it is reduced. In rheumatic cases, where there is much aching
pain in the limbs and back, tincture of guaiacum, or fifteen to twenty
grains of salicylic acid, or the soda salt, given every two hoiu-s, will often
alleviate the symptoms. Tincture of aconite in small and frequently
repeated doses is useful in young children. In parenchymatous ton-
sillitis, especially, guaiacum lozenges should be prescribed, six to eight
being slowly dissolved in the mouth in the twenty-four hours. Gargling
Avith dilute solutions of chlorate or permanganate of potash to which
phenazonum, ten or fifteen grains to the ounce, has been added, is most
useful ; and sucking ice often gives considerable relief. But if the pain
and swelling are considerable, gargling may be out of the question ; then
hot fomentations applied to the neck and lower angle of the jaw, or a
spray of cocaine (2 to 5 per cent) or of menthol (10 to 15 per cent)
dissolved in colourless oil of vaseline or in oleum adepsin, will lessen the
pain. The two solutions may be combined ; for menthol has the
additional advantage of being antiseptic. Firm compression with the
tips of the fingers applied just in front of the external auditory meatus Avill
greatly relieve the pain on swallowing. In some cases a few longi-
tudinal incisions in the tonsils will relieve congestion and pain. Any
indication of suppuration should be watched for, especially in peri-
tonsillitis ; in such cases the inhalation of steam or gargling Avith warm
water relieves the pain and tends to make the pus point. In cases of
peritonsillitis, when the soft palate is seen to be bulging forwards and
fluctuation is felt through it, the incision always ought to be made — not,
as many practitioners still do, behind the palate into the substance of the
tonsil itself, but through the palate in the direction from without and
below, inwards and upwards.
The tonsils, as a rule, should not be removed while inflamed : to
this rule, however, two exceptions may be given ; namely, when in
children respiration is greatly embarrassed by the tonsillar swelling, and
when in adults tonsillitis has repeatedly occurred, but removal during the
period of quiescence is for one reason or another impossible.
Patients are generally much weakened by tonsillitis, and need
feeding up, and suitable tonics such as iron and quinine.
As tonsillitis, or at any rate the acute lacunar form of it, is certainly
infectious, it is Avell to advise the patient's friends to avoid such
immediate contact as kissing ; children and persons specially prone to
the affection should keep away, but strict isolation is not so necessary as
in the case of diphtheria.
Chronic Enlargement of the Tonsil. — Causes. — Hypertrophy of the
tonsils is one of the affections in which the influence of heredity is
most obviously seen, particularly in families in which other evidences of
774 SYSTEM/ OF MEDICINE
" scrofula " or of the " strumous " diathesis exist. Various exanthems,
measles, for instance, scarlet fever, and diphtheria, strongly dispose to
it, Avhile in many cases it results from repeated attacks of tonsillitis.
The enlargement may date from infancy or occur at puberty. Large
hypertrophy is rare after thirty-five ; and the tonsils, if enlarged in
childhood, tend to atrophy at puberty : although it is important to know
that this rule is by no means without exception. In many cases there is
no ol)vious cause for the condition ; but in most there i.s a combination
of several of the aboA'e contributory factors. Very frecpiently it is found
associated with hyi)ertrophy of the pharyngeal tonsil (adenoid vegetations),
and, not quite so often, with enlargement of the lingual tonsil and of the
cervical lymphatic glands.
Faflwloiji/. — The sul»stance of the healthy tonsil is composed of a
number of small nodules of lymphatic tissue arranged around a group of
seven to twelve crypts, and of connective tissue, blood-vessels and a few
nerve fibres ; the tonsils are covered by ordinary mucous membrane
which dips down into the crypts. There are no secretory ducts, nor does
the mucous membrane even in the crypts present any appearance of
muciparous glands ; but leucocytes pass out through minute spaces
between the epithelial cells, and the mucoiis membrane is capable of
secreting small quantities of mucus. In the large soft chronic hypertrophy
of the tonsils, such as is generally seen in young patients, the lymphatic
tissue nodvdes are increased in size and number, and the gaping crypts
contain a variable amount of mucus and of altered epithelium undergoing
fatty degeneration. In other cases, chiefly in adults, the hvpeitiophy is
mainly due to an excessive growth of the connective tissue elements,
which, by compression, cause more or less atrophy of the lymphatic
nodules and blood-vessels, and obliteration of the crypts; changes which
result in a hard, smooth, non-vascular tonsil.
We distinguish three clinical A^arieties : — (i.) Chronic lacunar tonsillitis
•with accumulation of caseous matter in the crypts, Avhich gape when the
yellow evil-smelling masses are extruded. These masses are sometimes
very consistent, and may be confused with pharyngomycosis leptothricia ;
but examination of the very adherent, clear, milky-Avhite, opa(pie, soft,
projecting pointed masses of the latter will reveal the characteristic threads
of the cryptogam, (ii.) Chronic parenchymatous hyperplasia. The tonsils
are soft and friable from the overgrowth of lymjihoid tissue, (iii.) Cltronic
Jihroid degeneration. This form is almost confined to adults, it represents
the advanced stage of the hyperplastic form, it is often the renuiant of
former frequently occurring attacks of acute tonsillitis, and it is especially
associated with the rheumatic or gouty hal)it.
Sometimes we meet with a smooth, ])ale yellowish swelling due to
occlusion of the mouth of a crypt with retention of the cheesy exudation
— a form of chronic tonsillar abscess.
The enlargement of the tonsils is sometimes very great, occasionally
enormous, j)rojecting far beyond the palatine arches, and meeting in the
middle line behind the uvula. Not infre(iuently the anterior pillar of
DISEASES OF THE PHARYNX 775
the fauces has become adherent to the tonsils, and extends over the
Avhole anterior surface, completely concealing the tonsil itself.
Sijmptoms. — Owing to the enlarged tonsils encroaching on the oro-
pharyngeal space, and interfering with the movements of the soft palate,
the voice is throaty and thick, with a nasal twang. Pain is generally
absent, except in subacute attacks of tonsillitis, which generally occur at
frequent intervals. In children especially, in whom most of the cases
are met with, post-nasal adenoids are generally present also, and many of
the symptoms attril)uted to enlarged tonsils — sucli as anaemia, buccal
respiration, pigeon breast, and infra-mammary depression of the ribs,
small ill-developed lungs, snoring, suffocative symptoms, and night-terrors
during sleep, difficulty in deglutition, and particularly Eustachian deaf-
ness— are in the main due to the concomitant adenoids ; though most
of these symptoms may be due to the tonsillar disease alone, without
adenoids. The mouth is often kept open, the under lip protruding ; and
thickening behind the angle of the jaw and enlargement of the cervical
lymphatic glands are frequently present. Dry reflex cough is a very
common symptom, and various reflex neuroses, such as darting pains in
the ears, vomiting and gastric pains have been attributed to enlarged
tonsils. The constantly recurring attacks of tonsillitis, in addition to
the suffering they entail, are attended by high fevt^r and followed by
great prostration ; thus they greatly interfere with occupation, develop-
ment, and general health.
. Chronic enlargement of the tonsils may then act injuriously in three
different ways — namely, {a) by mechanically obstructing the food and air
passages ; (b) by maintaining a liability to frequent, often very painful
attacks of inflammation Avithin the glands themselves or in their immediate
neighbourhood ; {r) by forming a perpetual source of danger from
infection by various micro-organisms, such as those of diphtheria or
tubercle.
The prognosis, as regards the life of the patient, is invariably good ;
the ultimate effect on the health of the patient will depend to a certain
extent on his age, on the relative degree of hypertrophy of the tonsils as
compared with the size of the fauces, and on the ])resence or aljsence of
concomitant adenoid vegetations in the rhino-pharynx.
In children under the age of ten marked hypertrophy greatly inter-
feres with growth and healthy development ; and the coexistence of
adenoids adds to the pernicious effects that will almost certainly ensue to
his permanent disadvantage. A tonsil not excessively hypertrophied
may undergo the physiological retrogi'essive changes soon after the age
of puberty ; but in most cases we shall await such a happy consummation
in vain, and meanwhile the child is exposed to the many risks Avhich we
have already described.
From a therapeutic standpoint the prognosis is excellent provided no
irremediable consequences have ensued ; thus the prospect of perfect
recovery depends on the absence of marked deformity of the chest Avails
and other secondary changes.
776
SYSTEM OF Af EDI CINE
Treatment. — The only s.atisfactoiy method of dealing with enlarged
tonsils which require treatment is to remove them; and at the outset we
would emphasise the uselessness of the so-called milder measures,
particularly the ridiculous painting with iodine solutions, tannic acid, and
the like : these prescriptions are so nuich waste of time, and generally
succeed only in causing considerable annoyance to the i)atient.
The tonsils should be reduced in size, {a) if they interfere with
respiration, either during waking or sleep, and lead to deficient aeration
of the blood ; {}>) if the}' lead to changes in the character of the voice and
to defective articulation ; (r) if they lead to defective develojDment of the
face and chest ; ((/) if the chronic enlargement, though not very consider-
able, be attended with frequent attacks of inflammation of the tonsils
themselves, by tumefactions of the cervical glands, or by catarrhal condi-
tions of the neighbouring nuicous membranes, especially of the Eustachian
tubes : even in the absence of symptoms, decided chronic hypertrophy,
especially in association with the strumous diathesis, renders an operation
advisable in patients under fourteen, so that a very active source of danger
from infection may be removed.
Removal of the tonsils may be accomplished by various methods :
by cutting with the bistoury or tonsillotome, by enucleation, or by
the gal va no -caustic point or snare. Our practice is confined to two
methods, namely, tonsillotomy and the galvano-caustic point. When it
has been decided to remove the tonsils we have to consider Avhich is the
best method to choose, (a) If the patient be under twenty, and the
enlargemeiit be mainly transverse, so that the tonsil or tonsils project a
good deal beyond the arch of the palate, the cutting operation should be
preferred. (/3) Local conditions being the same, but the patient over
twenty years of age, and in all cases Avhere the tonsils are entirely con-
cealed behind the palatine arches, or onl}^ project a little beyond them,
let broad applications of the galvano-cautery be made by means of a large
flat burner of platinum or jwrcelain. The tonsils are reduced in size by
the cautery quite as rapidly and eftectually by this method as by galvano-
piincture ; and it has the advantage of greatly reducing the risk of sharp
hemorrhage, a risk which cannot altogether be disregarded. The cutting
operation in patients over twenty is more lia])le to be attended with
serious and uncontrollable hoemorrhage than is the case in younger
patients.
The object of the operation should be to reduce the tonsil to the
normal size ; and therefore in using the tonsillotome it is well at the
moment of performing the operation to push the tonsil a little inwaids
by firm pressure from without just underneath the angle of the jaw, so
that the portion of the tonsil lying l)etween the palatine arches is removed
without either injuring the anterior arch of the palate or running a risk
of injury to the hu'go vessels in close relation with the base of the tonsil.
It is idle to remove a superficial slice in the hope that the remainder
will atrophy.
"When the galvano-cautery is employed, the reduction of the tonsils
DISEASES OF THE PHARYNX m
will require six, eight, or ten sittings, according to the degree of enlarge-
ment, at intervals of three days to a week. The amount of reduction
will have to be determined on the merits of each case.
Eemoval is most readily accomplished by the tonsillotome. We
employ Mackenzie's instrument, though \>j one of us (W. W.) Reiner's
modification is often preferred. In young and nervous children the
operation may be done under chloroform administered as in operating
on post-nasal adenoids. Again we wish to emphasise the rule that in all
cases of enlargement of the tonsils adenoids should be sought ; and, if
present, they should be removed first. In adults and in older children,
when the tonsils only require removal, a general anresthetic may be
dispensed with, and a strong solution of cocaine or eucaine used instead
to produce local anaesthesia. After operation the patient should be
directed to keep quiet for a few days, and only bland, cold, and soft food
should be taken.
Haemorrhage is always pretty free after tonsillotomy, but usually
ceases spontaneously in a few minutes. Dangerous haemorrhage occurs m
a very small percentage of cases, however skilfully the operation is per-
formed ; yet so rarely in proportion to the number of operations, that it
can never be urged as a general objection to the practice. In children
it is extremely rare ; and it is in the older patients whose enlarged
tonsils have undergone cicatricial degeneration that haemorrhage is to be
feared, and this more especially after cutting operations.
The causes of hceviorrhage may be stated briefly as (a) abnormality in
the distribution of the blood-vessels : (b) fil)roid tissue deposit and
degeneration of the walls of the vessels, which gape when they are
divided; (c) haemophilia; (d) eating solid food, and (e) over -use of the
voice too soon after the operation.
If the haemorrhage do not soon cease spontaneously, or if secondary
haemorrhage occur, the patient should be kept quiet and have small pieces
of ice to suck, and a mixture of tannic and gallic acids dissolved in water
to sip ; or the solution may be applied directly to the bleeding tonsil.
Perchloride of iron, which is sometimes recommended, should never be
applied, as it produces clotting without arresting the haemorrhage, conceals
the bleeding spot, and often enough makes matters worse by inducing
retching from the mechanical irritation of the fauces j^roduced by the
blood-clots. If ordinary styptic measures fail, we must seek for the
bleeding point, and, if possible, the vessel from which the haemorrhage
flows should be seized and twisted with torsion forceps ; or the sources
of haemorrhage may be touched with the galvano-cautery. Direct per-
sistent digital compression has sometimes to be resorted to, and if even
this fail, ligation of the carotid arteries, especially of the external carotid,
remains as our last resource.
There still exists in the minds of the public and even of many
practitioners a prejudice against operations on the tonsils ; it is necessary,
therefore, to refer briefly to some of the objections raised. First, it is
urged in the case of children that they will "grow out of it," and
778 SYSTEM OF MEDICINE
that if matters are left to nature the tonsils Avill spontaneously atrophy
at puberty or soon alter that lime. It is true that in a certain proportion
of the cases about two- thirds of the tonsils, by the age of twenty,
either atrophy or cease to be inconvenient enough to urge the patient
to seek advice; but in the remaining one-third of the cases this
spontaneous disappearance does not occur, and therefore, although we
may certainly tell the parents of a child suffering from enlarged tonsils
that there is a chance of their atrophy after puberty, we nnist warn
them that this event is by no means certain. But suppose our best hopes
ful tilled, we have still to consider the great risks of serious and lasting
consequences of great hypertrophy of the tonsils during the earlier
years of life. If a child has not begun to suffer from the consequences
of obstruction to the respiratory, alimentary, and auditory passages till the
age of ten (and nearly half the total numlwr of cases display marked
symptoms before that age), and if we atlmit that his tonsils may atrophy
by the age of eighteen, can it be fairly urged that eight years of constant
interference with some of the most important functions of life, and that
during the most important period of development, will not leave behind
them lasting injury 1 The number of adult patients suffering since
childhood from "throat deafness," and gradually getting worse, the con-
figuration of countless faces seen in the streets, the defective articulation
and intonation so often met with in {)eople in society — all these defects
tell their own tale and give the best reply to the (|uestion. And even
if such sequels do not follow, the patient is liable to frequently recurring
acute attacks of throat disorder.
Further, it is sometimes stated that the tonsils, even when h3'per-
trophied, are protective against infectious disease ; now it has been
conclusively proved that tonsillar hypertrophy adds very greatly to the
danger of infection, a point Avhich we have fully emphasised in our open-
ing remarks on diseases of the tonsils.
Kemoval of the tonsils never impairs the voice ; on the contrarj', in
cases in which the masses of hj'pertrophied tissue are lai'ge enough to
interfere with the normal vibrations of the column of air, and to divert it
into an anomalous direction, and at the same time to interfere with the
movements of the jialatine arches and soft jtalate, and peiliaps to maintain
a chronic catarrhal pharyngitis, the voice will certainly be gi'catly
improved in strength, quality, and timbre ; although the removal of the
tonsils will not of itself increase the range of the voice.
That removal of tlic tonsils has any tendency to result in sterility is
a superstition so absurd that it is only worth mentioning to show that
no belief is too foolish and groundless to be advanced against tonsillotomy.
In cases which urgently call for operative interference, not only are
all the risks of local complications due to the eidarged tonsils removed,
but there is almost invaiial)ly a rapid and mai-kcd alteration for the
better in general health and development where these have been im])aired.
The appetite and digestion are improved, there is l)etter aeration of the
lungs, the child becomes fat, rosy-faced, bright and cheerful, and is a
DISEASES OF THE PHARYNX 779
marked contrast indeed to the lialf-nourishcd, listless, ana?mic, more or
less deaf creatui-e with open mouth and noisy respiration. The operation
shoulil not be postponed on account of the weakly condition of the patient ;
for though it seems reasonable to suggest that it would be well to Avait until
a course of careful dieting and general treatment have made the child
stronger and better able to undergo operative treatment, we should
remember that the local conditions are in themselves chiefly responsible
for the adverse state of health, and that until the tonsils are removed but
little amelioration can be anticipated ; whereas the tonic treatment which
has usually been tried before and failed will be attended with very much
happier result after the operation, or, indeed, is usually rendered
unnecessary, thereby. W^e have never in the M'hole of our experience
seen any benefit derived from a postponement of the operation in the
class of cases now under discussion. — F. S. and W. W.
REFERENCES
1. Allbutt and Teale. On Scrofulous Kcc.l: Lond. 1885. — 2. Bosworth, F.
Diseases of the Nose and I'/iroat. New York, 1897. — 3. Buschke. Deutsch. Zeit. f.
CItir. 1894, Bd. xxxviii. Hft. 4, 5. — 4. Butlin, H. 3Ialignant Diseases of the Larynx.
Lond. ISSS. — 5. Idem. Sarcoma and Carcinoma. Lond. 1882. — 6. Cheyne, Watson.
The Objects and Limits of Ojyerations for Cancer, Lettsomian Lectures, 1896. — 7. Chiari.
" Ueber Lymphosarkome des Racliens," JVien. klin. Woeh. 1894. — 8. Cornil. Acad,
of Med. May 14 ; La Semaine Med. 1895, p. 234.-9. Courmont. Eevue de mM.
Sept. 1894.— 10. DiEULAFOY. "Masked Tuberculosis of the Tonsils," i/c*^. Week,
London, 1895, p. 234. — 11. Frankel, B., and Macintyke, J. "The Lifectious Nature
of Lacunar Tonsillitis," Brit. Med. Journ. 1895, vol. ii. p. 1018. — 12. Hall, F. de
Havillank. Diseases of the Nose and Throat. . London, 1894. — 13. Krueckmann,
Emil. "Ueber die Beziehungen der Tuberculose der Halslymplidriisen zu der Ton-
sillun," Virch. Archiv f. pathol. Anat. etc. Berlin, 1894, No. xviii. Bd. 138, Hft.' 3.
— 14. Langenbeck. Archiv fur klinische Chiriorgic, vol. xlii. 1891, p. 325 et scq.
— 15. Lewix. " Klinik der Syphilis-Statistik," Charite-Annalen, Berlin, 1874-77.
— 16. Mackenzie, Morell. Di^-eascs of the Throat and Nose, vol. i. Lond. 1884. —
17. M'Bride, J. Diseases of the Throat, Nose, and Ear, 2nd ed. Edin.— 18. "Malig-
nant Disease of the Larynx, Discussion on the Lidications for Early Treatment of,"
Brit. Med. Journ. 1895, vol. ii. p. 1029. — 19. Newcomb, J. E. " Ludwig's Angina,"
New York Med. Jo^irn. Nov. 23, 1895. — 20. Newman, David. Maligjiant Disease of
the Throat and Nose. Edin. 1892.— 21. NiCHOLLS, J. E. H. "Sequelae of Syphilis
in the Pharynx and their Treatment," Trans. Amer. Laryng. Assoc. 1896. — 22.
Retterer, E. "Sur le develojipement des tonsilles chez les manimiferes," Compt.
rendu Acad, des sciences, Paris, 1885, ci. — 23. Idem. " Origine et evolution des amyg-
dales chez les mammiferes," Journ. de I'anat. et physiol. etc. Paris, 1888, vol. xxiv.
— 24. Schlenker. Virchow's Archiv, vol. cxxxiv. pp. 161 et seq. and 247 et scq. 1893.
— 25. Seiler, Carl. Diagnosis and Treatment of Diseases of the Throat and Nasal
Cavities. Philad. 1883.— 26. Semon, F. "The Indications for Uvulotomy," St.
Thomas's Hospital Reports, 1882, p. 80. — 27. Idem. "Indications for and Method
of Removal of the Tonsils," St. Thomas's Hospital Beporls, Lond. 1883, new series, xiii.
— 28. SoKOLOWsKi and Dmochowski, and Sendziak. Journ. of Laryng. 1895, p. 287.
— 29. Stoehr, Philip. Biologisehes Centralh. vol. iv. No. 12 ; and Sitznngsbericht der
physicalisch-medici/nischen GeseUschaft zu, Wurzhurg, 1883, No. 6. — 30. Idem. "Ueber
Mandeln und Balgdrtisen," Arch, fur pathol. Anatom. etc. Berlin, 1884, xcvii. — 31.
Strassmann and Dmochowski. Med. Werk, 1895, p. 213. — 32. Turner, W. Aldren.
"The Innervation of the Muscles of the Soft Palate," Journ. of Anat. and Phys. 1889,
vol. xxiii. part iv. p. 523. — 33. Williams, P. Watson. Diseases of the Upper
Respiratory Tract, the Nose, Pharynx, and Larynx. Bristol, 1897.
7 So
SYSTEM OF MEDICINE
III.— DISEASES OF THE LARYNX
Laryxooscopy. Felix Semon ami Wat-
sou AVilliains.
AUTOSCOPY AND SKIAC.ltArHY OF THE
Lauynx. Felix Senioji.
Anaemia and HYPEUiEMiA :
AcLTE Lauyngitis :
Chronic Laryngitis :
(Edema :
H^MOiiKHAGE : — r. de Havilland Hall.
TrBEKCULOSis. Felix Semon.
Lupus :
Leprosy: — Felix Senion and Watson
"Williams.
Larynx in Acromegaly. "Watsou
Williams.
Syphilis :
Perichondritis :
Diseases of the Crico-Aryt^noid
Joint :
Stenosis :
Benign Growths (including Pachy'-
dermia) :
Malignant Growths :
Neuroses: — Felix Semon and Watson
Williams.
Laryngoscopy
Inspection of the Larynx. — For this purpose a small mirror attached
to a handle must be introduced into the back of the mouth, and a strong
light thrown on the reflecting surface, which is directed oliliquely down-
wards so as to reflect the image of the larynx. The small laryngoscopic
mirror should be attached to the handle at an angle of about 120°. At
least three sizes of these flat circular mirrors are desirable, of diameters
of half an inch, one inch, and 1|- inch respectively, adapted, that is, to the
size of the fauces at different asjes.
The forehead reflecting mirror is concave and of about fourteen inch
focus. It should be adjusted, by a freely adjustable ball and socket joint,
to a forehead band or spectacle - frame carrier ; the latter has the
advantage of being more readily put on and olT, and for hypermetropic or
myopic observers spectacle glasses can be attached to the frame. In
the centre it should have an oval opening, the long axis of which
corresponds with the long axis of the observer's eye. It is essential that
the central opening should come immediately in front of the pupil of
the examiner's eye, and that the mirror be freely adjustable.
For a satisfactory examination a good light is of the utmost import-
ance. Bright sunlight answers admiralily when it is available ; but it is
usually more convenient to employ some form of artificial light which is
wholly under control. In a darkened room a candle or oil lamp may
.suffice in some cases for diagnostic purposes ; but an Argand Inirncr, or,
better still, the sixty -candle -power Welsbach incandescent burner, the
electric, or the oxyhydrogen limelight is necessary for finer operations
and for higher degrees of accuracy of diagnosis in many of the less gross
or more obscure laryngeal aff'ections, and for posterior rhinoscopy. Tlie
artificial light should be freely movable in every direction, so as to allow
of ready adjustment and focussing of the light on the part to be examined.
DISEASES OF THE LARYNX 781
The examiner should also accustom himself to the use of ordinary bright
daylight concentrated by the forehead mirror upon the patient whose
back is to a window, as this may give a better illumination than the poor
light often afforded by the lamps available in private houses.
In proceeding to examine the larynx strict attention to the following
method is advised. The patient is to sit on a common cane chair facing
the examiner, who is similarly seated. The light should be placed on
the left side of the patient, as close to the ear as is convenient, and so
supported on a bracket, or a table, or held by an assistant, that the con-
centrated rays of light fall directly on the forehead mirror. The light
returning from the centre of the forehead mirror and the laryngoscopic
mirror when in place in the patient's mouth should be in the same
horizontal ])lane during the examination ; neglect of this fundamental
rule is one of the commonest sources of failure in beginnei's. The patient
with the head slightly thrown back should be directed to open his mouth,
to breathe naturally, and to put out his tongue, which is to be immediately
l)ut gently grasped in a small towel by the examiner's left hand. The
light having been concentrated at the back of the mouth, by adjusting the
forehead mirror, the laryngoscopic mirror, lightly held in the right hand
as one holds a pen, is introduced horizontally into the mouth till it
reaches the uvula, when it is brought to an angle of about 90'^ by raising
the handle and held steadily but gently against the uvula and soft palate
but not so far back as to touch the posterior jjharyngeal wall. The
upper rim of the mirror should be about as high as the free margin of
the velum palati. Before introduction the face of the laryngeal mirror
should be warmed over the lamp so as to prevent the condensation of
the moisture of the breath upon it. The proper temperature is obtained
at the moment when the film of moisture, which at first forms on the
reflecting surface, has disappeared ; but to avoid the risk of introducing
the mirror too hot, its temperature should always be tried on the back
of the hand before it is introduced into the patient's mouth.
At first perhaps only the dorsum of the epiglottis may be seen in the
small mirror ; but by altering its angle the other parts of the larynx will
Ije successively brought into view. "While keeping the mouth widely
open, the patient should be directed to sound " eh ! " or " ee," which causes
the larynx to be raised and the epiglottis to be retracted so that the larynx
is brought more perfectly into view. The vocal cords can then be seen
approaching and diverging alternately in phonation and respiration.
It will be noticed that the laryngeal image is inverted antero-
posteriorly, but that the right and left sides of the laryngeal image
correspond to the same sides of the patient ; there being of course no
transposition of the reflected image in the horizontal plane.
The laryngoscopic image brings the following structures into view :
the part first seen is the epiglottis ; it appears in the upper portion of the
mirror, mox^e or less bent and saddle-shaped, so that it shows parts both
of the upper and lower surfaces. The epiglottis varies greatly in form in
different patients, being sometimes erect and only slightly curved, at
782 SYSTEM OF MEDICINE
other times pendulous, or very much bent and curled. The epiglottis is
attached to the base of the tongue hy three ligamentous folds : one central
(superior glosso-epiglottic ligament), and two right and lift (lateral glosso-
epiglottic folds). The spaces between these folds are named the vallecuhe.
Below the epiglottis the pearly white vocal cords passing Ijackwards to be
attached to the arytaiuoid cartihiges stand out clearly ; between them is
the triangular glottic chink through Avhich a variable extent of the anterior
wall of the trachea and sometimes even the Infvu'cation and the commence-
ment of tlie bronchi may be seen. The true vocal cords are attached
posteriorly to tlie processus vocales and to the anterior surfaces of the ary-
tajnoid cartilages ; and anteriorly they are attached together in front in the
angle of the thyroid cartilage forming the anterior commissure just l^elow
the projection or thickening called the cushion of the epiglottis. Along
the outer sides of the vocal cords, and on a slightly higher level, lie the
pink ventricular bands. In some cases, especially if we tilt the nn'rror
laterally, the opening of the sacculus laryngis, or ventricle of Morgagni,
can be seen on each side as a rim or chink l)etween the ventricular band
and the vocal cord. The aryt;enoid cartilages are seen as rounded
swellings in the lower part of the image ; between them is the inter-
arytaenoid space or fold forming the posterior wall of the larynx. The
folds of mucous membrane stretching on each side between the epiglottis
and the arytaenoid cartilages are the aryta'no-cpiglottidean folds; and
posteriorly, just in front of the arytitnoid cartilages, the cartilages of
Wrisberg and Santorini can often be recognised in the outline of these
folds. Between the arytoeno-epiglottidean folds and the prominence of
the great cornu of the liyoid bone are the pyriform sinuses or hyoid fossae.
In making a laryngoscopic examination we first observe {n) the colour
of the various parts ; secondly (//), the foi-m and contour ; and lastly (c),
the functional activity of the vocal cords during phonation and respiration.
As regards the colour, the epiglottis should be slightly yellowish and the
rest of the laryngeal mucous membrane pale pink or red, while the vocal
cords are, normally, pearly Avhite or A^ery slightly pink, though they are
often of a more pronounced reddish colour, particularly in male professional
vocalists. The vasomotor changes in the larynx are very rapid : on first
introducing the mirror, anaemia may be present ; this on a second in-
spection may have given place to the normal tint, and on the third to
hypcraemia. As isolated anaemia of the larynx is a valual)le diagnostic
sign, this inconstant condition should be carefully noted on the first
inspection, while the structural alterations and the movements of the
vocal cords may be left to a later observation. The structural alterations
to be noted are tumefaction, ulceration, abscess, oedema, new growths,
foreign bodies, malformation.*, and dislocations of the arytasnoid cartilages.
Any unevcnness of the vocal cords should be particularly noted. Finallj^,
the position and moV)ility of the cords will engage attention. No
definite conclusion concerning the mobility of the vocal cords can be
gained, as a rule, unless the larynx be examined both during phonation
and deep inspiration. The neglect of tliis fundamental rule often results
DISEASES OF THE LARYNX 783
in overlooking laryngeal paralysis. During quiet respiration they should
lie midway betAvcen adduction and al)duction, " the position of rest or
quiet respiration " ;' this is not the same as the " cadaveric " position in
which the glottic chink is nan-owed, for the wider aperture of rest, as lias
been shown by one of us (F. S.), is maintained by a persistent reflex
tonus of the abductors. On phbnating " eh ! eh ! " the vocal cords should
come into symmetrical apposition in the middle line ; the arytsenoid
cartilages at the same time being approximated by the aryttenoideus
muscle so as to obliterate the interarytai^noid space. During deep
inspiration the cords are widely abducted, so that the glottic opening and
the interaryta3noid space are considerably Avider than during quiet
respiration. It is not enough simply to observe that the vocal cord
moves out on taking a breath ; it is important to note also Avhether the
degree of abduction on deep inspiration amounts to the normal.
There are then four named positions of the vocal coids, namely, those
of (a) quiet respiration, (/5) deep inspiration, (y) jDhonation, and (S) the
cadaveric position of death or complete paralysis.
Finally, it may be necessary to test the tactile sensil»ility of the larynx
by means of a long curved laryngeal probe. The normal larynx is very
sensitive, and on contact violent cough is immediately set up, particularly
when the interaryta^noid fold is touched. In anaesthesia this sign is absent.
Difficulties in l(ir//ngoscopi/ may be encountered ; sometimes this is due
to the faulty method of the examiner, sometimes to structural peculiarities
in the fauces or larynx of the patient. The following faults should be
avoided : undue haste, flurrying the patient and rendering him nervous,
attempts at examination without having the light properly concentrated ;
clumsy introduction of the mirror, or introduction of a mirror either not
properly warmed or made too hot ; dragging on the tongue or pressing it
against the lower incisors ; omission to tell the patient to breathe quietly
and naturally ; holding the mirror too long in the mouth, and neglect of
the various little manteuvrcs for bringing the larynx into view by getting
the patient to tilt his head backwards or forwards as may be required.
A common fault is to hold the laryngoscopic mirror at the wrong
angle, or too far forward, so that oidy the dorsum of the tongue and the
anterior surface of the epiglottis are reflected in it. By placing the mirror
somewhat farther back and less horizontally, a complete image will
probably be obtained.
Difficulties may arise on the side of the patient. Of these the most
common are : (a) Excessive irritability of the fauces, leading to gagging
and retching on the introduction of the mirror. To overcome this the
patient may suck ice for fifteen or twenty minutes before the examination,
or a 2 per cent cocaine solution may be sprayed on the fauces. (/3)
The dorsum of the tongue may rise so much that either the mirror cannot
be introduced, or its reflecting surface is out of vieAV. If forcible pro-
trusion of the tongue by the patient or taking a deep breath does not
overcome this difficulty, the patient should be asked to hold his oavu tongue,
while the examiner depresses it with a tongue spatula held in the left
7S4 SYSTEM OF MEDICINE
hand. Sometimes the best view is to be had by simply depressing the
tongue without protrusion ; and if the patient be tongue-tied or protrusion
impossible, this procedure should be adopted in the first instance, (y)
'flic tonsils may be so enlai-ged that the usual mirror cannot be used ; in
these cases it may bo possible to introduce a smaller one. If the uvida
be excessively long, it may get in the way ; this obstacle will bo over-
come by using a large mirror. (5) The most serious difficulty is a
])cndulous epiglottis so overhanging the larynx that the anterior portion
of the larynx is concealed from view, and perhaps nothing but the
posterior border is reflected. There are several ways of overcoming this
difiiculty. In slighter cases the act of phonating " ee ! ee ! " or coughing
with the mirror in ])lace may suffice to raise the epiglottis ; then the vocal
cords may come into view. If this manoeuvre fail, direct the patient to
throw his head well back, and place the mirror nearer the posterior Avail
of the pharynx, and somewhat moi'c vertically than usual, the observer's
eye being well above the level of the patient's mouth. In a few cases,
however, it is only possible to sec the vocal cords by raising the epi-
glottis with a retractor, (e) The patient may hold his breath from
nervousness ; but a little patience Avnll soon overcome this difficulty.
It is important to remember that in nervous patients the vocal cords,
inste.id of being widely abducted on deep inspiration, may be partially
adducted, so that to the careless or inexperienced observer they may
appear to be affected with paresis of the abductors.
The chief congenital defects that are met with are a deep central
notch in the free border of the epiglottis, which may extend so far down-
wards as to produce a bifid or double epiglottis, and a membranous web
between the vocal cords, which in some cases extends backwards as far as
the vocal processes. In a case observed by one of us (F. S.) the web
was associated with coloboma iridis.
Finally, wo would emphasise the great importance of bearing in mind
that it is as necessary in laryngeal affections as in all local maladies to
have due regard to the general condition of the patient ; to his facial
aspect, his gait, and the state of his pulse, heart, lungs, and so forth :
neglect of this fundamental rule may lead to the gravest errors in
diagnosis. Thus, for instance, acute laryngitis may be due to gout,
or recurrent attack's of laryngitis to early pulmonary tuberculosis ;
while a persistent and troublesome cough may be the earliest manifesta-
tion of tabes dorsalis ; not to mention the grosser laryngeal lesions that
may baffle the diagnosis unless the facts of the previous history and of a
general e.xamination of other regions arc taken into consideration ; for
example, in syphilitic disease. — F. S. and W. W.
Autoscopy of the Air-Passages. — Quite recently a method of direct
inspection of the uj)pcr air-passages has been introduced by Kirstein of
Berlin, for which the inventor proposes the name of " autoscopy." He
has found that on depressing the tongue bv means of a suitable spatula
it is possible in many cases to obtain a direct view of the posterior parts
DISEASES OE THE LARYNX 785
qe — ■ — .... ■ . ... I-I I I ■ !■ I I I _ .
of the larynx and of the trachea. Eecent as the method is, it has been
repeatedly modified by its inventor since its introduction ; at first it
was somewhat complex, and a tolerably expensive apparatus was needed ;
it has now been so much simplified as to demand nothing more than
a suitable spatula ; indeed it is nothing more than a modification of
pharyngoscopy as practised from times immemorial.
According to Kirstein's latest directions the practitioner should stand
in front of the patient, who sits in an ordinary chair with his head slightly
raised, so that an inspection from above doAvn wards becomes possible.
The spatula should be gently but firmly applied to the root of the tongue
(not to its front or middle parts), whereby a furrow is formed, along
which in many cases it is possible, with suitable illumination by means of
a frontal mirror, to look directly down into the larynx; the epiglottis being
usually raised by the pressure on the root of the tongue. It appears most
important to avoid the production of retching ; previous cocainisation of
the parts may be of use, particularly when a subsequent operation is
intended. Should a long upper lip or a moustache obstruct the view, the
practitioner's other hand may be applied to get the obstacle out of the
view.
Opinions concerning the usefulness and applicability of the method are
as yet rather conflicting. Kirsteiii and Bruns recommend it particidarly
in cases of children ; and the former states that the larynx and the trachea
of deeply chloroformed children can always be inspected in their entirety
by means of the autoscope ; whilst by the help of this method Bruns has
actually succeeded in removing papillomata from small children by
endolaryngeal operation.
Skiagraphy of the Larynx. — It is as yet impossible to foretell the
ultimate value of Rontgen's X rays in the diagnosis of laryngeal diseases.
That the method promises to be very useful for the discovery of such
foreign bodies impacted in the larynx as are impenetrable to these
rays, has already been said in the chapter on foreign bodies in the
upper air and food passages. It may be hoped, however, that the method
will be so much extended as to make it serviceable for the diagnosis of
other aifections as well, as for instance of anchylosis of the crico-arytEBnoid
articulations ; and it would prove an inestimable boon for this branch of
our science, if by its means an early difterential diagnosis could be arrived
at between benign and malignant growths of the larynx. We may
anticipate that malignant growths, from their infiltrating character,
may oflTer greater obstacles to the passage of the rays than the benign ;
it remains to be seen, however, whether it will be possible so to perfect
the method that these finer differences may become recognisable. — F. S.
Anaemia of the Larynx. — The larynx partakes in the general pallor
of the mucous membranes which is seen in anaemia. Isolated anaemia of
the larynx is not infrequently the precursor of laryngeal tuberculosis ;
it is therefore an indication which should lie carefully watched.
Hypersemia of the Larynx. — All inflammatory states of the larynx
VOL. IV 3 E
7S6 SYSTEM OF MEDICINE
are preceded by hyperaMiiia ; hence hyper?emia of the larynx is in genei-al
an indication of the catarrhal process. One exception, however, deserves
attention, namely, that in a certain innnber of men who constantly use
the voice, as in singing, the vocal cords become slightly hypertemic Avith-
out in any way artecting the purity of the voice.
Acute Laryngitis. — Acute catarrhal inllanimation of the larynx.
As men are more exposed to the rauites of acute laryngitis they
suflTer more from it than women. Sudden changes of temperature,
especially if a fall occur in an atmosphere highly charged with nu)isture,
have long l)een recognised as likely to produce the iliscase. Exposure to
draughts or wet acts in a similar manner. These causes are especially
active in ptviple who live in hot rooms, who over-clothe themselves, oi'
drink too nnich.
The over-use of the voice, as in shouting, screaming, or even in
prolonged sjieaking or singing, is sometimes suthcient to start an attack
of laryngitis. When several of the above-mentioned causes are combined,
as for example when a man, Avho has been shouting or singing in a public-
house, and drinking and smoking at the same time, goes out from a heated
room into the cold night air, an attack of acute catarrh of the larynx is a
common result. The inhalation of certain irritant vapours, such as
chlorine, sulphurous fumes, or ammonia, or of steam, as when children
drink from the spout of a kettle, the application of caustics to the laiynx,
and surgical procedures for the removal of growths in the larynx, may
give rise to laryngitis.
In most of the acute specific diseases, especially in measles, small-pox,
and influenza, acute catari'h of the larynx is a common symptom. The
rheumatic, gouty, tuberculous, strumous, and syphilitic habits dispose to
catarrh of the larynx.
Before dismissing the causes of acute laryngitis, it is most important
to bear in mind the part jilayed by defective nasal res])iration in render-
ing the larynx vulnerable to influences w'hich would otherwise be in-
nocuous. It has been pointed out that laryngitis is of common occurrence
in cyclists who keep the mouth open in their need of air. In many cases,
again, the acute attack of laryngitis is grafted on a condition of laryngeal
catarrh more or less chronic.
The laorhid appearances in acute laryngitis difl"er in no respect from
those seen in acute catarrhal affections of other mucous membranes. The
only point al)OUt which there has been any dispute is on the occurrence
of ulcerations in sini])lc acute laryngitis. That superficial and symmetric-
ally disposed idcerations may occur in the vocal ])rocesses, the inter-
arytaenoid fold, and anterior commissure is now pretty generally admitted.
They seem to be due to contact of the inflamed mucous surfaces, especially
in violent coughing. The ulcers which ai'e observed in measles, influenza,
and Avhooping-cough are only the ordinary catarrhal ulcers moditied in
their course and appearance by secondary infection.
The s}/inptnms of acute laryngitis depend greatl}^ upon the severity of
the attack, and the age and sex of the patient. In an adult sutt'ering
DISEASES OF THE LARYNX 787
from an attack of moderate severity, the chief complaint is a feeling of
heat and soreness in the larynx ; the voice is hoarse and there is usually
an irritating cough, with at first little or no expectoration ; but after a
time pellets of mucus, in some cases streaked with blood, are coughed
up : in inhabitants of towns the sj^uta are usually pigmented with soot
or other impurities. Should the expectoration be abundant and frothy,
in all probability the bronchial mucous membrane participates in the
catarrh. There may be hardly any symptoms indicative of general
disturbance of the system, except perhaps slight pyrexia and malaise. In
women attacks of laryngitis are more lialjle to occur at the catamenial
period, and in cases of uterine disorder. This is another of the many
instances of the connection between the vocal and genital organs which we
have indicated. Women are more likely than men to become aphonic
during an attack of acute larj-ngitis.
In the most severe attacks there is usually some pain or tenderness
over the larynx ; this is particularly the case in patients of a rheumatic
diathesis. There may be some discomfort in swallowing. Adults rarely
suffer from dyspnoea unless the case be complicated with oidema of the
larynx. The constitutional symptoms are well marked, and there may be
high temperature and increased frequency of the pulse and respiration.
In children, the comparative narrowness of the glottis and their great
proclivity to nervous reflex excitability add elements of danger which
are almost entirely absent in the case of adults. A child may go to bed,
apparently suff'ering from coryza and slight hoarseness, to awake in the
night with a loud, croupy cough, urgent dyspnoea, and cyanosis. During
the day the child seems much better, but at night there may be a
recurrence of the croupy attack. The pulsus paradoxus has been found
in children suffering from the dyspnoea of acute laryngitis.
Laryngoscopically the appearances of acute laryngitis vary very much.
In some cases the cords have a pale pinkish colour ; in cases of greater
severity the cords may be of so red a hue as hardly to be distinguishable
from the rest of the larynx. Occasionally the congestion of the cords is
irregularly distributed ; or the brunt of the attack may fall on one cord,
the other escaping almost entirely. Usually some sticky mucus may be
seen on the curds, and on inspiring after phonation the cords may
momentarily stick together. Accompanying the congestion of the cords
there is usually some amount of infiltration of the submucosa and
muscles, so that on phonation there is a want of tension in the cords. In
rare cases small, round, or oval abrasions or ulcers, to which attention
has already been directed, may be seen on the free margins of the cords.
The term acute epiglottiditis has been applied to cases in which the inflam-
matory mischief is more or less limited to the epiglottis. As previously
mentioned, the sputa may be streaked with blood ; if the amount of blood
poured out is considerable, some writers Avould designate the case as
one of hsemorrhagic laryngitis. In these cases streaks of blood may
be seen on the cords, and occasionally small varicosities have been
recognised.
788 SYSTEM OF MEDICINE
Since the introduction of _ the laryngoscope the dh\(jn(ms of acute
laryngitis is a comparatively simple matter ; the only difficulty occurs in
children in whom it may sometimes be very difhcult to distinguish acute
laryngitis from laryngismus stridulus, on the one hand, and on the other
from membranous laryngitis. In adults the prognosis as regards life is
almost invariably favourable ; death from acute laryngitis hardly comes
■within the pale of practical medicine. As regards complete restoration
of voice a somewhat more cautious opinion must be expressed ; for
occasionally cases occur in which some amount of feebleness or impurity
of voice persists, even after the most persevering treatment. The
laryngitis of influenza, for example, is of a severe type ; the hoarseness is
dithcult to treat, relapses are frequent, and paralytic phenomena may
occur. In children, as already mentioned, there is a certain amount
of risk due to spasm of the glottis.
Treatment. — In the most severe forms of acute laryngitis occurring in
adults it is advisable to keep the patient in bed, in a room of the
temperature of about 65° ; and if the external atmosphere be very dry, a
bronchitis kettle may be employed to moisten the air of the room. The
patient should be enjoined not to talk, and his food should be soft and
unstimulating. Equal parts of hot milk and Ems or Seltzer water
make a pleasant and soothing drink. In most cases sucking small
pieces of ice, and an ice-collar or cold compress round the neck, will
afford the patient much comfort. In other cases the inhalation of the
fumes of nascent chloride of ammonium, or of compound tincture of
benzoin in water at a temperature of 140° F., will be found very soothing.
I have given great comfort by spraying the throat by means of an oil
atomiser with a 5 per cent solution of menthol in paroleinc. If the
cough is frequent and irritating, pastilles of cocaine and rhatany or the
morphia and ipecacuanha lozenges may be used. Tabloids of chloride
of ammonium or the Soden mineral pastilles Avill be found useful in
relieving the dry and irritable condition of the throat. Internally the
bowels should be kept open by saline aperients, and a diaphoretic mixture
is generally of use. Should there be any delay in the disappearance of
the symptoms the larynx may be painted with a solution of. chloride of
zinc — twenty to thirty grains to the ounce. If want of tone be a marked
feature, faradisation, massage of the larynx, and the administration of full
doses of strychnia will accelerate the cure. The importance of seeing
that the nasal respiration is free must be insisted on.
In children, the use of emetics — such as ipecacuanha or sulphate of
copper, or apomorphia (gr. -g^g- to ■^■^) injected subcutaneously — is useful
in removing secretions. As a rule, hot compresses, or sponges Avrung
out in hot water and placed over the larynx, give more relief than the
applications recommended for adults. The tendenc}'^ to spasm should
be controlled by the use of bromide of potassium or chloral. Where
life is threatened by asphyxia, intubation or tracheotomy should be
performed.
Chronic Laryngitis. — Chronic laryngeal catarrh. Inasmuch as all
DISEASES OF THE LARYNX 789
the causes of acute laryngitis are capable of exciting chronic catarrh,
provided either that they are less active or the individual less prone to
acute mischief, it "will be only necessary here to lay stress on those
which are peculiarly apt to set up chronic laryngitis. Indeed chronic
laryngeal catarrh frequently follows an acute or sub -acute attack of
laryngitis.
The first place should undoubtedly be given to over-use or faulty use
of the voice ; especially the use of the voice in the open air, in cold
damp weather, or in an atmosphere vitiated by smoke, acrid fumes, dust,
or other sources of irritation. Hence chronic laryngitis is most frequently
met with in open-air preachers, costermongers, itinerant musicians, and
stone-masons. Secondly, any interference with normal nasal respiration,
either as a result of stenosis or of atrophic changes preventing the proper
functional activity of the nose, is a potent cause of chronic laryngitis.
A notable example of the connection between nasal and laryngeal
affections is furnished by the occurrence of laryngitis sicca in cases of
chronic atrophic rhinitis. Thirdly, syphilitic, tuberculous, malignant, or
other diseases of the larynx, and the presence of neoplasms, are invariably
accompanied by chronic catarrh.
The morbid appearances met with in chronic laryngitis are, for the
most part, such as are commonly seen in a chronic inflammation of other
mucous surfaces. It need only be said here that three more or less
distinct forms of chronic laryngitis may be recognised. The first, or
hypertrophic variety, as its name implies, is attended with hyperplasia of
the mucous membrane of the larynx ; this may be genei'al or local. At
times the ventricular bands are so much thickened as partially or entirely
to obscure the vocal cords ; or the cords themselves may be thickened
and irregular, constituting one of the forms of Virchow's pachydermia.
In the second, or atrophic variety, there is a shrinking or contraction of
the mucous membrane ; this is sometimes associated with similar changes
in the nose and pharynx. The third variety has been named "glandular
laryngitis " ; in it the mucous membrane is somewhat thickened, but the
most marked feature is the enlargement of the racemose glands.
Of the symptoms of chronic laryngitis, that which necessarily attracts
most attention is an alteration in the voice. This may vary from slight
hoarseness to complete loss of voice. As a rule it is most marked in the
morning, the patient usually regaining a certain amount of power after
he has used his voice for a time. In addition to the hoarseness, the
patient finds that speech requires more effort than under orditiary circum-
stances, consequently he soon becomes tired and the voice feeble. Cough
is not a constant symptom ; when it does occur it is usually harsh and
dry, or accompanied by the expectoration of a few pellets of mucus.
Abundant expectoration, as a rule, betokens participation of the trachea
and bronchi in the catarrhal process ; there are, however, cases of pro-
fuse secretion from the larynx to which the term laryngmrhoea has been
applied.
In laryngitis sicca the patient, after repeated efforts, may succeed in
790 SYSTEM OF MEDICINE
bringin<:j up di-y crusts of inspissated mucus ; and he may suffer from
intermittent attacks of dyspnoea due to the formation of large dry crusts
in the hypoglottic region of the larynx. In some cases the sputa are
blood-stainod, or pure Idood may be expectorated. The patient frequently
feels liot and uucomfortal)le in the thioat, but rarely has actual pain.
General symptoms are almost, if not entirely absent.
The laryngoscopic appearances of chronic laryngitis vary considerably.
In the slighter cases there may be only a M-ant of the clear white hue of
the cords in health ; they have a dull grayish or pinkish colour, and
they do not exhibit the vivid redness seen in some cases of acute
laryngitis. Usually both cords are affected ; but the iuHammatory
change may be confined to one cord, or even to a part of a cord.
Accompanying the congestion there is a want of muscular tone, so that
on phonation the vocal cords do not come into complete ajjposition, but
an oval gap is left between them. Mucus may be seen on the ventri-
cular bands and in the aryttenoid commissure ; and occasionally the
vocal cords are momentarily stuck together by the viscid mucus. In
the more chronic cases the cords are thickened and irregular, and erosions
are sometimes seen ; but anything like distinct ulceration is so uncommon
that some authors deny its existence as a part of simple chronic
larynizitis. As ali-cady mentioned, the larynx may exhibit the changes
to which Yirchow has applied the name of pachjiderwia laryncjk. He
describes two varieties : in the Avarty form the change is limited to
isolated spots, chiefly in the anterior extremities of the vocal cords ; in
the diffuse form the vocal processes are chiefly affected. The most
characteristic appearance is an oval swelling on one vocal process, with
a corresponding depression on the other. In chi-onic subglottic larvn-
gitis there is a hyperplasia of the connective tissue beneath the vocal
cords ; and on a laryngoscopic examination the lumen of the larynx
below the cords is narrowed by a tumefaction which is of a red or pale
gray colour. In some instances there is reason to believe that sub-
glottic hypertrophy is a manifestation of rhinoscleroma. In larjnigitis
sicca crust may be seen in the larynx, especially at the posterior com-
missure.
The diagnosis of chronic larj'ngitis is easy, save under two conditions ;
the one is laryngeal tuberculosis, the other malignant disease of the
larynx. Many cases of tuberculosis of the larynx begin with all the
appearances of an ordinary chronic catarrh of the larynx ; and it is the
subsequent course only which unfolds the real nature of the disease. Hence
the importance of iitilising any assistance that can be afforded by the
examination of the sputa for tubercle l)acilli and by the detection of
phthisical processes in the lungs. In people over forty, and still more
in those over fifty, limitation of the affection to one cord, especially if
there be thickening associated with impaired mobility of the cord,
should lead to a guarded prognosis in view of the possibility cf the
disease being of a malignant nature.
Treatmenl. — The first two things to be done, if the treatnuMit of
DISEASES OF THE LARYNX 791
chi'onic laryngitis is to be conducted on rational principles, is to order
complete rest of the voice, and the removal, if possible, of the cause or
causes of the disease. It will hardly be necessary to insist on the
importance of giving the voice rest ; but, unfortunately, the patients who
most frequently require treatment are those who earn their living by
the use of their voice, and who are consequently most reluctant to
give up the use of it. Nevertheless, it is hopeless to expect a cure if the
patient continues the excessive use of the voice. As regards the
removal of the causes of this complaint, the patient must be instructed
in the proper method of voice-production ; the nose should be carefully
examined, and any departures from the normal conditions should be
remedied so far as possible. The general health of the patient should
be attended to, and anaemia, dyspepsia, constipation, and any other
ailments present should receive appropriate treatment. As regards
local treatment, inhalations of creasote or of the oil of Scotch
pine may do a certain amount of good ; but the chief remedy is
the application of astringents to the cords by means of the laryngeal
brush under the guidance of the mirror. In cases of moderate severity
solutions of chloride of zinc (twenty and thirty grains to the ounce)
may be employed ; but in severe and ol)stinate cases nitrate of silver
answers better. It should be used in solutions of gradually increasing
strength, beginning with sixteen grains to the ounce, until ninety -six
grains to the ounce or even stronger solutions are reached. The appli-
cation should be made daily at first, until a certain amount of reactive
inflammation is set up ; and then at less frequent intervals, and the
solutions gradually decreased in strength. In cases where there is much
thickening of the cords, lactic acid in 30, 40, or 50 per cent solutions
yields excellent results.
During convalescence various astringent sprays, such as chloride of
zinc (two grains to the ounce), iron-alum (three grains to the oiuice), or the
perchloride of iron (three grains to the ounce), will be found of assistance.
Pastilles of benzoic acid or of the chloride of ammonium are also of
service. If, after the congestion has been removed, the voice remain
feeble, electricity, in the form either of the continuous or interrupted
current, should be applied percutaneously ; and massage over the larynx
is sometimes of servit;e. Internally, strychnia in full doses has a
powerful effect in improving muscular tone, and is consequently useful
in cases in which the approximation of the vocal cords on phonation is
imperfect. Much good often results from sending the patient to a spa,
such as Ems or Aix-les-Bains, for a course of two or three weeks,
followed by a fortnight's stay in some bracing locality.
In the treatment of pachydermia laryngis rest of the voice is
absolutely necessary ; alcohol and tobacco should be prohibited. Small
doses of iodide of potassium or of the green iodide of mercury seem to
have a beneficial effect in some cases. The inhalation of a 3 per cent
solution of acetic acid, and painting the growth with the same fluid, are
said to have yielded favourable results.
792 SYSTEM OF MEDICINE
(Edema of the Larynx (not including acute septic oedematous
inflammation). — Though oedema of the larynx does not represent a
distinct disease, but a complication of various diseased states general
and local, still on account of its danger to life, and for the sake of
obtaining a comprehensive view of its clinical features, a separate
section may well be devoted to its consideration. The name oedema
of the glottis was originally applied to the condition in question. Inas-
much, however, as the glottis is a space and cannot therefore become
a'dcmatous, the term is inappropriate, the more so as the vocal cords,
which form the boundaries of the glottis, are of all parts of the larynx
the least often oedematous.
EiioJogij. — Two varieties of oedema of the larynx may be described,
namely, primary and secondary, or passive, oedema. Primary cedema
may again be subdivided into the simple or non-infectious variety and
the infectious or septic variety. Simple or non-infectious oedema of the
larynx arises as the result of traumatism — as from swallowing some hard
or pointed body, the application of caustics to the larynx, the entrance
of brandy (given perhaps during an attack of syncope) into the larynx,
and swallowing boiling water.
A form of primary oedema of the larynx, associated with a similar
change in the jiharynx and on the skin, has received the name of angio-
neurotic cedema ; in cases of this sort, there is an absence of any
inflammatory cause, and the urine does not contain albumin. It
usually occurs in early adult life, and most frequently in women.
Oedema of the larynx is also seen occasionally as a result of the ad-
ministration of iodide of potassium ; and it is probable, from analogy
with angio-neurotic oedema, that the salt causes oedema by way of some
influence on the nerves. The curious featixre about the iodic oedema is
that it may come on after the administration of a few small doses.
Other symptoms of iodism, such as headache and coryza, are commonly
absent. The possibility of the occurrence of oedema of the larynx while
the patient is taking iodide of potassium should always be borne in
mind, as a considerable number of cases have been met with ; and in two
instances recorded by Fournier death occurred before tracheotomy
could be performed.
The infectious or septic forms of oedema of the larynx depend upon
the entrance of infective germs into the tissues in or around the larynx.
This form, which includes purely (t'dematous as well as the sero-puru-
lent and phlegmonous exudations into the tissues which are due to the
action of these microbes, and comprises primary erysipelas of the larynx,
has already been dealt with in the section on " Acute septic inflamma-
tion of the throat."
(Edema of the larynx ma}' also be met with in the early stage of
infectious diseases without previous ulceration ; it has been seen, for
example, in a case of hydrojjhobia ; and as a complication of ambulatory
typhoid fever it has caused death by suff'ocation.
The causes of secondary a'dema of the larynx may be arranged under
DISEASES OF THE LARYNX 793
two heads — local and general. The local causes include all the diseases
of the larynx, such as tuberculosis, syphilis, carcinoma, and the laryn-
gitis of influenza, sinall-pox, measles, and especially any disease which
sets up perichondritis. I have seen it arise and prove fatal as a
complication of quinsy. It has been noticed as a result of isolated
suppuration of one of the deep cervical glands, even before the pus has
broken through the capsule of the gland.
The general causes of o?dema of the larynx are those which are
capable of giving rise to general dropsy, such as valvular disease of the
heart, chronic pulmonary or renal affections, the cachexy produced by
malaria or lardaceous degeneration, and, lastly, passive congestion of the
vessels of the larynx, such as arises from growths in the mediastinum,
bronchocele, enlargement of the bronchial glands, or any growth in the
neck compressing the branches of the superior vena cava.
Pathology. — In oedema of the larynx, the epiglottis, the ary-epiglottic
folds, and the ventricular bands are the parts chiefly affected, on account
of the lax nature of their submucosa ; whereas the vocal cords, which are
more firmly attached to the siibjacent tissue, are very seldom oedematous.
In some cases, however, the oedema is infraglottic ; this variety has
occurred as a result of the administration of iodide of potassium. The
exudation varies from a purely serous to a sero-purulent or purulent
quality, and the fluid is sometimes blood-stained. The serous variety is
met with in all kinds of diseases which give rise to general dropsy, and in
passive congestion of the part. In the septic and inflammatory varieties
the oedema is due to a sero-purulent or purulent infiltration. Unilateral
oedema usually points to an inflammatory cause ; partial oedema has also
been noticed in the course of Bright's disease. In most cases of acute
oedema, in which the immediate causes are not apparent, primary
erysipelas of the larynx is the true diagnosis. In all prolmbility in many
cases infective germs enter the system through slight injuries of the root
of the tongue, and the inflammatory mischief passes thence to the
epiglottis.
The connection between oedema of the larynx and Bright's disease
has been denied by some authors. Peltesohn has collected 210 cases of
oedema, and in 25 cases there was disease of the kidneys. That there is
a connection between the two seems certain, but the nature of it is not
equally clear. Probably the presence of Bright's disease detei'mines the
onset of oedema where there is a lesion too slight to cause it under
ordinary circumstances. (Edema of the larynx in connection with Bright's
disease may come on very gradually ; in some cases, however, the oedema
may form the first symptom or sign of the disease. Oedema of the larynx
has also been met with in diabetic and myxoedematous patients, and it
has been known to cause death in the new-born infant. The intimate
connection existing between the genital organs and the vocal apparatus is
shown by the fact that attacks of oedema of the larynx may correspond
with the catamenial period. According to Binz, oedema of the larynx, due
to iodide of potassium, can only come on if there be already some breach
794 -S" ys TEM OF MEDICINE
of surface in the laryngeal mucous membrane. The angio-neurotic oedema
described by Striibing depends upon an increased irritability of the vaso-
dilator nerves. Osier has reported two fatal cases.
Si/mptoms. — One of the first symptoms of which the patient complains
is the feeling of a foreign body in the throat ; there is difficulty or pain in
swallowing, and, owing to this, the saliva, which the patient tries to expel,
accumulates in the pyriform sinus. The voice is at first somewhat thick
and muffled, and in severe cases the patients may become almost aphonic.
Owing to defective closure of the glottis patients easily choke on taking
fluids. In some cases inspiration only is difficult and accompanied
with stridor ; this is especially the case if the ary-epiglottic folds are
affected alone. If, however, the ventricular bands and the laryngeal
aspect of the epiglottis participate in the a?dema, then expiration is inter-
fered with also.
On laryngoscopic examination the mucous membrane covering the
affected part looks tense and pale, though the margins may have an
inflamed appearance. If the epiglottis is involved, it becomes swollen and
erect ; and the swollen ary-epiglottic folds resemble plums in shape. If
the oedema is of the subglottic variety, two red fleshy swellings Avill be
visible below the vocal cords. In the absence of a laryngoscope the
swollen condition of the epiglottis and ary-epiglottic folds may be detected
by digital examination. Clinically two forms of cedema of the laryi^x
may be distinguished ; the acute foi'm runs a rapid course, a high degree
of dyspnoea has been noticed within fifteen minutes after an infliction of
an injury to the larynx, and death has been known to ensue within a few
minutes ; in the chronic form the symptoms arise more gradually, but
even in these cases a sudden exacerbation is not uncommon.
In oedema of the larynx running a fatal course the patient presents
all the symptoms met with in death from suffocation.
Prognosis. — Thanks to the more general use of the laryngoscope,
which leads to the earlier recognition of the disease and to the more
prompt performance of tracheotomy, the outlook in cases of oedema of
the larynx is much better than it Avas formerl}^ General oedema of the
larynx is of course more dangerous than an oedema confined to one
side of the larynx. The subglottic oedema met with in connection with
caries of the cricoid cartilage is a dangerous variety. In estimating the
risk to life in any particular case it is necessary to bear in mind the
possible sui)ervention of spasm of the glottis. Again, the prognosis may
directly depend upon the cause of the nnlema ; the septic variety, for
instance, is especially dangerous on accoiuit of its secondary results. The
oedema due to chronic dropsy will usually disappear quickly if the general
cause be removed.
Treatment. — In all cases of oedema of the larynx absolute rest in bed,
in a room kept at an even temperature, with the air somewhat moist, is
essential. The patient should be forbidden to speak, and, in order to
diminish the dilficidty in swallowing, the food should be liquid or semi-
solid. I have seen much benefit from feeding the patient per rectum.
DISEASES OF THE LARYNX 795
Pellets of ice to suck and an ice-bag or Leiter's coil around the neck
are more suitable than hot applications. To prevent the tendency to
spasm, bromide of potassium may be given in 10 to 20-grain doses every
three or four hours. Three injections of jiilocarpin (gr. \) at intervals
of twenty minutes have given excellent results ; in one case all threaten-
ing symptoms disappeared fifteen minutes after the last injection. If,
in spite of these measures, the oedema increase and dyspnoea become
more marked, the larynx should be sprayed or painted with a 20 per
cent solution of cocaine, and the oedematous parts freely incised with
Mackenzie's guarded laryngeal lancet. Should this procedure not give
speedy relief, no time should be lost in resorting either to intubation or
to tracheotomy ; usually the latter will be necessary, as ' the swelling of
the soft parts prevents the introduction of the tube.
Free administration of the bicarbonate of sodium in cases of oedema
due to the iodide of potassium will be found of service, provided the
oedema be not of dangerous dimensions. In angio- neurotic a'dema
Striibiiig recommends ice and morphia, and scarification if necessary.
Small doses of atropine may be tried.
Laryngeal Hsemorrhage. — In some cases haemorrhage takes place
into the laryngeal mucous membrane ; in others there is a free escape of
blood, and the blood may be seen to issue from an ulcerated vessel, or
the two conditions may be combined. In acute cases of laryngitis it is
not unusual for the sputa to be streaked with blood ; this was especially
the case during the influenza epidemic : to cases in which the bleeding
is profuse the name hceworrhagk lari/vgitis has been a])plied. Hcemorrhage
from the larynx occurs more frequently in women than in men, especially
in pregnant women and after parturition ; cases in which it has co-
incided with the catamenia have also been recorded. Exposure to cold,
violent cough and retching and strain of the voice are the chief
direct causes of laryngeal hperaorrhage, and the issue is most likely to
occur in persons with degenerate vessels. Laryngeal haemorrhage is met
with in purpura, leukaemia, chlorosis, the malignant fevers, and other
diseases in which there is an alteration in the composition of the blood.
There seems to be no connection between the occurrence of laryngeal
hsemorrhage and pulmonary consumption.
Symptoms. — As a rule, laryngeal hsemorrhage is so slight that it does
not appreciably modify the symptoms of the laryngitis which it accom-
panies ; occasionally, however, the blood is poured out in considerable
quantity, and the blood-clots, by blocking the glottis, may give rise to
dyspnoea ; an attack of coughing will dislodge the clots and render the
breathing free until the clots again form. If the hsemorrhage should
come on suddenly, while the person is talking or singing, the voice
immediately fails, and a spasmodic cough, followed by expectoration of
blood, is set up.
In cases in which the hsemorrhage is due to altered blood states, the
laryngeal symptoms are overshadowed by the symptoms of the general
disease. On laryngoscopic examination blood may be recognised as an
796 SYSTEM OF MEDICINE
extravasation under the mucous membrane, or it may be seen on the
surface, sometimes forming clots ; occasionally a perforating ulcer may be
distinguished as the source of the bleeding.
Treatment. — If the bleeding be at all profuse, the patient should be
kept absolutely at rest and should not be allowed to talk ; he should
suck small pieces of ice, and have an ice poultice or Lciter's tubes applied
over the larynx. The larynx should be sprayed with astringent solu-
tions, such as 3 gi-ains of iron-alum and 10 minims of glycerine in an
ounce of water. If the hremorrhage can be seen to come from an eroded
spot, this may be touched Avith the galvano-cautery. Inhalation of
turpentine is said to be useful in checking laryngeal haemorrhage. If the
cough be troublesome, small doses of morphine must be employed to
check it. — F. de H. H.
Tuberculosis of the Larynx. — Causes. — Laryngeal tuberculosis forms
one of the most frequent complications of the same disease in the lungs,
and, according to Heinze's pathological investigations, is met with in
about '60 per cent of all cases of pulmonary phthisis. The occurrence
of primary laryngeal tuberculosis is now definitely established by the
results of a few post-mortem examinations, but it is an event of the
greatest rarity. It is much more frequently met with in men than in
women, and its more severe forms also occur more frequently in the male
sex. It is seen at all ages, but occurs rather in the years of early man-
hood. The determining cause of the disease is the bacillus tuberculosus,
and the disease may be either acquired or hereditary ; unfavourable
conditions of life play the part of favouring factors. AVhat determines
the occurrence of the laryngeal complication is not yet certain. Pro-
fessional vocalists are certainly less frequently attacked than others.
Whether the disease begin on the surface and penetrate into the lower
tissues, or whether the reverse be the order of events, is not yet
definitely settled : the former order seems to be the more prol)able.
Fathohgy. — The deposit of tubercles in the larynx is usually mani-
fested by infiltration and pseudo-oedematous thickening of the tissues.
This is most marked, as a rule, in the epiglottis, the arytteno-epiglottid^an
folds, the mucous membrane covering the arytsenoid cartilages, and the
interarytaenoid fold. In another series of cases, however, the disease
begins on the vocal cords or on the ventricular bands ; indeed, no
part of the larynx is immune against the invasion of tubercle. The
stage of actual infiltration is often preceded by marked isolated anaemia
of the whole mucous membrane of the larynx, usually associated with an
analogous condition of the pharyngeal mucous membrane ; and the
anaemia is most noticeable on the epiglottis. In very rare cases tubercles
themselves have been seen as small yellowish or grayish nodules in the
midst of the general infiltration ; the stage of their corpuscular existence,
however, must be extremely brief, and in the great majority of cases the
first sign of their ])resence is manifested by the small superficial ulcera-
tions which result from their break-down. These ulcers quickly coalesce,
DISEASES OF THE LARYNX 797
extend in width and depth, and after a time give a worm-eaten appear-
ance to the parts attacked. The epithelium, the mucosa, and submucosa
having been destroyed, they extend towards the perichondrium and lead
to perichondritis, caries, necrosis, and often to exfoliation of parts of the
cartilages. Sometimes actual tubercular tumours, consisting of an aggre-
gation of miliary tubercles and cellular infiltration of the mucosa and
submucosa, as well as of general d<^bris, are met with in any part of the
larynx, and this even in cases in which there is no evidence of con-
comitant lung disease.
Symptoms. — The subjective symptoms of laryngeal tuberculosis are,
according to the seat of the disease, either hoarseness and, in later stages,
more or less complete aphonia, or pain, difficulty in swallowing, cough
with more or less expectoration, and sometimes dyspnoea. Often all these
sym2)toms are met with simultaneously. The most troublesome of these
are usually cough, pain and dysphagia. Whilst all the symptoms named
depend, as a rule, upon these local conditions, the cough may also, of
course, be due to the concomitant pulmonary disease ; moreover, the vocal
troubles are not necessarily due to the swollen and ulcerated state of the
vocal cords, but may depend ut)on implication of the right recurrent
laryngeal nerve in pleuritic thickening at the apex of the right lung, or
upon pressure of enlarged bronchial glands upon one or both recurrent
laryngeal nerves, and subsequent paralysis of the corresponding vocal
cord : the shortness of breath often observed in these patients is more
commonly due to the concomitant pulmonary affection than to the
laryngeal trouble ; though in later stages it may be of laryngeal origin,
taking its rise either in general oedematous swelling of the larynx or in im-
plication of the crico-arytsenoid joints, with adducted position of the vocal
cords as the result of perichondritis. In very rare cases bilateral paralysis
of the abductors of the vocal cords, due to jDressure of enlarged bronchial
glands upon the recurrent laryngeal nerves, may produce the same effect.
Objectively, the pallor of the mucous membrane, preceding any definite
signs of actual tuberculous mischief, and persisting generally throughout
all subsequent stages, is of diagnostic value. When met with in any case
in Avhich there is not general anaemia the patient's lungs must be
minutely examined. More rarely the initial symptom may be some
laryngeal congestion, which at first is indistinguishable from ordinary
laryngeal catarrh.
When tuberculous infiltration takes place, and particularly when this
pre-eminently concerns the epiglottis and the mucous membrane over
the arytrenoid cartilages, as in many cases it does, the appearances often
become so characteristic as to enable an experienced .observer to diagnose
the existence of tuberculosis with tolerable certainty, independently of
the condition of the lungs, which, however, will never be neglected. In
such cases the epiglottis is changed into a pale, roimded sausage or
turban-like body, many times its normal size, lying across the pharynx ;
thus inspection of the interior of the larynx proper is often prevented,
whilst the arytajnoid cartilages are changed into two puffy, pale, rounded
798 SVSTEJf OF MEDICINE
or p3'rifoim bodies, which, together with the epiglottis, completely fill up
the image seen in the laryngeal mirror. The oedema is distinguished
from ordinary oidema by its greater density. Later, the surface of
these swellings, originally smooth and shiny, becomes completely riddled
with small superficial ulcers, which quickly coalesce and give to all the
parts afiected the worm-eaten appearance already described. In other
cases tumefaction first begins in the interarytaenoid fold ; and when
ulceration occurs, small stalactite-like projections may be seen in that
part. Again, in a third class of cases the infiltration and ulceration may
begin on one or both vocal cords or ventricular Ijands, and sometimes the
oidy laryngeal manifestation of tuberculous disease of that part consists in
complete erosion of one or both the cords by ulceration. In later stages
the whole laryngeal mucous membrane often forms one mass of ulcera-
tion, which does not remain superficial, but gradually spreads towards
the submucosa, the perichondrium and the cartilages themselves. The
epiglottis may be destroyed in part or entirely; often indeed a short,
irregular stiunp is the only evidence of its previous existence. The
arytfenoid cartilages may become carious and necrosed, and are sometimes
expelled in their entiret}', a crater-like ulcer in the middle of a i)uify
infiltration indicating their previous seat ; or in other cases partial or total
anchylosis of the crico-aryta?noid joint takes place, and the cartilage,
together with the corresponding vocal cord, becomes fixed and immov-
able. Apart from the last-named cause of complete or partial immobility
of a vocal cord in the course of laryngeal tuberculosis, such impairment
may be the result also of {a) functional weakness of the laryngeal muscles,
particularly of the adductors, which is sometimes met with even in the
earliest stage of laryngeal tuberculosis ; and (/>) of pressure upon one or
both recurrent laryngeal nerves. In this respect the right recurrent is
more exposed in laryngeal tuberculosis than the left, owing to its
anatomical situation close to the iinier aspect of the apex of the right
lung ; in this position it is not rarely implicated in the pleuritic thickening
which accompanies destructive processes in the apex itself.
The, diar/nosis of tuberculosis of the larynx is not often difficult ;
the pallor of the parts, the characteristic infiltratioii of the epiglottis and
aryttenoid cartilages, the worm-eaten appearance in the later ulcerative
stages, taken together with the pulmonary signs, the presence of Ijacilli in
the sputum, and the general symptoms attending tuberculous disease, will
in most cases find a ready interpretation. Greater difficulties may be met
with when the initial i^tagc is manifested by simple catarrh only. It
must be remembered that simple catarrhal laryngitis for a long time may
accompany a pulmonary tuberculosis. The apparent catarrh, however,
may affect one vocal cord only, in which case the experienced observer
will at once suspect some graver constitutional disease. The affections
with which laryngeal tuljcrculosis is most likely to be confountled are
syphilis, malignant disease, and lupus of the larynx. With regard to
syphilis, apart from the manifestations in other parts which accompany
tuberculous laryngitis on the one hand, and .syphilitic laryngitis on the
DISEASES OF THE LARYNX 799
other, it may be observed that tuberculous ulceration is usually preceded
hy a more or less prolonged stage of pseudo-oedematous infill ration ; that
the aspect of the parts, as already mentioned, is distinguished by its
great pallor, and the ulceration by its -worm-eaten and superficial character.
The syphilitic ulcer, on the other hand, the result of the breaking down
of a gumma, is produced much more rapidly, and shows its inflammatory
origin by the area of considerable inflammation which usually surrounds
it : further, it is usually solitary and often very large ; its rapidly
destructive tendencies also are greater than those of laryngeal tuber-
culosis. It must not be forgotten, however, that syphilis and tuber-
culosis of the larynx may occur simultaneously in one and the same
individual ; and that under such circumstances the aspect of the parts
may be anything but characteristic. In such cases the complex nature
of the laryngeal disease will be cleared up by the administration of iodide
of potassium.
With regard to the diff"erential diagnosis from malignant disease
the age of the patient may be of some help : tuberculous laryngitis
is most frequently met with in persons from twenty to forty years of
age ; malignant disease usually occurs after that period of life : but
there are many exceptions to this general rule. Further, laryngeal
tuberculosis is usually bilateral ; malignant disease, in its initial stages at
any rate, is almost always unilateral. Again, cancer of the larynx often
forms a much more distinct tumour than laryngeal tuberculosis, and
in the former case an area of intense, even oedematous congestion and
inflammation frequently exists around the new growth. Considerable
secondary infiltration of the cervical glands also points to malignant dis-
ease. Sometimes, however, the difterential diagnosis, especially in the
later stages Avhen secondary perichondritis may mask the original mani-
festations of either disease, is one of considerable difficulty ; and un-
doubtedly laryngeal carcinoma may coexist with pulmonary tuberculosis,
so that even the discovery of bacilli in the sputum, and the presence of
the usual constitutional symptoms, do not give a definite clue to the
nature of the laryngeal disease. In such cases, which fortunately are
very rare, the extii-pation and microscopic examination of a small piece
of the laryngeal tumefaction may be of assistance, although this test
again is anything but infallible.
Finally, with regard to the differential diagnosis from lupus, it may
be said that laryngeal lupus is rare, and as a rule associated with
analogous lesions in the nose, pharynx, and on the external integu-
ment. Further, laryngeal lupus usually is not painful, and gives rise to
dysphagia in the later stages of ulceration only. Its course also is much
slower than that of genuine tuberculosis ; and even during the ulcerative
stage the occuri-ence of fresh nodules wall assist in making a diff"erential
diagnosis from genuine tuberculosis. Bacteriological tests, of course, are
of no value for the diflferential diagnosis in these cases.
The prognosis in cases of laryngeal tuberculosis depends upon the
nature and extent of the concomitant pulmonary not less than of the
8oo SYSTEM OF MEDICINE
laryngeal lesions. In advanced cases of both, needless to sa)% it is bad ;
but the general character of the prognosis is not nearly so hopeless nowa-
days as it was fifteen yeaxs, ago. If the pulmonary lesions be still limited
to consolidation of the a])ico.s, and if the laryngeal ulcerations be not too
extensi\"e and are situated in the proper interior of the larynx, nowadays
one is enabled by a judicious combination of constitutional and local treat-
ment to arrest the disease in not a few cases ; although, of course, even
if we have succeeded in bringing about cicatrisation of a tuberculous ulcer,
we must always be prepared for fresh manifestations.
Treatment. — The constitutional treatment I now regularly employ con-
sists in the administration of large doses of pure creasote in small gelatine
capsvdes, containing each one minim of the drug, as first suggested by
Sommerbrodt. The patient begins by taking one capsule three times a day
immediately after meals, and at intervals of three to four days he increases
the dose gradually from one to five capsules each time ; so that finally he
takes fifteen minims of pure creasote three times a day. Some practi-
tioners give even much larger doses, but I have not found this necessary ;
and I prefer the long-continued use of the drug in moderate quantities.
Some of my patients have taken between ten and twenty thousand capsules
in the course of two to four years, and are doing very well under it. In
a few cases, of course, an idiosyncrasy against the use of creasote may be
met Avith, and in such cases carbonate of guaiacol may be tried ; but on
the Avhole the toleration even of large doses of the drug is very remarkable,
and in the cases in which it is said to have caused digestive troubles
these could often be traced either to the use of an impure preparation or to
the use of the capsules between meals instead of immediately after food.
Locally, when the ulceration is limited, I emplo}^, after previous cocain-
isation, applications of lactic acid varying in strength from a 20 to an
80 per cent solution. The drug is firmly rubbed into the ulcerated
parts by means of Krause's forceps round which a small pellet of cotton
Avool is firmly Avound. To ensure success the practitioner ought to
remember that these applications are not to be made in the gentle fashion
of an ordinary astringent application, but in that of the cleansing of a
tuberculous joint. If the ulceration be at all deep, the application of the
lactic acid must be preceded by scraping the base of the ulcers hy means
of Heryng's curette, exactly as one Avould scrape the granulating surfaces
of a tuberculous joint after it has been opened. This means, hoAvever,
ought to be practised only by operators fully conversant Avith more
delicate intralaryngeal operations, for by an indiscriminate use of the
curette more harm than good may be done. In not a few cases the
results of this tre;itment, Avhen properly carried out, are most gratifying.
Should the ulceration be too much advanced, and the general condition of
the patient be at too low an ebb to admit of energetic treatment, local
sedatives — such as powders containing acetate of morphia, boracic acid
and deodorised iodoform, or cocaine lozenges, or a cocaine spray Ijefore
the meals — ought to be employed. In such cases it Avill usually be found
necessary to increase the dose of the local anaisthetic after some time ;
DISEASES OF THE LARYNX 8oi
but as tlie main object of the treatment under such circumstances is to
promote euthanasia, one need not be afraid of the increase. In the more
hopeful cases, after completion of the local treatment and when cicatrisa-
tion has been obtained, it may be desirable to advise a change of
air; and either a sea -voyage or a stay at Bournemouth, or Torquay
or any of the health resorts of the Jxiviera, of Southern Italy, or of the
north of Africa may Ije advantageous. In accord with the experi-
ence of most practitioners in the Engadine, I have found that the exist-
ence of laryngeal complications is a serious drawback to residence at
those high altitudes, however desirable it may be from the point of view
of the pulmonary disease. — F. S.
Lupus of the Pharynx and Larynx. — Causes. — The nose and throat
are involved to a greater or less extent in a large percentage of cases of
cutaneous lupus ; in a small proportion, however, this disease originates
and may long exist in the pharynx and larynx, without the external
integument or the nose becoming affected.
As regards the etiology of the affection, it is directly due, no doubt,
to a specific bacillus ; and the great majority of writers are agreed in
regarding lupus and tuberculosis as one and the same disease under
different conditions. But while the identity of the specific microbe
of lupus and tuberculosis is generally, though not universally, admitted,
the cause of the i-emarkable diff"erencc in the clinical conditions seen in
these diseases, especially as it manifests itself in the mucous membrane of
the upper air-passages, has yet to be explained.
Women are much more prone to suffer from lupus than men ; it generally
reveals itself between the ages of two and ten years. It is more liable
to occur in persons of an inherited tuberculous proclivity, though lupous
patients are themselves but rarely the subjects of ordinary tuberculous
disease ; nor does the particular affection itself show any marked tendency
to hereditary transmission. The disease is in no way connected with
syphilis, although frequently in its physical aspects it is hardly distinguish-
able from the lesions of syphilis.
The nodules and tumefaction which are characteristic of lupus consist
of a cellular new growth in the mucous membrane in which giant cells,
and occasionally bacilli indistinguishable from tubercle bacilli, may be
found. When the deposit first manifests itself on the UAaxla or on the
free border of the soft palate, Ave may find localised tumefaction, generally
of distinctly heightened colour, less marked and more limited than in
syphilis or acute pharyngitis, but differing in aspect from the anaemia
premonitory of tubercle ; sometimes the deposit appears in mucous mem-
brane apparently healthy. In course of time, smooth, hard nodules
appear vaiying in size from a pin-head to a split pea, and generally of a
rosy pink colour.
The nodular deposit greatly deforms the parts ; and when arising in
the uvula or soft palate the distortion and twisted appearance of the
affected structures may be well marked.
VOL. IV 3 F
So2 SYSTEM OF MEDICINE
Soon the nodules become softer and chanicteristically " apple-jelly-
like " in appearance, and then as a rule ulceration begins. The ulcers
present a serpiginous ■\vorm-eaten appearance, Avith defined hard or soft,
granular and prominent margins, and a A-elvety, red, dry, indolent base.
The process of ulceration progresses very slowly, healing in one direction
while spreading in another; and periods of increased activity alternate with
long ])eriods during which the disease appears to remain in abeyance.
When the tonsils are involved, they become covered with irregidar red
nodules and pits of ulceration, but the course of the disease is precisely
similar to the faucial deposits.
In the larynx, lupus generally attacks first the free margin of the
epiglottis, which becomes tumefied; and the swelling gradually spreads to
the arytieno-epiglottic fold and ventricular bands. The epiglottis becomes
pale, "worm-eaten," and rough in aspect, and large portions may be com-
pletely lost. The vocal cords are usually the last part to be affected,
and so slow is the progress of the disease that they often escape. When
attacked, they become red and tumefied.
Sijmptoins. — As pain is practically never caused by lupus, the pharynx
and larynx are often invaded without any obvious symptoms until the
destruction of the soft palate causes flvtids to return through the nose on
swallowing, or gives a nasal tone to the A'oice and renders articulation
imperfect. From the invasion of the posterior commissure or the vocal
cords the voice becomes hoarse and aphonic. Some degree of stifihess in
the pharynx and slight soreness and tickling sensations may be felt in
the pharyngo-laryngcal region. In the advanced laryngeal disease cica-
tricial stenosis and dyspnoea very often arise and may necessitate tracheo-
tomy, but there is hardly ever any inflammatory exudation with acute
dyspnoea ; the laryngeal stenosis is always very slowly established, and
ample warning is given of the increasing urgency of the dyspnoea.
Perichondritis or necrosis of cartilages is excessively rare.
Diagnosis:. — The coexistence of cutaneous lupus will seldom leave
room for doubt as to the correct interpretation of the phaiyngeal and
laryngeal phenomena ; nevertheless it is sometimes a very difficult matter
to make the diagnosis sure. The difficulties in the earlier stages are very
much increased if the phaiynx or Luynx is affecteil piimarily ; the differ-
ential diagnosis has then to be made from simple chronic pharyngitis or
laryngitis, syphilis, tuberculosis, and carcinoma.
Chronic phaiyngitis is attended with increased secretion, and the
hypertro] shied lymphatic follicles are confined to the posterior and lateral
walls, while there is no distortion of the parts, and the alisence of lupous
tubercles is to be noted. In the earlier stages of syphilitic laryngitis,
especially in the catan-hal form with or without sui)erficial ulceration,
in the later stages with diffuse infiltration, and more especially in
hereditary cases, the laryngoscopic appearance and the age of the patient
often fail to settle the diagnosis till antisyphilitic remedies have been
tried. Yet even at first the aspect of the tumefaction, the distortion
of the parts, and the slow erosion of the tissues withotit distinct and
I
DISEASES OF THE LARYNX 803
obvious ulceration, are generally enougli to lead at any rate to a strong
suspicion of the real natui-e of the affection. The fact that lupus usually
occurs in theveryyoUng,is very slowly progressive, always with cicatrisation,
and is almost never painful, together with the peculiar appearances of the
growth, and the absence of wasting, fever, or quickened pulse, should rarely
leave any doubt as to the differential diagnosis from genuine tuberculosis,
which is characterised by general pallor of the mucous membrane, and
numerous mouse-nibbled, pale ulcers covered with grayish, disintegrating
tuberculous tissue, and is usually accompanied by considerable pain,
especially in swallowing.
The prognosis as regards life is favourable, the chief danger being
stenosis of the larynx ; hut this comes on so gradually, and is so little prone
to be suddenly increased by perichondritis or oedema, that tracheotomy
can almost always be performed in good time. Occasionally long-standing
lupus of the pharynx and larynx ends in pulmonary tuberculosis.
In cases in which the disease is confined to the pharynx and larynx,
and is accessible, good results may be obtained by vigorous treatment,
and occasionally complete cures.
Treatment. — Patients affected with lupus should be placed under the
most favoural)le hygienic conditions possible, and during the Avinter
months should take cod-liver oil ; while general tonic remedies such as
the syrup of iodide of iron or arsenic should be exhibited from time to
time.
■ As regards local treatment, the nodules and tumefactions should be
scarified or curetted, and strong lactic acid (80 .per cent) rubbed in after
the same manner as we adopt in tuberculous disease of the larynx. This
should be done once a week, successive portions being treated until the
whole of the diseased area has become cicatrised and no nodules or ulcers
are visible. The cases should be watched for at least a year after apparent
cure has been effected ; and any fresh manifestations of the disease should
be similarly dealt with at once.
Isolated deposits may be destroyed by the galvano-cautery. In a
case shown before the Clinical Society of London by one of us (F. S.)
some years ago, lasting and complete cure of a very extensive laryngeal
lupus had been obtained by persistent use of this form of cautery.
Stenosis of the larynx may be arrested for a time by intubation or
by the passage of Schrotter's bougies ; occasionally tracheotomy may be
unavoidal)le.
Leprosy of the Larynx and Pharynx. — For a general account of
this disease and its causation the reader is referred to the article
" Leprosy " in the second volume of this work.
Laryngeal symptoms. — The larynx is especially susceptible to leprosy, but
the disease never appears upon the larynx primarily. It usually attacks
this organ after it has invaded the skin, mouth, and fauces.
Leprosy of the throat may assume the tubercular or, very rarely, the
ana?sthetic variety. In either case the onset is extremely insidious,
oAving to the painless nature of the affection ; and patients will some-
So4 SYSTEM OF MEDICINE
times (Iccliire th;it they li;ive nothing the matter with the throut -when
examination reveals nndoubted evidence that it has been established
there for a long time.
Tubercular leprosy of the mucous membrane passes through three
stages. In the first stage the uvula and soft palate, in M-hich the altera-
tions are usually first ol)served, become red and vehety in a])pearance,
and the neighbouring tissues liecome aflected by continuity or by sepa-
rate foci of disease, so that the epiglottis and arytaeno-epiglottic folds
likewise become red, velvety, thickened, and hard, and appear as though
coated with varnish. At this stage epistaxis frequently occurs, and the
patient may complain of shortness of l)reatli and a sense of tickling and
dryness in the phaiynx and larynx. In course of time the red, hard
infiltration becomes soft, and the tissues somewhat n^dematous, the red-
ness soon giving place to pallor, till the aflected regions arc uniformly
pale and resemble the anaemia of tuberculous disease; and when the
infiltration and cellular elements become absorbed, the tissues appear, as
Mackenzie puts it, as though infiltrated Avith tallow.
The second stage l)egins with the formation of the characteristic
tubercles, antl with the diminution or disappearance of the swelling and
tumidity of the mucosa. At first they appear as small nodules of a
Avhitish yellow colour, or white and almost glistening, varying in size from
a pin's head to a split pea, isolated or in chains and groups, and sometimes
surrounded by a hj^pememic areola. In this condition they may remain
stationary for years, till the third stage is reached, provided the patient
do not succumb to the -general affection in the meanwhile. In this
stage ulceration and disintegration of the tubercles take i)lace. The
ulcers at first are small and rounded, are elevated above the surround inof
mucous membrane, and are compared by De la Sota to syphilitic nnu'ous
patches. Eventually they become deeper. The glottis assumes a
rounded form, and the voice is lost. The foe tor of the breath at this
stage becomes unbeai'able. The cartilages of the larynx become involved,
the epiglottis presents a knobby aspect and ma}^ become hard and dis-
torted, and in course of time the cartilages become necrosed and ex-
foliated.
The earliest indication of the throat affection consists in alteration of
the quality of the voice, which at first becomes nasal, and with the impli-
cation of the larynx may be thick ; yet the larynx may be extensively
diseased Avithout attracting the notice of the patient. Hoarseness or
aphonia appears later from implication also of the vocal cords. Dyspnoea
sometimes supervenes ; and stenosis of the larynx, produced either by
the nodular infiltration or wdema, may even necessitate tracheotomy.
The anaesthetic variety rarely affects the throat, and, according to
Hillis of Demerara, it never does so until the cutaneous affection has
existed for five years. The mucous meml>ranc is smooth, the alVected
regions become ana'sthetic, the velum palati is thin, tense, and paretic,
and the arches of the palate assume a violet colour.
Diagnosis. — Leprosy has to be distingtiished from syphilis, tubercu-
DISEASES OF THE LARYNX 805
losis, lupus, and cancer; though laryngeal leprosy practically never
occurs without cutaneous manifestations of the malady, and pharyngeal
leprosy very rarely. ■ Moreover, a leprous patient may be aft'ected also
with cancer, lupus, syphilis, or tuberculosis ; or, on the other hand,
patients suffering from any one of these diseases may bo attacked by
leprosy.
Syphilitic throat lesions have much in common with leprosy : first,
in that they are usually painless, although the actual anaesthesia of the
leprous larynx is not observed in syphilis ; secondly, in the hypertemia
of the affected tissues ; and, thirdly, in the tendency in the later
manifestations of both affections for the cartilages to be attacked.
De la Sota states that the resemblance l^etween syphilitic mucous
patches and leprous ulcers is sometimes very close ; but the dark reddish
or coppery tint produced by syphilis contrasts with the grayish red that
is observed in leprosy. Secondly, the anaesthesia in leprous patches is
distinguished from the hyperaesthesia that may attend syphilitic lesions
of the perichondrium. Thirdly, syphilitic ulceration does not go beyond
a superficial erosion, while leprous ulcers, though true ulcers, yet are not
so round and deep as tertiary syphilitic ulcers. They are much longer
in formation, and do not respond to antisyphilitic treatment ; indeed they
are often made worse by it. The lejDrous nodules of the second stage are
characteristic.
Tuberculosis in its earlier stages is attended with anaemia and hyper-
sesthesia of the parts ; leprosy gives rise rather to hyperaemic infiltration.
Leprosy is sometimes attended with febrile symptoms, but its onset is
usually most insidious. The vocal cords are often affected early in tuber-
culous laryngitis; in leprosy the epiglottis and ventricular bands are gener-
ally invaded befoi'e the vocal cords. Leprous idcers are more defined,
less irregular than the painful tuberculous ulcers. Lupus may attack the
larynx primarily, and De la Sota points out that the absence of cutaneous
lesions is therefore a sufficient distinction from leprosy. Lupus arises in
a healthy mucous membrane ; the leprous tubercles are always preceded
by a reddish coloration, which afterwards turns white. Leprous tubercles
are white, soft, and variable in size. They appear in the form of a chain
or a rosary, and their sensibility may be normal, diminished, or entirely
abolished ; lupous nodules are of a rosy or reddish hue, hard, resistant,
and elastic, larger in size than those of leprosy, and, though indolent,
of normal sensil)ility. Leprous ulcers are superficial, have indistinct
edges, and suppurate but little ; those of lupus have hard, elevated
borders, a narrow sinuous fundus, and an abundant secretion. The scars
in the two affections are not dissimilar ; but those of leprosy are in-
sensitive, while those of lupus retain the normal sensibility of the part
affected.
The bright red colour of cancerous nodules of the larynx, which fades
on pressure, contrasts with the dirty red, whitish, or yellowish opaque
tubercle of leprosy. Cancerous tubercles may be associated with lancinat^
ing pain ; and the irregular hard edges and irregular base of cancerous
8o6 SYSTE.U OF MEDICINE
ulcers, with saiiguinolent muco-purulent secretion, form u marked contrast
with the superficial, dry, leprous ulcer.
Such, according to De la Sota, are the main points of distinction
between the various diseases Avhich may simulate leprosy of the throat.
Treatment, as a rule, can only l)e palliative, and is cliieHy necessary in
the stage of ulceration, when alterative and antiseptic solutions may be
useful.
])e la Sota has obtained improvement by the application of a 1 per
cent solution of resorcin and of iodoform dissolved in ether, and by touch-
ing the diseased areas with a 10 per cent solution of chloride of zinc.
George Mackern has had favourable results with the galvano-cautery in
destroying the tul)ercles, especially those of the face and mouth ; the
eschars soon healed and the tubercles were not reproduced. When
larvngeal stenosis gives rise to severe dyspnoea tracheotomy should be
performed.— F. S. and W. W.
The Larynx in Acromegaly. — It appears, from a case observed by
Dr. W. F. Chappell, that the pharynx and larynx may become involved
in the hypertrophic manifestations of the disease. In a case of acro-
megaly in a man, Chappell found that external examination showed con-
siderable enlargement of the larynx. Internally the epiglottis was
thickened, the arytaenoid cartilages and the ventricular l)ands were
enlarged, but the glottic aperture Avas very small. As long as the
patient remained cpiiet, respiration was unembarrassed, but during excite-
ment the breathing was laboured, and the patient died in one of the
attacks of dyspnoea.
The ])illars of the fauces, soft palate, and uvula were much thickened,
and the tonsils and lingual glands were hypertrophied. — W. W.
Syphilis of the Larynx. — Pathology. — Syphilitic disease of the larynx
may be either inherited or acquired.
Inherited syphilis generally makes its appearance there either very
shortly after birth or within the first years of life, Avhen it usually takes
the form of laryngeal catarrh or the milder forms of secondary syphilis ;
although occasionally even at that early time of life very severe manifesta-
tions are met with. It also shows itself about the age of puberty. In
this later form tertiary phcuiomena are more frequently encountered.
Acquired syphilis of the larynx assumes the characters of the so-
called secondary and tertiary forms, but " secondary " phcjiomena may
arise and recur for many years after the primaiy sore, while " tertiary "
forms may sometimes be met with even within a few months of the
initial lesion. On the other hand, the tertiary manifestations may break
out thirty or foity years after the primary sore.
The subdivi-sion into "secondary" and "tertiary" forms is a very
loose one, and, especially when the question of treatment arises, it must
not be forgotten that a good many cases occupy intermediate stages ofj
the disease. Sometimes we see tertiary lesions in the pharynx, and then,
DISEASES OF THE LARYNX 807
years after, very similar lesions in the larynx, long after the pharyngeal
lesions have healed. The observations of Professor Lewin of Berlin
have shown that in 20,000 cases of syphilitic affections which came under
that author's observation during seventeen years in the S3 philis wards of
the Berlin Charite Hospital, in only about 3 per cent was the larynx
attacked, and that of this number again the great majority (namely, about
87 per cent) belonged to the earlier and slighter stages of the disease; while
in a small minority only (namely, in 13 per cent) were graver lesions found.
Syphilis of the larynx manifests itself in the following forms : (i.)
Simple catarrh (Lewin's erythema) ; (ii.) Papules (condylomas, mucous
patches); (iii.) Diffuse infiltration ; (iv.) Gumma; (v.) Ulceration; (vi.)
Fibroid metamorphosis; (vii.) Cicatrices, membranous adhesions ; (viii.)
Neoplasms ; (ix.) Perichondritis ; (x.) Paralyses.
Of these the first two are most frequently met with in the earlier
and so-called " secondary " stages. Ulcerations are common to all stages,
while the remainder belong to the group of "tertiary" phenomena.
Lastly, all these lesions may occur in the inherited forms of the disease,
though in congenital laryngeal syphilis the graver manifestations are
decidedly rare.
The primary lesion is practically never seen in the larynx (though one
case is reported by Moure), owing to the deep and inaccessible situation
of the parts.
Syphililic catarrh may occur as soon as six or eight weeks after the
initial sore, and it is often associated with general secondary lesions.
But it may appear two or three years or more after the infection, and
continually recur for years, with the more serious manifestations of the
disease. In no way does it differ in aspect from simple non-syphilitic
catarrh, though it is remarkable for its persistency. We have not
observed the distinction of colour which some observers have made, who
allege that the colour is more dusky in syphilitic than in simple catarrh.
The history and simultaneous appearance of syphilitic lesions in other
parts — for instance, roseola and papular eruptions on the skin, or mucous
patches on the tonsils and soft palate — generally lead to a correct
diagnosis ; though even when these are absent, the persistency of
syphilitic catarrh and its resistance to the usual treatment for simple
catarrhal laryngitis will arrest attention and lead to the suspicion of
syphilis.
Mucous patches and condijlomas are not often seen ; in fact their
occurrence in the larynx has been contested, and certainly the papulous
syphilide is one of the rarest forms in which syphilis appears in the
larynx. The circumscribed gray thickening of the infiltrated mucous
membrane may occur on the epiglottis, especially on its lingual surface ;
or on the arytpeno-epiglottic folds, posterior commissure, or the vocal
cords. The patches are generally single or, if multiple, are not symmet-
rical. Superficial erosions — yellow, oval, circumscribed, and surrounded
by an areola — may follow as the softened epithelium is abraded. As in
the case of other secondary forms of syphilis, the specific catarrh and
So8 SYSTEM OF MEDICINE
the other lesions just described tend to recur again and again for years.
The symptoms are hoarseness and sometimes slight expectoration.
Of the so-called tertiary forms, diffuse ivjiltraiion leads to tumefaction,
■which usually attacks the epiglottis, vocal cords, or intorarytanioid fold,
and sometimes causes considerable distortion of the atlected parts,
resulting in hoarseness and sometimes even in dyspnea. The inliltra-
tion is due to a small-celled proliferation, which on the one hand may
break down when small superficial ulcers are formed, or on the
other hand may ])ecome organised into connective tissue so as to lead to
a fibroid metamorphosis.
Gummas, before breaking down, are sometimes seen as smooth, red
or yellowish defined swellings, generally single, and occupying the epi-
glottis— especially its margin or the laryngeal surface — the arytaeno-
epiglottic folds, the posterior wall of the larynx, or the ventricular bands ;
or they may Ije infraglottic. Histologically they are very similar to the
diffuse infiltrations, but represent a more shar[)ly circumscribed round-
celled proliferation, developing as a rule in the submucous tissue, and
thence extending towards the surface ; so that the cartilages :ire only
affected in the later stages, if at all. Very rarely does the infiltration
begin in the perichondrium ; if so, perichondritis may occur whilst the
mucous membrane is still intact.
A minima when al)0ut to l^-eak down generallv becomes yellowish
about the centre, ulceration follows, and the whole gumma then rapidly
disintegrates from the centre towards the periphery, and a characteristic
tertiary syphilitic ulcer results.
Ulceralions, if occurring in the secondary stages, are generally super-
ficial, and most frequently are due to the breaking down of diffuse infil-
trations.
Deeper ulceration belongs especially to the later manifestations of
syphilis, and the ulcers present an undermined, slightly elevated, regular,
sharply-cut margin, surrounded by a well-defined areola, and a floor
covered by yellowish ropy muco-piLs and necrotic tissue. The ulcer
adA-ances more in depth than in superficial extent with resulting cicatricial
contraction, and often marked laryngeal stenosis and defoi-niity of the
parts afiected. This is due to the well-known fact that the central
portion of a syphilitic ulcer possesses the least healing capacity, and the
peripheral portion the most ; consequently the tough scars are often
more or less stellate. AVhen this scarring occuis at the level of the
glottis, or in the trachea, the resulting contraction may produce consider-
able stenosis and dyspnoea. Sometimes a cicatricial membranous web is
formed between the vocal cords or ventricular bands, which occludes
the lumen of the larynx more or less.
Infiammatory hyperjjlasia and nxlema often occur in the neighbour-
hood of acute and chionic ulcers of both periods, and aioujid the gummas,
leading to exacerbations of dyspnoea and other symptoms.
Fibroid metamorphosis of the diffuse infiltration occurs in some cases,
the deposit becoming transformed into connective tissue. This form,
DISEASES OF THE LARYNX 809
in which sometimes frequent relapses occur, each of them followed by a
renewal of the fibroid metamorphosis of the fresh infilti-ation, leads to the
justly dreaded forms of general chronic stenosis of the larynx.
Papillary excrescences or neoplasms may be found in any part of the
larynx, but most frequently project from the posterior commissure. They
resemble those seen in tuberculous laryngeal disease, but consist of pro-
liferated epithelium, and closely resemble the true neoplasms. Careful
examination should prevent these mammillated outgrowths from being
confounded with the steep and ragged margin of a syphilitic ulcer seen
in profile.
Perichondritis is undoubtedly the most serious form of syphilitic
disease of the larynx. It occurs in association with gumma, either by
dee]) extension of the infiltration, or, more rarely, by the seat of the
primary infiltration being between the perichondrium and the cartilage,
whence it proceeds upwards and downwards. In both forms necrosis
and destruction or exfoliation of the cartilage attacked is apt to follow.
The epiglottis is often partly or wholly destroyed in this way, while the
arytsenoid cartilages may be expectorated, or the cricoid or thyroid
cartilages laid bare till a necrosed portion comes away. But in rare
cases the perichondria! infiltration, like the diftuse submucous infiltration,
may escape the necrotic process, and undergo instead a form of adhesive
or sclerosing metamorphosis characterised by thickening of the afiected
parts.
• Paralysis of the vocal cords may be apparent only, and due to the
fibroid thickening of the perichondrium of the arytsenoid cartilages, to
anchylosis of the crico-arytsenoid articulations, or to fixation of the cords
from contraction in their neighbourhood.
True paralysis may be of local or distant origin. The local causes
are gumma in the crico-arytsenoidei postici muscles, implication of nerve
fibres in syphilitic deposits, or a syphilitic neuritis, which processes may
not be associated with any obvious pathological condition of the larynx.
Most frequently unilateral, these local causes of paralysis may be bilateral.
But the paralysis of the vocal cords may be due to bulbar nuclear disease
of syphilitic origin, or to implication of the nerve fibres in syphilitic
pachymeningitis or gumma either at the base of the brain, or anywhere
in their course to the larynx. In all these palsies the law of the pro-
clivity of the abductors to succumb earlier than the adductors holds
good.
The symptoms of laryngeal syphilis must obviously vary as the
particular nature of the lesion, but the most remarkable feature common
to them all is the almost entire absence of pain. Pain, however, is not in-
variably absent, and in rare instances it has been so severe as to lead to an
erroneous diagnosis of malignant disease. It is not safe, therefore, to rely
too much on the absence of pain. A gumma on the posterior surface of
the cricoid cartilage, for instance, may be attended with considerable pain
on swallowing. In the earlier manifestations patients complain of little
but hoarseness, yet when the graver lesions of tertiary syphilis appear,
8io SYSTEM OF MEDICINE
there is sometimes a certain degree of soreness, while ulceration of the
epiglottis may lead to dysphagia. The peculiar " raucous " hoarse voice,
or even complete aphonia, is met with in secondaiy as well as in ter-
tiary cases ; and if the lumen of the laiynx be encroached upon by
deposits or by cicatricial contraction, dysjDnwa will be the result. Cough
is very rarely troublesome. The dyspnoea, as we have said, is liable to
severe exacerbations from intercurrent hyjierplastic syphilitic laryngitis
and oedema.
Diagnosis. — It will be seen from the description of the various mani-
festations of laryngeal syphilis that it is impossible to lay down hard and
fast rules for the diagnosis of the lesions ; the objective and subjective
symptoms alike depend {a) upon the seat, (li) upon the intensity of the
syphilitic manifestation. As syphilitic catarrh has nothing characteristic
in its appearance, the diagnosis of its sjiecific nature will be derived
from concomitant syphilitic lesions in other parts, and from its submission
to antisyphilitic remedies, after it has resisted mere anticatarrhal treat-
ment. Yet, of course, the larynx of a syphilitic person may be the
subject of a simple laryngeal catarrh.
The diagnosis of tertiary lesions ■will depend on the laryngoscopic
appearance, and on the history and concomitant lesions elsewhere, if any.
It is, however, most important in regard to syphilis to trust to the
evidence of the eye rather than to the history of the case. The patient
very often does not know that he or she has been infected Avith syjjhilis ;
in many cases there is absolutely no history of anything to suggest this
disease even when the patient is most desirous of aftbrding all informa-
tion on the point ; in some cases, it is needless to say, the history of
syphilitic infection is concealed.
The hoarse voice of children suffering from snuffles or broad condy-
lomas about the anus will often lead to the suspicion that laryngeal
symptoms are syphilitic. Most important is it to act on this suspicion in
such patients when attacked with tedema supervening on hyperplastic
syphilitic larj'ngitis, the symptoms being then very similar to those of
membranous croup.
The two affections most likely to be confounded with laryngeal
syphilis are {a) tuberculous disease, and {h) malignant disease. We have
already spoken of the distinctive characteristics of syphilitic and tuber-
culous ulcers. In rare cases syphilis and tuberculous disease coexist in
the larynx, in wdiich cases there may be great difficulty in diagnosis.
Again, when in syphilitic disease the lungs as well as tlie larynx are
invaded, the real nature of the affection may be overlooked ; but, first,
the bacilli of tuberculosis will not be found in the expectoration ; and,
secondly, syphilis generally attacks the middle regions of the lungs, and,
as a rule, not the apices.
In all doul)tful cases iodide of potassium should be administered in
considerable doses as a test of the nature of the affection.
As regards carcinoma, the appearances may be very similar in both
affections, especially if the malignant new growth show itself in an
DISEASES OF THE LARYNX 8ii
infiltrating form. Here again the use of iodide of potassium, which test
should be applied in all cases of a doui^tful nature, will generally clear
up all difficulty c[Uickly ; though it is true that a temporary subjective
improvement under the use of iodide of potassium is often experienced
even in malignant disease ; the growth, however, steadily persists or
increases in spite of the drug. The absence of glandular infiltration
in the neck by no means excludes malignant disease, though, if present
in considerable dea-ree, it is more su2;2;estive of malignant disease than
of syphilis. In some cases, however, the diagnosis must remain for some
time in abeyance, until careful Avatchfulness discovers further indications
of its true nature.
Lupus may easily be confused M-ith some syphilitic lesions ; and in the
absence of cutaneous lupus the difficulty in excluding syphilis, acquired or
hereditary, is considerable : we may have even to wait in uncertainty
for the result of antisyphilitic treatment.
The significance of scars, thickenings, distortions, and webs, left after
the healing of syphilitic ulcers, will generally be interpreted correctly ;
but sometimes, in the absence of concomitant syphilitic phenomena or
characteristic syphilitic paralysis of the ocular muscles and the like, there
is the greatest difficulty in deciding whether the immobility of a A^ocal
cord lie due to anchylosis from previous syphilitic disease, or to true
paralysis.
Treatment. — The general treatment of syphilis of the larynx is
practically the same as for syphilitic disease in other regions, and is of
fundamental importance. It is necessary, however, as we have already
said, to dismiss the more rigid conceptions of the so-called secondary and
tertiary forms of the disease ; for some cases of what would certainly be
called secondary affections will only yield to iodide of potassium, while in
tertiary lesions, on the other hand, no improvement may follow the
usual course of iodides, and alleviation is only to be procured by a
mercurial course. Again, in other cases of tertiary syphilis, iodide of
potassium produces a temporary amelioration only, and to prevent
recurrence of symptoms the drug has to be continued for years. Finally,
there are cases in which the alternating use of mercury and iodide of
potassium produces the best results. Each case must, therefore, have its
individual treatment ; though no doubt the ordinary case of secondary
disease is most benefited by mercury, and of tertiary disease by iodide of
potassium in large doses.
In administering mercury our object should be to get the patient as
quickly under its influence as possible, rather than to administer small
doses over a long space of time, as advocated by some of the greatest
authorities on syphilis.
The mercurial treatment recommended by Zeissl of Vienna is
generally very satisfactory. Twenty grains of mercurial ointment are
rubbed dail}^ into various parts of the body : on the first day the
ointment is to be applied to the skin of the neck over the larynx ; on
the second day, to the inner sui-faces of both upper arms ; on the third
Si2 SYSTEM OF MEDICINE
day, to the inner surfaces of both thighs ; on the fourth day, to the inner
surfaces of both forearms ; on the fifth day, to the inner surfaces of both
calves ; on the sixth day, to the skin over both loins ; and on the seventh
day, to the skin of the l)ack. This sei'ies of aj)plieations is to lie repeated
four or five times according to the exigencies of the individual case ; each
series being preceded and followed by a Avarm bath. In order to avoid
mercurial stomatitis astringent and antiseptic gargles and vigilant
cleansing of the teeth must be used during the Avliole time. Zeissl's
method may be adopted in all stages of syphilis.
In tertiary syphilis we give iodide of potassium, beginning with at
least ten grains three times daily, and increasing this to doses of thirty
or forty grains. The depressing influence of iodide of potassium is
rarely observed in syphilitic cases ; and that in doubtful cases the patient
thrives on the larger doses is a valualjle diagnostic sign, apart from any
improvement in the local mischief. In other cases a combination of
mercury and iodide of potassium is most suitable. If the patient belong
to the wealthier classes, Aix-la-Chapelle may be recommended, liecause
"wath the simultaneous use of hot sulphur baths the mercury is pushed
through the system much quicker than under ordinary circumstances,
and general mercurialisation is avoided. The treatment of the congenital
cases is the same as that for the acquired forms, but the doses are smaller
in correspondence with the ages of the patients.
AVe very rarely use any local applications to the larynx in cases of
syphilis. To this general rule an exception is made in cases of obstinate
catarrh ; and the foul ulcers of tertiary syphilis may require some mild
antiseptic spray, while insufflations are sometimes useful in necrosing
perichondritis. But in the great majority of cases constitutional treat-
ment only is advisable ; under it the local manifestations will heal
quickly without local measures.
Stenosis of the larynx may be due to acute lesions, such as gumma
with oedematous inflammatioii ; and ti-acheotomy may be demanded.
Yet as a rule energetic antisyphilitic treatment will soon obviate the
necessity for relief in this way.
In chronic stenosis of the larynx, such as is due to chroiu'c hyper-
plastic thickening, the formation of membranous webs, and so forth,
tracheotomy or intubation may ultimately become luiavoidable. As a
rule, tracheotomy is to be pi-eferred, as syphilitic stenosis is liable to recur
after dilatation by Schrotter's bougies or by intubation tubes. O'Dwyer,
however, has most successfully treated some veiy obstinate cases of
extreme syphilitic stenosis by dilatation. Often only small tul)es can be
passed at first, l)ut after leaving these in for twelve or twenty-four hours
he finds it is generally possible to introduce larger ones, and eventually
to obtain a permanent stretching of the cicatrisation.
Cicatricial web formations should be divided by cutting dilators, and
intubation tubes worn till the edges have healed, so as to obviate reunion
and reformation of the web. But the stenosis is very likely to return
after a shorter or longer interval. In a few cases even partial laryngo-
DISEASES OF THE LARYNX 813
tomy and excision of the whole scar has been successfully performed
under such circumstances, in order to enable patients to dispense with
the canula.
Periehondritis of the Larynx. — Causes. — Perichondritis may be
primary or secondar}^, but a primary origin is extremely rare. No doubt
the vast majority of cases are secondary, although the immediate cause
may be very obscure, and not infrequently, indeed, can be determined
on post-mortem examination only. The term primary perichondritis
should be restricted to those cases which are due to acute inflammation
from cold, and are associated with more or less acute or chronic catarrhal
inflammation of the larynx generally.
Of the causes of secondary perichondritis the chief are syphilitic,
tuberculous, and malignant disease of the larynx ; septic inflammation ;
typhoid and typhus fever ; variola, diphtheria, and other acute infectious
fevers ; gout ; injuries, including Avounds and blows on the larynx ;
scalds ; and those cases in which perichondritis is set up by the impaction
of foreign bodies in the larynx, by swallowing hard masses of food, by
the pressure of the larynx against the bodies of the cervical vertebrse
in the continual dorsal decubitus of old people, or by the frequent passage
of oesophageal bougies.
Pathology. — As a result of the scanty vascular supply of the peri-
chondrium, and the absence of vessels in the cartilage itself, the
separation of the perichondrium from the underlying cartilage by
inflammatory exudation often results in suppuration followed by rupture
of the abscess externally with exposure and necrosis of the whole or
part of the cartilage — suppurative perichondritis; and undoubtedly this
is the usual consequence of acute laryngeal perichondritis. Yet these
very peculiarities in the vascular arrangement of the perichondrium and
its cartilage would lead us to expect that the less acute forms of
perichondritis should be followed by inflammatory degeneration rather
than by inflammatory secretion, suppuration, and consequent necrosis.
Thus we have a ready explanation of the relatively uncommon, but yet
by no means rare adhesive perichondritis to which attention was drawn by
one of us (F. S.) in 1880; in this form, without any free exudation
between the inner layer of the perichondrium and the cartilage, the
affected part becomes considerably thickened in consequence of an
inflammatory new formation of dense connective tissue.
If an abscess form, it may rupture into the larynx, pharynx, trachea, or
oesophagus ; or it may discharge externally and form a laryngeal fistula.
The exposed cartilage may maintain a chronic inflammation and
discharge of pus for years ; but sooner or later the necrosed cartilage is
usually exfoliated, and may be coughed up or swallowed. When it has
separated, the parts fall together and bring about great deformity of the
larynx. Laryngeal aff"ections in typhoid fever generally take the form of
ulceration in the interarytaenoid fold ; probably some forms of perichon-
dritis are secondary to these ulcerative processes, while in others it may
be a primary process ; but in both cases it usually attacks the posterior
8 14 SYSTEM OF MEDICINE
surface of the cricoid cartilage. Similar remarks api)ly to variola ; in
fact, apart from syphilis, tuberculosis, and malignant disease, the cricoid
cartilage is the most frequently affected ; and even in these diseases it
is implicated often enough, either primarily or by extension of the
inflammatory process from the arytfcnoid or thyroid caitilage. In tuber-
culosis the extension is most comniDnly from the arytienoid cartilages.
If the arytsenoidal perichondrium is involved, Avhether the inflammation
take the suppurative form with consequent necrosis of the cartilage, or
the more chronic adhesive form, the result is nearly always thickening of
the capsule b\' tense connective tissue with or without degeneration or
destruction of the crico-arytsenoid joint, but with more or less complete
mechanical fixation of the corresponding vocal cord. The strengthening
of the capsular ligament of the crico-aryttenoid joint externall}'- by the
tissue of the ueighboui-ing perichondrium of the cricoid cartilage explains
the very frequent occtirrcnce of this mechanical impairment of the move-
ments of the joint, even Avhen the arytaenoid cartilage itself does not seem
to have participated in the obvious inflammation of the cricoid cartilage.
In course of time a relati\'ely slight degree of thickening of the capsule,
which has nevei'theless been attended l)y fixation of the arytienoid joint,
may by contraction become less and less obvious ; so that it is almost
impossible from the laryngoscopic appearance to say whether a lasting
paralysis of a vocal cord is nervous or mechanical in origin. One of us
(\V. W.) has observed such a condition following diphtheria in a case in
which the mechanical fixation had been erroneously attributed to pressure
on the left recurrent nerve by an aneurysm.
S'/inploms. — Acute perichondritis may be tishered in with a sense of
chilliness, or in some cases by a severe rigor, followed by a rise of
temperature and other symi)toms of febrile disturbance. In other cases
the onset is less acute, and the earliest manifestation may 1)e no more
than a dull aching in the laryngeal region increased by ])ressure. If, as
is usual 1}^ the case, the ])osterior surface of the cricoid cartilage is
involved, painful deglutition is often a marked symptom.
Dyspnoea results from excessive tumefaction on the interior surface of
the thyroid or cricoid cartilages, even if it be only unilateral. If
bilateral, both vocal cords are very apt to become fixed more or less in
the phonatory position ; in which case the voice may be preser\ed while
the dyspnoea is urgent. The greater the opening of the glottis the less
will be the dyspnoea, but the weaker the voice ; it may fall in some cases to
complete aphonia. Hoarseness is by no means necessarily present : Imt
the diseases leading to perichondi'itis will as a rule aftect the vocal cords
also in greater or less degree, and thus hoarseness will be present in the
majority of cases. In the secondary forms of perichondritis, which as we
have said constitute the vast majority, the symptoms are generally more
or less modified by the primary aftection ; especially is this the case in
tuberculosis and malignant disease, and in the acute infectious fevers
with mental dulness and general apathy. Syphilitic perichondritis, like
all syphilitic aff"ections of the larynx, is seldom painful. Objectively in
DISEASES OF THE LARYNX S15
the early stage the only alteration in the laryngoscopic appearance may
be a smooth, or irregular, nodular, unilateral inflammatory swelling, Avith
or without immobility of the corresponding vocal cord according to the
part implicated. If the inner surface of the thyroid cai'tilage is the seat
of the inflammation, the ventricular band is push^■d up, forming a smooth
tumefaction. If the cricoid cartilage is involved, there Avill be a sub-
glottic swelling or tumefaction in the interarytsenoid fold, or on its
posterior surface, according to the part implicated.
When the arytasnoid cartilage and its capsule are affected, they are
generally red and swollen, but the tumefaction is not alwa3\s ob\ious.
Luxation of the crico-arytaenoid joint is sometimes observed. Permanent
anchylosis of the joint, or at least mechanical fixation, is the usual con-
sequence (see p. 817).
If the exudation and swelling do not undergo resolution, suppuration
with necrosis of the cartilage may occur, and crepitus may often be felt
in manipulating the larynx ; when the abscess has discharged, the bare
necrosed cartilage may be detected with the aid of a laryngeal probe.
In such cases jDurulent exudation, often associated with formation of
fistulous tracts opening outside or into the oesophagus or other organ,
may persist for years until the necrosed sequestrum is exfoliated ;
dui-ing this time the patient often presents a miserable aspect, and
becomes greatly emaciated from the pain and dysjDhagia and want of
sleep, while in syphilitic cases especially the accompanying fcetor is
often very pronounced. Ultimately cicatricial contraction and marked
deformity and stenosis of the laiynx are the too common consequences
of perichondritis, and the bilateral fixation of the vocal cords in the
phonatory position may entail dangerous dyspnoea.
Tlie diagnosis of perichondritis of the laryngeal cartilages presents
many difficulties ; for obviously in the earlier stages it will often be
impossilile to say definitely that the inflammatory exudation and
swelling involve tissues deeper than the mucous membrane ; and this
difficulty does not always disappear when suppuration has occurred,
unless crepitus can be felt or the bare cartilage detected. In tertiary
syphilitic disease especially, we often have to wait the advent of definite
signs of necrosis to determine the implication of the perichondrium ; in
tuberculosis, suppuration, apart from perichondritis, is rare.
The painful tumefaction with deep ulceration, and possibly profuse
hfemorrhage, -with general emaciation and constitutional weakness of
advanced necrosis of the laryngeal cartilages, may be mistaken for
malignant disease ; on the other hand, the difficulty of eliminating
perichondritis as a mere complication of malignant disease is sometimes
equally great. The clinical history, the usual limitation of perichondritis to
one cartilage, and, when the abscess has discharged, the less angry aspect
of the swellins' will assist us to arrive at a differential diagnosis : if
serious doubts as to the real nature of the case are entertained, anti-
syphilitic retnedies should always be administered nevertheless, and a
portion of the swelling removed for histological examination.
8i6 SYSTEM OF MEDICINE
The prognosis of lat-yngcal perichondritis is distinctly unfavourable,
both as regards the restoration of the voice and the patency of the
respiratory channel ; moreover, the dangers to life are not inconsiderable.
In the milder forms of adhesive perichondritis the movements of the vocal
cords are rarely left unimpaired, while fixation of one or both cords results
ill marked alteration in the character and strength of the voice, and often
in considerable dyspnoea. In the graver suppurative variety the patient
may succumb to the disease before exfoliation of the sequestrum has
occurred ; and, even if he survive, the su])sequent stenosis of the larynx
very frequently necessitates tracheotomy and the permanent retention of
the canula.
Treatment. — At the outset, during the stage of acute inflammation,
cold should be applied externally to the region of the larynx, either by
the ice-bag or by Leiter's tubes ; and ice should be sucked. Leeches may
sometimes be used with advantage on the affected side. The patient
sho\ild be kept absolutely at rest, in the recumbent position if the thy-
roid or aryttBnoid cartilages are affected ; if, however, the posterior surface
of the cricoid cartilage be the seat of inflammation, the patient should
lie on his side ; under no circumstances should he be allowed to
speak or whisper, so as to ensure absolute functional rest of the parts as
far as possible. If the temperature be raised, three or four grains of
quinine may be given at intervals ; and for pain, if considerable, opium is
useful. Food should be cold, soft and bland. The l)Owe]s should be
freely moved. If the cricoid is aff"ected and odynphagia is very pro-
nounced, it is better to feed the patient by rectal enemas for a few
days when it may still be hoped that active antiphlogistic measures may
avert suppuration. In syphilitic cases iodide of potassium should be
given internally, in considerable and increasing closes ; and mercurial
inunctions should be made in the laryngeal region externally.
There is always a danger of acute oedema coming on, with rapid
increase in dyspnoea ; when other measures have failed, asphyxia may
sometimes be averted by intubation or by cocaine applications followed by
scarification of the oedematous tissues ; but if these means fail, tracheo-
tomy must be performed.
When suppuration has occurred, with consequent necrosis, the dangers
are considerably increased ; therefore the patient's strength must be main-
tained by tonics and generous diet. As soon as possible the abscess
should be evacuated.
After the acute stage has passed, the necrosed sequestrum should, if
possible, be removed ; for it tends to maintain conditions which are ex-
tremely adverse to the patient's health, and may become dislodged and
either impacted in the glottic opening or pass into the trachea and
bronchi with resulting septic pneumonia. Other radical operations, such
as intubation and dilatation of laryngeal stricture, thyrotomy, removal
of thickened parts, and so on, will also come under consideration. If the
perichondritis be due to impaction of a foreign body in the larynx, it
may become necessary, even during the acute stage, to perform thyrotomy
DISEASES OF THE LARYNX 817
and remove the offending substance. In a case observed by one of us
(F. S.) this was done with complete success. In cases of fibroid stricture
thyrotomy with extensive removal of the obstructing tissue has recently
yielded very satisfactory results in several cases.
Diseases of the Crleo-arytsenoid Joint. — Inflammation, Anchylosis,
and Luxation. — When we call to mind the physiological functions of the
crico-arytpenoid joint, nameh^, those of respiration and phonation, we may
almost describe it, despite its small size, as one of the most important
joints in the body.
Attention has already been directed to the very frequent implication
of the capsule of the joint and its articular surfaces in perichondritis
affecting the cricoid and arytsenoid cartilages, which results either in
suppuration and destruction of the joint, or in adhesive inflammatory
degeneration with thickening of the capsule or true anchylosis of the
joint.
Lkflnit'idu. — AYe call every degree of stiffness of the crico-arytsenoid
joint, which is produced bv mechanical causes, an anchylosis of this joint ;
and we distinguish two forms, namely, first, the true anchijlosis, in which
the stiffness is produced by intra-capsular disease ; and, secondly, the
spurious ov false anchi/losis, in which extra-capsular changes lead mechanic-
ally to impairment of its functions. In some cases true anchylosis is a
consequence of a long-existing false one.
Luxation of the crico-arytsenoid articulation, first described by B.
Friinkel, means a displacement of the arytienoid cartilage from the
articiUar surface of the cricoid ; in some cases both anchylosis and luxa-
tion coexist.
Causes. — -Every true anchylosis is the product of an inflammatory
degeneration of this joint, however slow and insidious the degenerative
process may have been. The jDOSsible causes of anchylosis of the joint
are as follows : — ■
(a) Anchylosis from local inflammatory causes ; namely :• — Perichon-
dritis, suppurative or adhesive (by far the most frequent cause). Simple
plastic laryngitis (?). Lesion of the joint by wounds, ulceration, luxations,
contusions, and congenital causes.
(h) Anchylosis from constitutional causes leading to local affections ;
namely, typhoid fever, variola, syphilis, diphtheria, tuberculosis, gout,
and excess of the physiological senile ossification.
(c) Anchylosis from purely mechanical causes leading to permanent
immobility ; namely, cicatricial contractions of the mucous membrane or
of the muscles after injuries, enteric, syphilitic and other ulcerations
(false anchylosis), neuropathic or myopathic paralysis, diaphragms or
complete subglottic obliteration of the laryngeal passage, neoplasms.
The si/mptoms will depend, first, on the position taken l)y the ary-
taenoid cartilages, and consequently by the vocal cords ; and, secondly,
on the amount of tumefaction and inflammation in and around the crico-
aryta?noid joint. Thus the joint may be fixed in any position, from that
of deepest inspiration to that of phonation ; and the aryta?noid cartilage
VOL. IV 3 G
8 1 8 5 YSTEM OF MEDICINE
may be drawn even across the median line. These extreme positions are
mostly found as the result of cicatricial contraction after syphilis and
other ulcerative diseases ; while in true anchylosis the implicated cord
generally varies in position fioni the phonatorj'^ to what is called the
" cadaveric " position, which lies midway between phonation and deep
insjiiralion.
If bilateral anchylosis have occurred, the fixation of the cords is not
necessaiily symmetrical, but in the majority of cases it is unilateial.
Tumefaction is obvious in the niajorit}'- of cases of true ancliylosis ;
but in the spurious cases, even if true anchylosis should eventually super-
vene, it may be wholly absent. In short, immobility with tumefaction
favours the diagnosis of mechanical impairment ; immobility Avithont
tumefaction does not exclude this possibility. The swelling is some-
times very considerable, and may in itself be a serious impediment to
respiration.
In complete anchylosis there will l^e complete immobility of the ary-
tpenoid cartilage and corresponding vocal cord ; in incomplete anchylosis
the mobility will be cither restricted or jerky.
"When anchylosis is combined with luxation of the joint, the position
of the arytsenoid cartilage will be abnormal, in addition to the swelling
and immobility. In simple luxation the appearances are very similar to
those presented by the last-mentioned combination, except that it is pos-
sible to reduce the luxation.
The chief subjective symptoms are alterations in the voice and
dyspnoea. Each is determined by the position in which the affected
vocal cord or cords are fixed. The quality of the A'oice may be unaltered
or completely lost, though hoarseness, weakness, or dijilophonia are
usually observed. Dyspnoea occurs when both vocal cords are fixed near
one another.
These symptoms are met with in infinite variety and degree ; but
they are so frequently modified hy the jjrimary disease that we can only
draw attention to the main features.
Diagnosis. — When we consider the infinite variety of SA^mptoms and
objective appearances due to anchylosis, or associated with it, which may
be encountered, and the many complications that so frequently coexist,
it is easy to understand that in many cases a definite diagnosis of anchy-
losis cannot be made. More especially is this true of those cases which,
not being associated with any obvious thickening of the arytjenoid joint,
exactly .simulate palsy of the vocal cords of nervous or myo{)athic origin ;
on the other hand, the tumefaction of anchylosis may be mistaken for
exten.sive effusion into and swelling of the soft parts covering the
cartilaginous framework, with resulting tcmjiorary spin-ious anchylosis.
The most important points in favour of the diagnosis of anchylosis are
the presence of tumefa(tif)n around an immobile aryt;^noid ; altnormal
position of the arytaenoid cartilage ; unilateral distortion of the contour
of the larynx from cicatricial contraction or luxation ; fixation of the
vocal cord in the abducted position.
DISEASES OF THE LARYNX 819
The prognosis, as to life, Avill depend on the nature of the primary
disease ; on the amount of tumefaction, and on the position assumed by
the vocal cords : for instance, a position of bilateral abductor parah'sis
with the cords in the phonatory position is liable to end abruptly by acute
asphyxia.
As to recovery of function, we must regard the length of time the
anchylosis has existed, and again the nature of the primary disease.
False anchylosis is more hopeful than true anchylosis ; but if either have
existed for a few months, very little hope can be entertained of complete
recovery.
Treatment. — If the patient's life be in danger from asphyxia it may be
necessary to perform tracheotomy before any measures for the treatment
of the anchylosis can be undertaken ; indeed, the nature of the primaiy
disease may be such as to claim our entire attention, or may jDreclude the
possibility of any successful therapeutic measures directed to the crico-
aryta^noid joint.
On the other hand, the subjective symptoms may be unimportant and
unattended with any inconvenience ; in this case it is better to leave well
alone rather than run any risk of importing fresh and perhaps dangerous
complications. Especially is this the case when true anchylosis has
existed for a considerable time ; then indeed treatment is useless.
Thus the indications for operative treatment are limited to the cases
in which dyspnoea is a prominent symptom, in which there is no evidence
of true anchylosis of the joint of long standing. We may then hope to
obtain relief by mechanical dilatation by means of Schrotter's bougies, or
by O'Dvvyer's method of intubation continued for a long time.
But more help can 1)6 afforded by early methodical dilatation in pre-
venting the occurrence of extreme stenosis and cicatricial contraction or
luxation ; and by timely treatment of more recent cases due to typhoid
fever, syphilis, or to perichondritis from other caxises.
Cheval states that he was able to reduce a recent simple luxation of
the joint by means of a strong faradic current, a double electrode being
applied to the posterior wall of the larynx so as to tetanise the inter-
arytiBuoid and posterior crico-aryt?enoid muscles.
Stenosis of the Larynx. — Causes. — Laryngeal stenosis may be due to
a variety of causes, namely : —
i. Infiltration of the tissues of the lining membrane, (a) by inflamma-
tory exudation or oedema in the course of acute catarrhal or septic in-
flammations, scalds, typhus or typhoid fevers, measles and other exan-
thems, syphilis, tuberculosis, perichondritis, wounds, scalds and other
injuries ; or (h) by gummatous deposit, tubercle, cancer, lupus or leprosy.
ii. False membranes in croup and diphtheria.
iii. New growths, either benign or malignant.
iv. Congenital Avebs or adhesions between the vocal cords, cicatricial
contraction following syphilis, lupus, perichondritis, typhoid fever, wounds,
and so forth.
V. Bilateral abductor paralysis of the vocal cords, whether neuro-
820 SYSTEM OF MEDICINE
pathic or myopathic in origin, or due ro mechanical fixation of the cords
in the phonator}'' jiosition.
vi. Foreign bodies.
The occurrence of stenosis of the larynx is incidentally referred to
under the above-mentioned diseases, so that its characteristic symptoms
and laryngoscopic signs need not be related again. We have now strictly
to confine ourselves to the intra-laryngeal operations for the relief of
laryngeal stenosis, namely, intubation, dilatation by bougies, and so on,
without reference to the question of the removal of the obstruction in the
case of foreign bodies or new growths, or to the various antiphlogistic
procedures and scarification that have been fully discussed elsewhere.
Treatment. — Stenosis of the larynx may be either acute or chronic.
In acute laryngeal stenosis requiring operative interference the choice
lies between tracheotomy and intubation. If stenosis of the trachea be
present at the same time, as in the case of diphtheritic membranes which
have extended down the trachea and bronchi, or of compression of the
trachea by an aneurysm or growth which has also caused bilateral
abductor paralysis of the larynx, the question whether the dyspnoea
will be relieved by any o])erative procedure confined to the larynx will
arise. For the method of performing tracheotomy the reader Avill con-
sult text-books of surgery.
Intuhatioa of the hiri/iix. — It is to Joseph O'Dwyer of New York that
we owe the instruments Avhereby this method of treating laryngeal stenosis
has been made practicalile. His tubes for children are made of gilt
metal, vaiying in length from 1} inch up to 21 inches for the age of
twelve ; the longer and larger tubes for adults are made of vulcanite.
When the tube is in the larynx a flange at the upper end of it rests
on the ventricular bands, and the rest of the tube lies below the vocal
cords.
In proceeding to intubate young children the patient is closely
wrapped in a blanket with the arms included, and is held sitting upright
on the nurse's lap facing the operator. The mouth is kept open, and the
head held steadily in the vertical position by an assistant. The operator,
having passed the left forefinger into the larynx, hooks for'svard the epi-
glottis ; the tube suited to the patient's age is then rapidly introduced on
the obturator, which is attached to a handle held in the right hand, and
is guided into the larynx by the finger which is hooking up the epiglottis ;
then the sliding rod on the handle is made to disengage the tube from
the obtui'ator, which is at once withdrawn, the left forefinger meanwhile
fixing the tube and retaining it in position ; finally this forefinger is re-
moved. In the hands of a skilful operator the whole procedure occui)ies
from three to five seconds. The tube should now be in position ; but
should it have been inadvertently passed into the oesophagus it may be
extracted at once with the silk-thread loop attached jjrevious to intro-
duction. When the tube has been properly introduced the child gives
a few strong coughs at fiist ; but in the course of a few seconds the
breathing is manifestly relieved, and the larynx very soon tolerates
DISEASES OF THE LARYNX 821
the tube. The loop should not he removed for ten minutes, as it
tends to induce the coughing up of mucus and sometimes of small
pieces of false melnbrane. Unless false membrane or other causes of
obsti'uctive dyspnoea exist in the trachea or bronchi, the embarrassed
respiration gives place to quiet breathing, and the patient, who should
always be placed in the steam l^ed, drops oft' into a calm slec}). Of course
the patient is completely aphonic so long as the tulie remains in the
larynx ; and though it removes glottic obstruction to breathing at once,
inasmuch as the glottis cannot be closed, it acts exactly like a tracheo-
tomy tube in rendering coughing less efiectual.
The tul)e may be left undisturljed for five days or more if necessary,
but sometimes it becomes more or less blocked by false membrane ; in
other cases it may be desiralile, though rarely necessary, to remove the
tube occasionally to allow the patient to clear the lower air-passages of
tenacious mucus. For this purpose, and in order to enable the patient
to imbibe a large amount of liquid food without discomfort, one of us
(W. W.) makes a practice of removing the tube daily in older and docile
children ; for in them both intubation and extubation are rapidly accom-
plished without resistance, or the slightest risk of injury to the larynx.
Extubation is more difficult than insertion of the tube. For this
purpose the child is placed in the same position as for introduction, and
expanding forceps, specially made for the purpose, are guided into the
up23er orifice of the tube by the left forefinger, previously passed into
the larynx, till the instrument impinges on and fixes the posterior border
of the flange ; they ai-e then opened so as to hold the tube firmly while
it is rapidly withrawn. Neither intubation nor extubation should occupy
more than fifteen seconds at the outside, as respiration is necessarily
suspended during each process : if therefore an attempt be not promptly
successful, it is better to try again rather than, by prolonged manipula-
tion, to run any risk of asphyxia, or of setting up exhausting struggles
for breath. It is needless to say that no force should ever be used.
If false membranes be present in the larynx the thread should not
be cut short, but looped over the ear and fixed by plaister ; or O'Dwyer's
short tubes specially made for these cases should be used. These are short
hollow cylinders of large calibre, which do not push the false membrane
down. As they have no retention SAvell it is necessary to use the largest
size possible. The symptoms of false membrane are sudden obstruction
to the out-going air in expiration, and especially a flapping sound in
coughing and a croupy cough when the tul>e is in.
The greatest care in feeding the patient is necessary to prevent the
escape of food into the trachea. By intelligent children soft, semi-solid
food can often be gulped slowly without risk. Liquid food may be
taken if the patient can be induced to suck it through a tube, or to take
it from an ordinary feeding-bottle while lying face doAvnAvards on the
nurse's lap, or on a bed Avith its head pendent. If this does not answer,
the patient must either be fed through a nasal tube, or nutrient enemas
must be gi\^en.
822 SYSTEM OF MEDICINE
Intubation should be performed early so as to prevent the engorge-
ment of the lungs and the pulmonary collapse consequent on prolonged
dyspna^a.
The advantages of intubation over tracheotomy in the treatment of
acute laryngeal stenosis arc —
(a) Its sini{)licity and painlessness, "vvell exemplified by a case under
one of us (W. W.), a child seven years old, who, having on former
occasions experienced intubation and extubation at his hands, sat up and
enabled him to extract the tube without being held or in any waj'- re-
strained. Un account of the relatively simple character of intubation,
Ave can resort to this procedure much earlier than tracheotomy, and thus
avoid all ''cutting," to which parents sometimes Avill not consent.
(/3) In children under five years of age the percentage of recoveries
is considerably higher than after tracheotomy.
(y) The intubation tube is more comfortably worn than the tracheo-
tomy tube, in fact Avhen in place it cannot be felt at all.
(8) Respiration is conducted through the natural passages.
(e) Xo ana?sthetic is required as a rule, though cocaine may be
used with great advantage. If the patient struggle much, especially in
the case of an older child, chloroform should be given, and intubation or
extubation performed in the recumlient position, rather than run any
risk of exhausting the patient or of injuiing the larynx.
The folloAving ditticulties may arise: — (i.) False membranes may
occasionally be disengaged and crushed down into the trachea on
introducing the tube. In such an event the tube can be withdrawn at
once by the attached loop and the loosened membrane expectorated,
(ii.) The tube may be coughed out and the dyspnoea return licfore help
can be obtained, (iii.) Asphyxia may occur from blocking of the tube by
false membrane. Such an accident can only occur in A^ery feeble patients,
as the tube, if blocked, is always expelled at once by a vigorous cough.
Asphyxia may also ai'ise from cedema above the tube, but it is a very
unlikely occurrence, (iv.) Ulceration at the cricoid ring may be caused
by an ill-fitting tube, (v.) Careless and rough introduction may make a
false passage, (vi.) If the extubating forceps be opened Avidely outside
the orifice of the tube as it lies in the larynx, instead of Avithin it, the
tissues may be torn as the instrument is AvithdraAvn. (vii.) Ditticulty may
arise from subglottic stenosis at the narroAA^est part of the respiratory
passages — the cricoid ring ; but if the tube Avill not readily pass the
obstruction here, a smaller one should 1)6 used, (viii.) If special precautious
are not taken, " foreign body ])neumonia " may arise from inspiration of
liquid food, (ix.) Temporary ajjhonia sometimes persists for a few Aveeks
after removal of the tube.
Intubation is chiefly practised for the relief of acute laryngeal stenosis
in diphtheria and membranous croup ; but it is sometimes to be I'ccom-
mended in recurrent laryngeal crises Avithout abductor paresis ; and in
recent cases of crico-arytaenoid fixation folloAving typhoid fever, syphilis,
and perichondritis from other causes, in Avhich methodical dilatation
DISEASES OF THE LARYNX 823
by means of O'Dwyer's tubes or Schrotter's bougies may prevent the
occurrence of cicatricial contraction.
One of us (W. AY.) has observed several cases of acute laryngeal
stenosis in adults (due to inflammatory swelling from various causes)
in which a tracheotomy otherwise inevitable was o1)viated by intuba-
tion.
It is impossible from statistics alone to draw comparisons between
tracheotomy and intubation ; for whereas in diphtheria and acute inflam-
matory affections, at any rate, intubation is or should be adopted as soon
as urgent dyspncea is found not to be relieved by the use of the steam
bed, calomel fumigations, and other means, tracheotomy is always delayed
as long as reasonably possible. On the other hand, the early relief of
intul)ation undoubtedly saves many lives that woxild otherwise 1)e sacrificed,
not by asphyxia but l)y pulmonary engorgement and lo1)ular pneumonia.
Before the introduction of the diphtheria antitoxin statistics showed that
under the age of five the results of intubation are better than those of
tracheotomy ; after this age the percentage of recoveries was slightly in
favour of tracheotomy up to the twelfth year ; while above the age of
twelve tracheotomy yielded much better results.
But by the use of diphtheria antitoxin, not only has the mortality in
cases of laryngeal diphtheria been very materially decreased, but Avith
the relatively rapid relief of the laryngeal obstruction the difficulties and
dangers of intubation have greatly diminished. The tube can in many
cases be permanently removed in forty eight hours, and, not infrequently,
after a much shorter period. We should, therefore, give the preference
to intubation over tracheotomy whenever it is practicable, secondary
tracheotomy, speaking generally, being reserved for cases in which, for
any reason, intubation has failed to give relief.
On the other hand, it should be borne in mind that the favourable
influence of the diphtheria antitoxin injections on the results of intubation
extends equally to tracheotomised patients, nnd that, inasmuch as the
tracheotomy tube can often be safely discarded Avithin a very few days,
many of the secondary complications arising from tracheotomy are likewise
avoided.
Chronic laryngeal stenosis. — In cases of chronic laryngeal stenosis,
where the cause of the obstruction cannot be removed, tracheotomy is
generally preferable to intubation, inasmuch as the latter entails loss of
the voice, and the patient can only speak in a whisper ; Avhilc after
tracheotomy the patient very soon gets into the way of stopping the
tracheotomy tube with his finger while speaking, and may continue to
wear a tube for thirty years or more without discomfort.
O'Dwyer has obtained brilliant results in several cases of stenosis
from chronic cicatricial contraction of the glottis following syphilitic
disease. Often the tubes which can be passed at first are very small ;
but after leaving these in for twelve or twenty-four hours, it is generally
possible to introduce a larger size, and so by patience and perseverance
the largest tube can ultimately be passed; thus the cicatrix is more
824 SYSTE.U OF MEDICINE
or less permanently stretched, and the dilatation can be maintained by
passing a large tube once in three months.
The use of Schriitter's zinc l)ougies over a long period is sometimes
successful in producing sullicieiit dilatation to obviate the further
necessity for Avearing a tracheotomy tube ; in other cases, especially of
membranous cicatrices between the A'ocal cords, intubation or mechanical
dilatation, after section of the web by a cutting dilator, will yield favour-
able results : thyrotomy, with i-escction of the cicatricial tissue, is an
alternative procedure suitable in a few cases.
Benign growths in the Larynx. — Causes. — Although benign growths
of the larynx are of fairly common occurrence — a fact well demonstrated
by the collective investigation instituted l)y one of us (F. S.), which
resulted in bringing together no less than 10,747 cases observed by 107
laryngologists between 18G2 and 1888 — yet it is very ditlicult to assign
their occurrence to any particular or definite causes. We are Avoiit to
look upon chronic laryngeal catarrh ns the most prolific cause of innocent
laryngeal tumours ; but although chronic inflammatory affections of the
lar3"nx are common enough, we are not aware of nwy trustworthy
observation of a new growth actually making its appearance in the
course of a chronic laryngitis under the eyes of the observer, except,
perhaps, the little inflammatory thickenings on the borders of the first
and middle thirds of the vocal cords, known as "singers' nodvdes," often seen
in singers and actors who have over-used their vocal organs. No doubt
some laryngeal catarrh may be seen in association with benign growths ;
but this is a consequence of the presence of the neoplasm rather than
the caiise : moreover, in the majority of cases catarrhal processes are not
present. Again, several cases of congenital new growths in the larynx are on
record, and this fact, together with the relative infrequency of laryngitis
in cases of benign groAvths, seems to exclude the probability that chronic
catari'h is an essential factor in their occurrence. AVhether occupation
exercises much influence in tlie matter is also open to discussion. Ex-
cessive use of the voice has been held responsible for their apijearance ;
but the very large number of benign groAvths occurring in 3'oung children,
and their appearance not only in the newly-born liut even in deaf
mutes, show that such a cause cannot be Avidely operative ; though Ave
frequently meet Avith small circumscribed thickenings of the vocal cords,
chiefly in singers Avho over-use their vocal organs or use them improperly.
Men are more frecjuently attacked than Avomcn ; 3'et the diflcrence is
not so striking as in the case of malignant growths of the larynx. No
time of life is free from them ; but they are most commonly met with
between the ages of tAventy and forty ; and, next to this period, the first
few j-ears of life furnish the most cases. Though there have been
instances of benign growths beginning in patients over seventy years of
age, it is a good rule to look' Aviih suspicion on all growths which arise
after the fiftieth year ; as expei-ience teaches that growths arising at this
time of life arc much more frequently m:dignant than benign.
As regards the A-arious forms of benign growths in the larynx, in
DISEASES OF THE LARYNX 825
order of frequency they are as follows : — Papilloma, fibroma, cystoma,
myxoma, adenoma, lymphoma, lipoma, angioma, ecchondroma, and
growths consisting of normal thyroid tissue. Practicall}^, of all these
varieties only three are of common occurrence ; namely, papilloma,
fibroma, and cystoma : all the others are so very rare as to be but
pathological curiosities.
Papilloma. — This is by far the commonest variety, constituting fully
39 per cent of all laryngeal growths. It is met with at all ages, but
especially in young adults. Papilloma may be single or multiple, varying
in size from a millet seed to a walnut, and of a white, delicate pink or
red, granular, cauliflower-like appearance. These growths are usually
pedunculated, not so often sessile, firm in texture, and do not readily bleed.
Histologically they are composed of a number of vascular papillae, covered
by an epithelial layer. Their favourite seat is on the vocal cords ; and
of these, again, the anterior commissure and anterior thirds are more
often attacked. Next in frequency come papillomata of the ventricular
bands, where they are generally observed only in cases of multiple
papillomatous degeneration. Sometimes they are .seen projecting from
the ventricle of Morgagni ; in other cases they are attached to the arytseno-
epiglottidean folds and to the epiglottis. In the latter positions they are
very rare, and if obserA-ed in patients over fifty they should always be
looked upon with suspicion of malignancy. Unlike epithelioma, their
area is distinctly restricted ; they do not infiltrate the surrounding tissue,
and they are practically never seen in the interarytsenoid fold. Early
epithelioma of the larynx may very closely resemlile a benign papilloma ;
the difterential diagnosis is fully discussed on p. 837.
In syphilis and tuberculous disease of the larj'ux false excrescences
are frequently observed in the interarytsenoid fold or on the vocal
processes ; these and " pachydermia verrucosa " might be mistaken by
the inexperienced for a benign growth if due attention were not given to
their characteristic features, which are elsewhere described (p. 831).
Fibrovia consists of the same tissue ;is the vocal cords, and originates
in inflammatory thickening of their fibrous basis. It consists of connective
tissue with an admixture of elastic fibres, is vascular, and may contain
cavernous blood-spaces. These tumours are covered by epithelium, and
serous infiltrations and haemorrhages are common in them, especially in
the softer A-arieties. The vascularity, particularly that of the sessile
forms, is very considerable ; and the licemorrhage on removal is often
much greater than in the case of papilloma.
Fibroma occurs in two forms, sessile and pedunculated, and in both
forms is generally single, with a white, pink, cheiry red or even bluish,
smooth surface. It generally occupies the upper surface of the middle or
anterior half of a vocal cord, and varies in size from a millet seed to a
walnut. The multiplicity common in papilloma is not seen in fibroma.
Sessile fibroma is almost always semi-globular ; in the pedunculated form
the stalk may be slender or stout, long or short. Sometimes the pedicle
is long enough for the growth to hang down into the subglottic cavity,
826 SYSTEM OF MEDICINE
and to escape from sight except on forced expiration or cough, when it may
be thrown above the level of the vocal coi-ds ; whilst on deep iiisi)iration
it is sucked into the subglottic cavity, and may completely disappear in
it, the vocal cords on the next phonatiori meeting over it, so that the
slight inequality in one cord, indicating the origin of the ])edicle, alone
betrays its existence. Fibromas vary greatly in size, from a pea to a
hazel nut or more.
Cystoma. — As cysts result from obstruction in the duct of a muciparous
gland, they generall}^ occur where these are ])lentiful, and especially on
the dorsal surface of the epiglottis. But they may occur in an}' part of
the larynx where glands exist ; and then they are fovmd on the ventricular
bands, or growing from the venti'icle or the arytrenoid region, and, in rare
cases, even from the vocal cords. They are smooth, tense, globular, semi-
translucent, covered with light red or grayish pink mucous membrane, and,
if considerable in size, have blood-vessels coursing over their surface.
Sometimes they attain so large a size as to be visible with the naked eye
when situated on the epiglottis ; and if arising in the larynx itself they
may actually threaten sufibcation.
The other forms of laryngeal benign growths, as idready stated, are
very rare ; some of them, such as lymphoma and mycosis fungoides, need
only be mentioned by mime.
Angioma is generally unilateral and single, occurring in the sinus
pyriformis, or on the ventricular ])aiids, vocal cords, or epiglottis, of
characteristic aspect, and com])Osed of a mass of blood-vessels held together
by a small quantity of loose connective tissue. The gi'owth is red or
purple in colour, and rarely exceeds a filbert in size. A case has been
described by Semon and Shattock in which a malignant growth, originat-
ing from the left arytseno-epiglottidcan fold, closely simulated an angioma
(28).
Myxoma usually occurs on the vocal cords. It lilcewise is generally
solitary, small, pink, or grayish white, sessile, translucent, and well
defined. If pedunculated, the growth partakes rather of the fibro-
myxomatous nature, and then may present a mammillated surface and
resemble a papilloma in aspect.
Ecchondrorna mostly arises from the cricoid cartilage. It has been
observed growing from the epiglottis, thyroid and arytaenoid cartilages.
Ecchondromas are usually firmly attached, hard, sessile growths, present-
ing a smooth surface of irregular outline and covered with healthy
mucous membrane.
Lipnma may attain considerable size. One removed by Sydney Jones
from the right arytaeno-epiglottidean fold partly projected into the
patient's mouth, so enormous was the size it had attained.
Prolapse of the ventricle of Movfjagiii, though strictly speaking not a new
growth, clinically resembles a laryngeal neoplasm so closely that it may
be conveniently mentioned here. A smooth, pink, lobulated, supra-
glottic mass, generally unilateral, sometimes bilateral, is seen resting on
the vocal cords, and corresponding to the opening of the sacculus, ■which,
DISEASES OF THE LARYNX 827
being inverted, of course no longer exists. That such an inversion should
be possible seems hardly credible ; yet several cases have been observed
both during life and on the post-mortem table by trustworthy observers.
It is most frequently seen in phthisis pulmonalis, and appears to result
from atrophy of the thyro-arytsenoidei muscles, and to be directly brought
about by violent coughing. As it is useless to replace it, the ]irojecting
portion should be snared or excised. It should be borne in mind that
the dislocation is exceedingly rare, and may be closely simulated by out-
growths from the ventricle.
Tlte symptoms of benign laryngeal growths, it is needless to say, will
vary according to their size and situation. By far the most frequent
symptom met with, and indeed in most cases the only one, is alteration
of voice. This explains itself when we remember that the vocal cords
are the j^rincipal seat of these gi-owths. The degree of vocal impairment
will depend, of course, on the amount of interference with the free vibra-
tion of the vocal cords. Even a very small growth occupying the anterior,
commissure or the free border of the cords in their anterior third may
greatly impair the voice or even produce complete aphonia ; whereas
growths which do not encroach on the free borders, or which are situated
on the middle parts of the cords, may give rise to a much less marked
vocal impairment ; in some cases, indeed, no symptoms whatever occur.
When the growth is sufficiently large to encroach considerably on the
glottic space, and to narrow the canal of the larynx, dyspnoea must result,
and the degree of dyspncea will of course depend on the degree of
narrowing of the canal.
Cough is rarely a prominent symptom, but in ver}'- young children
with papilloma it may be present and be croupy in character, as the
growths are apt to excite some degree of laryngitis and glottic spasm.
Pain is hardly ever felt, and only in a few cases, particularly of pedun-
culated growths, are strange sensations noticed, while spontaneous
haemorrhages practically never occur. Dysphagia may be present when
a large growth is attached to the upper surface of the epiglottis.
The prognosis as regards life and health is nearly always most favour-
able, but the possible developments which these growtlis may take if left
untreated must not be forgotten. We have already mentioned that
papillomas occur either in the solitary or multiple form. In the former
case, after having attained a certain size, they may remain stationary for
a long time ; but they are more likely to become gradually larger, and this
is, indeed, the rule with the multiple forms ; in this case they encroach
on the glottic space and threaten asphyxia, an event which has indeed
occurred in several cases.
Fibroma, after having attained a certain size, not rarely becomes
stationary ; in other cases, however, it continues to grow slowly, and may
sometimes, after many 3'ears, cause serious respiratory difficulties. In a
case of a large pedunculated fibroma recently observed by one of us (F. S.),
suffocation occurred quite suddenly, probably from impaction of the
growth in the glottis. No post-mortem examination was obtained.
828 SYSTEM OF MEDICINE
Spontaneous expulsion of now groAvths has been reported very rarely
indeed ; so excessively rare is it that the prospect of it ouiiht not to be
held out to any patient. One of us (F. S.) has seen involution take
place in the course of years in a few cases of growing children with small
nodules, apparently fibromatous, on their vocal cords ; but this, too, is
certainly very rare. On the whole it may be said that l)enign laryngeal
growtiis, when left to themselves, though they may become stationary at
a certain period, are more likely to increase gradually in size ; and papil-
lomas do so sometimes rather rapidly. The ])rognosis from the thera-
peutic point of view is nowadays almost universally good, although the
tendency of papilloma to recurrence must always be remembered. Also
the prognosis as to the recovery of voice is, on the whole, very good,
though in cases of sessile or very multiple growths some small vocal dis-
turbances may remain behind after their removal. The one class of
benign growths in which the prognosis ought to be very guarded, if not
as to life, yet at any rate as to duration of disease and to sul>sequent
function of the parts, are the cases of papilloma in early childhood in
which it may be found necessary to ]ieifoi-m prophylactic tracheotomy to
pi-eveut suHbcation, or in which thyrotomy has been carried out for
removal of the growth.
"We must here refer to a question which has of late been the subject
of a good deal of controversy, namely, whether benign growths of the
larynx ever undergo malignant degeneration, and, if so, whether this
tendency is increased by intra-laryngeal operative interference. This
question could only be answered definitely by a critical review of a very
large number of cases, and to this end the collective investigation (2) already
referred to was instituted by one of us (F. S.) Avith the foUoAving result :
— Of 10,7-47 cases of innocent laryngeal growths observed by 107
laryngologists, 8216 had been operated on intra-laryngeally ; of these in
33 cases malignant degeneration Avas reported, that is to say, 1 degenera-
tion in 249 cases; but on critically analysing the indiA-idual cases of
reported degenerations, in 5 only AA'as such degeneration found to have
been quite or almost undeniable ; and even if 7 further cases in Avhich
the degeneration Avas more or less probable be added to the. number of
the certain cases, the proportion of degeneration Avould be but 1 in 685
cases. The remaining cases of repoi'ted degeneration Avere of an exceed-
ingly doubtful character, and in most of them it was probable that a
diagnostic mistake had been made from the very beginning. Under
all circumstances the occurrence of a malignant degeneration of a pre-
viously benign laryngeal groAvth must be considered as an event of the
greatest rarity ; and the very number adduced affords sufficient evidence
that the alarm which has been raised concerning the influence of intra-
laryngeal operation upon the occurrence of such degeneration is absolutely
unfounded. A further proof of this conclusion is that a positively larger
number of s)X)ntaneous degenerations in non-operated cases Avere reported
in the collective investigation than of degenerations after remoA'al ; the
percentage in the first class of cases Avas 1 to 211, in the second class
DISEASES OF THE LARYNX 829
1 to 249. Of course we do not deny the possibility of benign laryngeal
growths sometimes undergoing malignant degeneration like benign growths
in other parts of this body ; but there is no evidence that this is aided by
intra- larj-ngeal operations. It is much more probable that cases are
diagnosed as benign which were really malignant from the outset.
Di(t gnosis. — It is needless to say that the diagnosis of Ijenign laryngeal
growth can only be made by means of a laryngoscopic examination, as
the symptoms consist almost entirely of vocal impairment and perhaps
dyspnoea, the former of which may equally well be due to chronic laryn-
gitis and numerous other causes, Avhile both sj-mptoms may be produced
by syphilitic, tuberculous, or inflammatoiy disease, or by paralytic dis-
orders. The differential diagnosis between benign growths on the one
hand and these several diseases on the other is not usually difficult,
though it is sometimes impossible to distinguish between benign growths
and tuberculous tumours ; sometimes indeed this can only be definitely
settled by a microscopical examination of the fragment removed. The
appearances presented by the various forms of new growth have already
been sufficiently noted, and the very important question of the differential
diagnosis between benign and malignant tumours is fully discussed
further on (p. 837 et seq.).
Treatment. — A very few cases of benign laryngeal growths are best
left alone ; they are chiefly cases of small sessile fibroma situated on the
vocal cords, and causing very slight symptoms. In such cases removal is
sometimes exceedingly difficult, and in the endeavour to remove them
there is a risk of injuring healthy parts in the neighljourhood and of
bringing about still greater vocal impairment. These cases, however, are
very exceptional, and in the vast majority it is not onl}^ desirable, but
even necessary, on account of the symptoms, to remove the neoplasm.
Astringent local remedies have been advocated, and it has been stated
that growths have been made to disappear by their use ; but we have
never seen such a happy consummation, and in our opinion not only is it
mere waste of time to resort to the use of these applications, but they
are apt to set up injurious irritation. Voltolini's method of running a
little sponge attached to a laryngeal prolte up and down the larynx, by
which process soft growths are supposed to be torn from their attachments,
has not proved very satisfactory in our hands.
The only really satisfactory method of getting rid of the growths is
to remove them by operation. In the great majority of cases this should
be accomplished by the intra-laryngeal operation under the guidance of
a laryngoscopic mirror held in the left hand, the right hand being free
for manipulating the instruments. We need not enter into any detailed
descriptions of the methods of jirocedure to be adopted; their technique
can only be acquired by long and careful practice, and without this the
intra-laryngeal removal of growths is attended Avith grave risks of serious
injury to the healthy structures. The use of a 20 per cent solution of
cocaine or eucaine hydrochlorate does away Avith the necessity for long
and repeated introduction of instruments in order to inure the patient's
830 SYSTEM OF MEDICINE
larynx to the interference of foreign bodies. In our opinion, Mackenzie's
cutting forceps is the most generally serviceable instrument, but in special
cases others may be preferable : thus Duntlas Grant's safety forceps are
very well suited for growths on the fi-ee edge of the vocal cords about
their middle thirds. In some cases the galvano-cautery, the laryngeal
snare, or cutting curettes may be better adapted for dealing with the
neoplasm ; in fact the choice of instrument a\ ill depend almost as much on
the tastes and habits of the operator as on the shape of the growth.
Often orcat ditficidties have to be overcome before the srrowths are
finally eradicated, and some cases even now baffle the most skilful
operator for a long time ; yet by patience and perseverance a very
satisfactory result may be confidently anticipated in the overwhelming
majority of cases.
Should the growth be very large, and should there be a risk of its
impaction in the glottis, and of suffocation, prophylactic tracheotomy
should be considered, even if removal of the tumour by intra-laryngeal
operation may be fairly anticipated ; or at any rate during the time of
this peril the patient should be placed where tracheotomy could l)e per-
formed in an emergency. Such measures, of course, are only required
in very exceptional cases.
In dealing with multiple papilloma in young children we have some
special difficulties to face, both in regard to diagnosis and treatment : in
diagnosis from the obstacles to a satisfactory laryngoscopic examination,
though there are surprising exceptions to this rule ; and in treatment
from the clouding of the mirror by mucus, even when a general anaesthetic
is used. The ordinary intra-laryngeal method has succeeded in but very
few of these cases ; and thyrotomy, in addition to its added risks of
permanent impairment of the voice, has given no immunity against their
recuiTence in a great many instances, in spite of removal of the growths
apparently very thorough.
Lambert Lack has found it com])aratively easy to obtain a view of
the larynx in young children by passing the tip of the left forefinger into
the right pyriform sinus and hooking forward the hyoid bone, and with
it the epiglottis and base of the tongue ; or instead of the finger a long
tongue-depressor may l)e used, with the distal end bent down abruptly to
the extent of half an inch.
Scanes Spicer, also, has recently introduced a method which combines
general chloroform narcosis with frequently-repeated local moppings of
the pharynx and larynx of the patient until all secretion is thereby
arrested, when he finds it possiljle to examine the patient laryngoscopic-
ally, and, if necessary, to proceed at once with the removal of the new
growths, should such be found. These methods certainly deserve further
trial. The same may be said of the employment of autoscopy (see p.
704) for the purpose of detection and prompt removal of growth from
the larynx of a small child.
In young children, if there be no respiratory embarrassment, removal
of the growths may be deferred with advantage : first, because of the
DISEASES OF THE LARYNX 831
tendency to recurrence ; and, secondly, of the special difficulties in operat-
ing. Should there be any dyspnoea, tracheatomy ought to be performed,
and the removal of ' the growths themselves postponed to a later period
of life, when the child may have gained self-control enough to allow the
intra-laryngeal interference.
We do not hope for much help from intubation, which has been
recommended under these circumstances in order to do away with the
dyspncea and to promote absorption of the new growths. In the first
place, no authenticated case is known to us in which absorption of the
growths has resulted from this method ; and, secondly, there must be
serious risk of detaching fragments, and of pushing them down into the
lower air passages.
"When, from the peculiar nature of the case, external operation is
necessary, there are two alternatives : (i.) Thyrotomy ; (ii.) Subhyoid
pharyngotomy. For subglottic growths, prodixcing respiratory embarrass-
ment, thyrotomy is sometimes unavoidable ; but the cases which cannot
be dealt with by the natural passages are very few ; and it has justly
been laid down as a rule that a radical external operation in a case of
benign laryngeal growth ought never to be undertaken unless an ex-
perienced laryngologist has failed to remove it by intra-laryngeal methods.
Pachydermia Laryngis. — Slng-ers' Nodes. — The term pachydermia
laryngis was originally applied by Virchow to circiimscribed or diffuse
thickening of the epithelium and subepithelial tissue of the vocal cords
and other parts of the larynx covered by pavement epithelium, and of
the ventricular bands.
Causes. — The affection generally occurs in men between the ages of
thirty-five and sixty. Amongst its immediate causes are chronic alcoholism
and excessive tobacco-smoking ; it is especially prone to occur in those
who subject the voice to prolonged strain. In not a few cases, however,
no definite cause can be assigned for its appearance.
Pafholoijy. — In addition to the thickening and cornification of the
epithelium, the subepithelial connective tissue is thickened and sends
papilliform processes into the epithelial layer. Inflammatory round-cell
infiltration appears, but there is always a distinct line of demarcation
between the epithelium and the connective tissue. The local thickening
is often surrounded by more or less diffuse congestion and inflammatory
thickening. Yirchow describes the cases due to syphilitic or tuberculous
laryngeal disease as secondary or symptomatic forms of pachydermia ;
these varieties, however, need not be noticed here. Every degree of
thickening may occur, from the slightest elevation, due to the heaping up
of a few epithelial cells, to a well-defined lenticular tumid outgrowth a
quarter of an inch or more in length.
Si/mpfoms. — Often no symptoms are noticeable ; but hoarseness and
discomfort, slight pain, and considerable im})airment in the compass,
strength, and quality of the singing voice may be produced.
Olijectively the thickening is generally observed on the vocal processes,
or interarytainoid fold, on one or both sides of the larynx. If bilateral.
832 SYSTEM OF MEDICINE
the wart-like growths are symmetrically placed, and, in the later stages,
there is invariably a crateriform depression or pouch at the summit of
one side into which fits a corresponding elevation on the other ; thus
apposition of the vocal cords is retained and the v(jice is ])reserved. This
unilateral crateriform depression, as pointed out by Friinkcl, is probabl}^
the result of jjressure by the opposite elevation, and not of the firmer
fixation of the mucous membrane to the connective tissue at this spot,
as Yirchow believes ; if the latter view Avere correct, the depression
would not be invariably unilateral. Diffuse chronic laryngitis, chronic
inflammation of the mucous membrane of the larynx, and even chronic
adhesive perichondritis may coexist with the pachydermial afifection, and
sometimes render the diagnosis less easy.
Chonlifis tohcrom, or " singers' nodule," or " teachers' node," is a clinical
variety of pachydei'mia. A peculiar small poppy-seed-likc growth api)ears
on the upi)er surface and free border of one or both vocal cords, generally
about the junction of the anterior third with the posterior two-thii*ds of
its length. Possibly the tendency in them to occur at this particular
spot may be that in singing there is a nodal point here which is subject to
continual attrition. These nodules are the consequence of over-use or
wrong use of the voice ; they interfere particularly with the production
of the notes of the upper register, and are most comnionly seen in sopranos
and tenors.
The nodes are merely local hypertrophies of the epithelium and sub-
epithelial connective tissue of the vocal cord, and are usually vciy hard
and consistent. If considerable in size, a small blood-vessel may often be
seen coursing over the surface, and circumscribed hj'pera^mia of the
immediate neighbourhood is frequently j^i't^sent.
Tlic diagnosis rarely presents much difficulty unless the pachydermia
be complicated by chronic laryngitis or perichondritis. The cr'ateriform
depression above referred to is pathognomonic of the affection, and, in
our experience, the mobility of the vocal cords is unimpaired : impaired
abduction of the vocal cords, however, has been described. Early malig-
nant disease of the vocal cord may simulate pachydermia, l)ut in this case
impaired mobility of the vocal cord would almost certainly be, present ; and
bilatei'al affection of the cords favours the diagnosis of pachydermia. In
doubtful cases examination of a removed fragment may lie possible ; but
only positive evidence of cancer would be of any value, and the failure
to discover anything characteristic of malignant disease should have
no weight in cases Avhere the clinical appearances were indicative of
malignancy.
A difficulty may arise in distinguishing between simple or idiopathic
pachydermia and the epithelial thickenings and outgrowths that some-
times spring from syphilitic deposits ; especially as these forms are but
little affected by antisypliilitic ti-eatment. Similarly tuberculous d('])()sits
in the interarytaenoid fold may give rise to difficulty in diagnosis, if bacilli
cannot be found in the sputum and if the pulmonary conditions are
indefinite.
DISEASES OF THE LARYNX 833
Frognosix. — The prognosis as regards Hfe and function is invariably
favourable ; but the affection resists treatment and is very apt to recur.
Treatment. — In our experience the patient practically always gets well
under jjrolonged vocal rest and the steady use of iodide of potassium ;
especially if any contributory causes, such as smoking and alcoholism,
are corrected. Attempts at removal by operation are liable to set up
perichondritis ; but electrolysis, under cocaine, Avitli bipolar instruments
has been recommended by Chiari.
Malignant disease of the Larynx. — Etiology. — The causes oi malig-
nant growths in the larynx are as obscure as are the causes of malignant
growths in other parts of the body. Heredity, excessive use of the voice,
and long-continued local irritation are commonly, held to have some
influence in their production ; bv;t the experience of one of us (F. S.), who
has had the opportunity of seeing an unusually large number of cases of
malignant disease of the larynx, and has paid special attention to these
factors, lends no support to these surmises. As a matter of fact, it is
hardly ever possible to assign the cause of the occurrence of malignant
disease of the larynx.
Men are certainly much more frequently affected than women, and
the disease belongs especially to late adult life, being seldom met with
before forty. The thirty years of life betw een forty and seventy supply
the overwhelming proportion of all cases of malignant disease of the
larynx coming under ol)ser\ation ; and of these thirty years by far
the. largest place is taken by the decade between fifty and sixty. It
must be stated, however, that a comparatively large number is met with
in the decade from forty to fifty ; that is to say, in that jjortion of life
in which innocent growths also are not uncommon, and in which the
differential diagnosis between benign and malignant growths, particularly
in the earliest stages, is sometimes one of the greatest possible difiiculty.
Fatliologij. — Both carcinoma and sarcoma occur in the larynx ; and of
these the former is met with far more frequently than is generally
believed, while the latter are very rare. Carcinoma of the larynx is
almost always either primary, or arises by direct extension from neigh-
bouring structures ; it almost never arises by metastasis or secondary
infection. This immunity is owing to the arrangement of the lymphatics
of the interior of the larynx, which are very richly developed, but form
a network of their own without anastomosis with the lymphatics of
neighbouring structures ; they empty themselves into two small glands on
each side, one beneath the greater cornu of the hj'oid bone, the other at
the side of the trachea. Tiiis peculiar arrangement of lymphatics is a
point of the greatest clinical importance, for it explains, in the first place,
Avhy the larynx does not become affected secondarily in carcinoma of
other parts of the body ; and, secondly, why malignant disease occurring
in the interior of the larynx tends to remain localised for a long time
without affecting neighbouring lymphatic glands of the neck and other
tissues : sometimes, indeed, secondary glandular enlargement may be
absent to the very end. Consequently, following Krishaber, we shall
VOL. IV 3 H
834
svsti:ji/ of medicine
subdivide cases of malignant disease of the lannix into the extrinsic varietij,
affecting the epiglottis, arytseno-epiglottidean folds, arytenoid regions,
intcrarytaenoid fold, and the posterior surface of the cricoid plate, and
into the intrinsic rariefi/, including the gi'owths originating from the vocal
cords, the ventricular bands, the ventricles of Morgngni, and the sub-
glottic growths within the borders of the larynx proper.
In the great majority of cases the cancerous growths appear in the
form of epithelioma ; much more rarely we meet with medullary
carcinoma and scirrhus.
Sarcoma occurs in the round-celled and spindle-celled forms as lympho-
sarcoma, myxo-sarcoraa, fibro-sarcoma. The histological characters of the
varieties of maliiinant growths in the larynx difiFer in no essential charac-
ters from malignant growths generally.
As regards the situation of the growth, intrinsic cases are met with
more frequently than extrinsic. Amongst the extrinsic forms, malignant
disease of the posterior surface of the cricoid cartilage seems to occur by
far the most fi-equently ; while in the intrinsic variety, so far as can be
made out, malignant disease of the vocal cords heads the list by a long
way. But in a very large proportion of cases the exact starting-jDoint
cannot be ascertained Avith certainty ; only too often patients do not
seek the advice of the specialist until the disease is already in an ad-
vanced stage. These statements are well exemplified by a series of 103
casfS seen in private practice by one of us (F. S.). In 38 the growth
was of the extrinsic variety, in 55 it was intrinsic; while in 10 it was
mixed, that is, both extrinsic and intrinsic. Excluding these 10 the
cases were distributed as follows : —
Extrinsic
Epiglottis .... 8
Arytteiio-epiglottic ligament (prob-
ably) .... 5
Interarytrenoifl fold (probably) . 6
Posterior surface of cricoid cartilage 19
Total . . 38
Inteinsic.
Vocal cords ....
Ventricular bands .
Ventricle of Morgagni
Not to be made out with certainty .
Total
If.
3
2
35
55
Symptoms. — These vary greatly, not only in diflerent stages of the
disease but also with the situation of the growth ; and while there is
comparatively little difticulty in diagnosing the real nature of the aflec-
tion when it has attained even a modoiate degree, it is of the greatest
importance from the therapeutical standpoint duly to recognise its earliest
manifestations. Thus it is essential that careful attention should be paid
to symptoms and to laryngoscopic aspects of the larynx that at first
sight may appear almost trivial.
Hoarseness, in intrinsic cases, is nearly always the earliest and most
frequent symptom. Its degree, even in the earliest stages when but a
small tumefaction or projection from the vocal cord is to be seen, often
is out of proportion to the size of the neoplasm. This is due to the
infiltrating character of malignant growths, in consequence of which
DISEASES OF THE LARYNX 835
the mobility of the affected vocal cord, as a rule, is impaired at an
early period also. As the disease progresses the hoarseness is changed to
complete aphonia ; but, on the other hand, the voice may return to some
extent as the growth begins to break down, and thus temporarily the
vocal cords are brought better together. In cancer of the epiglottis
the voice may remain normal to the end ; Avhile in cases where the
arytaeno-epiglottic folds or the posterior surface of the cricoid cartilage
are first attacked it may remain unaffected for a long time.
Pain may occur either at an early or at an advanced stage ; but it is
often insignificant, and we have observed cases in which this symptom
was almost entirely absent throughout the whole course of the disease.
Especially is this the case in the intrinsic variety. If present, it may
radiate from the throat to the ear, the irritated fibres of the superior
laryngeal nerve transmitting the irritation to the auricular branch of the
pneumogastric nerve ; yet this irradiation of painful sensation is by no
means characteristic of malignant disease. Tenderness on pressure
over the affected side of the larynx may often be elicited ; and when
the growth is considerable the larynx is sometimes found notaljly
broadened in consequence of pressure from within. Pain on swallowing
is sometimes observed in epiglottic growths, but is most marked when
the disease is situated on the posterior wall of the larynx.
Cough, as a rule, is not a prominent symptom. Increased salivation
from refiex irritation and increased secretion from the mucous glands are
generally present, and, in consequence of the odynphagia, the saliva
collects and, in the more advanced stages, may dribble out of the mouth.
The secretion is at first frothy ; later it is tenacious, semi -purulent, and
streaked with blood. When the growth ulcerates, and especially when
the perichondrium becomes affected, the secretion is fcetid, and a peculiar
sickly, foul, musty odour is imparted to the breath. Eespiratory obstruc-
tion depends on the size and situation of the growth. In the later stages
of the intrinsic variety it is usually one of the most prominent symptoms.
In the extrinsic variety it may result from tiie growth, if this be
situated on the posterior surface of the cricoid cartilage, gradually
destroying the muscular substance of the posterior crico - arytaenoid
muscles, and thus producing more or less complete paralysis of the
abductors of the vocal cords. In the earlier stages slight hamtiorrhages
are common, and when ulceration of the growth has gone far, considerable
haemorrhages may occur.
Cancerous cachexia is sometimes absent throughout; particularly in
intrinsic cases, owing to the arrangement of the lymphatics to which
attention has already been drawn : but when the growth has spread to
the pharynx the characteristic cachectic aspect is seldom long delayed.
In large ulcerating growths, especially when extending into the o?sophagus,
the constant difficulty in deglutition may result in rapid wasting and loss
of strength. Moreover, when the pharynx is involved, the lymphatic
glands beneath the sterno- mastoid and the posterior cervical glands
become enlarged.
,
836 SYSTEM OF MEDICINE
Signs. — ^laligiiaiit disease of the larynx, in its earlier stages, may
appear, on the vocal cords as (i.) a single unilateral congestion ; (ii.) a
diffuse infiltrating growth, with a red, uneven surface ; (iii.) a white, dirty
white or reddish gray, broad-based, rarely pedunculated, semicircular or
oblong wart, generally single and bearing a resemblance to a benign
papilloma or fibroma ; (iv.) an uneven fringe-like outgrowth from the
cord. On the ventricular l)ands or aryta?no-cpiglottic folds and other
parts of the larynx it may appear as a definite tumour, or as a deep
grayish pink infiltration with a coarsely mamniillated or uneven surface.
E{)iglottic growths are fi-equently more of a grayish or whitish pink, and
may look almost fibrous in texture, but with uneven surface.
The disease may progress very slowly indeed at first, so that, even
after the detection of a definite "Avart," no appreciable alteration in size
may have taken place after an interval of three or four months ; on the
other hand, rapid increase in size and early implication of neighbouring
portions of the larynx is the more usual course, and points to malignity,
especially if a growth which originally occupied the middle or posterior
part of a vocal cord extends towards the aryta?noid cartilages and
posterior wall of the larynx. As the growth progresses it tends to
ulcerate, at first superficially ; and it readily bleeds. But deep ulceration
is seldom long delayed : the floor of the ulcer is then covered with foul
grayish muco-pus and debris tinged with blood. As the growth and
ulceration extend, the cartilages often become involved ; and a secondary
perichondritis, which may proceed to suppuration and exfoliation of
cartilages, not infrequently complicates the disease and may c^uite
obscure its objective symptoms.
Sarcoma generally originates in the ventricular bands or epiglottis, or
as an ill-defined, infiltrating growth the primary seat of which cannot
be ascertained. The growth, if defined, is smooth, globular, and semi-
translucent ; but it may take the form of a grayish pink infiltrating
tumefaction, with smooth but uneven surface. The rapidity with whicli
it extends varies greatly in different cases.
Tlie patient very rarely lives more than three years after the appear-
ance of malignant disease of the larynx, if, that is, it be left to run its
ordinary course; usually, indeed, the duration of life is considerably
shorter. With advancing Aveakness and emaciation, and sometimes in a
general cachectic condition, the patient sinks and dies ; in many cases
he is carried off by some intercurrent affection, such as bronchitis and
congestion of the lungs, or by "foreign body pneumonia," due to the
escape of particles of food or secretion through the distorted glottis into
the lower air-pas.sagcs.
Diagnosis. — The chief points Avhich should attract our attention in
cases of early malignant disease of the larynx are the age of the patient,
the symptoms, especially that of hoarseness coming on without an obvious
cause, the laryngoscopic appearances, the absence of general symptoms
pointing to phthisis, syphilis, or gout (which, of course, do not exclude a
concomitant cancer of the larynx), and — where possil>lc — the histological
DISEASES OF THE LARYNX 837
character of portions of any growth removed for diagnostic purposes.
The affections with which laryngeal carcinoma is most likely to be con-
founded are inflammatory diseases, larj-ngeal palsies, syphilis, tuberculosis,
lupus, gout, benign growths, pachydermia laiyngis, and perichondritis.
In those cases where malignant disease first manifests itself as a
diffuse hyperemia, it is distinguished from chronic laryngitis by its being
unilateral ; this character in itself would suggest to an experienced
laryngologist the beginning of some serious affection, such as carcinoma,
tuberculosis, or syphilis.
After a t.me in most cases increasing heaviness in the movements of
the diseased vocal coid Avill be observed, which, taken in conjunction
with the accompanying circumstances, the age of the patient, abnormal
sensations or pain, and sensitiveness to pressure on the involved side, is a
very suspicious symptom ; and, in those cases in which it is present, it very
usefully serves to distinguish malignant growths from benign neoplasms
and pachydermia verrucosa. Sometimes this sluggishness of movement
is seen at a very early stage of the disease, when the growth may be
no larger than a pea. If this sign be absent from a case in which almost
the entire vocal cord appears to be embedded in a papilloma-like mass,
and in which age and other symptoms point towards malignancy, it is
well to remember that the growth may have arisen from the ventricle of
Morgagni ; an origin which would explain the absence of this valuable
sign. The growth, whether pedunculated or sessile, is generally sur-
rounded by a circumscribed, diffused, dirty pink hypersemia, which is
often in striking contrast with the Avhitcness of the remainder of the
cord and of the healthy one. Such growths may start from any part of
the vocal cord, but — in contrast to the usual seat of benign papilloma —
are very apt to originate from the middle or posterior thirds of the vocal
cord, a site Avhich when seen in patients over fifty years of age should
always suggest grave suspicions. In colour they vary from an almost
chalky white to a pink or dusky red ; and their surface may be either
smooth or granular, or mammillated. In a case observed by one of us
(F. S.), the surface, its white colour apart, could best be compared
to a newlj^-cut grass lawn ; in another the appearances were those of a
pedunculated angioma.
In other cases, again, the neoplasm is almost indistinguishable from a
benign papilloma ; yet a particularly fine branching of the individual
papillae, or the embedding of an entire vocal cord in a grayish white or
reddish papilloma-like mass, or the appearance of a fringy papillomatous
edge along its entire length, especially if one or more of these signs be
observed in an elderly patient, will put the experienced observer on his
guard. If, after removal of an apparently benign growth, rapid recurrence
take place — especially if the recurring neoplasm be covered with an
abiuidant growth of vegetations — or if the wound left by the removal of
the whole or a portion of the growth fail to heal and present a sloughing,
unhealthy aspect, malignancy should be strongly suspected. When the
growth is larger in size the diagnosis is, of course, much easier. Large
838 SYSTEM OF MEDICINE
malignant growths would be distinguished from benign ones l)y their
early ulceration and tendency to bleed. A gunniia appears as a large,
smooth, red tumefaction ; and Avhen it begins to ulcerate it Ijreaks
down and very rapidly disintegrates from the centre toAvards the
periphery, so that a characteristic crater-like syphilitic ulcer results.
Sj'philitic ulceration is usually easily distingiiished from malignant by its
relative painlessness and its rapid extension ; sometimes, however, the
diflfei'ential diagnosis may present considerable difficulties, and a final
decision may only be possible after long observation and the trial of
iodide of potassium. Tuljerculous disease of the larynx is accompanied
by an antemic appearance of the mucous membrane, while the tuberculous
ulcers are superficial, often multiple, " mouse -nibbled " at the edges,
difficult to define from the surrounding ])ale gray infiltration, and covered
with pale grayish white debris. These ulcers tend to spread slowly and
superficially rather than deeply. The concomitant pulmonary signs and
bacteriological investigation will help to solve diagnostic difficulties ; ]jut
it must be remembered that laryngeal cancer may coexist with pulmonary
tuberculosis.
Definite malignant growths on parts of the larynx other than the
vocal cords present similar features ; while the general sulimucous
infiltration, gradually involving various laryngeal structures, could only
be mistaken for a sign of perichondritis from causes other than malignant.
The posterior third of the vocal cords and the interaryta;noid fold
are practically never the seat of benign growths ; but these are the
regions in which Virchow's pachydermia verrucosa is most frequently
developed. The free movements of the vocal cords in the last-named
disease, the crateriform depression on the summit of the tumefaction
which forms in later stages of pachydermia, the relatively less pronounced
hoarseness, and especially a history of chronic alcoholism, are strong points
in the diagnosis of these excrescences, which, moreover, particularly in
more advanced stages, tend to become bilateral.
It is a very good practical rule, in all cases of suspected malignant
disease, to administer iodide of potassium for a while, even when there is
no history of syjjhilis, in ten-grain doses at first, rajiidly increased to
thirty grains, three times a day. But we would again draw attention to
the fact that mere subjective improvement after administration of this
drug is not to be trusted ; for patients, undoubtedly suffering from
malignant disease, often declare themselves better after taking the
iodide ; we must, therefore, be guided by the changes in the size of the
growth or infilti-ation.
Finally, the value of a microscopical examination of a removed frag-
ment of a suspected growth has to be considered. AVhen this reveals
to a competent pathologist positive and unmistakable evidence of the
malignancy of tlie growth — as in cases of squamous -celled carcinoma
(epithelioma) — there is, of course, no room for doubt as to its character ;
but we cannot too strongly emphasise the importance of remembering
that a mere negative verdict of the pathologist must not set aside clinical
DISEASES OF THE LARYNX 839
apprehensions otherwise well founded. The possihility of the growth
being of a mixed chaiacter, or a papillomatous surface growing from a
malignant basis, ought always to be remembered. In short, microscopic
examination of fragments remov^ed intra-laryngeally is a valuable but not
an infallil)le aid to diagnosis. Eveiy portion of the removed fragment
should be cut into sections and each one carefully inspected ; and if the
examination reveal no characters of malignancy a furtlier and deeper
portion should be removed if the clinical appearances suggest any manner
of suspicion as to its nature. However, there arc but too many cases in
which the disease appears in the form of a general smooth infiltration
from which it is almost impossible, intra-laryngeally, to remove portions
for microscopic investigation. In such cases the clinical observer must
have the courage to form a definite diagnosis from clinical signs only.
Prognosis. — The prognosis varies enormously according to («) the
original situation of the growth ; (//) the stage and extent of the disease
at the time at which the patient comes under observation ; (c) the
patient's age and general health. Although a small intrinsic malignant
growth in an otherwise healthy middle-aged patient allows of a much
better prognosis (provided that immediate radical operation be consented
to), than was considered possible a few years ago, the outlook in cases
of extrinsic or very extensive intrinsic growth in very old patients, or in
those whose general health has suflered from other causes, is still extremely
grave.
The treatment may be considered under two headings, radical and
palliative.
The radical treatment of malignant disease of the larynx may be said
to have undergone a cnmplete transformation within the last few years ;
for whereas attempts to extirpate the disease were so disastrous that
they were rarely considered justifiable, the experiences of one of us (F. S.),
who has been fortunate in having exceptional opportunities of treating
malignant laryngeal growths surgically, and those of Mr. liutlin likewise,
have yielded results which, when we remember the inevitable and speedy
end of all such neoplasms Avhen left to their natural course, are most
gratifying. Taking as the basis of our remarks Semon's series of 103
cases seen in private practice between 1878 and 1894, we find that of
12 cases in which radical operations were undertaken no less than 7
ended in recovery, a percentage, tlmt is, of 58"3 of the patients saved
from a death otherwise inevitable.^ In two of the fatal cases death
was due to preventable complications not connected with the opera-
tion ; otherwise the successful result might have been brought as high
as 66 "4 per cent. This gross result becomes even more important
Avhen the question of recurrence is considered. Hitherto it has been
almost universally believed that even if radical operations in malignant
disease be for the moment successful, a recurrence of disease within a com-
^ Since the above was -wTitten I have performed four more tliyrotomies for malignant
disease of larynx, all of which were successful. The percentage of recovery in my 16 cases,
therefore, now is about 69 per cent I — F. S.
840
SYSTEM OF MEDICINE
paratively short time is an almost unavoidable contingency. The re-
sults in the above-mentioned cases give the most emi:)hatic denial to this
belief, for the duration of life in the operated cases was severally 7|
years (patient dying of heart disease), 6 years,^ 4 years, 3 years, 2 years,
H year, the last four patients being alive and well and free from
recurrence. In the seventh case, in Avhich recurrence ajjpeared to 1)C
threatening when one of us last saw the patient, subsequent examination, as
Dr. Hicks of ^Madeira informs us, did not prove this suspicion. The patient
died suddenly ten months after the operation. At the iiecrops}^ a thick-
walled abscess was found in front and extending to tlie left of the trachea.
This had caused the dyspncea and dysphagia from which he had been
suffering during the last few months of his life, and which had given rise
to the suspicion of recurrence.
Equally pleasing and surprising are the results from the phonatory
point of view, the voice in all cases being fair and in some almost
normal ; although the whole of one side of the soft parts of the larynx
had been removed.
It is when we come to the selection of cases which are suitable for
operative treatment that we see the necessity for emphasising the
importance of recognising the early symptoms of malignant disease of the
larynx. Only in a very few exceptionalhT^ favourable cases can we
undertake radical operations with any chance of success if the disease be
not strictly intrinsic in its limitations. As regards the mode of the
operative procedure, a few cases of successful extirpation through the
mouth are recorded ; but in early cases of intrinsic cancer this could.be
very rarely attempted Avith any prospect of success ; nor even in such
cases could we recommend the intra-laryngeal operation when Ave consider
the infiltrating character of malignant growth, and the fact, proclaimed
years ago by one of us (F. S.), and since corroborated by many observers,
that Avhen the larynx is opened the disease is almost always found to be
much more extensive than Avas apparent on laryngoscopic examination.
Thyrotomy, or sul)hyoid pharyngotomy, Avith removal of the groAvth by
excision and partial laryngectomy, offers the best chance of getting rid of
the Avhole disease.
The methods of performing these operations, and of carrying out the
after-treatment, are beyond the scope of this Avork ; for their full descrip-
tion the reader is referred to a paper published by one of us (F. S.) in
189-i (21).
Subhyoid pharyngotomy appears to be the most suital)le procedure
for removing growths of the epiglottis and arytanio-epiglottic folds.
Concerning the technique of total extirpation of the larynx and its
after-treatment Ave must refer the reader to the text-l)Ooks of siu-gery.
Piillitdivp, measures. — In cases Avhich are unsuited for radicid operation
we have to rel}'' on maintaining the patient's general health and strength
by suitable tonic remedies, food and rest. If swalloAving be painful, the
^ This patient has since died from an acute abdominal disease quite unconnected with the
original laryngeal affection. — F. S.
DISEASES OF THE LARYNX 841
food shovikl be soft and bland : it is not well to urge patients to go on
taking solid food when the local pain and irritation are increased thereby.
With the supervention of respiratory obstruction, tracheotomy should
be performed. Life may be prolonged a good many months in some cases
by this operation, if the latter l)e not too long postponed ; and in many
patients there is a considerable improvement in other symptoms besides
the dyspnoea. The low operation is preferable to the higli, as the growth
may spread down so as entirely to surround the tube. When ulceration
has occurred, the use of antiseptic applications containing morphine is
called for.
Laryngeal Neuroses. — (L) Motor Neuroses
Introductory Remarks. — Whilst the vagus nerve by its superior
laryngeal branch supplies sensation to the larynx on each side, and is the
motor nerve to the crieo-thyroid muscle, the recurrent laryngeal branches
of the vagi supply motor innervation to all the other intrinsic muscles of
the larynx. Hitherto the generally accepted view has been that the
fibres of the recurrent laryngeal nerve are ultimately derived from the
spinal accessory nerve through its communication with the vagus before
it leaves the cranial cavity. According to the experiments of Grabower,
Grossmann, and Walter Spencer, however, the recurrent nerve is derived
from the vagus and not from the spinal accessory. This question is
still an open one, and as yet Ave cannot give unqualified adherence to
Grabower's statements. Moreover, his explanation of the cases in which
paralysis of one vocal cord is associated with paralysis of the same side
of the soft palate, of the tongue, and often also of the corresponding sterno-
mastoid and trapezius muscles — an association which so clearly points to
a nuclear lesion of the spinal accessory — has not qiiite satisfied us.
Exner's exp Timents on rabbits lead him to the conclusion that the
thyro-arytsenoid us interims is supplied by the siiperior laryngeal as well
as by the recurrent, the thyro-arytgenoideus externus by the superior
and recurrent on each side, and the crico-arytsenoidei laterales and postici
by fibres from the superior and recurrent laryngeal nerves ; while the
depressors of the epiglottis are innervated by tlie superior laryngeal. It
must be remarked, however, that clinical evidence is not in accord with
Exner's views ; and it is impossible as yet to regard them as a correct
representation of the motor innervation in man.
The experiments of Semon and Horsley, corroborating Krause's
investigations, demonstrated that there is in each cerebral hemisphere a
bilateral cortical centre for adduction of the vocal cords (as in phonation) ;
and that in the left hemisphere this centre corresponds with the speech
centre, which in man lies in the anterior portion of the lower extremity of
the ascending frontal convolution. Irritation or stimulation of either
centre Avill produce bilateral adduction of the vocal cords, that is,
spasm of the glottis ; whilst destruction of one centre produces no
corresponding paralysis so long as the other is intact. Thus in motor
S42 S YSTEM OF MEDICINE
aphasia the vocal cords are not aftocted ; and a unilateral cortical lesion
has never been proved to cause unilateral paralysis of the opposite vocal
cord, although French observers (Garel, Dor, Rauge, Dejerine) strongly
maintain that this is possible ; indeed they allege that it has been
observed. It is impossible here to enter moi'e fully upon this hotly-debated
question ; and we must refer those interested in it to a paper published
by one of us (F. S.), in which it is fully discussed (22).
Semon and Horsley found a centre for abduction of the vocal cords in
the cat lying close to the border of the olfactory (rhiiial) sulcus ; no
abductor centre was found by these observers in any of the other classes
of animals experimented upon, although the existence of such a centre in
the cortex was almost certain fi'om their discovery of a spot in each
internal capsule, excitation of which gave rise to bilateral abduction of the
cords. More recently, however. Dr. Ilisien llussell has discovered cortical
centres for abduction in the dog also, which on unilateral excitation })ro-
duce bilateral abduction of the cords; if, that is, the more powerful abductor
movements have been to a certain extent abolished by previous section of
the abductor fil:)res in the recurrent laryngeal nerve of one side. Abduc-
tion of the A'ocal cords was obtained from the anterior composite gyi'us
just in front of and below the adductor centre, and therefore a little in
front of and below the anterior extremity of the coronal sulcus.
In further exploring the cortex Eisien Ihissell found that on the
anterior composite gyrus, below the abductor centre, there exists a focus,
excitation of which results in what is described as a clonic abductor ettect
on the cords ; in this action the cords Avere first brought into a position
of moderate adduction which was followed by rapid short to-and-fro
excursions.
On passing within the confines of Spencer's area for ai'rest of respira-
tion, it was found that in the peripheral parts of this area there exist
three foci, excitation of which ati'ects the cords in ditlereut waj^s. The
most anterior of these foci is res})onsible for arrest of the cords in adduc-
tion ; that is, in the expiratory stage of their excursion. Excitation of the
focus behind this, corresponding probably to Horsley and Semon's abductor
centre in the cat, is followed by arrest of the cords in abduction, that is,
in their inspiratory position ; while stinudation of the most posterior
focus, which is situated about the junction of the anterior composite and
anterior sylvian convolutions, results in intensification with acceleration
of the movements of the cords. Excitation of Mr. Spencer's chief focus
for arrest of respii-ation on the olfactory lol)e resulted in arrest of the
cords in the position they occupy during expiration in dogs, and in tho
position they occupy during inspiration in cats.
Ill no instance in the whole of the experiments of Semon and
Horsley, and Kisien liussell, was there any indication of unilateral repre-
sentation of tlie cords ; on the contraiy, excitation of the centre on cither
side produced an equal abduction eflect on both cords alike. The experi-
mental evidence on this point was corroborated l>y a remarkable case of
Jacksonian epilej^sy observed by one of us (W. W.), in which the patient,
DI.^ EASES OF THE LARYNX 843
after a fit, while remaining perfectly intelligent, Avas the subject of com-
plete motor aphasia, being unable to utter a single word, although he
could produce inarticulate sounds ; in him adduction and abduction of
the vocal cords were found to l)e perfectly normal and bilaterally equal.
Another point of interest has been investigated by liisien liussell,
namely, the inhibition of antagonistic muscles by electrical excitation of
the cerebral cortex, on the lines adopted by Professor Sherrington with
regard to antagonistic muscles in other parts of the body. This was
tested by first dividing the fibres in both recurrent laryngeal nerves,
leaving the abductor fibres intact, and then exciting the adductor centre
with strong induced currents ; but no evidence of inhibition of the
abductor muscles Avas obtained.
Before entering on the discussion of the various forms of laryngeal
motor disturbances, it will be well to refer to a law established by one
of us (F. S.), namely, that in all progressive organic lesions of the
centres or trunks of the motor laryngeal nerves the abductors of .the
vocal cords succumb much earlier than the adductors (8). Although
a Lu'ge number of such cases of progressive organic disease acting
upon the whole of the nerve-trunk have been recorded, and pulilicly
shown, in which the abductor muscles had undergone degeneration and
atrophy, either alone or at any rate more advanced than in the adductors,
not a single specimen has yet been demonstrated Avhich, under similar
conditions, exhibited the opposite order of events in the development of
degenerative changes in the individual laryngeal muscles : all attacks
made so far upon the law rest exclusively upon clinical observations,
which are either incomplete, or are cajDable of an interpretation other than,
that adopted by their authors.
To explain this diff"erence between the abductor and adductor muscles
various hypotheses have been advanced. Thus Sir W. R. Gowers con-
sidered it might be a consequence of the advantage at Avhich the most
important adductor — the lateral crico-arytaenoid muscle — works in
comparison with the abductor (in so far as the former goes in at a right
angle, the latter at a very acute angle towards the muscular process
of the arytsenoid cartilage), which renders the adductors capable of
a longer resistance to disabling influences atlecting the whole nerve-
trunk. Griitzner appears inclined to regard the adductors as belonging
to the class of " white," and the abductors to the " red " class of muscles ;
and su2;2;ests that the difference in the muscles accounts for the diff'erence
in susceptibility to degenerative processes. Kiause s suggestion is that
the pathological process underlying the median position assumed by the
vocal cords, under the conditions now referred to, does not consist in a
primary paralysis of the abductor muscles followed by a paralytic contrac-
ture of the antagonists, but of a primary neuropathic contracture of all the
muscles supplied by the recurrent, with preponderance of the adductors.
He attempted to imitate experimentally the pathological process upon
which during life the median position of the vocal cords most frequently
depends— namely, the pressure of a tumour upon the motor nerves of the
844 SYSTEM OF MEDICINE
larynx — by fixing a jiicce of cork to the previously isolated recurrent laryn-
geal nerves, which were then replaced. After a few hours he first observed
slight vibratory twitchings, afterwards a somewhat temporary median
position, and after about twenty-four hours a permanent median position.
This median position persisted without any change for two or three
days, Mhen it passed over into complete palsy. If the same experiment
be performed on the pneumogastiic nerve (it deserves special mention that
Krause always operated on both sides), the vocal cords permanently
assume the quiet position of expiration.
But in his explanation Krause did not distinguish between the sudden
and intense irritation he had experimentally produced, and the slow and
gradual increase of irritation by chronic pathological processes. The median
position produced by him was probably correctly interpreted as an irritative
phenomenon ; and we do not deny that in a few human cases of acute
character a neuropathic median position of the A'ocal cord may be of a
similar nature. But in the enormous majority of cases in man a slow
destruction of the nerve takes })lace, in which alterations of pressure, and
with them irritative phenomena, can no doubt occur, though they are very
frequently absent ; and even in cases of the former kind the crico-ary trenoid
muscles succumb first. Krause fell into a self-contradiction when inter-
preting the atroj^hy of these muscles, as " atrophj' due to inactivity " ;
since, according to his hypothesis, all the muscles supplied by the recurrent
laryngeal, and therefore also the abductor, were supposed by him to be
in a state of chronic irritation : moreover, in cases of slow pressure on
nerves in other parts of the body — such as pressure on the facial nerve or
on the brachial plexus, as in crutch-paralysis — we do not find contracture
(that is, active primary muscular contracture as distinguished from second-
ary paralytic contracture), but paralysis. Further, from Semon and
Horsley's experiments on different species of animals it appears that {a) the
abductors are the first of all the laryngeal muscles proper to lose their
excitability after death ; and (//) that, when an animal is killed a week after
thrusting a thread saturated Avith chromic acid solution through a recur-
rent nerve, the corresponding posterior crico-arytsenoid muscle is the first to
lose its excitability. Again, Hisien Bussell has also shown (a) that the
abductor and adductor fibres in the recurrent larvns:eal nerve are collected
into several bundles, the one distinct from the other, and each preserving
an independent course throughout the nerve-trunk to its termination in the
muscle or muscles which it supplies with motor innervation ; {(i) that
when the abductor and adductor fi1)rcs are exposed in the living animal
to the drying influence of air under exactly similar circumstiuues, the
abductor fibres lose their power of conducting electrical impulses very
much more rapidly than the adductors ; in other words, that they are
moic prone to succumb than are the adductors. Moi'cover, the fact, fre-
quently observed, that in certain chronic central nerve affections — such
as tabes dorsalis — paralysis of the internal tensors of the vocal cords (the
thyro-arytainoidei interni) occurs with the vocal cords in the middle line,
proves that the latter condition is due to primarj^ paralysis of the ab-
DISEASES OF THE LARYNX 845
ductors, and not to primary neuropathic contracture. Finally, the co-
existence of other undoul^ted palsies with median position of one or both
vocal cords, all of which lesions are due to one and the same cause, such
as ccreljral syphilis, renders it more than improbable that the laryngeal
condition under such circumstances should be an irritative phenomenon.
Nor are we any longer quite in the dark as to the cause of the
liability of the abductors to succumb. The fact discovered by Hooper,
and corroborated and explained by Horsley and Semon, that ether has a
peripheral and differential effect upon the laryngeal muscles Avhich can
be produced only by means of the circuhition, the fact that the abductor
muscles die sooner than the adductors, and the fact, demonstrated by B.
Frankel and Gad, that gradual cooling of the recurrent laryngeal nerve
paralyses the crico-aryt?enoicleus posticus sooner than the glottis-closers —
all these facts, taken together with the clinical and pathologico-anatomical
experiences concerning the earlier destruction of the abductors in progress-
ive organic lesions, imply that there is a positive difference in the biological
composition of the laryngeal muscles and nerve-endings ; whilst the fact
that in central (bullDar) organic affections also, such as tabes, the cell
groups of the abductors succumb earlier than those of the adductors,
points to the probability that there are similar differentiations in the
nerve-nuclei themselves. The phenomenon, hitherto obscure, thus finds its
explanation in biological differences between the components of the
laryngeal nerves and muscles. This constitutes an addition to our know-
ledge of the nervous morphology, but does not necessitate a revolutionary
postulate such as is involved in the contracture hypothesis, namely, that
the motor laryngeal apparatus possesses a pathology peculiar to itself.
We formerly knew that differences existed as regards the irritability and
power of resistance of the sensory and of the motor nerves, but Ave
assumed complete equality among motor nerves. Now we have also learnt
that differences of a more subtle kind exist among these nerves and the
physiological conditions of the muscles they supply (2, 23, 24).
Spasmodic affections. — Laryngeal spasms may be due to affections
of the nerve-centres, nerve-trunks, or single nerve-twigs. With regard
to the nerve-trunk affections, considering that stimulation of the peri-
pheral end of the cut recurrent laryngeal nerve (that is, of all its fibres)
results in adduction of the corresponding vocal cord, it is quite possible
that, in cases of so-called " spasm of the glottis " of peripheral origin, not
the adductors only, but also the abductors may be in a state of spasmodic
contraction ; the former, however, preponderating.
The various spasmodic affections may be conveniently divided into
two groups : — (i.) Eespiratory glottic spasm, and (ii.) Neuroses of co-
ordination.
Respiratory glottic spasm. — Laryngismus stridulus. — Etiology. —
This affection is almost invariably associated with rickets, and occurs
chiefly in children from six months to two years of age. or up to the
eighth or ninth year.
846 SYSTEM OF MEDICINE
While the remarkable excitability of the nerve-centres in rickets disposes
to the affection, the spasms are often excited directly by some reflex
irritation in the alimentary tract, such as uniligested food or parasites ; or
it may lie due to post-nasal adenoids, or to such sources of excitation
as teething, a ]iendulous epiglottis, or enlarged bronchial glands. It is
sometimes directly l)rought on by emotion ; and it is veiy likely that
defective nutrition and consetjuent irritability of the cortical adductor
centres may cause laryngismus (Semon and Horsley). This would also
explain the " carpo-pedal " contractions, general convulsions, and so forth,
"which not rarely accompany laryngeal spasm in children, and which the
authors just named consider as an overflow of energy from the iri'itated
laryngeal adductor centre or centres to the neighbouring centres. The
patients are often ill-nourished, unhealthy, micro-cephalic or hydro-cephalic
children.
Laryngismus may arise as a complication of measles or whooping-cough,
especially in children otherwise predisposed ; and whooping-cough in
particular leaves a strong disposition to laryngeal spasm for some months
after its own disappearance.
Sij)iiptoins. — In a well-marked attack, after a few stridulous inspira-
tions, short at first but gradually more prolonged, spasmodic closure of
the glottis occurs, the respiratory movements of the chest and respiration
ceasing absolutely. The child presents a most painful aspect, with the
head thrown back, the neck forward, the eyes staring, the pupils con-
tracted, and the countenance bearing an expression of extreme anxiety, at
first flushed, then in a few seconds pallid or livid ; the veins of the neck
are swollen, and perspiration gathers on the face. The glottic spasm lasts
from fifteen seconds to two minutes, and the glottis may remain closed
till loss of consciousness or even death occurs. The attack, if not fatal,
ends as it began with a few short stridulous inspirations, either con'tinuous
or intei'mittent, as in sobbing. In severe cases these symptoms are ac-
comjianied by spasms of the facial muscles, and b}' spastic, so-called carpo-
pedal contractions ; in these the thumbs are turned in and flexed on the
palms and the fingers closed over them or rigidly extended ; the carpal
joints are turned inwards, the feet somewhat flexed and turned inwards.
\_Fide art. on " Tetany " in a later volume.] In some cases general convul-
sions supervene on these phenomena. In the less severe forms, the carpo-
pedal spasms are absent and the symptoms less pronounced, the parents
often speaking of the attacks as "passion-fits" or "holding the breath."
Generally as soon as the attack is over the child resumes its play, and
seems as well as ever. These attacks may occur very occasionally, or they
may follow one another in quick succession ; generally there are one or
two attacks daily.
Prorjnosis. — In very severe cases death from asphyxia is by no means
rare, and the prognosis should therefore be guarded, although the mean
mortality of all casfs is very small. From a therapeutic standpoint the
prognosis is generally distinctly favourable, especially Avhen tliei-e is a
prospect of removing the underlying cause, as in rickety children who
DISEASES OF THE LARYNX 847
constitute the vast majority of the cases ; yet some cases are very
persistent, anJ, particularly in those which result from pressure by an
enlarged bronchial gland, the attacks are liable to recur till the child has
attained the age of eight or .nine, or even more. In the " silent cases "
— those in which there is no inspiratory stridor— the prognosis is especi-
ally grave.
The diagnosis of laryngismus stridulus rests upon the suddenness of
the attack, the complete cessation of the respiratory movements at the
height of the attack, the aljsolutely free intervals, and the absence of
symptoms of inflammatory disease in the larynx, such as cough, hoarseness
or aphonia, fever, and so forth.
Spasm of the glottis in adults is generally a reflex phenomenon
brought about by irritation of a vagus or, in very rare instances, both
recurrent laryngeal nerve-trunks by aneurysms or mediastinal growths ;uid
the like, or by direct irritation of the larynx by foreign bodies, neoplasms,
adenoid hypertrophy of the lingual tonsil, an elongated uvula, and so on.
Glottic spasm also occurs in certain lesions of the nerve-centres, as in the
laryngeal crises of locomotor ataxia, in hydrophobia (in wliich, according
to a very interesting observation made by Dr. Newton Pitt, the abductors
of the vocal cords only appear to be afi'ected by the spasm), tetany, and
hysteria.
The symptoms are usually much less severe, though of the same
character as in infants and children ; they often amount to no more than
a succession of stridulous inspirations.
In other cases, however, the spasm may be prolonged till consciousness
is lost, or even life itself suspended. In very rare cases, according to
some authors, there is a slight but constant spasm. In hysteria it may
occur either in the paroxysmal or in the more contiinious form : in the
latter, which has also been termed functional inspiratory spasm, the vocal
cords, instead of separating on intended inspiration, ajtproach each other,
remain together during the inspirations so that the air enters with
difficulty and stridor through the narrowed glottis, and only separate to
some extent during expiration.
Treatment. — As a rule, the spasm passes off spontaneously after a few
seconds ; but prompt measures should be taken to shorten the attack as
far as possible by removing any tight garments, opening the window,
placing the patient in the semi-recumbent position, and applying cold Avater
to the face and head and smelling-salts to the nostrils, while the legs and
body may be immersed in a hot bath. If asphyxia be threatening,
tracheotomy should be performed without delay, followed, if necessary, by
artificial respiration.
The general treatment depends on the exciting cause of the neurosis.
Warm clothing, fresh air, simple diet, and avoidance of mental excitement
or hard brain-work are of first importance. Faecal accumulations, or in-
testinal parasites, when present, must of course be removed. Above all, if
any indications of rickets are noted, treatment must be directed to overcome
this condition by the administration of cod-liver oil, and especially of small
848 SVSTEJ/ OF MEDICINE
doses of phosphorus. In strumous children the syrup of the iodide of
iron and cod-liver oil will be useful. If the attacks recur frequently,
small doses of bromide of ])ot;vssium, belladonna, or chloral will tend to
keep them off and render thoiu less severe. In a case recently observed
by one of us (F. 8.) the use twice daily of a 2 j)er cent spray of cocaine,
directed to the larynx, succeeded — probably by gradually diminishing
the peripheral hyper-irritability — in causing attacks of very serious laryn-
geal spasm in a gouty adult to disappear completely within a fortnight
(see p. 750).
Neuroses of Co-ordination. — («) CJwreic movements of the vocal
cords may accompany general chorea ; and have also been noticed inde-
pontlontly. AVe here refer to disorderly action of the cords in contra-
distinction to the glottic spasm with forced expiration in cases of
" barking cough." In disseminated cerel)ro-spinal sclerosis a tremulous
action of one or both cords, similar to the tremors of the limbs on intended
movements, is sometimes present.
Functional inspiratory spasm has already been referred to as one of
the forms of hj'.sterical laryngeal spasm, the vocal cords coming together
on inspiration, and separating but slightly on expiration. The symptoms
in these cases are very similar to those of bilateral paralysis of the ab-
ductors ; lint when the vocal cords are watched by the laryngoscope
during expiration they are occasionally seen to separate well. This affec-
tion appears to occur only in nervous or hj'sterical persons, though a
minor degree of it is often witnessed in nervous people examined Avith the
laryngoscope for the first time ; the vocal cords in such cases are ap-
proximated instead of separated on attempted inspiration. Psychical treat-
ment, bromide of potassium, the cold douche or intra-laryngeal faradic
current usually effects a cure.
(i) Nervous laryngeal cough. — Thei'e is a condition in Avhich spasmodic
closure of the glottis a])pears in the form of sepai'ate, sud^len, short con-
tractions of the adtluctors, in association with similar contractions of other
respiratory muscles, which results in an extremely loud, harsh, abrupt cough,
the " barking cough of puberty " (Sir Andrew Clark). It occurs in young
persons of both sexes. We have seen more men than Avomcn affected by
it, and it is not limited to the period of puberty ; it is most common
between sixteen and twenty, but the ages of the })atients vary from ten
to twenty or more. The cough generally ceases during sleep, though not
always ; usually it is single, not a series of successive coughs, in which
character it differs from the cough due to sensory laryngeal irrita-
tion ; throughout the day it recurs persistently, even during rest.
This nervous laryngeal cough is not associated Avith any demonstrable
lesion, and the voice is not in any A\'ay impaired ; there is no shortness of
breath involving forcible inspiration after the cough. In fact, it is simply
a sudden closure of the glottis, Avith a forcible expiration, duo to affection
both of the laryngeal and respiratory branches of the A-agus. The general
health is cuiiously little affected, and the cough often appears to be a
much greater nuisance to the patient's family than to the sufferer himself.
DISEASES OF THE LARYNX 849
This affection is really one of the " convulsive tics " ; and is not in.
any way associated with volitional acts. It may last for weeks, months,
or even years, but finally almost always ceases spontaneously. In young
women it is often removed by the use of iron in strong doses for a few-
weeks.
Nervous laryngeal cough is very little amenable to ordinary treatment.
The remedy which, with one single exception, has best answered in all the
cases observed by oiie of us (F. S.) is a sea-voyage, which usually acts like
a charm within a few days. Removal of the patient from home, a stay
at the seaside, general sedatives, and the like, are not to be compared in
efficiency to a sea-voyage, which ought to be urged upon the patient's
friends, however great the difficulties. If a sea-voyage be altogether
impossible, the internal use of bromides in large doses [sulphate of iron —
Ed.], and local cocaine applications may be tried.
(c) Phonic spasm (Dysphonia spastica). — This is a form of contraction
of the adductors, originally de&cribed by Schnitzler, which is })robably
always allied to a similar contraction of the tensors of the vocal cords
and of the thoracic expiratory apparatus, which only occurs on attempted
phonation. The affection is analogous to writer's cramp, and one of us
(F. S.) has seen a case of spastic aphonia associated with similar spasm
of the masseter and orbicularis oris ; another coexisted with writer's
cramp.
This form of glottic spasm, like the preceding from which it differs
in that it only occurs on attempted phonation, is rare. It is a disease
of adult life and almost always occurs in highly-strung men who
have to use their vocal organs professionally (especially clergymen), so that
it may be classed amongst the " professional " neuroses. Occasionally,
however, both men and women in robust health, and whose occupation
is of a silent kind, may be attacked.
In its earlier manifestations the patient, after producing a few
words, especially when using the voice in a professional capacity,
such as preaching or i-eading the lessons in church, suffers from
notable impairment or complete loss of voice. As the disease increases,
any attempt at phonation residts in spasmodic closiu^e of the glottis,
and the words are lost in fruitless attempts to force a current of
air through the closed part. The voice under these circumstances assumes
such a curiously oppressed character that even one who has never before
seen a well-marked case of the disease may be enabled to diagnose sub-
sequent cases from the particular timbre of the voice alone. Laryngo-
scopically the vocal cords are seen to act normally during respiration ; but
on attempted phonation the cords come into complete apjiosition ; in fact,
so forcibly are they adducted that they may seem to overlap one another,
and one arytaenoid cartilage may push itself in front of its fellow. The
spasm lasts as long as attempts are made to speak ; but as soon as volun-
tary effort at phonation ceases the glottis opens. Whispering is some-
times less difficult and may be possible. Respiration is free and noiseless.
To this class belong the cases described by B. Fx'ankel under the name
VOL. IV 3 I
850 SYSTEM OF MEDICINE
modiphonia, in which spasm with impairment or loss of voice occurs only
on singing or attempts at public speaking, the ordinary conversational
voice being unimpaired.
Treatment in tliese cases, in our experience, is almost always futile. All
the remedies usually recommended in text-books fail— tonics, electricity,
rest of voice, hydropathic treatment, sea-voyages, and so forth. The only
method from which any improvement may be hoped for, and this in
the earliest stages only, consists in rational l>reathing and elocutionary
exercises : it is characteristic of these patients that they almost always
attempt to pronounce or to read long sentences without taking an inter-
mediate inspiration.
{d) Lari/nrjeul vertigo. — There is a curious and rare form of spasm of the
larynx, followed immediately by vertigo and loss of consciousness, to which
Charcot originally applied this term. He considered it to be analogous
to Meniere's disease, the afferent nerve being, according to his view, the
superior laryngeal. The views of its pathology differ widely : thus
Krishaber regarded the vertigo as due to spasm of the glottis and
arrested action of the respiratory muscles, and Gray looks upon the
affection as a form of epilepsy. M 'Bride explains the phenomena by the
action of forced expiration into a closed glottis ; he made experiments on
the effect of forced expiration under these conditions, and foinid that
sphygmographic tracings of the pulse showed a rapid and continuous
diminution of the upstroke. This author states that in larj'ngeal vertigo
there is a complete closure of the glottis, and thus the whole expiratory
effort is felt, through the air contained in the lungs, by the alveoli, the
large lilood-vessels in the thoracic cavity, and the heart itself. As
a result syncope— or a tendency to syncope — is produced, but almost at
the same moment the spasm of the glottis relaxes and the attack is over.
The patient may seem to be in perfect health ; or he may suffer
from a catarrhal affection of the nasal passages. A tickling sensa-
tion in the larynx results in an effort to cough. This is immediately
followed by giddiness and obscurity of vision, and the sufferer falls
down in a state of unconsciousness which lasts a few seconds only, from
which, as already stated, recovery is immediate and complete. The fnce
is either pale or turgid — there may be slight twitchings of the face or
limbs. In slighter cases consciousness may not be completely lost, the
seizure terminating only with the occurrence of the vertigo. The attacks
recur at intervals varying from a few days to months.^
As regards the treatment, the main indications are to improve the
general health by rest and change of air, and by the administration of
cod-liver oil and general nervine tonics such as iron, quinine, phosphorus,
and arsenic ; tlie tendency to spasm may be averted by bromide of
potassium and similar remedies. Any catarrhal affection of the respira-
tory tract should Ijc renio\'cd by approjiriate treatment.
^ In a case of this kind under my o^v'n ob<erv:ition the patient, on one occasion at least,
bit his tonpiie sharjily. He never i)ri.sse.l liis urine in tlie attacli, but I think there are all
degrees of these seizures up to detiuite epilepsy. — Ed.
DISEASES OF THE LARYNX 851
Paralysis. — Motor laryngeal paralysis may be due to —
(i.) Degenerative changes in the nuclei of the laryngeal motor nerve-
fibres in the floor of the fourth ventricle ;
(ii.) Pressure on or destruction of spinal accessory fibres before their
junction with the vagus nerve ;
(iii.) Degeneration, injury or pressure on the vagus trunk, or its
superior and recurrent branches ;
(iv.) Functional neuropathic impairment ;
(v.) Paralysis which, in its initial stages at any rate, may be reflex;
although the nerve involved in a reflex paralysis generally undergoes
actual organic changes ; or finally,
(vi.) The paralysis may be myopathic in origin. .
A. Paralysis of the muscles supplied by the recurrent laryngeal
nerve. — The adductors and abductors of the vocal cords act by rotating
the triangular arytsenoid cartilages on their axes and by drawing them
inwards and outwards respectively.
(i.) Paralijds of the adductors of the vocal cords. — Adduction of the
vocal cords is brought about by the action of the crico-arytgenoidei later-
ales, which arise from the sides of the cricoid cartilage, and pass back-
wards and upwards to the external angles of the arytsenoid cartilages.
By their contraction they cause inward rotation of the arytsenoids on
their axes, and the vocal cords approach in the middle line. But for
perfect adduction the aryta?noids must be brought into apposition by the
arytienoideus and the thyro-arytsenoidei muscles.
Paralysis of the adductors is almost invariably bilateral and due to
functional disorders, probably cortical ; as in hysteria, in cases of reflex
uterine origin, and the like. Often it is a sign of general weakness of the
muscles, as in phthisis, antemia, or cholera ; or it is caused by infiltration
of the muscles, as in catarrhal conditions. The paralysis is very rarely
complete ; as a rule, there is only a greater or less degree of paresis of
the adductors, and thus, laryngoscopically, the vocal cords may either
remain widely divergent on attempted phonation, or more frequently
are but insufficiently approximated and do not completely close the
glottis : or if they do so, they promptly recede from apposition. The
result of the deficient closure of the glottis is more or less complete
aphonia. While in hysterical cases the voice is lost, the cough and some-
times the laugh are phonic, even if the voice has been lost for months
or years ; on the other hand, in the very rare cases due to local lesions,
the cough is aphonic, or, rather, altogether impossible.
The onset of the afl^cction is quite sudden in the hysterical cases, the
duration most variable, from hours to years, and its ending pei'haps
as sudden as its onset. In cases of catarrhal origin, both the beginning
and the passing off" are, in accordance with the nature of the lesion, more
gradual. If unilateral, the paralysis is nearly always due to local causes
affecting the nerve-twigs or muscles. Unilateral adductor paralysis is
extremely rare : cases are reported as having occurred from cold, syphilis,
small-pox, and so forth, and some cases of unilateral adductor paralysis
852 SYSTEM OF MEDICINE
ascribed to reflex influences from the nose are recorded ( W. R. H. Stewart).
The appearance presented by the larynx in the unilateral cases is not
very characteristic, and is liable to be mistaken for total recurrent
paralysis of one cord ; therefore the laryngoscopic examination of these
rare cases ouijht ahvavs to extend not merely to observation of the cords
during quiet respiration and during phonation, but to inspiration as well,
when further al>duction will take place. It need scarcely be added that
inasmuch as the healthy cord is widely abducted at the same time,
the eye must be very expert to observe the increased excursion of the
paralysed cord on inspiration ; for it is the slightness of the outward
movement of the cord — not merely the widening of the glottic chink —
that must be detected.
The voice would be more aff'ected in unilateral adductor paralysis
than it is in complete unilateral recurrent paralysis, in which case the
cord is in the " cadaveric " position ; and the healthy cord can easily pass
across the middle line to meet its fellow. In adductor paralysis the cord
would be more or less abducted, or at any rate in the position of quiet
respiration, and the healthy cord could hardly pass across and meet it.
The cases described by Solis Cohen under the name apsithijria, in
which the patient not only loses the speaking voice but is unable even
to whisper, arc a form of functional paralysis of the adductors of psychic
origin.
(ii.) Farali/sis of the abductors. — The vocal cords are abducted by the
crico-arytsenoidei postici muscles, which, arising from the posterior surface
of the cricoid cartilage, pass upwards and outwards to the external angles
of the aryti^noid cartilages. By their contraction the arytivnoids are
rotated outwards on their axes, and the vocal cords are abducted for the
purpose of inspiration. It has been stated above that, in a case of incom-
plete organic paralysis of a recurrent nerve, those of its fibres which
supply the abductor muscles are always first or pre-eminently palsied.
In such cases there is at first of course only impaired abduction on the
affected side ; later, however, the unopposed antagonists of the i')aralysed
muscles fall into a state of paralytic contracture and draw the vocal cord
into the position of phonation, where it becomes imna,ovably fixed.
These remarks apply to both neuropatliic and myopathic paralysis.
Abductor paral3sis may be due to pressure on one or both recurrent
laryngeal nerves, either by an aneurysm or tumour in the neck (particularly
by goitres) or within the thoracic cavity — such as enlarged mediastinal
glands, tuberculous thickening of the pleura covering the right apex of the
lung, or by malignant disease of the a'sophagus, or by a foi-eign body in
it. It is also frequently due to central nerve-lesions in the medulla, or
to implication of the vagus or spinal accessory nerves at the base of the
brain, particularly in tal)es doi'salis, and also in ceril)ral syphilis, dis-
seminated cerebro-spinal sclerosis, l)ulbar paralysis, tumours of the brain,
haemorrhages into the bulb, or thickening of the dura mater.
Further, the paralysis may be due to the toxic neuritis of pneumonia,
typhoid fever, diphtheria, scarlet fever, rheumatism, or influenza, or to the
DISEASES OF THE LARYNX 853
effects of lead, arsenic, or atropine ; or again it may be myopathic in
wasting diseases, or due to local myopathic impairments as in progressive
muscular atrophy.
Finally, if there be pressure on the trunk of one pneumogastric nerve,
the result may l)e bilateral paralysis of the alxluctors of the vocal cords ;
a reflex paralysis ingeniously explained by Sir George Johnson as the
result of a centripetal irritation of the trunk of the vagus acting on the
nervous centre, and through it upon the nerve-supply to the laryngeal
muscles of the opposite side.
The left recurrent nerve is more frequently affected than the right ;
and the most frequent cause of this paralysis is aneurysm of the
arch of the aorta; the right recurrent is more -liable to compression
by pleuritic thickening accompanying tubeiculosis of the right lung
and by aneurysms of the innominate, though it also may suffer from
aortic aneurysm. The left recurrent nerve branches off from the
left vagus on a level Avith the concavity of the aortic arch, and winds
round it from before liackwards to ascend to the larynx ; -while the right
recurrent begins on a level with the right subclavian artery, around
which it winds ])efore passing upwards. Thus not only is the left recur-
rent very liable to be affected in the earlier stages of aneurysms of the
aortic arch, even before there are any other manifestations of aneurysm,
but as both the recurrent and the vagus above its recurrent branch
have the longer course within the chest on the left side, there is also
gT-'cater liability for the left cord to be affected by other intrathoracic
tumours.
If any of these causes act on the recurrent nerve of one side, uni-
lateral abductor paralysis results ; while if the conditions obtain on both
sides — that is, if there be a bilateral incomplete lesion of the bulbar centres,
or of the trunks of both recurrent larj^ngeal nerves, or if there be pressure
on one pneumogastric only with resulting reflex paralysis — bilateral
abductor paralysis will result. Of course if the paresis result from
interference with the vagus trunk above the superior laryngeal branch,
anaesthesia of the larynx will be present, in addition to motor paresis. If
the lesion be high up and due to a tumour, or to diffuse pachymeningitis,
other cranial nerves, such as the spinal accessory, glossopharyngeal, and
hypoglossal, may be involved.
In unilateral abductor paralysis the affected cord remains fixed in the
median line, that is, in the position of phonation ; and as the opposite cord
is unaffected, respiration is not embarrassed unless the cause of the
paralysis simultaneously produces direct compression of the lower air-
passages, as in not a few cases of aortic aneurysm. Under such circum-
stances, that is to say, in the initial stages of all the severe lesions men-
tioned as "causes" which may implicate the laryngeal nerves — and
indeed not rarely up to the patient's death — neither vocal nor respiratory
symptoms need occur in adults : thus the laryngeal lesion, which may be
of the greatest importance for the correct diagnosis of the whole case,
will entirely escape notice unless it be a part of routine practice to
SS4 SYSTEM OF MEDICINE
examine all cases in Avhich lesions of the lai-yngeal nerves could occur ;
■whether there be sym])tonis j)ointing to the larynx or not.
Ill hilatcral abductor parraly.sis both cords are defective in abduction
on inspiration ; and when the abductor paralysis is complete, the cords
remain in or near the median position by the gradual supervention
of paralytic contracture of the adductors, a very small chink only
being seen between them. Laryngoscopically this looks like a continu-
ous position of phonation. Inspiration is, of course, greatly embarrassed
in complete paralysis ; but fortunately bilateral abductor ])aralysis is
often only partial ; or while one cord is aiVected by complete abductor
palsy the other is only partially palsied. Paroxysmal attacks of lu'gent
dyspncea, with characteristic stridulous inspiration, are prone to occur on
slight exertion or mental excitement, and may at any time end in sudden
and fatal asphyxia. In the intervals there is sonorous or sti'idulous in-
spiration, particularly in sleep ; but expiration is free and the voice
normal.
The prognosis of bilateral abductor paralysis is obviously very grave,
and at any moment tracheotomy may be necessary. In pi'ogressive
lesions the adductors may eventually become involved ; and with the
complete paralysis of the cords, which then assume the cadaveric position,
respiration becomes less impeded, whilst the voice becomes impaired and
finally quite aphonic. Such secondary implication of the adductors may
not occur for several years ; and, as the voice meanwhile is in no way
impaired, bilateral abductor paralysis may exist without the slightest
suspicion of such a disorder on the part of the patient ; particularly in
cases in which the patient is unal)le to make strong muscular efforts,
as in the more advanced stages of tabes dorsalis.
(iii.) Complete recurrent jMirah/m (that is, involving all the muscles
supplied by the recurrent laryngeal nerves) of the vocal cord results from
lesions which are equivalent to a transv.erse section of the nerve affected.
Any of the lesions mentioned as causes of abductor paralysis may gixa rise
to complete recurrent paralysis. Probably abductor paralysis is always
present for a longer or shorter time in the earlier stages of pressure on a
recurrent nerve ; but sooner or later the adductors are also involved.
If only one nerve is paralysed, the respii-ation is not affected, and the
voice is either aphonic, hoarse, or sometimes almost normal when the
healthy cord " compensates" — that is, crosses the median line in phonation
to join its paralysed fellow ; but it is apt, under such circumstances, to
l)reak into falsetto. During quiet respiration the larynx appeal's nearly
normal, but in phonation the healthy cord is sometimes over-adducted
and passes across the middle line to meet the paralysed cord, producing a
peculiar distortion of the laryngeal image, the position of the glottis
being oblirjue. The arytienoid cartilage on the paralysed side, being un-
supj)orted Ijy its muscles, may be pushed aside so that it lies behind the
sound and over-adducted aryta?noid ; and, like the corresponding vocal
cord, lies at a somewhat lower level than on the sound side. In deep
inspiration the paralysed cord and its arytajnoid remain immobile in
DISEASES OF THE LARYNX 855
the cadaveric jDosition, whilst the aryta3noid on the healthy side passes
farther back.
In bilateral complete recurrent paralysis, which is extremely rare, the
vocal cords remain in the cadaveric position both during phonation and
inspiration. There is no dyspnoea during rest, but there is complete
aphonia. It is usually the result of pressure on both recurrent nerves ;
or represents the final stage of laryngeal paralysis due to central nerve-
lesions, as in tabes, syphilitic nuclear disease, and the like ; but it may
be due to any of the causes enumerated under the heading of abductor
paralysis.
(iv.) Parali/ds of fhe fhijrn-ari/tcenoidei interni, or internal tensors of the
vocal cords, is usually bilateral ; and is most frequently the result of
over-straining the voice ; or of catari-hal laryngitis, especially in anaemic
and neurotic persons. The vocal cords are practically the tendons
of the thyro-arytjenoidei interni muscles which are inserted into their
whole length. The function of these muscles is to render tense the
free margin of the vocal bands ; when therefoi-e they are weakened,
or paralysed, the vocal cords lose their normal flat appearance and
become rounded and narrowed ; thus they cannot approximate perfectly,
and a narrow elliptical space, extending throughout the length of the
glottis, is left between the cords during phonation, which consequently is
weak and husky ; or the voice may even be lost. The thyro-arytaenoidei
muscles are often paralysed in central nerve-lesions, and their paralysis
is often associated with or follows next (F. S.) upon paralysis of the
glottis -openers. It is, however, important to remember that some
elliptic gaping of the vocal cords during phonation is by no means rarely
seen in persons who are in full possession of their voice.
(v.) The interarytcpnoideus muscle may be paralysed alone in catarrhal
conditiotis and in hysteria. The paralysis is always bilateral, and the
voice is generally much impaired, or even quite lost. In these cases the
anterior three-fourths of the vocal cords are seen to come together on
attempted phonation, while a triangular chink is left between the vocal
processes. Paralysis of the thyro-aryta^noidei muscles ma}?- be associated
with paralysis of the interarytsenoideus, giving a characteristic double
elliptic glottic chink.
B. Paralysis of the muscles supplied by the superior laryngeal nerve.
— Isolated paralysis of the cricothyroid muscles. — The function of the crico-
thyroid muscles is to render the vocal cords tense on phonation ; they
are the external tensors of the vocal cords. Paralysis of the crico-thyroid
alone is very rare. According to Mackenzie, it may be caused liy cold
or overstrain of the voice ; and it is characterised by a wavy outline of
the glottis with a slight depression of the central portion of the vocal
cords in inspiration, and a corresponding elevation in expiration and
vocalisation (see also Sensory Laryngeal Neuroses, p. 858). In unilateral
paralysis of a crico-thyroid muscle the corresponding vocal cord stands
on a higher level than its fellow. Mackenzie also pointed out that
crico-thyroid paralysis can be detected by applying the finger to the crico-
856 SYSTEM OF MEDICINE
thyroid space on either side during phonation, when a want of tension
will be felt.
For the treatment of paralysis of the superior larj^ngeal nerve
and the muscles it supplies, see Sensory Neuroses.
Diag'nosis. — The significance of laryngeal paralysis is of very eon-
sideralilc importance in medical practice; not only on account of the
symptoms that may be produced, or the danger to life that may be in-
volved in various forms of paralysis, but still more on account of the valuable
aid to the diagnosis of many ol)Scure intrathoracic or central nerve
affections that may be afforded by a due aj^preciation of the pathological
source of the laryngeal condition.
Even when the impaired movements of the vocal cords are undoubtedly
due to local causes, it is necessary to distingiiish between true neuroses,
myopathic palsies, and the simulation of })alsy by fixation or impaired
freedom of action in the crico-arytsenoid joint ; or the impairment may
be the earliest indication of early malignant disease in the cords or
in their immediate neighbourhood. Local paralysis due to neuritis is
generally of diphtheritic or rheumatic origin ; myopathic paralyses mostly
fullow catarrhal inflammations. Mechanical fixation of the arytjenoids by
cicatricial contraction of the mucous membrane, after ulcerative diseases
or injuries, may account for the immobility of the cords. Any thicken-
ing in the neighbourhood of the arytienoid cartilage, or abnormal disten-
sions of the folds of mucoits membrane, or tumefaction at the base of an
immobile arytsenoid cartilage, are in favour of mechanical fixation. In
unilateral recurrent paralysis the arytsenoid cartilage on the paralysed
side may be displaced by the sound and over-adducted aryta^noid cartilage.
Bilateral anchylosis is rather liable to give rise to error in diagnosis,
inasmuch as it may so closely resemble bilateral recurrent paralysis ; but
complete paralysis of both cords (apart from anchylosis) is extremely rare.
Abductor or complete paralysis, whether unilateral or bilateral, may
be the earliest symptom of a thoracic tumour — and especially of an intra-
thoracic aneurysm, of malignant disease of the a?sophagus, intracranial
disease, tabes, disseminated cerebrospinal sclerosis, or general paralysis ;
even although all other signs be still absent. The possibility of any
of these conditions being the cause of the paralysis should ever 1)e present
in the mind of the physician, who will endeavour to detect further
indications of their existence. Points in favour of bulbar lesions are —
((/) Persistent increased pulse frequency without any pulmonary affection or
febrile disturbance to account for it; (//) Implication of both cords:
but it is particularly to be noted that the fact of the parah'sis being
unilateral does not in itself indicate that the disease is peripheral ; (c)
Coexisting paralysis of the soft palate and tongue.
The treatment of laryngeal paralysis will depend upon the nature of
the chief cause of the laryngeal condition. ^Vhen it is due to pressure
on a nerve-trunk or to central nerve disease, the prognosis is generally
most tmfavourable. In any form of organic laryngeal paralysis the chief
indication is, if possible, to remove the cause of the mischief. When it is
DISEASES OF THE LARYNX 857
caused by syphilitic disease the usual antisj-philitic treatment is indicated.
If enlarged glands or tumours are pressing on the nerve-trunks it may
be possible to remove them (this applies particularly to goitre) ; but
when the pressure is within the thoracic cavity, Ave can rarely hope
to cure the paralysis by operative or medicinal treatment. In advanced
bilateral abductor paralysis, since at any moment sudden and fatal
asphyxia may arise, tracheotomy ought always to be proposed, not as
a curative but as a prophylactic measure, pending the adoption of
any further treatment by which we may hope to obtain a permanent
cure, in Avhich event the tube can be removed. A cure may be possible
Avhen the paralysis is due to pressure, as in goitre, syphilis, or diphtheria ;
but not Avlien it is due to bulbar disease, -as in tabes or labio-glosso-
laryngeal paralysis : though in these bulbar cases complete recurrent
paralysis may eventually supervene and render the tracheotomy tube
unnecessary. In all cases in Avhich the bilateral abductor paralysis is
brought about by pressure within the thoracic cavity, the possibility of a
second stenosis loAver down, due to pressure on the trachea by the same
tumour or aneurysm which is pressing on the nerve-trunk and causing
the abductor paralysis, should be borne in mind ; and in order to prevent
disappointment the chances should be explained to the patient. A second
seat of stenosis is probably present Avhen there is marked expiratory as
Avell as inspiratory stridor, and difficulty in respiration. But Avhen the
narrowing of the glottic chink is in itself sufficient to account for the
dyspnoea, tracheotomy should be performed ; and the low operation should
always, if possible, be so chosen that the tube may be inserted below the
compressing tumour, if it be in the neck ; if it be in the thoracic cavity,
it may be possible to pass a long flexible tube doAvn the trachea and past
the stenosis.
If the condition is due to maladies amenable to remedies — such as
syphilis, or the neuritis of diphtheria or of cold — the general treatment
will not be forgotten ; Avhile direct treatment of the paralysis itself, by
local faradisation and hypodermic injections of strychnine (gr. J^ gradu-
ally increased to gr. -^q), should be steadily pursued, in the hope that the
conductivity of the nerve may not be wholly lost. In cases of functional
paralysis of the adductors, due to excessive use of the voice in ana?mic,
overworked, or Avcakly persons, rest and tonic treatment must be enjoined.
The patient must abstain from using the voice, live as regularly as
possible, avoid all fatigue and mental Avorry, and take plenty of sleep, food,
and open-air exercise, and a sufficiency of cold baths. Iron, strychnine,
phosphorus, quinine, and arsenic and similar tonic remedies may be
advantageously administered; and locally applications of mild galvanic
or faradic electric currents must be applied to the region of the pneumo-
gastrics. In cases due to inflammation, the usual remedies suited to
laryngitis may be employed, as Avell as local faradisation.
In hysterical paralysis of the adductors, emotional effects, or anything
that gives a shoclc to the system, will often produce a cure ; and a similar
result often follows stimulation of the larynx, as by inhalation of ammonia,
85S SYSTEM OF MEDICINE
tho application of a larviit,'cal hinsh. nnd so forth. Nothing is so satis-
factory, however, as local faradisation ; and, though this may be given ])y
applying an electrode to either side of the larynx externally, it is much
more eft'ectual if Mackenzie's endo-laryngeal electrode is used. The
current, though not so powerful as to be actually painful, should lie
fairly strong at the outset; by timid handling the beneficial elTects of the
shock arc often spoiled. One strong application is generally sufficient,
but sometimes it has to be repeated once or twice.
Tn reflex paralysis the eccentric cause, such as uterine disorder for
example, should be sought for and remedied.
Paralyses of the arytsenoideus and crico-thyroid muscles, when due to
cold or diphtheria, are often very obstinate ; and local faradisation at
frequent intervals may have to be continued over a long period.
Laryngeal Neuroses. — (II.) Sensory Neuroses
Ax.ESTlTESlA. — The superior larytigeal branches of the vagi supply
sensation to the mucous meiul)ianc of the larynx on each side ; and loss
of sensibility occurs when these nerves are paralysed. The loss of
sensation may vary from slight diminution to complete anaesthesia ; and
the area affected may be on one side only, or may extend to the epiglottis or
supraglottic portions of the larynx ; or it may be complete, and invade
the whole of the larynx and the upper part of the trachea. The
anaesthesia may be due to peripheral lesions, as in diphtheria, syphilis, or
injury to the vagus or superior laryngeal nerves ; or it may be central in
origin, as in bulbar paralysis, locomotor ataxia, general |)aralysis of the
insane, apoi)lexy, after an ei^ileptic fit, and generally, though in a minor
degree, in hysteria.
But the superior laryngeal nerve also supplies motor innervation to
the crico-thyroid muscles ; and therefore in cases due to peripheral lesions,
and sometimes in bulbar and other central nerve lesions, these muscles ai'e
paralysed at the same time. Obviously other motor laryngeal paralyses
and lesions of other cranial nerves may coexist, according to the situation
and extent of the disease.
The sijinptonis consist mainly in a tcndenc}' for mucus and food to enter
the larynx. The mucous membrane of the larynx itself being insensitive,
the particles of food often enter the lower air-passages. When the
anaesthesia is complete and su1»glottic, the larynx does not react by reflex
spasm upon the ingestion of food ; so that the particles often enter the
lower air-passages, ;ind may either cause most violent cough — the tracheal
mucous membrane having retained its reflex irritability — or may obstruct
the passage and produce dangerous attacks of suflfocation ; or, again, may
become impacted in the bronchi and give rise to pneumonia — the " Speise-
pneumonie " of the Germans. Hence it is also desirable, in all operations
in which blood may enter the larynx, not to push the narcosis to the
abolition of the cough-reflex.
DISEASES OF THE LARYNX 859
In one-sided aiifesthesia there is a tendency, for mucus and saliva to
collect on the insensitive side.
The diagnosis can only be made with certainty by touching the
laryngeal mucous membrane in various jmrts with a probe under guidance
of a laryngoscopic mirror, when defects of sensation and loss of reflex
cough are readily detected. It is hardly necessary to emphasise the
importance of noting any coexisting paresis or anaesthesia of the fauces,
pharynx, or tongue.
The prognosis depends on the cause of the anaesthesia; in most cases
the prospect of ciire will be very remote. Post-diphtheritic anaesthesia
tends to disappear spontaneously in the course of five or six weeks ; but
in all cases, so long as complete anaesthesia lasts, it is a very dangerous
affection.
Treatment consists, in the fii^st place, in special care in feeding the
patient. In all forms in which anaesthesia is bilateral, food must be given
by means of the oesophageal tube only, or by enema. Great care should
be observed in introducing the tube, and it should lie guided by the fore-
finger of the left hand lest it enter the open and anaesthetic glottis without
producing cough. To be quite certain that the tube is in the correct
position, the patient should be told to speak a word or produce a sound
before the food is administered, as with the tube in the trachea phonaT
tion would be impossible.
Secondly, in those cases which are due to diphtheria, the faradic and
galvanic electric current should be applied with one pole to the anterior
Avail of the pyriform sinus, near which the superior laryngeal nerve runs;
and hypodermic injections of strychnine shovild be given. In syphilitic
disease of the central nervous system iodide of j)otassium and mercurial
inunctions are indicated.
Hyper.esthesia, Par^esthesia, and Neuralgia. ^ — Increased sensi-
tiveness of the laryngeal mucosa, tickling and pricking sensations or a
sense of a foreign body in the larynx, burning sensations, pressure, pain,
constriction, rawness, and other perverted sensations are commonly met
with in hysterical, hypochondriacal, or anaemic patients. Sometimes these
sensations are set up by an hypertrophied lingual tonsil impinging on the
epiglottis, by caseous masses in the tonsillar crypts, or by pharyngitis ; for
any source of irritation in the pharynx or rhino-pharynx is usually referred
subjectively to the larynx : in the majority of the purely neurotic cases,
however, the laryngeal symptoms are associated with similar sensations in
the pharynx (see Sensory Neuroses of the Pharynx, p. 7C1).
The result of laryngoscopic examination in these cases is generally
negative, or at most reveals an anaemic condition of the mucosa. Hyper-
a^sthesia is often a marked feature in gouty and rheumatic laryngitis ;
and a similar condition with perverted sensations is sometimes a pre-
monitory symptom of tuberculous disease of the lungs ; in all these
cases, if there be the slightest suspicion of a tuberculous proclivity,
the lungs should be examined by the physician. When associated with
central nerve affections, such as tabes, the occurrence of laryngeal crises
cS6o SYSTEM OF MEDICINE
and tho presence of abductor paresis and increased frequency of the pulse
should suiiKest their real natvue.
In these affections the indications are to improve the general
health by nervine and tonic remedies, sea-bathing, and the like. If
the pain be intermittent, and suggestive of neuralgia, quinine or croton-
chloral-hydrate may l)e given, and locally a menthol spray may be used.
Treatment, however, in these cases is generally most unsatisfactory, and
on no account should the patient become habituated to narcotics. (See
also Pharyngeal Sensory Neiu-oses, p. 761.)
III. — Laryngeal Manifestations of Chronic Diseases of the
Central Nervous System
In tabes dormJis the medulla oblongata is very often invaded ; and
among bulbar nerves the vago-accessory is by far the most frequently
attacked. Hence the laryngeal nerves are very frequently afiected.
The various conditions that may arise are : — (i.) Sensory disturbances,
such as anaesthesia, hyper^esthesia, partesthesia, and the various
abnormal sensations that precede or accompany laryngeal crises, such
as tickling, constriction, inclination to cough, and in some instances
anresthesia. (ii.) Incoordination of the laryngeal muscles or of the vocal
cords. The voice may be thick and jerky, or it may suddenly disappear
after a few words have been uttered, as in dysphonia spastica. On
attempted phonation, as observed by Krause, the cords may be suddenly
adducted, then remain for a short interval in the semi-adducted position,
and finally become adducted in the median line ; dvu'ing inspiration the
cords, after being strongly adducted, are suddenly abducted to an extreme
degree. Burger has drawn attention to the analogy between these
irregular movements of the vocal cords, on attempted phonation or
deep inspiration, and the ataxic movements of the lower extremities,
in which the voluntary movements are very irregularly accomplishcrl.
(iii.) Laryngeal crises are frequently present in locomotor ataxia,
particularly in its earlier stages, and may indeed constitute the
earliest manifestation of this disease. In a considerable proportion of
cases they are associated with abductor paresis, though they tend to
become less severe and less frequent as the paretic condition becomes
more marked. The onset of an attack is usually preceded by a sense of
tickling in the larynx, with tendency to cough, quickly followed by a
sense of constriction and dyspnoea due to the spasmodic closure of the
glottis. A succession of abrupt coughs, resembling Avhooping- cough,
continue till the patient feels almost asphyxiated ; and are followed by
inability to inspire, or by a long-drawn whoop, during Avhich air is drawn
into the chest with very great diiiiculty. The wliole attack may last but
a quarter of a minute, or may persist for five or ten minutes. Death
from asphyxia is unusual but is not unknown. In some cases the laryngeal
crises are attended by sneezing, vomiting, vertigo, pains in the chest and
DISEASES OF THE LARYNX 86i
limbs, or even by general convulsions and loss of consciousness, (iv.)
Paralysis, usually of the abductors of the cords, unilateral and bilateral.
The symptoms of abductor paralysis are described on p. 853.
After abductor paralysis has lasted for some time it may be followed
by adductor paralysis ; but it should be noted that aljductor paralysis may
be the lirst, and for a long time the only demonstrable sign of tabes, and
that adductor paralysis may not appear until the abductor paralysis has
for many years been associated with the supervention of many definite
symptoms of tabes. Thus one of us (F. S.) has met with a case in which
the abductor paralysis had existed twelve years at least, and yet, though
paralysis of the internal tensors — the thyro-arytsenoidei — had occurred,
the adductors were still unaffected. (The internal tensors, as already
mentioned, are the muscles next in order to the abductors to succumb to
progressive organic disease.)
In tabes, in association with abductor paresis, the jiulse rate is very
often persistently accelerated. This is due to the fact that the inhibitory
nerve of the heart, like the motor nerves of the lai-ynx, is derived from
the accessory nucleus.
No necessary connection appears to exist between crises and paralysis.
In a number of cases unilateral or bilateral palsy of the abductors, or
complete recurrent palsy, are met with without any previous crises ; in
a second series no paralysis ensues, even after occurrence of frequent and
severe crises ; whilst in a third series both spastic and paralytic pheno-
m-ena coincide in the same case. Should palsies occur, the law
of the greater vulnerability of the abductors holds good. The spastic
phenomena are probably due to an increased irritability of the adductor
centres (F. S.). A peripheral stimulus conducted along the centri-
petal fibres of the superior laryngeal to those centres which, accord-
ing to this hypothesis, are in a condition of increased irritaliility, does
not set up a mere cough, as under normal conditions, but spas-
modic coughing, spasm of the glottis, general convulsions, in short
"a crisis." It also explains the influence of cocaine applications upon
the larynx in laryngeal crises. The course of these palsies is generally
slow and progressive, and the prognosis always unfavourable. The spas-
modic attacks vary greatly in frequency. They may occur but two or
three times in the course of years, or they may occur daily, or even two
or three times a day. In some cases they occur spontaneously ; they may
come on suddenly during sleep, or they may be set up by slight forms of
irritation, such as coughing, swallowing food or cold fluids, or on slight
exertion.
In patients subject to laryngeal crises it is most important to observe
the greatest caution in taking food. As a laryngeal crisis may come on
suddenly, food should always be minced, lest a mass become impacted in
the glottis and drawn in during the long inspiration ; although the initial
phase of coughing, if it occurs, would be a safeguard to the patient. All
sources of local irritation, such as the ingestion of cold or very hot food,
should be avoided, A cocaine spray or a solution applied to the larynx
862 SYSTEM OF MEDICINE
■will often cut short ;in attack or a series of attacks ; and one of us (W. W.)
has seen marked relief from the inhalation of nitrite of aniyl.
In labio-glosso-lari/ngeal paralysis anaesthesia of the larynx has heen
observed, l)ut laryngeal crises are almost unknown. In several cases
Aveakncss of the glottis -openers has been noted. One of us (W. W.)
observed bilateral })aralysis of the internal tensors alone, without any
abductor paresis ; although the other usual features in the tongue and soft
palate were well marked. Permewan has observed complete recurrent
paralysis within nine months of the commencement of abductor i)aresis.
In dissciiaiKited cerebro-spiind sclerosis, laryngeal paralysis is very rare.
One of us (W. W.) has observed tremor of the vocal cords on phonation,
and coarse tremor on abduction. The slow monotonous tone, with jerky
voice and scanning sj^eech, is an early feature in most cases.
In sijrin'jiimijelki both motor and sensory lesions, either unilateral or
bilateral, are often present in the larynx; particularly the latter. Cartaz,
analysing eighteen cases observed by French laryngologists, found that
the larynx Avas involved in al)out 50 per cent of the cases. In some
there was diminished tactile sensation in the larynx, amounting in a few
to total anaesthesia ; in others thermic sensation alone was aftected.
Palsies of the muscles supplied by the recurrent laryngeal nerves have
also been observed, the al)ductors failing first. In total paralysis of
long standing the vocal cord or cords arc said to become atrojihied.
Laryngeal crises do not appear to have been observed.
In general paralysis of the insane, Permewan concluded, from an examina-
tion of thirty-four cases, that in at least 20 per cent there is more or less
marked abductor paresis. His observations again confirmed the general
truth of the law laid down by one of us (F. S.) as to the special liability
of the abductors. to succumb in organic disease.
Felix Semon.
Watson AYilliams.
REFERENCES
1. BoswoRTH, F. Diseases of the Nose and Tltroat. New York, 1S97. — 2. Brain,
Earts lix.-lx., 1892. — 3. Burger. Die laryngcalcn Storungen dcr Tabes Dorsalis.
,eiden, 1891.— 1. Chappell, W. F. Amer. Med. Sunj. Bull. Jan. 18, 1896.— -5.
CliiAUi and RlEHL. "Lupus des Keblkopl'er," Vierteljahrcssclirift fur Dermal, und
Sypli. Wien, 1882. — 6. Delavan, Bkyson. "Recent Advances in tlie Siir<,'ical
Treatment of Malignant Disease of tiie Larynx," Trans. Aincr. Lari/ny. Assoc. 1896.
— 7. French, T. R. "Laryngeal and Post- nasal Pliotograiiliy," Trans. Amcr.
Laryng. Assoc. 1896. — 8. Guttsteix. Die Kranklieitcn dcr Kehllarpfcr. Leipzig and
Wien, 1888. — 9. Internationales Ctintralblatt fiir Laryngologic, etc., vols. v. vi.,
1888-89. — 10. KiRSTEiN. Autoscojnj of tlie Larynx and Trachea, 1897. — 11.
Kui.sUAiiER. " La Pathologic de la Plitliisie Larj-ngee," Trans, of the Internal.
Mnl. Jour. 1881, London, p. 208. — 12. ^Iacken'ZIE, jMcUiell. Diseases of the Thrmt
and Nose, vol. ii. London, 1>84. — 1;5. JI'Bkide. Diseases of the I'hroat, Nose, and
Eur. Etlinburgh, 2nd ed. — 14. Newman, D. Malignant Diseases of the Throat
ami Nose. Edinburgh, 1892. — 15. I'erichondritis of tiie Larynx, a Discussion on,
at the Brit. Med. Assoc. Meeting at Leeds, 1889, Brit. Med. Jour. 1889, vol. ii. p.
588. — 16. PrzedroPiSKI. " Ueber Lahniungen der Keblkojifniuskeln beini Uiitirleibs
und Flecktyphus," Sommlvng klin. Fort. Lciiizig, 1897, No. 182. — IJ. Saai.i'ei.d.
"Ueber die sogenauutc Pliaryngitis granulosa," Arch, pathol. Anut. etc. Berlin,
DISEASES OF THE LARYNX 863
1880, Ixxxii. p. 147 ct scq. — 18. Schrottek. Bchandlung dcr Larynx-stcnosen. Wien,
1876. — 19. Semon, Felix. "Die Nerveii Krankheiten in Larynx und Trachea,"
Heyman's Handbuclt dcr Kranklieitcn des Halser und' der Nasc. Berlin, 1897.
[In the Press.] — 20. Idhti. "On Mechanical Impairments of the Functions of the
Crico - Arytcenoid Articulation, with remarks on Pericliondritis of the Laryngeal
Cartilages," 3Ld. Times and Gazette, vol. ii. 1880. — 21. Idem. "The Radical
Operation for Malignant Disease of the Larynx," Lancet, Dec. 15, 22, 29, 1894. — 22.
Idem.. " The Study of Laryngeal Paralysis since the Introduction of the Laryngoscope,"
Brain, 1892. — 2;J. Semon, Felix, and IIorsley, Victor. "An Experimental Iil-
vestigation of the Central Motor Innervation of the Larynx," Phil. Trans, of the Loyal
Society, voL clxxxi. (1890), pp. 187-211. — 24. By the same Authors. On an a-p-
parently Peripheral and Differential Action of Ether upon the Laningca.l Muscles.
1886.— 25. Simpson, W. K. H. " The Sequelae of Syphilis in the Pharynx and their
Treatment," Trans. Amer. Laryng. Assoc. 1896. — 26. So.ta, de la. Burnett's
System,, vol. ii. p. 4-36 ct scq. — 27. Idem. " Lu]ius and Le])rous Laryngitis,"
Burnett's System, 1893, vol. ii. — 28. I'rans. Pathol. Soc. of London, vol. xlii. p. 37;
vol. xliv. p. 26. — 29. Turner, W. Aldren. " The Central Connections and Relations
of the Trigeminal, Facial, Glosso - Pharyngeal, Vago- Accessory, and Hypoglossal
Nerves," Joitr. of Anatoni. and Physiol. 1895, vol. xxix. pt. i. p. 1. — 30. Watson
Williams, P. Diseases of the Upper Respiratory Tract; the Nose, Pharynx, and
Larynx. Bristol, 1897.
F. S.
w. w.
LIST OF AUTHORITIES
Abelmattn, 270
Abelous, 541 et seq.
Abercronibie, J., 101, 446
Aberle, 342
Abram, 312
Adami, 529
Addison, T., 326, 540 et seq.
Afanassiew, 61
Affleck, 571
Ahlfeld, 345
Albarran, 341
Albers-Schoiiberg, 339
Albrecht, 527
Alexais, 541
Allbntt, T. C, 383, 595, 599
Allchiu, 547
Althaus, 347, 700
Ames, 208
Anderson, 257
Andral, 56
Audrewes, 541
Annesley, 130
Apolant, 345
Arnaud, 541
Ashby, 260
Attlee, 567
Aubert, 252
Auld, 58, 636
Baker, M., 608
Balfour, 14
Ball, J. B., 537
Ballance, 517
Baly, W., 141
Bamberger, 56, 117, 640
Ban.Uer, 693
Banting, 616
Baratoux, 705
Barbacci, 217
Bardach, 521
Bartels, 343
Bartbolinns, 339
Basedow, 497
Batten, F. E., 598
Baudoin, 345
Baumann, 468
Baylis, 581
Beevor, C, 760
VOL. IV
Becher, 270
Becquet, 343
Begbie, W., 496
Bennett, W. H., 233
Bernard, Claude, 8, 44, 360, 625
i Berry, 344
Bertrand, 144
Bichat, 184
Bidder, 32
Bigg, 347
Biggs, G. P., 220, 527
BiUroth, 573, 691
Bindley, 342
Binet, 15
Binz, 356, 793
Birch, 217
Birch-Hirschfeld, 145, 259
Birkett, 455
Bizzozero, 523
Block, 210
Boas, 273
Boccher, 486
Boerhaave, 55
Boinet, 555
Bonfils, 573
Bonnecken, 217
Bosworth, 675
Botkin, 172
Bottazzi, 523
Bouchard, 45, 330, 617, 646
Bouchut, 258
Bouisson, 255
Bourredi, 546
Bramwell, Byrom, 555, 565
Braun, 103
Bright, 101, 200, 390
Bristowe, 55, 180
Brockbank, 234
Brodie, B., 648
Brodowski, 97
Brown, M., 339
Brown -Sequard, 551, 646
Browne, John, 599
Bruhl, 523
Bruns, 785
Brunton, Lauder, 37, 65, 242
Bryant, T., 128
Br y don, 139
3r
S66
SYSTEM OF MEDICINE
Buchanan, 217
Build, 55, 105, 127, 164
Buhl, 101
liiirger, S60
Buwhan, 489
Buschke, 770
Busk. G., 101, 130
Butlin, 754, 839
Campbell, A. D., 255
C.ipparelli, 272
Carboiie, 563
Carniichael, 643
Cartaz. 862
Carter, B., 390
Carter, V., 396
Car^-ille, 105
Cattane, 522
Cavlev, H., 140
Cayley, W., 110
Ceccherelli, 348
Chamney, Sophia, 343
Chainpuevs, 343
Chappell,' W. F., 806
Charcot, 35, 172, 217, 249, 489, 850
Chauffarel, 70, 137
Chauffaud, 562
Chauveau, 658
Cheadle, 506
Cheval, 819
Cheyue, W., 101, 605
Chiari, 0., 754, 833
Church, 115
Clark, Andrew, 342, 524, 848
Clark, Bruce, 340
Clutton, 486
Coats, J., 210
Coelius Aurelianus, 607
Cohen, Solis, 852
Cohnheim, 260, 324, 534, 573, 630, 645
Cole. 345
Collier, W., 538
Con well, 135
Copeman, 14, 71, 526
Coppola, 646
Cordone, 560
Cornil, 117, 183, 568, 573, 598, 770
Cossy, 573
Councilman, 153
Coupland, 418, 523, 577
Courbis, 452
Coiirniont, 760
Courvoisier, 223, 249
Cowley, 262, 269
Craigie, 573
Creed, 106
Crum. 340
Cruse, 259
Cruveilhier, 132, 343
Cullen, 53
Culliugworth, 110
Cunningham, D. J., 340
Curling, 475
Curschmann, 343
Dance, 130
Daranyi, 343
d'Ar.sonval, 646
Davidson, 707
Debove, 538
Defontaine, 343
Dcjerine, 842
De la Sota, 804
Delbet, 588
Delepine, 210, 536, 544
Dickinson, W. H., 345, 357 [note), 442, 452
Dietl, 341
Dieulafoy, 770
Dinochowski, 598
Divel, 489
Dmochowski, 745
Domiuici, 218
Dominicis, de, 269
Donkin, 213, 537
Dor, 842
Dora, 344
Dowson. W., 770
Drago, 136
Draper, 262
Dreschfeld, 87, 113, 489, 574
Drumnioud, 341
Drysdale, J. H., 736 (note)
Ducamp, 97
Duckworth, D., 104
Dumreicher, 349 (note)
Duuin, 97
Durante, 272
Durham, A.. 342
Dusch, von, 77, 104
Ebstein, 93, 316, 345, 617
Eccles, S., 345
Edebohls, 344
Edmunds, W., 466, 502
Ehrle, 105
Ehrlich, 578
Eiffelinann, 19
Eisenberg, 347
EUinger, 347
Elliot, 266
Englisch, 339
Epstein, 260
Erichsen, 691
Escherich, 217
Euleuburg, 489
Euricli, 570
Ewald, 342
Exnor, 841
Fagge, C. Hilton, 55, 119, 205, 212, 556
Farquharsoii, 646
Fayrer, 10
Feuger, 239, 249
Ferber, 343
Fcrcol, 577
Ferguson, J., 344
Fetzer, von, 99
LIST OF A UTHORITIES
867
Fiedler, 97
Filehne, 27, 504
Fischer-Benzon, 346
Fitz, 562
Fleiner, 546
Fleischl, 75
Flexiier, 520
Flint, A., 655
Fliigge, 145
Foerster, 101
Foster, M., 611
Fotheringhani, 456
Fournier, 792
Fourrier, 343
Fox, T. C, 537
Foxwell, 640
Fraenkel, B., 90, 99, 643, 705, 817, 849
Fraucis, 649
Franks, W. K., 340
Fraser, T. R., 596
Frerichs, 21 et seq., 53, 101, 204, 260
Freund, 257
Frisch, 693
Fritz, 345
Gabbi, 526
Gad, 845
Gairdner, 45
Galen, 52
G allot, 106
Gamgee, 17, 110
Giirel, 842
G.irrod, A. B., 316
Garrod, A. E., 28, 45, 69, 286, 528
Gaucher, 538
Gautier, 646
Gee, 536
Generali, 466
Geoffredi, 554
Geppart, 643
Gerliardt, 537
Gibbons, R. A., 444
Gibson. G. A., 647
Giese, 257
Gilbert, 36, 172, 216, 273
Gilewski, 345
Gilford, 341
Gilmore, 348
Girard, 340
Girode, 36, 217
Glaister, 256
Glass, 17
Glenard, 342
Glisson, 56
Globig, 97
Glynn, 111
Goldmann, 91
Gombault, 172, 217, 256
Goodhart, 103, 244, 503
Gottlieb, 270
Gottstein. 762
Gougenbeim, 705
Gowers, W. R., 500, 574 et seq., 843
Grabower, 841
Grandidier, 257
Grasset, 342
Graves, 85, 105, 138
Gray, 850
Greenfield, 210, 502
Greenhow, H., 541 et seq.
Griesiuger, 99, 573
Grossmann, 841
Grlitzner, 843
Guarescbi, 646
Gubler, 55
Giiillet, 446
Gull, W. W., 382, 467, 471
Gulland, 581
Guthrie, 125
Guttmann, 346
Guye, 717
Guyon, 343
Haas, 97
Hal)ershon, S. 0., 77
Hack, 690
Haddon, W. B., 545
Hager, 348
Hahn, 348
Hajek, 676
Halberstam, 259
Haldane, 644
Hall, M., 648
Halle, 438
Halliburton, 33
Hamilton, D. J., 538
Hankin, 521
Hanot, 172, 562
Hansemann, 270
Hardie, 106
Hare, C. J., 345
Harley, G., 55, 244, 548
Harley, V., 75, 645
Hartmann, 273, 705
Haspel, 139
Haughton, S., 338
Haward, J. W, 341
Hayem, 30, 70, 184
Hayward, 104
Head, H., 198
Hebra, 692
Heffter, 91
Heidenhain, 78, 324
Heinze, 796
Heitler, 99
Henderson, 340
Henoch, 343, 44-1. 537
Herczel, 348
Herringham, 276
Hertz, 343
Heryng, 683
Hessler, 88
Heymann, 390
Hickinbotham, 345
Hicks, 840
Hilbert, 341
868
SYSTEM OF MEDICINE
476, 486, 720, 760, 841
224
Hildebrand, 265
Hiliier, 361
Hillis, 804
Hipiioi rates, 661
Hirsch, 134
Hirschspning, 341
Hodgkin, 573
Hofmeier, 259
Hofnieister, 259
Ho£;l>en, 537
Hoiil. 339
Holl, 349 [note)
Holmes, 458
Holsti, 210
Holt, 258
Holzniann, 272
Hooper, 845
Hopkins, G., 28, 69
Hoppe-Seyler, 69
Horba<;ze\vski, 13
Horsley, V.. 467,
Hotchkiss, L. W
Howard, 648
Howitz, 340
Huebe, 97
Hunter, J., 705
Hunter, W., 65, 111, 256, 523 et seq.
Hu^chke. 468
Hutchison, K., 469
Israel, 340 [note), 447
Jaboclat, 508
Jaccoud, 252, 549
Jackson, H., 760
Jacques, 37
Jacquet, 645
Jaeger, 97
Jale, 69
Jago, 341
Jakscb, von, 72
Jeniier, \V., 86, 99, 197, 340, 458, 537, 577,
635
Johnson, George, 853
Jolly, 527
Jones, H., 101
Jones, S., 826
Jonnesco, 520
Jordan, Max, 737
Jounlanet, 137
Jurgens, 546
Kahlden, von, 546
Kanth.-ick, 522, 579, 736, 738
Kartulis, 144, 153
Keen, 348
Kehrer, 260
Kelsch, 46, 127, 171, 187
Kelynack, 193, 531
Ki-pj.ler, 341, 348
Kidd, 344
Kic-ner, 46, 127, 171, 187
Kirstein, 784
KLshkin, 244
Klebs, 268
Klein, 172, 519
Koch, 113, 598
Koclier, 227, 475
Koranyi, von, 343
Korolkow, 5
Korte, 267
Kotliar, 37
Krause, 468. 676, 841, 860
Krisliaber, 751, 833
Krueckmann, 598, 745
Kruse, 153
Kiihne, 54
Kunde, 59
Kundrat, 754
Kimkel, 70
Knpfer, 5
Kuster. 343
Kuttner, 340, 537
Laborde, 650
Lalwulbene, 598
Lack, L.. 830
Laeunec, 170
Larteur, 153
Lake, 220
Lancaster, Le Cronier, 394
Lancereaux, 262, 343
Landau, 339 et seq.
Lane, A., 223
Lange, 349 (note)
Langenbuch, 349
Langerhans, 265
Lauglois. hi\ et seq.
Larrey, 138
Latliam, A., 527
Laudenbach, 517
Lebert, 101, 276
Le Deutu, 348, 440
Legendre, P., 607
Legg, W., 55 et seq., 101, 172, 210, 256
Lehmann, 645
Leichteustern, 194
Leith, 571
Leidiarz, 346
Le Ray, 343
Letulle, 570
Leube, 295
Lewaschew, 16
Lewin, 104, 544, 807
Leyden, 54
Lielitlieim, 271, 641 {note)
Liebermeister, 56, 99, 101 et seq.
Liebreich, 391
Lieutaud, 235
Lindner, 346
Lister, 507
Littcn, 346, 533
Lloy.l, 272, 348
Lochhead, 344
Lockwood, C. B.,
Loe\venl)erg, 676
Louis, 130
217
LIST OF A UTHORITIES
869
Lowit, 57
Lowsou, 349
LuLarscli, 571
Liicas, E. C, 345
Liidwig, 75
LuflF, 13, 316
Luys, 184
M'Bride, 705, 850
M'Cosh, 348
Macfadyen, 144
Maclean, 138
Mackenzie, H., 477, 486
Mackenzie, M., 751, 804, 855
Mackenzie, S., 468
Mackeru, G., 806
MacMunn, 28, 69, 286, 552
Macnamara, F. N., 144
Macnaught, 135
M'Weeney, 571
Malpighi, 573
Maly, 69
Manasse, 570
Manassein, 343
Mann, J. D., 548
Marcet, 637
Marie, P., 499
Markhani, 503
Marsh, 101
Marston, 129, 141
Martin, E., 650
Martin, Ranald, 138
Martin, S., 519
Massei, 715
Mathieu, 341
Meinert, 114
Mentouri, 521
Mering, von, 262, 269
Meriwether, 348
Mesne, 342
Metschnikoff, 521
Meyer, 27
Meyer, Wilhelm, 714
Michel, 675
Mikulicz, 349
Minkowski, 57, 262, 269
Minuich, 271
Mirallie, 276
Mitchell, Weir, 617
Mcibius, 493 e.t seq.
Moleschott, 59
Moore, 113
Moore, N., 538, 572
Moore, W. 0., 499
Morehead, 127
Morgagni, 55, 101
Morris, H., 341, 571
Mosler, 342, 574
Mosso, 646
Mott, F. W., 557
Moure, 807
Moxon, 56 et seq., 215, 411, 445
Miihlmann, 555
Muir, R., 578
Miiller, 28, 69, 574, 643
Muller, P., 500
Miiller-Warueck, 343
Muuk, 467
Mlinzer, 72 et seq., 90
Murchison, 5 et seq., 55, 64, 99, 119, 206,
212, 574
Murray, G., 477, 486
Musser, 163, 230
Mussy, Gueueau de, 343
Naunyn, 32 et seq., 57, 217, 452
Nauwerck, 97
Netter, 145, 216
Neumann, 58 -
Neumeister, 17
Newman, D., 340 et seq.
Niehans, 341
Niemeyer, 141, 574
Nissen, 15
Norton, 221
Nothuagel, 552
Notta, 538
Obratzow, 587
O'Brien, 101
O'Dwyer, J., 820
Oertel, 611
Oesterreicher, 489
Oestreich, 566
Oliver, G., 541 et seq.
Oppeuheimer, 345
Ord, W. M., 239
Orlandi, 521
Orth, 145, 568
Oser, 341
Osier, 153, 185, 223, 249, 267, 541 et seq., 576
Ozanam, 101
Paget, J., 577, 608
Paget, S., 535
Pausini, 154
PaiTot, 259
Pasquale, 153
Paton, N., 14
Paul, F. T., 502
Paw, 573
Payne, F., 692
Peiper, 37
Peltesohn, 793
Peremeschko, 538
Perls, 332, 345
Permewan, 862
Pernice, 345
Peter, 598
Pfliiger, 5
Pfulil, 97
Phear, 564
Phillipeaux, 548
Phillips, S., 535
Picon, 538
Pilliet, 520
870
SYSTEM OF MEDICINE
Piutlierle, 113
Piseuti, 19
Pitt, G. N., 847
Pitts, 517, 769
Pohl, 14, 440
Politzer, 103
Polk, 348
Porak, 258
Portal, 235
Potain, 223
Power, DArcy, 599
Prevost, 15
Price, J. A. P., 531
Priestley, W. 0., 340
Prince, 262
Prout, 442
Pye-Smith, 208, 272, 394
Quincke, 69, 260
Rake, Beavan, 563
Ralfe, 110
Ramond, 538
Ranvier, 068, 573
Raugt's 842
Rauzier, 342
Raver, 436, 454
Reclus, 5<t5
Reigner, 517
Reil, 52
Reiueboth, 349
Renzi, de, 349
Reverdin, 475
Richardson, 272
Riedel, 230, 349
Riess, 71
Righi, 522
Rindrteisch, 687
Ringer, 564
Rivington, W., 767
Roberts, W.. 327, 340, 446, 454, 647
Robin, 259, 448
Robinson, 345
Robinson, A. H., 546
Robson, Mayo, 14
Roger, 37, 256
Rokitansky, 77, 101
Rolleston, 208
Rollet, 342
Roos, 468
Rosenbacli, 124
Rosenberg, 16
Rosenstein, 345, 411
Rosenthal, 640
Ross, 103
Rouis, 137
Ruge, 598
Range, 258
Russell, Kisien, 842
Rutherford, W., 16, 76
Sachs, 151
Salkowski, 295
Salzer, 273
Sanderson, J. B., 574, 641
Sandstriiin, 465
Sandwitli, F. M., 135
Saunders, 52
Sawyer, 343
Schadewaldt, 762
Schiifer, E. A., 541 et seq.
Schatz, 338
Schech, 705
Schiff, 26, 76, 466
Schlenker, 770
Schmi<lt, 27
Schmidt, H., 391
Schmidt. M., 705
Schniiedeberg, 60
Schmorl, 570
Schnitzler, 849
Schottiu, 332
Schroeder, 72, 234
Schueppel, 197, 205
Schultz, 582
Schultzen, 71
Schunk, 285
Schweiniger, 617
Scot-Skirviug, 106
Scudamore, 45
Sedillot, 126
Seeligmann, 702
Segre, 276
Semmola, 547
Senion, F., 692. 841
Senator, 46, 341, 743
Sendziak, 770
Sharp, G., 583
Shattock, S. G., 452, 530, 826
Sherrington, 36, 843
Shield, 221
Sibson, 5
Silbermann, 66, 260
Simon, J., 466
Siredey, 342
Sisley, 536
Skodii, 657
SkarcZL-wsky, 341
Smith, 347
Smith, Angus, 646
Smith, Eustace, 716
Smith, F. L., 645
Smith, Lorrain, 644
Sokolo\vski. 770
Solbrig. 499
Soniinerbrodt, 800
Sondakewitch, 521
Spaeth, 103
Spencer, H., 532
Spencer, W. G., 841
S])ender, J. K., 544
Sjjicer, Scanes, 830
Stadelmaini, 15, 60 et seq. 256
Starck, von, 537
Starling, 72, 91
Starr, A., 508
LIST OF AUTHORITIES
871
Steiner, 65, 341
Stengel, 585
Stern, 58
Steven, J. L., 340, 590'
Stewart, T. Grainger, 411
Stewart, W. R. H., 852
Stifler, 347
Stiles, H. J., 581, 605
Still, 536
Stiller, 346
Stilling, 551
Stirl, 97
Stockman, 524
Stoehr, P., 769
Stokes, W., 349
Stone, W. H., 665
Strassmann, 598, 745
Stroganow, 643
Striibing, 794
Suclianuek, 770
Sucklin-, 113
Sulzer, 349
Sumbera, 97
Sutton, H. G., 382
Sutton, Bland, 527
Swain, W. P., 223
Sylvester, 648
Tait, L., 227
Tarcliauotf, 65
Terrier, 232, 252, 345
Thayer, W. S., 268, 563
Thierfelder, 77, 102, 128
Thiroloix, 549
Thornton, J. K., 532
Thudichum, 28, 236, 285, 559
Tictine, 521
Tiedeman, 646
Tillniauns, 348
Tinno, 554
Tissier, 675
Tivy, 208
Tizzoni, 522, 546
Trafoyer, 267
Traube, 329-427
Trelat, 348
Treves, 342
Triomi, 348
Tripe, 356
Trousseau, 56, 125, 420, 486, 495, 540, 573
Toeiiiessen, 643
Tomkins, 113
Tornwaldt, 713
Tuffier, 339
Tiirck, 390
Turner, F. C. , 537
Udranezky, 287
Urag, 342
Valentin, 646
Van der Lee, 348
Vassale, 466
Vedrenes, 125
Velpeau, 573
Venn, 103
Verneuil, 594
Vignal, 76, 147
Vigouroux, 495
Villemin, 544
Villeueuve, 77
Virchow, 54, 103, 260, 343, 390, 448, 486,
569, 573, 688, 751, 790
VoltoUni, 698
Wagneb, p., 99, 102, 340, 562
Wain Wright, W. L., 542
Walker, T. J., 262
Walshaiii, H., 598
Walther, 349
Waring, E. J., 140
Washbourn, 518
Wassilieff, 99
Watson, T. , 56
Weber, 260
Wegner, 391
Weichselbaum, 538, 709
Weil, 95
Weisker. 338 el seq.
Weiss, 97
Weissgerber, 345
Welch, 172, 265, 529, 563
Wells, Spencer, 446
Wertheimer, 27
West, 87
West, C, 362
West, S., 557
White, E., 468
White, F. F., 344
White, Hale, 177, 218, 500, 546
Whitney, 265
Wilks, S., 341, 452, 486, 496, 535, 540
et seq., 573
Willard, 220
Williams, M., 221
Williams, R., 571
Williamson, R. T., 269, 501
Willigk, 276
Winston, 14
Woakes, 708
Wunderlieh, 102, 573
Wyss, Oscar, 93
Wyssokowitsch, 145
Yeoman, 103
Zaufal, 675
Zeissl, 811
Zenker, 262
Ziem, 705
Ziemssen, von, 539
Zuckerkandl, 705
Zuntz, 645
INDEX
Abductor and adductor muscles, difference
between, 843
Abscesses, of liver, 153 ; of spleen, 53-i ;
perinephric, 417 ; renal, 427
Acanthosis nigricans, 562
Accessory suprarenal bodies, tumours in,
570
Acetonemia in Graves' disease, 496
Acetone in urine, tests for, 312
Acromegaly, larynx in, 806
Acute catarrhal pharyngitis, 725
Acute yellow atrophy of the liver, 101 ; age
in, 102 ; bibliography. 117 ; duration,
111 ; etiology, 102 ; history, 101 ; mor-
bid anatomy, 112 ; nature of the jaundice,
116; pathogeny, 114; sex in, 103;
symptoiijs, 106
Addison's disease, 540 ; bibliography, 566 ;
course, 560 ; diagnosis, 561 ; duration,
560 ; etiology, 541 ; history, 540 ; morbid
anatomy, 542, 550 ; nervous theory, 548 ;
onset, 555 ; pathology, 548 ; prognosis,
561 ; symptoms, 556 ; termination, 561 ;
theory of auto-intoxication, 552 ; theory
of inadequate secretion, 553, 555 ; theory
of suprarenal inadequacy, 550 ; treatment,
564; "without symptoms," 544
Adenoid growths, see Pharyngeal tonsil, 714 ;
hypertrophy of, 714
Adenoid tissue, 586
Adenoma of the fauces, 752 ; of the liver,
210 ; of suprarenal bodies, 569
Adrenal tumours in the kidney, 448
J^^gophony, 665
Ague-like paroxysms in cholelithiasis, 239
Albuminuria, 300 ; causes, 302 ; in Graves'
disease, 497 ; of renal disease, 303 ; patho-
logical, 301 ; "physiological," 301 ;
quantitative estimation of, 307 ; tests,
304
Albuminuric enteritis, 385, 393
Albuminuric retinitis, 390
Albumosuria, 302
Alcohol, as cause of cirrhosis of the liver,
171 ; as cause of granular kidney, 377 ;
as cause of nephritis, 363
Alcoholic cirrhosis of the liver, 173 ; com-
plications, 186 ; multilobular form, 173 ;
course and prognosis, 180 ; morbid
anatomy, 173; symptoms, 176; uni-
lobular form, 181 ; morbid anatomy,
181
Alimentary system in Hodgkin's disease,
579, 584
Amcebic abscess of the liver, 153 ; bacterio-
logy, 153 ; bibliography, 169 ; diagnosis,
167 ; etiology, 153 ; lesious in the liver,
156 ; in the lung, 160 ; in the peritoneum,
161 ; pathological anatomy, 156 ; pro-
gnosis, 168 ; symptomatology, 161 ; treat-
ment, 169
Amphoric breathing, 664
Anaemia in Graves' disease, 496 ; in Hodg-
kin's disease, 578 ; in nephritis, 366 ; in
renal disease, 336 ; spleen in, 522
Anesthesia of the larynx, 858 ; pharynx,
761 ; treatment, 763
Angina Ludovici, 737
Angioma of the fauces, 752 ; of the larynx,
826; of the liver, 211
Angio-neurotic oedema, of larynx, 792
Anosmia, 695
Antrum, empyema of, 705
Arteries in renal disease, 333
Arterio-sclerotic, see Granular kidney, 373
Artificial respiration, 648
Ascites in cancer of the liver, 199, 207 ; in
perihepatitis, 120
Asphyxia, treatment of, 648
Asthenia in Addison's disease, 558
Asthma, 698
Atrophic pharyngitis, 728
Auscultation, 658
Autoscopy of the larjTix, 784
"Bacillus proteus fluorescens," 97
Bacterial infection, spleen in, 518, 520
" Bantingism," 616
Benign growths in the larj'nx, 824 ; causes,
824 ; malignant degeneration of, 828 ;
prognosis, 827 ; symptoms, 827 ; treat-
ment, 829
874
SYSTEM OF MEDICINE
Bile, "circulatiou of," 7G ; composition of,
14 ; coiulilions iuHueiicing aiiiount, 14 ;
diniinislied tlow, 18 ; iatliiencu of diugs
ou, If) ; intlueiice of fe\er on, IS ; in-
fluence of poisons on, 19 ; relation of
blood-pressure to secretion, 78
Bile acids, 32 ; tests, 33
Bile-ducts, congenital oliliteiation of, 253 ;
bibliography, 257 ; etiology. 25G ; morliid
anatomy, 254 ; nature and progress, 255 ;
symptoms, 253
Bile-ducts, diseases of, 211 ; bibliograpliy,
248, 257 ; catarrh, acute, 212 ; chronic,
215 ; infective, 249 ; suppurative, 218,
250 ; fistula and stricture, 222 ; primary
carcinoma, 208 ; tumours, 208, 226, 232;
ulceration, perl'oration, 220
Bile-ducts in alcoholic cirrliosis of tlie liver,
182 ; intrahepatic catanh of, 38, 64 ;
spasm of, 79
Bile passages, suppurative inflammation of,
216 ; bacteriology, 217
Bile pigments, excretion of, 22 ; ha?niato-
genous origin, 57 ; hepatic ori;^in, 58 ;
lessened formation, 27
qualitative
variations, 28 ; relation to urinary pig-
ments, 28
Bile salts, excretion of, 32
Biliary cirrhosis, 184; symptoms, 185
Biliousness, 21
Bilirubin cahuli. 30
Blood in llodgkiu's disease, 578 ; in
urreniia. 331
Blood sounds, 658
Bowel in granular kidney, 393
Brain in granular kidney, 31)0 ; in uraemia,
399
Breath sounds, conduction of, 661 : pro-
duction, 653, 659 ; in consolidation of
the lung, 663 ; in emphysem:i, 663
Bright's blindness in uneinia, 398
Bronchiectasis due to cough, 635
Bronchitis as result of renal disease, 393
Bryson's symiitom in Graves' disease, 496
Cachexia stnimipriva, 468
Calculi, biliary, sec Cholelithiasis, 234 ;
renal, 439
Calculous suppression, latent uraemia in, 327
Cancer, see \arions organs
Carcinoma of the fauces and pharjTix, 753 ;
diagnosis, 755 ; ]>rogiio>is 757 ; symp-
toms, 755 ; table of distinction from
other diseases of the pliarynx, 759 ;
treatment, 758
Carcinoma of the kidney, 447 ; pancreas,
276
Carcinoma of the larynx, 833
Carcinoma of the liver, primary, 204 ; age
in, 205 ; forms, 205 ; prognosis, 207 ; sex
in, 206 ; symptoms, 206 ; melanotic, 210
Car. Ho- vascular clianges in renal disease,
332, 367 ; causation of, 335
Cardio-vascular system in granular kidney,
387 ; in lardaceous kidney, 406
Casts, urinary, in lardaceous kidney, 407 ;
in nephritis, 369
Cavernous breathing, 664
Chancre of the fauces and pharynx, dis-
tinction from other diseases of the
pharynx, 759
Cheyne-Stokes breathing, 646
Chlorides in urine, 299
Chlorosis, spleen in, 524
Cholangitis, infective, 249 ; bibliography,
253 ; diagnosis, 249 ; etiology, 250 ; sup-
purative, 219
Cholecystitis, 214 ; acute phlegmonous, 223 ;
diagnosis from appendicitis, 225
Cholelithiasis, see Gall-stones, 34, 234 ; dia-
gnosis from chronic cholecystitis, 214
Cholesterin, excretion of, 34
Choluri.a, 290
Chonlitis tuberosa, 832
Circulation, disturbances of, in Graves' dis-
ease, 493
Circulatory system in Hodgkin's disease, 578
Cirrhosis of the liver, 170 ; alcoholic. 173 ;
bibliography, 193 ; biliary, 184 ; etiology,
170; general considerations, 170; m.'ila-
rial, 187 ; pericellular, 190 ; syphilitic,
188 ; treatment, 191
Cirrhosis of kidney, 373 ; see Granular
kidney ; of jiancreas, 268
Climate in congestion of the liver, 46 ; in
renal disease, 402
Cold as cause of nephritis, 359
Colic, biliary, 237 ; renal, 441
Collapse in cholelithiasis, 238
Condyloma of the larynx, 807
Coryza cedematosa, 701
Cough, barking, of puberty, 848
Coughing, 630 ; eti'ects of, in different dis-
eases, 634 ; mechanism of, 631 ; more
remote consequences, 637
"Cracked pot" sound, 657
Crei)itations, 665
Cretinism, sporadic, 484 .
Crico-arytienoiil joint, diseases of 817;
diagnosis, 818 ; symptoms, 817 ; treat-
ment, 819
Cyanosis, 643
Cystin and cystinuria, 298
Cystoma of the larynx, 826
Cysts of the jjancreas, 272 ; of kidney, 450 ;
liver, 211
Deafness in adenoids of naso-pharynx, 717,
722
Diabetes as cause of nephritis, 360
Dialietes mellitus, liver in, 46
Diacetic acid in urine, 313
Diarrlio-a in cirrhosis of liver, 192 ; in lard-
aceous kidney, 405
Dietary in obesity, 618
Dietl's crises, 344
INDEX
875
Digestive system iu Graves' disease, 497
Dilatation of the stomach ia nephroptosis,
346
Dipbtlieria as canse of nephritis, 362
Di.ssemiuatcd sclerosis, vocal cords in, 862
Dropsy, iu granular kidney, 383 ; in lard-
aceous kidney, 405 ; in nephritis, 364
Dropsy, renal, pathology of, 320 ; causation,
322 ; experimental, 324
Ductless glands, diseases of, 465
Dysentery, relation to sujapurative hepatitis,
"140
Dysphouia spastica, 849
Dyspnoea, 638 ; compensatory actions in,
642 ; degrees iii ditt'erent diseases, 638 ;
effects, 640
EccHONDROMA of the larynx, 826
Eclauipsia, blood in, 331
Emaciation in Graves' disease, 495
Emphysema due to cough, 635
Empyema of the antrum, 705
Eudocarditis in lardaceous kidney, 408
Enteric fevei-, throat allections olj 736
Epiglottiditis, acute, 787
Epistaxis, 680 ; in Graves' disease, 496
Excretion by liver of bile acids, 32 ; of bile
pigments, 22 ; of bile salts, 32 ; of choles-
terin, 34 ; of drugs ami poisons, 36 ; of
haemogloljin, 26 ; of water, 15
Exophthalmic goitre, .see Graves' disease, 489
Exophthalmos in Graves' disease, 492, 499
Fat, 610
Fauces, 725 ; growths of, 753 ; syphilis, 759
Fibroma of the fauces, 752 ; of larynx, 825
Floating kidney, see Nephroptosis, 338
Foreign bodies iu the air and upper food
passages, 764 ; treatment, 768
Francis' method of artificial respiration, 650
Gall-bladde", diseases of, 211; acute phleg-
monous cholecystitis and gangrene, 223 ;
bibliography, 248 ; cancer, 230 ; catarrh,
acute, 212: chronic, 214; suppurative,
216 ; catarrhal empyema, 218 ; gall-
stones, 234 ; primary carcinoma, 208 ;
tumours, 2u8, 226 ; ulceration, perforation,
fistula and stricture, 220
Gall-bladder, tumours of, 226 ; diagnosis,
229 ; etiology, 226 ; signs, 227
Gall-stones, 234 ; age in, 235 ; bibliography,
24S ; complications, 240 ; diagnosis, 240 ;
diagnosis from cancer of the liver, 203 ;
influence of diet on, 236 ; pathology and
etiology, 234 ; sex in, 236 ; symptoms^,
237 ; treatment, medical, 242 ; surgical, 245
Gastro-renal fistula, 416
General paralysis of the insane, abductor
paresis in, 862
Genito-urinary system in Hodgkin's disease,
580, 585
Glanders of the nose, 693
Glychocolic acid, 32
Glycogenesis. 11
Glycosuria, 308 ; tests, 311
Glycuronic acid in urine, 312
Goitre, exophthalmic, 489
Gout as cause of granular kidney, 377 ; and
obesity, 611
Gouty throat affections, 750
Granular kidney, 373 ; age in, 376 ; causes,
376 ; duration, 385 ; pathology, 373 ;
secondary changes, 387 ; sex in, 375 ;
svmptoms, 383 ; treatment, 401 ; uraemia,
395
Graves' disease, 489 ; bibliographj', 508 ;
death in, 500 ; etiology, 489 ; morbid
anatomy, 502 ; o)ierative treatment, 507 ;
pathology, 50 \ ; prognosis, 501 ; relapses,
500 ; result, table of, 501 ; symptoms,
491 ; treatment, 505 ; varieties, course
and duration, 499
Gumma of the larynx, 808
Gummata in syphilitic cirrhosis of liver, 188
H.EMATEMESis in cirrhosis of liver, 178, 192
Htemato]]orphyrin, 286, 290
Haiuiaturia, 288 ; in renal calculus, 441, 443
HsemoglobiuEemia and jaundice, 65
Haemoglobincholia, 27
Hfemogldbinuria, 289; and jaundice, 65
Hfemokatitonistic function of the spleen,
523, 525
Hsemorrhage, pancreatic, 262
HEemorrhages in phosplionis poisoning, 88
Hair in Graves' disease, 496
" Hay fever," 698
Headache in urjemia, 398
Heart in granular kidney, 387 ; in Hodgkin's
disease, 579, 585
Heart, physical signs of disease of, 652
" Hemaphein," 68
Hepato-pulmonary abscess, amoebir, 1 64
Hip disease, diagnosis from perinephritis,
419
Hodgkin's disease, 573 ; bibliography, 596 ;
diagnosis, 589 ; etiology, 574 ; history,
573 ; ordinary course, duration, and ter-
mination, 588 ; jiathogeny, 585 : patho-
logical anatomy, 580 ; prognosis, 592 ;
symptoms, 576 ; treatment, 592 ; varie-
ties 575
Howard's method of artificial respiration,
649
Humus pigments in urine, 286
Hydatid of kidney, 454 ; of the liver, dia-
gnosis from cancer, 203 ; of the spleen, 532
Hydrochinon, 291
Hydronephrosis, 430 ; congenital, 433 ;
diagnosis, 432 ; pathology, 431
Hypersesthesia of the larynx, 859 ; of the
pharynx, 761
Hyperosmia, 695
ICTfcRE bilipheique, 68 ; hemapheique, 67
876
SYSTEM OF MEDICINE
Icterus gravis, 81 ; see Acute yellow
atroiiliy, 101
Icterus neonatorum, 258 ; bililiography, 261 ;
etiology, 259 ; morbid anatomy, 259
Imlican, 287
InlliK'Uza, throat affections of, 736
luterniittent hepatic fever, 239, 249
Intestinal obstruftiou, diagnosis from acute
pancreatitis, 267
Intubation of larynx, 820
Jaundice, Yiy suppression, 67, 80 ; from
pigments other than bile, 68 ; absence of
bile from bile passages as evidence of
jaundice by suppression, 73 ; from changes
in metabolism, 71, 80
Jaundice by increased secretion, 74, 26
Jaundice febrile, 95 ; infectious, 95 ; hfema-
togeiious, 25, 54 ; ha;mohepatogeuous, 60 ;
malignant, 81 ; meustrual, 46 ; non-
obstructive, 83 (and see Toxeemic jaun-
dice) ; obstructive, 82 ; of phosphorus
poisoning, 87 ; of yellow^ fever, 93 ;
toxajinic, 82, 83 ; "urobilin," 69
Jaundice, general pathology of, 51 ; biblio-
graphy, 94 ; causes, 81 ; cause of the
obstruction in toxic, 62 ; factors in pro-
duction of, 57 ; Frerichs' hypothesis, 5:5 ;
Kiihne's hypothesis, 54 ; obstructive
nature of toxic, 61 ; relation to blood-
destruction, 64 ; summary of factors, 79 ;
suppression hypothesis, 55 ; theories, 52 ;
toxic, 60
Jaundice in cancer of the liver, 198, 206 ; in
cholelithiasis, 239; in hepatic cirrhosis,
179
Jaundice of phosphorus poisoning, 87 ; mor-
bid anatomy, 91 ; nature of, 92
Kidney, cysts of, 450 ; diagnosis, 453 ;
general cystic degeneration, 451 ; hyda-
tids of, 454 ; paranephric, 454 ; symp-
toms, 452 ; treatment, 453
Kidney, diseases of, characterised by albu-
minuria, 352 ; bibliography. 414 ; classiti-
cation, 352 ; granular kidney, 373 ;
lardaceous disease of kidney, 404 ; nei)h-
ritis, 353
Kidney, fatty, 353 ; large white, 355 ; mov-
Able, sec Nephrojitosis, 338 ; small white,
355 ; small red, sec Granular kidney, ;.73
Kidney, normal position of, 338 ; abnormal,
340
Kidney, tumours of, 445 ; adrenal, 448 ;
bibliography, 461; carcinoma, 4l7;
clinical characters, 449 ; diagnosis from
other tumours, 457 ; epithelioma, 448 ;
malignant disease, 446 ; method of ex-
amining, 45!) ; myxoma, 448 ; sarcoma,
446 ; j>ai)illoma, 448
Kidneys, the, 313 ; circulatory changes in
disease, 318 ; epithelial changes, 319 ;
excretion of water, 313 ; of salts, 315 ;
functions, 313 ; in perihe])atitis, 121 ;
metabolic activity, 317 ; physiological con-
siderations, 313 ; synthesis of some of the
constituents of urine, 316
Kreatinin, 296
Labio - glosso - laryngeal paralysis and
ana-sthesia of the larynx, 862
Lardaceous disease of kidney, 404 ; causes,
405 ; causes of death, table, 410 ; duration,
408 ; symptoms, 406 ; treatment, 412
Laryngeal manifestations of chronic diseases
of the central nervous system, 860
Laryngeal motor neuroses, 811 ; choreic
movements of the vocal cords, 848 ; in
syringomyelia, 862 ; laryngeal vertigo,
850 ; nervous laryngeal cough, 848 ;
neuroses of co-ordination, 848 ; ])aralysis,
851 ; phonic spasm, 849 ; respiratory
glottic spasm in children, 845 ; spasm of
the glottis in adults 847
Laryngeal paralysis, 851 ; complete recur-
rent, 854 ; diagnosis, 856 ; isolated, of
the crico-thyroid muscles, 855 ; of muscles
supplied by the recurrent laryngeal nerve,
851 ; of muscles supplied by the superior
laryngeal nerve, 855 ; of the abductors of
the vocal cords, 852 ; of the adductors,
851 ; of the interarytaenoideus muscle,
855 ; of the thyro-arytsenoidei interni,
855 ; treatment, 856
Laryngeal sensory neuro-es, 85S ; auresthesia,
858 ; in syringomyelia, 862 ; hyperaisthesia,
neuralgia, paraesthesia, 859
Laryngismus stridulus, 845
Laryngitis acute, 786 ; symptoms, 786 ;
treatment, 788 ; chronic, 788 ; symptoms,
789 ; treatment, 790 ; ha>morrhagic, 795 ;
treatment, 796 ; sicca, 789
Laryngorrhrea, 789
Laryngoscopy, 780 ; difficulties in, 783
Larynx, angio-neurotic, oedema of, 792
Larynx, diseases of, 780 ; acute septic in-
tiaminations, 737 ; anajmia, 785 ; auto-
scopy, 784 ; benign growths, 824 ; bililio-
graphy, 862 ; inspection of, 780 ; haemor-
rhage, 795 ; hyijcrsemia, 785 ; laryngitis,
786; leprosy, " 803 ; lupus, 801; malig-
nant growths, 833 ; neuroses, 841 ;
oedema, 792 ; pachydermia laryngis, 831 ;
])urichondritis, 8(i9, 813 ;. skiagraphy,
785 ; stenosis, 819 ; syphilis, 806 ; tuber-
culosis, 796
Larynx in acromegaly, 80G ; intubation of,
in stenosis, 820
Larynx, malignant disease of, 833 ; diagnosis,
836 ; extrinsic and intrinsic varieties,
834 ; palliative measures, 840 : jiathology,
833 ; i)rognosis, 839 ; signs, 836 ; symp-
toms, 834 ; treatment, 839
Larynx, oedema of, 792 ; and Bright's dis-
ease, 793 ; clinical forms, 79 t ; elinlogy,
792 ; pathology, 793 ; treatment, 794
INDEX
877
Lead as cause of granular kidney, 377
Leprosy of the pharynx and larynx, 803 ;
diagnosis, 804 ; laryngeal symptoms, 803 ;
treatment, 806 ; tubercular and anaes-
thetic forms, 804
Leuchsemia, spleno-lymphatic, 591
Leuchffimia, splenic, diagnosis from Hodg-
kin's disease, 591
Leucin, 296
Leueocytosis in Hodgkin's disease, 579
Lingual tonsil, diseases of, 744 ; chronic
hypertrophy of, 744
Lipoma of the larynx, 826
Lithsemia, 39 ; symptoms, 9
" Lithuria," 9
Liver, al)scesses of, amcehic, 153 ; pyemic,
124 ; pyosepticieniic, 133 ; tropical, 134
Liver, cirrhosis of, 173 ; see Cirrhosis
Liver, congestion of, 42 ; active, 43 ; biblio-
graphy, 48 ; etiology, 44 ; morbid ana-
tomy, 47 ; symptoms, 46 ; passive, 49 ;
symptoms, 50 ; treatment, 51
Liver, functional disorders of, Murchisou's
classification, 8
Liver, functions of, 6 ; assimilative, 11 ;
bibliography, 41 ; biliary, 14 ; digestive,
40 ; excretory, 14 ; glycogenetic, 11 ;
haemolytic, 23 ; metabolic, 12 ; proteo-
lytic, 12
liiver in acute yellow atrophy, 107 ; in
amoebic abscess, 156 ; in Hodgkin's dis-
ease; 584 ; phosphorus poisoning, 88, 91 ;
in perihepatitis, 119
Liver, malignant disease of, 194
Liver, topographical anatomy, 3 ; as a
hfemolytic organ, 23 ; bile - ducts, 5 ;
blood-supply, 6, 43 ; influence of respira-
tory movements on, 44 ; nerve-supply, 5 ;
relations on percussion, 3
Locomotor ataxia, laryngeal crisis in, 860
Lumbago in renal calculus, 442
Lung lesions in amoebic abscess of liver, 1 60
Lungs and heart, physical signs of diseases
of, 652 ; auscultation, 608 ; bibliography,
667 ; conduction of sound, 661 ; percus-
sion, 655 ; production of sound, 653 ;
resonance, 654
Lupus of the jiharynx and larynx, 801 ;
causes, 801 ; symptoms, 802 ; treatment,
803
Lymphadenoma, of the liver, 210 ; and see
Hodgkin's disease, 573
Lymphatic glands in Hodgkin's disease, 576,
581 ; microscopical appearance, 582
Lympho-sarcoma, 590 ; of the fauces and
pharynx, 755
Maggots in the nose, 704
Malarial fever as cause of granular kidney,
381
Marasmus in renal disease, 336
Marshall Hall's metliod of artificial respira-
tion, 648
Measles, throat affections of, 735
Melanin, 290
Menstruation in Graves' disease, 497
Mental changes in Graves' disease, 498
Mogiphonia, 850
Mucous polypus of nose, 687 ; clinical
aspects, 689 ; treatment, 690
Myxcedema, 469 ; bibliography, 478 ; men-
tal symptoms, 473 ; morbid anatomy,
475 ; pathology, 474 ; picture of the
disease, 470 ; prognosis, 476 ; symptoms,
471 ; treatment, 476
Myxoedema, congenital, see Sporadic cretin-
ism, 484
Myxoma of the larynx, 826
Myxo-sarcoma, renal, 446
Nasal cavities, new growths of, 687 ; benign
growths other than mucous polypi, 690 ;
malignant disease, 691 ; mucous polypus,
687
Nasal neuroses, 694 ; asthma, 698 ; coryza
oedematosa, 701 ; idiopathic rhinorrhoea,
700 ; nasal cough, 697 ; olfactory neuroses,
694 ; paroxysmal sneezing, 698 ; sensory
and reflex neuroses, 696 ; vaso-motor,
697
Nasal polypi, 687
Naso-pharynx, catarrh of, 713 ; adenoid
vegetations, 714 ; post-nasal growths, 714 ;
syphilis, 714 ; tuberculosis, 714
Nephritis, 352 ; acute, 353 ; age in, 357 ;
causes, 357 ; chronic, 355 ; duration, 367 ;
fatty kidney, 353 ; morbid anatomy, 353 ;
scarlatinal, 361 ; sex in, 356 ; chronic
interstitial, see Granular kidney, 373 ;
symptoms, 364 ; treatment, 371 ; urinary
changes, 368
Nephritis, sujijiurative, 422 ; diagnosis, 425 ;
etiology, 422 ; pathology, 423 ; symptoms,
424 ; treatment, 426
Nephritis, traumatic, 421
Nephroptosis, 338 ; bibliography, 350 ;
causes, 342 ; diagnosis, 346 ; symptoms,
343 ; treatment, 347
Nervous system in Addison's disease, 546,
559 ; in Graves' disease, 498 ; in Hodg-
kin's disease, 580 ; influence of, in pro-
ducing jaundice, 77
Nose, accessory sinuses of the, diseases of,
704 ; empyema of the antrum, 705 ;
posterior ethmoidal cells, 711 ; suppura-
tion, 705 ; suppuration in the frontal
sinus and ethmoidal cells, 708 ; suppura-
tion in the sphenoidal sinus, 712
Nose-blowing, 632
Nose, diseases of, 671 ; affections of bones,
691 ; bibliography, 722 ; foreign bodies,
701 ; glanders, 693 ; lupus, 684 ; maggots,
704 ; methods of examination, 671 ;
neuroses, 694 ; new growths, 687 ; syphi-
lis, 685 ; tuberculosis, 683 ; see also
Khinitis, Nasal cavities, Nasopharynx
878
SVSTE.V OF MEDICINE
Obesity, 607 ; anaemic form, 612 ; biblio-
grapliy, 6"22 ; intnuluction, 607 ; jiletlioric
form, 612 ; treatment, by dry diet, 619 ;
by increased water-drinking, 620 ; by spa
waters, 621 ; by tliyroid extract, 622 •,
dietetic, 616 ; preventive, 615
(Edema glottidis, 792
Gidcina in Graves' disease, 496 ; iu renal
disease, 366
Osteo]ihytii' periostitis, 601
Otitis media after operation ou naso-pharynx,
72-2
Oxalates in urine, 300
Oxybntyric arid in urine, 313
Ozwua, and chronic atrophic rhinitis, 675 ;
" tracheal," 677
Pachtdkhmia laryngis, 790, 831 ; diagnosis,
832 ; jiatliology, 831 ; treatment, 791, 833
Pancreas, .diseases of, 262 ; bibliography,
27S ; calculi, 270; cancer, 276; cysts,
272 ; haemorrhage, 262
Pancreatitis, acute, 264 ; chronic, 268
Papilloma of the fauces, 752 ; of larynx, 825
Paresthesia of larynx, 859 ; of pharynx, 761
Parathyroiiis, 465
Parosmia, 695
Percussion, 655
Pericarditis in granul ir kidney, 385
Pericellular ciri'hosis, 190
Perichondritis of the larynx, 813 ; adhesive,
813 ; diagnosis, 815 ; pathology, 813 ;
suppurative, 813 ; symptoms, 814 ; syphi-
litic, 809 ; treatment, 816
Perihepatitis, 118; bibliography, 123 ; dia-
gnosis from hepatic cirrhosis, 122 ; local,
118 ; symptoms, 121 ; universal, 119
Perinephric abscess, 417 ; extravasations,
414, 445 y
Perinephritis, 417 ; etiology, 419 ; symp-
toms, 418 ; treatment, 420
Peritonsillitis, 771
Pernici HIS ana;mia, spleen in, 524
Pharyngeal muscles, spasm of, 760
Pharyngeal neuroses, 760
Pharyngeal paralysis, 760 ; treatment, 761
Pharyngeal tonsil, hypertrophy of, 714 ;
bililiography, 722 ; diagnosis, 719 ; etio-
logy, 714; pathology, 715; prognosis,
719 ; symptoms, 716 ; treatment, 720
Pharyngeal tuberculous ulceration, distinc-
tion from other disea ss of the pharynx,
759
Pharyngitis, acute catar 72r( ; atrophic,
728 ; chronic, 727 ; s, ,a, 72s
Pharyngomycosis leptothricia, 743
Pharyngoscopy, 723
Pharynx, diseases of, 723 ; acute septic
inflammation, 737 ; bibliography, 779 ;
foreign Viodies, 764 ; gout, 750 ; hiemor-
rhase, 730 ; inherited syphilis, 748 ;
leprosy, 803 ; lupus, 801 ; neuroses,
motor, 760 ; sensory, 761 ; new growths,
752 ; rheumatism, 751 ; syphilis, 747 ;
tuberculosis, 745 ; see also Pharyngitis,
Tlu'oat alicctions. Tonsils
Phonic sjiasm, 849
Phosphates in urine, 298
Phosphorus poisoning, jaundice of, 87 ; and
acute yellow atrophy, 113 ; morbid ana-
tomy, 91 ; symjitoms, 87
Pigment tumours of the liver, 209
Pigmentation in Addison's disease, 547. 562 ;
in chronic phthisis, 562 ; in Graves' dis-
ease, 495
Polycholia, 21
Polychromia, relation to jaundice, 25, 63
Pluml)ism as a cause of renal disease, 377
Portal pyaemia, 127
Porto-pya3mic liver abscess, 127 ; diagnosis,
132 ; etiology, 127 ; morbid anatomy,
129 ; symptoms, 130 ; treatment, 133
Post-nasal growths, 714
Pregnancy as cause of granular kidney, 380
Professional laryngeal neuroses, 849
Pruritus in unemia, 397
Puberty, barking cough of, 848
Pulse in granular kidney, 388 ; in lardace-
ous kidney, 406
Pyaemic liver abscesses, 124 ; etiology, 124 ;
morbid anatomy, 124 ; symptoms, 126
Pyelitis, 422 ; diagnosis, 425 ; etiology,
422 ; patliology, 423 ; symptoms, 424 ;
treatment, 426
Pyelonephritis, 422 ; diagnosis, 42.'> ; etio-
logy, 422 ; pathology, 423 ; symptoms,
424 ; treatment, 426
Pylephlebitis, 127 ; see Porto-pyaemic liver
abscesses, 127
Pyonephrosis, 434 ; diagnosis, 436 : etio-
logy, 434 ; symptoms, 435 ; treatment,
437
Pyosepticsemic abscess of the liver, 133
Pyrocatechiu, 291
Pyuria, 307
Renal abscess, 427 ; etiology, 427 ; patho-
logv, 428 ; symptoms, 428 ; treatment,
429
Renal calculus, 439 ; diagnosis, 443 ; in
infants, 444 ; pathological results, 440 ;
symiitoms, 441 ; treatment, 443
Renal disease, general pathology of, 318 ;
alterations in urine, 318 ; bibliography,
337 ; cardio ■ vascular changes, 332 ;
dropsv, 320 ; marasmus and auffimia,
336 ; secondary inflammation, 336 ;
uriBiuia, 324
Renal listulre, 416
Renal functions, general pathology of, 281
Renal tumours, see Kidney, 445
Respiratory diseases, general pathology of,
625 ; asphyxia, treatment of, 648 ;
bibliography, 647 ; Cheyne-Stokes breath-
ing, 646 ; coughing and sneezing, 630 ;
cyanotic condition, 643 ; dyspnoea, 638 ;
INDEX
879
mechaiiisia of breathing, 626 ; nose-
blowing, 632 ; yawning, 632
Respiratory system in Graves' disease, 496 ;
in Hodgkin's disease, '580, 585
Retina in grannlar kidney, 390
Retropharyngeal abscess, 741
Rheumatic throat affections, 725, 751
Rheumatisni as cause of nephritis, 363
Rhinitis, acute, 672 ; chronic atrophic, 675 ;
chronic hypertrophic, 673 ; niembranons,
fibrinous, or crouijous, 679 ; purulent, 678
Rhinoliths, 702
Rliino-pharynx, 724
Rhinorrhoea, idiopathic, 700
Rhinoscleronra, 692
Rhinoscopy, 671
Rhonchus, 665
Ribs, llexiV)ility of, in breathing, 626
Rotheln, throat affections of, 735
"Sago" spleen, 537
"Salisbury " treatment of obesity, 617
Sarcoma of the fauces and pharynx, 754 ;
diagnosis, 755 ; distinction from other dis-
eases of the jiharynx, 759 ; prognosis, 757 ;
treatment, 758
Sarcoma of the larynx, 833 ; of the liver,
209 ; melanotic, 210 ; renal, 446
Scarlatinal nephritis, 361 ; morbid anatomy,
353
Scarlet fever, throat affections of, 735
Scrofida, 597 ; bibliograjjliy, 599, 606 ;
surgery of, 599
Singers' nodes, 831
Skatol pigments in urine, 286
Skiagi'aphy of the larynx, 785
Skin, affections of, in Graves disease 495 ; in
Hodgkin's disease, 580
Skodaic resonance, 657
Small-pox, throat affections of, 735
Sneezing, 630
Spasm, phonic, 849
Specific fevers, throat affe:tions of, 735
Si^leen, diseases of, 516 ; abscess, 534 ;
atropliy, 528 ; bibliographj', 539 ; capsu-
litis, 529 ; chronic venous congestion, 531 ;
congenital absence of, 528 ; cysts, 532 ;
general pathology, 516 ; haemorrhages,
532 ; in liacterial infection and in toxag-
mia, 518 ; infarcts, 533 ; lardaceous
disease, 537 ; malfornritions, 526 ; malig-
nant disease, 538 ; jiart of, in bacterial
infection, 520 ; in immunity, 521 ; in
various forms of antemia, 522 ; post-
mortem changes, 529 ; rickets, 537 ;
senile, 528 ; special jiatholog.v, 526 ;
syphilis, 536; tuliercnlosis, 535
Spleen in acute yellow atrophy of liver, 113 ;
in hepatic cirrhosis, 179, 186 ; in
Hodgkin's disease, 577, 583 ; in pernicious
anaamia, 524 ; in toxaemia, 518
Spleens, accessory, 527 ; multiple, 528
Splenectomy in man, effects of, 516
Splenic anaemia, 523
Sjjoradic cretinism, 484 ; l)ibliography, 489;
treatment, 486
Sputum in ama'bic abscess of the liver, 164
Stelhvag's sign in Graves' disease, 492
Stenosis of the larynx, 819 ; causes, 819 ;
intul)ation and tracheotomy for, 822 ;
syphilitic, 812 ; treatment, 820
Stethograph, 628
Sulphates in urine, 297
Suppuration as cause of lardaceous kidney,
405 ; treatment, 412
Suppurative hepatitis, 123 ; bibliography,
134 ; forms of, 123
Suprarenal bodies, diseases of, 567 ; adeno-
mata, 569 ; atrophy, 544, 56/ ; cloudy
swelling, 568 ; cysts, 570 ; fiitty change,
567 ; haemorrhage into, 567 ; lardaceous
disease, 568 ; malignant disease, 545, 571
Suprarenal bodies, disorders of, 540, 567 ;
bibliography, 572 ; in Addison's disease,
542 ; in Hodgkin's disease, 585 ; physio-
logy of, 551 ; theories of functions of, 551
Suprarenal extract, 564
Suprarenal "rests," 570
Sylvester's method of artificial respiration,
648
Sympathetic in Addison's disease, 546
Sypliilis,ac<juired, pharynx in, 747; inherited,
pharynx in, 748
Syphilis as cause of lardaceous kidney, 405 ;
treatment; 413
Syphilis diagnosis from cancer of the liver,
202 ; from Hodgkin's disease, 591
Syjihilis of the fauces and ]iharynx, distinc-
tion from other diseases of the pharynx,
759
Syphilis of lar)'nx, 806 ; condylomas, 807 ;
diagnosis, 810 ; fibroid metamor])hosis,
808 ; gummas, 808 ; neoplasms, 809 ;
paralysis of vocal cords, 809 ; pathology,
806 ; perichondritis, 809 ; syphilitic
catarrh, 807 ; treatment, 811 ; ulceration,
808
TABEg dorsalis, laryngeal manifestation of,
860
Tuurocholic acid, 32
Temperature in Addison's disease, 558 ; in
Graves' disease, 495 ; m Hodgkin's disease,
580
Throat affections, gouty, 750 ; of the specific
febrile dL^'^ftses, 735 ; rheumatic, 751
Throuibo?, )f splenic vein in acute pan-
creatit.-'"!i?5
Tliymus gl'rtiid in Graves' disease, 503 ; in
Hodgkin's disease, 585
Thyroid gland, diseases of, 465 ; in Graves'
disease, 492, 499 ; in myxoedema, 475 ;
pjliysiology of, 465
Tliyro-iodine, 469
Toluylendianiin, 19, 38
Tonsillitis, 770 ; acute, 770 ; chronic, 773
S8o
SYSTEM OF MEDICINE
clinical forms, 770 ; diagnosis, 772 ;
pare^u-hvin.-itous, 770 ; prognosis, 772 ;
superficial or lacunar, 770, 774 ; symptoms,
771 ; table of distinction from other
diseases of the pharynx, 759 ; treatment,
773
Tonsils, diseases of, 769 ; acute tonsillitis,
770 ; calcareous concretions, 744 ; olironic
enlargement, 773 ; chronic fibroid de-
generation, 774 ; clironic parenchymatous
hyperplasia, 774 ; diseases of lingual tonsil,
744 ; new growths, 752 ; removal, 776 ;
syphilis, 747
Tonsils in scrofula, 597
Toxremia, spleen in, 518
Toxsemic jaundice, 83 ; bibliography, 94 ;
etiology, 86 ; general characters, 83
Tremor in Graves' disease, 494
Tropical abscess of the liver, 134 ; biblio-
gi-aphy, 152 ; death-rates, 135 ; diagnosis,
150 ; etiology, 134 ; evolution and nature
of lesions, 144 ; geographical distribution,
134 ; meteorological condition, 137 ;
morbid anatomy, 141 ; race, 139 ; relation
to dysentery, 140 ; symptomatology, 148 ;
treatment, 151
Tuberculosis of the larjmx, 796 ; diagnosis,
793 ; pathology, 796 ; prognosis, 799 ;
symptoms, 797 ; treatment, 800
Tuberculosis of the spleen, 535
Tuberculosis of the suprarenal bodies, 568 ;
in Addison's disease, 543
Tuberculous kidney, diagnosis from renal
calculus, 443
Tubular breatliing, 662
Tumours of the gall-liladder, 208, 226 ; of
the kidne}', 445 ; spleen, 538 ; suprarenal
Ijodies, 589
Tumours of the liver, 194 ; a^e in, 197 ;
bibliography, 211 ; cancer of the liver,
secondary, 194 ; diagnosis, 200 ; diagnosis
from tumour of the gall-bladder, 229;
moibid anatomy, 194 ; prognosis, 200 ;
sex in, 197 ; symptoms, 197 ; treatment,
204
Typhoid fever, throat affection, 736
Typhus fever, throat att'ections of, 737
Tyrosiu, 296
Urates, 295
Uraemia, 324 ; acute forms, 326 ; blood in,
331 ; cerebral anaemia in, 329 ; cerebral
oedema in, 328 ; in nephritis, 367 ; latent,
327 ; of graindar kidney, 395 ; symptoms,
396 ; types, 325
Ursemic asthma, 397
Urea, 292
Ureter in nephroptosis, 345
Ureteral fistulfe, 417
Ureterectomy for diseases of ureter, 437
Uric acid, 293 ; quantitative estimation, 294
Urine, 281 ; albuminuria, 300 ; alterations
in disease, 318 ; conditions influencing
excretion, 282 ; constituents, 316 ; glyco-
suria, 308 ; nitrogenous extractive*, 292 ;
pigments, abnormal, 287 ; normal, 285 ;
pyuria, 307 ; quantity, 281 ; reaction,
284 ; salts, 297 ; specific gravity, 284
Urine in acute yellow atrophy of liver, 107,
110 ; in granular kidney, 383 ; in jaundice
of phosphorus poisoning, 88 ; in lardaceous
kidney, 411 ; in nephritis, 364 ; in urienua,
399
Urine, obstruction of, as cause of renal
fibrosis, 382
Urine, Pettenkoffer's test for bile acids in, 33
Urobilin, 28, 285 : relation to jaundice, 69
Urobilin icterus, 58, 67
Urobilinuria, 288
Urochrome. 28, 286
Uroerythrin, 29, 286
Urohiematoporphyrin, 28, 552
Uvula, bifid, 725 ; diseases of, 732
Valvular disease of the heart as a cause of
granular kidney, 378
Varicella, throat affections of, 735
Vascular system in Addison's disease, 558
Ventricle of Morgagni, prolapse of, 826
Vocal cords, 841, 853
Vomiting in Addison's disease, 565 ; in
cholelithiasis, 238 ; in grnnular kidney,
384 ; in Graves' disease, 497
Von Griife's sign in Graves' disease, 492
Water, excretion of, by the kidney, 281 ;
by the liver, 1 5
Weil's disease, 95 ; bibliogi-aphy 100 ; etio-
logy, 96 ; morbid anatomy, 97 ; nature
and relation to other forms of jaundice,
98 ; pathogeny, 97 ; symptoms, 95
Whooping-cough, throat affections of, 737
Yawning, 632
Yellow fever, jaundice of, 93
END OF VOL. IV
RC
A52
Allbutt, (Sir) Thomas Clifford
A system of medicine
BioMed
1
91
PLEASE DO NOT REMOVE
CARDS OR SLIPS FROM THIS POCKET
UNIVERSITY OF TORONTO LIBRARY
I
i
"Ml..".' ' " "W^"'/! —ri'T^Tn-
■*■•
^M
Live Music Archive
Librivox Free Audio
Metropolitan Museum
Cleveland Museum of Art
Internet Arcade
Console Living Room
Books to Borrow
Open Library
TV News
Understanding 9/11