Volume 2 — DISEASES OF THE DIGESTIVE SYSTEM. (continued 22)

This species, the common liver-fluke, occasionally occurs in the human body, but is especially frequent in the sheep and other ruminating animals, as the ox, goat, and deer, and it likewise occurs in the horse, hog, and some other animals. It usually inhabits the liver, occupying the bile-ducts, but is also sometimes found in the portal and other veins and in the intestine, and more rarely in abscesses beneath the skin. It is the cause of the affection in sheep called rot, of which many thousands die annually.

The liver-fluke is a flat, tongue-shaped, brownish worm about an inch long and about half as wide. It is invested with minute scale-like spines. The head end is somewhat prolonged, and terminates in a small oral sucker, a short distance behind which is a small ventral sucker. The intestine is forked and much branched. The genital aperture is situated between the oral and ventral suckers. The commonly yellowish eggs are numerous and large, oval, and measure about 0.135 mm. long.

The common liver-fluke frequently occurs in large numbers, even hundreds, in the liver of the sheep, obstructing the bile-ducts and occasioning more or less destruction of the organ. The eggs pass off with the bile into the intestine, and are discharged with the excrement. In water the eggs are hatched, and deliver a ciliated and freely-swimming embryo. This in favorable positions, such as marshy pastures, obtains access to small fresh-water snails and penetrates to the interior of their body. Here the embryo sheds its ciliated integument and is transformed into a sporocyst. This is an elliptical pouch containing reproductive bodies, which become developed into individuals of more elongated form than the sporocyst, provided with a mouth and stomach, and named redias, or nurses. The nurse penetrates to the liver of the snail, and there develops within itself new forms called cercarias, which resemble the parent fluke-worm, but are provided with a long, powerful tail and have no apparent generative apparatus. The cercaria escapes through an aperture of the nurse, and makes its way out of the snail into the water, where it swims about actively by means of the tail, much in the manner of a tadpole. The cercaria after a time fixes itself to a submerged plant, becomes encysted, shakes off its tail, and remains in a quiescent state. If in this condition, in the feeding of sheep or other animals, the tailless cercaria or incipient fluke-worm is transferred to the stomach, it makes its way to the liver, and there grows and is developed into the sexually mature worm.

Recently it has been ascertained both in England and Germany that the juvenile state of the fluke-worm is passed especially in the little fresh-water snail Lymneus truncatulus. As, however, the common liver-fluke occurs in America, while the last-named species of Lymneus does not, it is rendered probable that the juvenile condition of the parasite also occurs in other species of snails. Incidentally, the writer may here mention that he has found certain of our smallest fresh-water snails, such as Planorbis parvus, frequenting meadows in the vicinity of our rivers and creeks, swarming with nurses of several different species of fluke-worms.

Notwithstanding the frequency of the common liver-fluke in the sheep and other domestic animals, its occurrence has been rare in man, and in all the cases reported it has been few in number, either single or from two to half a dozen. In man it has been found to occupy the bile-ducts, the portal vein, and abscesses beneath the skin.

DISTOMUM LANCEOLATUM.—SYNONYM: Smaller Liver-fluke.

This species, much smaller than the preceding, is of lanceolate form, acute behind, smooth, and about a third of an inch long. Its suckers are moderately large, and the bifurcate intestine is unbranched. It infests the liver of the sheep and ox and some other animals, and not unfrequently is found in association with the former species. It usually does not occur in such great numbers together as in the latter; from which and other circumstances, as the smaller size and smooth investment, it does not produce the same serious results. Its continuous history remains unknown, though it is probable that its course is similar to that of the common liver-fluke. Several cases are reported of its occurrence as a parasite in man.

DISTOMUM SINENSE.—Under this head Cobbold has recently described a species somewhat larger than the D. lanceolatum. It occurs in the liver of Chinese.

DISTOMUM CONJUNCTUM.—Another species described by Cobbold under this name, originally found in the liver of an American fox, has also been detected in man. The worm is about one-fourth of an inch long.

SYMPTOMS.—Cases of fluke-worms in the human liver have occurred so rarely that we are not prepared to indicate with certainty what may be the nature of the peculiar symptoms. If the parasites were numerous, they would give rise to more or less obstruction of the bile-ducts, with accumulation of bile, accompanied with jaundice and other symptoms usually attendant on functional disturbance of the liver. As in sheep, they would occasion dilatation of the bile-ducts, catarrhal inflammation, incrustation with biliary matters, hyperplasia of the surrounding tissues, and more or less disorganization and atrophy of the secretory structure.

TREATMENT.—As regards the treatment, we can say almost nothing. In the destructive disease of rot in sheep there are no known means to expel the parasites from the liver. If present in man, as they occur but few in number, we may hope for their spontaneous expulsion in due time without leaving any serious result. As a means of prophylaxis persons should carefully avoid salads prepared from subaquatic vegetables, like cress, which may harbor little fresh-water snails.

DISTOMUM HETEROPHYES.—This is a small species, about half a line long, with the fore part of the body covered with minute spines, and having a large, nearly central, ventral disk. It has been but once observed, and was reported by Bilharz, in Cairo, as having been found, in the post-mortem examination of a boy, in the small intestine, in which it existed in hundreds.

DISTOMUM CRASSUM.—This is the largest of the fluke-worms infesting man, and measures from one to three inches in length. It is elliptical, comparatively thick, and smooth. The two suckers have nearly the same relative size and position as in the D. hepaticum. It inhabits the duodenum, and has been observed a number of times infesting inhabitants of China and India.

DISTOMUM RINGERI.—A species by this name, about half an inch long, has recently been described by Cobbold as infesting the lungs of people in Formosa and China.

DISTOMUM OPHTHALMOBIUM.—A minute species, described under this name, has been detected several times in the human eye.

BILHARZIA HÆMATOBIA.—SYNONYM: Distomum hæmatobium.

As a human parasite this is the most important of the fluke-worms, being the most common and dangerous. It is apparently restricted to Africa and Arabia, and is especially frequent in Egypt, Abyssinia, the Cape of Good Hope, and Natal. So far as known, it is peculiar to man and monkeys, and inhabits the veins, especially those of the portal system, and it lives on the blood.

The blood fluke-worm is remarkable among its kind in having the sexes distinct. The female is slender, cylindrical, and tapering toward the ends, looking more like an ordinary thread-worm than a fluke-worm, and is about three-fourths of an inch long. The male is about half an inch long, but wider than the female, which it partially embraces at maturity by doubling upon it laterally.

This parasite, of the same essential nature as the more ordinary fluke-worms, is most probably introduced in the juvenile condition into the stomach by drinking unfiltered standing waters, and perhaps also by eating vegetables which grow in wet places and upon which the young fluke-worms may be encysted. From the stomach the worms gain access to the portal venous system, within which they undergo development to sexual maturity. The worms, proportioned to their number, occasion more or less sudden and dangerous hæmaturia. According to Bilharz, who first discovered the parasite, it also induces inflammation of the ureters, bladder, and rectum, accompanied with ulceration and incrustations and concretions in the same, due to the abundant deposit of eggs in the mucous membrane. The symptoms in the hæmaturia are obvious; all treatment fails, but the prophylaxis is evident.

AMPHISTOMUM HOMINIS.—The genus Amphistomum is distinguished from Distomum in having the ventral disk placed at the posterior extremity of the body.

A species has been recently described by Cobbold under the above name, and is reported as having been observed several times in natives of India. It is a red worm, about the fourth of an inch long, and inhabits the cæcum and ascending colon, in which it was found in hundreds together. The mucous membrane exhibited venous congestion and was marked with numerous red spots resembling leech-bites, produced by the parasites. One of the patients died of cholera.

We have too little information as to the symptoms induced by this parasite, and of its treatment, to say anything. It is probable that calomel, turpentine, and castor oil would be appropriate remedies.

Several other fluke-worms which have been reported as having been found in the human body are generally viewed with doubt as to their genuineness. Such are the Hexathyridium pinguicola, from a tumor of the ovary; the H. venarum, said to have been found in the blood and in the sputum of hæmoptysis; and the Tetrastomum renale, said to have been found in the urine.

The Acanthocephali, or Thorn-head Worms.

The thorn-head worms in the mature condition are comparatively robust cylindrical worms, with a body-cavity or coelum, but devoid of mouth and alimentary canal. They are provided with a protrusile and retractile proboscis-like head armed with circular rows of recurved hooks, by which they firmly cling to the wall of the intestine of their host. The sexes are distinct. There are many species, which mostly in the mature state live in fishes. In the juvenile or larval condition they live in other animals, mostly crustaceans and insects. It is doubtful whether any species naturally infests man.

ECHINORHYNCHUS GIGAS.—The great thorn-head worm is a common parasite of the hog, living in the small intestine. It is a large white worm, the female of which reaches a foot in length, while the male is about one-third the size. It is doubtful whether it occurs as a human parasite, though a worm less than the fourth of an inch found in a man in Prague has been attributed to this species.

The Nematodes, or Thread-worms.

The nematodes, or thread-worms, are slender, cylindrical, and inarticulate, and usually more or less tapering toward one or both extremities. They have a distinct coelum or body-cavity, with thick muscular walls limited by a transparent elastic, chitinous integument, which is sometimes more or less distinctly and regularly transversely wrinkled. The alimentary canal extends the length of the coelum, with the mouth at the anterior extremity, and usually an anus at or near the posterior extremity. In some forms in the mature condition the intestine is atrophied and the anus absent. The sexes are distinct, and commonly the male is very much smaller than the female. The organs of generation occupy the coelum along the sides of the intestine. The female aperture is commonly situated ventrally near or in advance of the middle of the body, while the male aperture is at or in the vicinity of the anus. Mostly, the worms are oviparous, but many are viviparous. The development is direct, and usually the transformations are inconspicuous, so that the embryos mostly differ but little from the parent, except in the absence of the generative apparatus.

OXYURIS VERMICULARIS.—SYNONYMS: Ascaris vermicularis; Seat-worm; Pin-worm; Maw-worm; Maggot-worm; Thread-worm; Ascarides.

The seat-worm is the most common intestinal parasite of man, prevails everywhere, and is peculiar to him. It is a lively, wriggling creature which inhabits the small and large intestines and feeds on their contents. It frequently occurs in large numbers together, and in such cases incessantly makes its appearance, associated with multitudes of eggs, in the evacuations.

The female, which is ordinarily seen alone in the greatest abundance, is a white cylindrical worm tapering toward both extremities. The head end is thickened, and is provided with three prominent labial papillæ enclosing the mouth. The posterior end extends from the anal aperture in a long and straight, narrow, conical, sharp-pointed tail. The double uterine tube, distended with eggs, terminates in a vagina, the external aperture of which is situated ventrally near the anterior third of the body. The smaller male hardly tapers behind, but is incurved and ends in a short, blunt, conical tail. The penis is a single chitinous spicule, the end of which is usually seen projecting from the cloacal aperture.

The young seat-worms, in various degrees of growth and development, and the mature males are chiefly to be met in the lower portion of the small intestine, while the pregnant and mature females chiefly occupy the cæcum.

The seat-worm is exceedingly prolific, it being estimated that a single ripe female contains from 10,000 to 12,000 eggs, and these, it is suspected, may be renewed several times before her functions become exhausted. From time to time the ripe females proceed along the large intestine to the rectum, in which position they lay most of their eggs. These are discharged, together with many of the worms, in the feces.

The eggs are ovoid in shape and about 0.05 mm. long. After they are laid under favorable conditions the embryos are rapidly developed. Left in water, they soon die.

The investigations of the helminthologists of the day make it appear that it is necessary that the eggs of the seat-worm should be swallowed and pass through the stomach, in which the embryos are freed, before they can undergo development to sexual maturity. Moreover, observations go to show that infection may, and probably ordinarily does, occur from eggs scratched from the anus and conveyed to the mouth directly or by being applied to food from uncleanly hands. It is evident that itching of the anus, induced by the presence of the parasites in the rectum, often accompanied by itching of the nose and lips, may lead to alternate scratching of the parts and the transference of eggs from one to the other. Thus, too, uncleanly nurses who may be infested with seat-worms after scratching may handle food and infest children under their charge. Children are commonly more liable to the parasites than others, no doubt from the circumstance that they are less capable of avoiding the conditions favorable to infection. Seat-worms prevail in all conditions of society, but their prevalence is largely proportioned to the more or less uncleanly habits. Persons sleeping with others infested are liable to infection, especially if they are uncleanly and in the habit of eating in bed. Obvious hints to avoid the parasites are obtained by regarding the statements thus given.

SYMPTOMS.—The presence of a few seat-worms is usually attended with no obvious inconvenience, and they may remain unnoticed unless accidentally observed in the evacuations. The symptoms occasioned by them are in great measure proportioned to their quantity and the susceptibility of the patient. The most prominent symptom is excessive itching of the anus; often trifling or even absent during the day, it becomes very annoying and distressing in the evening or during the night. This periodic change appears to be due to the movement of the worms to the rectum, apparently induced by the position and repose of the patient and the increased warmth of the body in bed. Under these circumstances the patient attempts to relieve the incessant itching by scratching, and often by boring with the finger in the anus. In this way eggs become adherent to the finger-nails, under which they have been repeatedly detected, and may thus be inadvertently transferred to the mouth. Occasionally, some of the worms wander from the anus, and in women may thence penetrate into the vulva. The itching of the anus may induce more or less sexual irritation, which in the young may further lead to onanism and its attendant evils. Other symptoms of the presence of the parasites are itching of the nose and lips, restlessness in sleep, grinding of the teeth, startings, twitchings, and general nervous disturbance. When the worms are very numerous they may produce intestinal catarrh, with discharges of mucus, pain, and diarrhoea. In children especially they may give rise to more serious nervous symptoms, as epileptic fits and chorea.

TREATMENT.—Generally, persons are readily relieved of seat-worms. Epsom salt alone or with senna as a purgative, repeated once or twice, often answers to completely expel them. Castor oil, also alone or with a few drops of the oil of turpentine or of wormseed, is also an effectual remedy. The tincture of aloes, in the dose of from half a fluidounce to two fluidounces, once or twice repeated, the writer has found to fully answer the purpose. Besides the purgatives, medicated suppositories, in obstinate cases injections of olive oil, and enemata of a solution of castile soap introduced by means of an elastic tube, so as to wash out the entire length of the large intestine, may be employed.

ASCARIS LUMBRICOIDES.—SYNONYMS: Round-worm; Long round-worm; Maw-worm; Lumbricus.

The round-worm is the largest of the nematodes which ordinarily infest man, and is second only in frequency to the seat-worm. It is a well-known parasite, and prevails everywhere in all conditions of society. It is less lively in its movements than the seat-worm, and is remarkable for possessing a peculiar disagreeable odor, which is independent of the medium in which it lives. It inhabits the small intestine and feeds on the contents. It also infests the hog and the ox.

The round-worm is cylindrical, reddish or brownish, and tapering toward both extremities. The head end terminates in three prominent labial papillæ surrounding the mouth, and the tail end is short and conical. The female, as commonly seen, ranges from six inches to a foot in length, and is about a fourth of an inch in thickness. The ovarian tubes are long, thread-like, and tortuous, and, with the shorter, nearly straight, and wider uterine tubes, contain many millions of eggs. The genital aperture is situated ventrally near the anterior third of the body. The male is about half the size of the female, but is capable of considerable extension, and the tail end is incurved. The penis consists of a pair of slender, clavate, chitinous spicules, the ends of which protrude from the cloacal aperture at the root of the tail.

The round-worm is exceedingly prolific, it being estimated that the genital tubes of a large mature female contain the enormous number of 60,000,000 of eggs. The ripe eggs are laid in the intestine, and are discharged with the evacuations in great numbers, and often in considerable masses together. They are oval, about 0.05 mm. in length, and are provided with a thick shell and an additional tuberculate albuminoid envelope, usually colored by the intestinal contents.

The eggs of the round-worm after being expelled from the body are very tenacious of life, and under ordinary favorable circumstances they may remain in a condition capable of development for several years. Experiments have shown that they have great power in resisting the destructive influences of heat and cold, dryness, and the agencies of decomposition. In water and moist earth they have been retained alive for a year or two. When ripe eggs are placed in water the development of the embryo is observed to proceed very slowly, and is only completed after five or six months. The embryo while still contained within the egg sheds its skin and becomes provided with a tooth-like spine to the head end. The smallest examples of reputed round-worms found in the human intestine measured only about a line in length.

The further history of the round-worm is unknown, nor has it yet been positively ascertained in what manner man becomes infected with the parasite. Repeated experiments, not only on the hog and other animals, but on man himself, go to show that he is not directly infected by swallowing the recently-laid ripe eggs. It is rendered probable that the eggs are swallowed by some common but yet unknown minute aquatic animal, within which the embryo may undergo further development, and in this condition may be swallowed by man in drinking-water. In confirmation of the view that man becomes infected in the latter way, Davaine remarks that the "people of Paris, who drink only filtered water, are rarely infected with the round-worm, which is otherwise the case in the rural districts of France."

The round-worm is most prevalent in warm climates, and especially among the less-civilized peoples. The better classes among the more enlightened nations suffer comparatively little from the parasite, and it is the lower classes, especially the ill-fed and uncleanly, who are most afflicted. It is exceedingly frequent in the Orient, in Africa, the West Indies, and Brazil.

Most commonly, only a few round-worms—one, two, three, up to a dozen—occur together in the same person, but they often occur in considerable number, even to several hundreds. Not unfrequently they are found in association with seat-worms. They are more frequent and usually occur in greater abundance in children, perhaps in a measure due to the circumstance that they are less able to discriminate the conditions favorable to infection and avoided on other grounds by adults.

The natural and ordinary habitation of the round-worm is the small intestine, especially the jejunum, and it commonly only occurs in the large intestine, mostly dead, on the way to be discharged with the evacuations. Under disturbing circumstances, as the character of certain irritating food, the parasite is disposed to become restless and wander from its usual position. Not unfrequently it enters the stomach, and thence may ascend to the mouth or nose, and perhaps the first intimation of the presence of such an unwelcome guest is in its expulsion from the mouth. From the pharynx the worm may enter the larynx and trachea, or advance farther into the air-passages, giving rise to the usual symptoms of foreign bodies in these parts. Occasionally the parasite forces its way through the bile-ducts into the liver and gall-bladder, creating disturbance in those organs proportioned to the number and size of the worms and the extent of their progress. In the liver it may occasion inflammation and the formation of an abscess attended with all the usual symptoms of hepatitis. It has been reported that it may penetrate the intestinal wall and enter the peritoneal cavity, but it is generally regarded as doubtful whether the worm can do so in a healthy state of the intestine, but only where there may be ulceration or other similar condition.

SYMPTOMS.—The symptoms indicating the presence of the round-worm in the intestine vary with its numbers and with the age and susceptibility of the patient. In general, the presence of one or two worms is unattended with any marked disturbance, and is mostly unsuspected until the parasite is accidentally seen in the discharges. The ordinary symptoms are disordered appetite (usually increased), flatulence, hiccough, foul breath, dyspepsia, abdominal pains, itching at the extremities of the alimentary canal, furred tongue, darkening of the eyelids, and emaciation. The nervous symptoms are restlessness in sleep, unpleasant dreams, starting in fright, grating of the teeth, and muscular twitchings. In more aggravated cases, especially in children, epileptic fits may occur. If the parasites are numerous, they produce diarrhoea with copious mucus discharges, and may induce enteritis with all its attendant symptoms. When the worms wander into the stomach, they induce colic, nausea, retching, and vomiting, all of which disappear with the expulsion of the parasites.

TREATMENT.—The remedies employed for seat-worms often serve to expel the round-worm, and not unfrequently the two are discharged together. Wormseed, or the seed of Chenopodium anthelminticum, has been a favorite remedy for the round-worm, especially in children. The dose in these cases is one or two scruples of the powdered seeds in electuary with syrup or molasses, administered in the morning before breakfast and at bedtime for three or four days. It should be followed by calomel or other brisk cathartic. The volatile oil, in the dose of from five to ten drops in emulsion, may be used in the same manner.

A much-extolled remedy to destroy and get rid of the round-worm is santonin, given in doses of from one-third to one and a half grains three or four times a day, the larger dose being used only for adults. It should be followed by a purgative, for which a dose of castor oil answers a good purpose.

ASCARIS MYSTAX, the common round-worm of the cat and dog, has been reported as occasionally infesting man. It resembles the former species, but is much smaller, commonly from one to four inches in length, and has the head end furnished with a pair of lateral narrow, wing-like expansions of the integument. It inhabits the small intestine, and when present in man would no doubt induce symptoms like those of the ordinary round-worms which infest him.

TRIOCEPHALUS DISPAR.—SYNONYMS: Long thread-worm; Whip-worm.

The long thread-worm is a not unfrequent intestinal parasite of man, though rarely observed unless specially sought, as it ordinarily gives rise to little or no disturbance. It is common in England, Southern Europe, and the Orient. Davaine reports that half the cases of persons investigated in Paris were infested with it; it also occurs in this country. It inhabits the lower end of the ileum, the cæcum, and vermiform appendix, and feeds on the intestinal contents. It commonly occurs in small numbers, two or three to a dozen, occasions no evident inconvenience, and is rarely discharged with the evacuations.

The long thread-worm is yellowish-white and cylindrical, with the anterior half or more of the body attenuated in a hair-like manner. The female reaches about two inches in length, has the tail end conical, and the anus subterminal. The male is about two-thirds the length of the former, has the thicker portion of the body enrolled, and the tail end blunt. The eggs are laid in the intestine and discharged with the feces. The subsequent history of the parasite and its mode of infecting man remain unknown.

Only in cases where long thread-worms are numerous do they give rise to trouble. According to Leuckart, Pascal gives as constant symptoms of the presence of large numbers of the parasite, headache, redness of the face, prominence of the eyes, small, irregular, and intermittent pulse, and pains in the lower part of the abdomen.

The usual remedies addressed to the seat-worm and round-worm will most probably be equally applicable to the long thread-worm.

LEPTODERA STERCORALIS.—SYNONYMS: Anguillula stercoralis; Rhabditis stercoralis.

This is a minute nematode worm recently observed infesting French soldiers in Cochin China. It is about half a line in length, and inhabits the small and large intestine, and also penetrates into the biliary and pancreatic ducts. It occurs in myriads and occasions diarrhoea and dysentery. Another species, Leptodera intestinalis, nearly three times as large, has been noticed in smaller number associated with the former. The eggs of these worms are laid in the intestines, and both together are discharged in multitudes with the feces. They are probably introduced into man by drinking stagnant water, and undergo complete development after passing through the stomach.

It is probable that the remedies employed in the treatment of the familiar seat-worms and round-worms would be equally efficacious in the expulsion of these parasites.

ANCHYLOSTOMUM DUODENALE.—SYNONYMS: Strongylus duodenalis; Dochmius duodenalis; Sclerostoma duodenale.

This intestinal parasite, first noticed in Milan by Dubini in 1838, is of more dangerous character than any of the nematode worms previously described. In Europe, besides Italy, it was frequently observed among the workmen of the St. Gothard tunnel. It is exceedingly common in Egypt, and Bilharz found it in nearly all his post-mortem examinations of bodies. It probably prevails to a considerable extent in most tropical countries, including the East and West Indies and Brazil. There is also reason to suspect, from the nature of the affection it induces, that it may exist in the Southern States.

The Anchylostomum is a red, cylindrical worm, with the anterior extremity tapering and recurved. The head end, somewhat enlarged, encloses a capacious oral capsule armed with strong hook-like teeth. The caudal extremity of the female ends in a conical point, and the genital aperture is situated behind the middle of the body. The caudal extremity of the male ends in a trilobate pouch, within which projects the bispiculate penis. The female is from five lines to three-fourths of an inch long; the male is about half the size. The eggs are oval and measure 0.05 mm. long.

The worm inhabits the small intestine, especially the duodenum and jejunum, clinging tenaciously to the lining membrane by means of the armed mouth. It penetrates the mucous membrane to the submucous coat, from which it sucks the blood that forms its food. In the position of its attachment it gives rise to little ecchymoses. It often occurs in large numbers, even to hundreds and thousands. The eggs are laid in the intestine and are discharged with the evacuations. Externally, in water, the embryo undergoes development within the egg, and then escapes to lead for some time an independent existence. Subsequently, it is most probable that the worm obtains access to the human stomach by drinking standing water, and completes its development in the intestine.

The Anchylostomum proves to be a prolific source of wasting diseases in tropical countries, and is pernicious to an extent proportioned to the numbers infesting the intestine. By depriving the body of blood it produces a greater or less degree of anæmia. The affection begins very insidiously, and the general nutrition of the body may not be visibly disturbed until a late period. In moderate cases the disease is indicated by general paleness of the skin and mucous membranes, fatigue on slight exertion, and a tendency to palpitations and quickened pulse. In more severe cases there is constantly increasing debility, with increase of paleness, indisposition to exertion, excessive sleepiness, and feeling of coldness. Dyspeptic symptoms sometimes appear, and loss of appetite may alternate with ravenous hunger. Accompanying this there is often a disposition to eat innutritious articles, as coal, clay, wool, etc. Feeling of weight and oppression in the epigastrium and abdominal pains are frequent. In the advance of the affection shortness of breath appears, increased on exertion to violent dyspnoea. Emaciation becomes obvious in the later stage of the disease. In the worst cases the symptoms increase in severity, the patient becomes dropsical, is attacked with profuse diarrhoea and vomiting, and finally dies.

The severity of the affection is proportioned to the number of parasites present and the quantity of blood they consume and cause to be lost. Bad cases may end fatally in a few weeks, but generally the disease lasts for months, and where the patient is provided with abundance of good food it may continue for years.

The prognosis of the disease is rather unfavorable; if, however, the nature of the affection is ascertained before it has greatly exhausted the patient, and the parasites can be expelled, the result should be favorable.

We have thus far obtained but little information as to the best treatment for Anchylostomum. Calomel and turpentine have been recommended, and, as these are most powerful vermicides, we have reason to believe they would prove most effectual remedies.

In regard to the prophylaxis for Anchylostomum—and we may add in general for all parasites which gain entrance to man through drinking-water—all stagnant or standing waters should be filtered, so as to remove any source of infection, whether by eggs or free embryos of parasites or of larval forms existing within minute aquatic animals which serve as intermediate hosts to parasites. Standing waters, such as those of puddles, ditches, marshes, and ponds, more or less swarm with minute animals, all of which may be entirely removed by filtration. Even the water of cisterns and wells, if supplied from the free surface of the country, may not be free from minute animals, and especially eggs, and therefore requires filtration to be safe. Only spring and freely-running water of rivers and creeks and of lakes is commonly free from microscopic animals and their eggs, and therefore devoid of all danger in these respects.

STRONGYLUS LONGEVAGINATUS; S. bronchialis.—This nematode has been only once satisfactorily observed. Many occurred in the lungs of a boy in Germany, but the real cause of his death was not stated. The female worm is about an inch long, the male about five-eighths of an inch.

Certain worms previously discovered in the bronchial glands of a case of phthisis, and described under the name of Hamularia lymphatica, are regarded by Cobbold as the same with the former; but the descriptions of the two render this improbable. Treutler's drawing of Hamularia, as copied by Leuckart, looks like an Ascaris upside down.

EUSTRONGYLUS GIGAS; Strongylus gigas; Palisade-worm; Kidney-worm.—This worm, recorded in the catalogue of human parasites, is doubtful as such. Pertaining to the same family as Anchylostomum, as the common name indicates its usual habitation is the kidney. It is the largest of the nematodes, and is a long, cylindrical red worm, slightly tapering, and blunt at the ends. The mouth is enclosed by six rounded labial papillæ. The caudal extremity of the male ends in an inverted cup-like pouch, from which the penal spiculum protrudes. The female commonly ranges from one to three feet in length and from a fourth to nearly half an inch in thickness. The male ranges from six inches to a foot in length and from one to three lines in thickness.

The mature parasite is common in many fish-eating mammals, from which it is inferred that fishes are the intermediate host for the juvenile condition of the worm. It is frequent in the wolf, dog, mink, weasel, raccoon, otter, and seal. It also occurs in the hog, and is reported to have occurred in the horse, ox, and man. Usually it is solitary, and occupies one of the kidneys coiled upon itself. Under its influence the kidney is atrophied and reduced to the condition of a capsule of connective tissue, often containing bony spicules. It feeds on blood and on the purulent matter resulting from the inflammation it produces. The worm is occasionally found in other positions, as the mesentery, the abdominal cavity, the intestine, liver, urinary bladder, and lungs, but perhaps in most of these cases has been derived from its usual habitation. In this country the writer has repeatedly observed the kidney-worm in the mink, the dog, and the wolf. In one instance in the former animal he found a female and a male associated together in one kidney, which was reduced to the condition of a fibrous capsule containing in its wall a large radiated plate of bone.

The cases on record of the occurrence of this formidable parasite in man are of very early date, and are mostly doubtful as to the authentic nature of the worm, and are all unsatisfactory as to the attendant phenomena.

TRICHINA SPIRALIS.—The trichina, or flesh-worm, a minute nematode, is a common parasite of man, and from its wide prevalence and results may be regarded as the most dangerous of all. Perhaps from the earliest ages it has been dealing death freely and indiscriminately to our kind without its existence having been suspected until within the last half-century. Frequently, the affection, now named trichinosis, produced by its presence has been so prevalent in communities as to appear epidemic. The parasite was first discovered, and is commonly observed, as a little worm coiled up and imbedded in the flesh of man. In the same manner it is frequently seen in the flesh of the hog. In the adult or mature state it lives in the small intestine of both man and the hog, but its duration of life in this position is comparatively brief.

Trichinosis, or the disease induced by the introduction of trichinæ into the intestinal canal and the migration thence into the voluntary muscles, varies in symptoms and gravity with the number, condition, and position of the parasites and the susceptibility of the patient. The presence of trichinæ in the alimentary canal, though often accompanied by violent symptoms, is comparatively free from danger, whereas in the muscular system they not only produce the greatest suffering, but often the most disastrous results.

Man is ordinarily infected with the trichina by eating the raw or insufficiently cooked meat of the hog, or pork in any of its varieties of food. Infected meat often contains immense numbers of the parasite, a single ounce at times being estimated to contain from 50,000 to 100,000 worms.

The trichina was first distinctly noticed in the muscles of the human body by Paget in 1835, and was described by Owen with the name it now bears. It was subsequently observed under the same circumstances by other investigators. In 1846 the parasite was found by the writer in the muscles of the hog, but neither he nor others for some time afterward suspected the significance of the discovery. In 1860, Zenker of Dresden treated a supposed case of typhus complicated with excessive muscular pain and oedema. On post-mortem examination the muscles were found swarming with trichinæ, and to these the affection altogether was attributed. Nearly at the same time the investigations of Leuckart confirmed the relationship of the parasites as the cause of the disease. In 1862, Friederich first diagnosticated the affection and experimentally determined the presence of the worms in the living patient.

The trichina is also found infesting other animals of the same class besides man and the hog, especially the rat, mouse, rabbit, cat, and fox. Experiments further prove that mammals are generally more or less susceptible to infection with the parasite, though some appear to resist its extension to the muscular system, as in the case of the dog. The horse, ox, and sheep exhibit little disposition to artificial infection of the muscles, and hence from this circumstance and the nature of the food of these animals they are rarely found to be infested with trichinæ. In experiments on birds and lower classes of animals, though trichinæ were ascertained to advance in development in the intestine, they failed to invade the muscular system.

Ordinarily, it appears that while man is infected with trichinæ through the hog, this animal becomes infected by eating infested rats, mice, and cats, fragments of waste pork, and perhaps occasionally by feeding on the excrements of infested animals.

The trichinæ occupying the muscles are immature, and it is only after they are swallowed and the parasites are freed by digestion of the envelopes and pass into the intestine that they undergo development to sexual maturity. In this state the female is viviparous and gives birth to a multitude of active embryos, which immediately commence to migrate to the muscular system. As it is estimated that each female may give birth to upward of a thousand embryos, it is readily conceived to what an extent the body may become infested from eating a few ounces of trichinous pork.

The immature or larval trichinæ are also distinguished as muscular, and the sexually mature ones as intestinal, trichinæ, in accordance with their position in the two principal conditions.

Muscular trichinæ vary in condition from the embryo, which works its way among the muscular fibres or has obtained entrance into these, to the coiled-up worm lying quiescent in a capsule imbedded among the muscular fibres.

Infected flesh in the early state is scarcely distinguishable as such with the naked eye, but in old cases the trichina capsules become imbued with calcareous matter, and are thus rendered visible as minute white or grayish specks scattered through the red meat.

In the recent state of invasion the worms are found free among the muscular fibres or within these. Later, they appear mostly solitary and at rest, coiled within a fusiform mass of semi-liquid granular matter resulting from the degradation of the muscular substance. Subsequently, they become enclosed in an elliptical capsule, apparently derived from the myolemma of the muscular fibre they had entered. The capsules, situated among the bundles of sound muscular fibres, are arranged with their long diameter parallel with the latter. The trichina capsules commonly measure about one-fifth of a line long, and the coiled worm within is scarcely a half-line long.

If muscular trichinæ remain with their host, after a year or more they exhibit signs of decay. Commonly, little fat-globules appear at the poles of the capsules, and these become the seat of calcareous deposit. Finally, the worms die and undergo degeneration.

When meat with living trichina capsules is swallowed, the freed worms pass into the intestine, and here in the course of four or five days reach maturity.

The adult intestinal trichina is a minute, filiform white worm, thicker behind and tapering forward. The female is about an eighth of an inch long, and has the genital aperture at the anterior fourth of the body. The male is little more than half the length of the former, and has the caudal end provided with a pair of conical processes, between which is the genital aperture.

The ripe female trichinæ give birth to living embryos, and continue the function for about a month, after which they appear exhausted, ordinarily die, and disappear from the intestinal canal. The new-born embryos, about ¹/200 of a line long, quickly leave the intestine to be disseminated throughout the body. Penetrating the mucous membrane, they probably enter the blood-vessels to be carried onward by the blood-currents, and perhaps also, in part, directly migrate to their destination in the muscles. The latter mode of progress is rendered the more probable from the circumstance that the muscles contiguous to the intestinal canal, as the diaphragm and those of the abdominal walls, are commonly most abundantly infested with the parasites. In the muscles of the limbs they are sometimes noticed to predominate toward the extremities of the former, as if retarded in their course by the tendinous connections.

It would appear that muscular trichinæ, to be capable of producing infection—that is to say, of further development—must have reached a certain stage, corresponding with the encapsulated condition, before they are swallowed. In this stage they may remain within their host probably for a year or two.

Children seem to suffer less in proportion to the quantity of trichinous meat they eat than adults, and they appear less susceptible to muscular invasion of the parasites. The difference is probably in a measure due to the greater susceptibility of the intestinal canal and the consequent production of more copious diarrhoea in children, with more complete expulsion of the worms.

SYMPTOMS.—In general, the effect produced by eating trichinous meat is proportioned to the number and condition of the trichinæ ingested and to the susceptibility of the patient. A few of the parasites may pursue their entire career and die within their host without ever exhibiting any obvious evidence of their presence. Sometimes the symptoms of trichinosis are obscure or trifling, sometimes sufficiently well marked, but moderate, and often they are more or less striking and violent. The period of incubation of the affection varies from a few hours to a week or more, and the duration of the disease also varies—both in a measure proportioned to the number and condition of the parasites.

In mild cases of trichinosis the patient may pass through the course of the disease without being confined to bed, and in a few weeks may be regarded as convalescent. The majority of cases pursue a slow course of from six or seven weeks to three or four months. A fatal termination is frequent, and is most common from the fourth to the sixth week, and appears mainly to be due to the loss of respiratory power. Fatal cases rarely happen after the seventh week.

From a few hours to a few days after eating trichinous meat the patient may be seized with dyspeptic symptoms—nausea, cardialgia, flatulence, eructations, and vomiting. These may be accompanied with complete loss of appetite, excessive thirst, bad taste, and fetid breath. There is also commonly a feeling of general uneasiness, with fulness of the forehead or headache, and feeling of weakness and fatigue to exhaustion or complete prostration. Neuralgic pains are felt in the abdomen and limbs, and the muscles generally are more or less relaxed and flabby.

Violent disturbance of the alimentary canal occurs only when large quantities of active trichinæ are taken with the food. The subsequent symptoms, due to invasion of the muscular system, may, but do not necessarily, accord in degree with the former.

Diarrhoea usually comes on early, and the evacuations, at first more consistent, become thin and clay-colored, like those of typhus or like the rice-water stools of cholera. In the severest cases the patient may die in this stage from extreme exhaustion and with all the appearance of cholera. Sometimes the diarrhoea subsides and gives place to obstinate constipation.

The muscular symptoms induced by the invasion of the trichinæ may be trifling or moderate, varying to a most violent character. They commonly appear after a week, and later up to the sixth week. The muscles become more or less swollen, hard and tender to the touch, or highly painful under pressure. Motion is extremely painful, and the patient usually lies in a helpless state with the limbs flexed—adults on the back, children on the side. Difficulty, with pain, in chewing and swallowing ensues, and even complete trismus, due to the presence of the parasites in the muscles of mastication and deglutition. Difficulty of breathing also arises from the presence of the trichinæ in the respiratory muscles, especially the diaphragm and those of the larynx. Even movement of the eyes is painful, due to the parasites in the orbital muscles. Bronchial catarrh comes on early, attended with hoarseness and asthmatic cough.

Fever may be absent in mild cases of trichinosis, but is considerable in the severer forms, though not in the first few days. The pulse accords with the increase of temperature.

Profuse sweating is a common symptom of the affection, commencing early and continuing throughout. Generally there is considerable decrease in the quantity of urine, which is highly colored.

Adults suffer with insomnia, while the reverse state prevails in children, who commonly lie in a soporose condition. Formication and dilatation of the pupils are frequent symptoms.

Oedema is a characteristic and pathognomonic symptom of trichinosis, and is seldom so slight as to escape attention. It commonly appears in the eyelids and face about the end of the first week, and may disappear after several days, to recur after several weeks. It usually commences in the limbs in the second week, and is more marked and persistent, and increases, especially in severe cases.

Peritoneal and pleuritic irritation and inflammation, with bronchitis and pneumonia, are not unfrequent complications in the more aggravated form of trichinosis.

Most cases of the disease reaching the seventh week advance in convalescence, while those of mild character by this time have recovered, except from the weakness and emaciation, which remain as evidences of serious illness.

Trichinosis in children is distinguished by greater mildness, less danger, abundant oedema, less muscular pain, a dormant condition, and more rapid convalescence.

The distinct recognition of trichinosis is difficult in isolated cases, but becomes more evident where it occurs in numbers, as in an entire family or in large portions of a community. The proof that the patient has partaken of trichinous pork helps to establish the diagnosis.

In the beginning of severe cases of the affection symptoms of a more or less violent gastro-intestinal catarrh are commonly present, often associated with slight fever and almost invariably excessive perspiration. Muscular lameness, both in mild and severe cases, is an early symptom. The disease is distinguished from cholera by the profuse perspiration and the peculiar muscular symptoms; from ordinary rheumatism by the gastro-intestinal catarrh and general exhaustion. With the appearance of oedema of the eyelids and face at the end of a week the diagnosis becomes more certain. The further progress of the affection is so characteristic that its distinction can scarcely remain in doubt. The general prostration, the violent muscular symptoms, the bronchial catarrh, the hoarseness and dyspnoea, the profuse sweating, and the sleeplessness, render the case pretty clear.

In the prognosis of the disease no positive conclusion can be derived from the severity or early appearance of the initial symptoms. Commonly, the more speedily they occur and the more violent they are, the less favorable will be the prognosis, while the later they appear, the more propitious it is. Long-continued diarrhoea is especially unfavorable, while a profuse diarrhoea at the beginning is to be viewed as a fortunate event. The prognosis is more favorable in cases in which sleep and the appetite are maintained, and in those in which the disturbance of the respiratory organs is slight. A favorable termination of the affection is the rule with children.

TREATMENT.—The treatment of trichinosis is not generally promising in favorable results. No means have yet been discovered to destroy or remove trichinæ which have migrated from the intestinal canal. While the parasites continue within the latter we may have reasonable hope of expelling them from the body by means of the usual remedies for intestinal worms. Experience, however, with these remedies has not been in accordance with expectations. In the mean time, until some more potent vermicide is discovered applicable to the destruction and removal of trichinæ from the intestine, we are disposed to place most reliance on such purgatives as oil of turpentine and castor oil and calomel and jalap. Subsequently, a good nutritive diet with wine is recommended to preserve the life of the patient until the affection has reached that period when the parasites become capsulated and there is no longer danger from them as irritants.

As a preventive of trichinosis, besides the avoidance of pork or its varied preparations of ham, sausages, etc. when it is known or suspected they may be infested, thorough cooking of meats is a certain means. A boiling temperature surely kills all animal parasites, but care is requisite that large pieces of meat should be cooked sufficiently long that the desired heat may extend to the interior throughout. The writer may add that it was in a slice of boiled ham, from which he had partly made his dinner, that he first discovered trichina in the hog.

Of the nematode worms there are many species of comparatively long, slender proportions, which constitute the family of Filaridæ. As parasites they rarely occupy the interior of the intestinal canal, except by way of transit, and live in most other organs and tissues of the body of both vertebrate and invertebrate animals.

FILARIA MEDINENSIS.—SYNONYMS: Dracunculus; D. medinensis; Medina-worm; Guinea-worm.

The Medina-worm has long been recognized as a parasite of man, and by competent authorities has been regarded as the fiery serpent which afflicted the children of Israel in the wilderness of Judea. It prevails in the tropical regions of Africa and Asia, and thence has been introduced into tropical America. It is ordinarily observed as a long, white, cord-like worm, situated beneath the skin in any part of the body, but mostly in the lower limbs, and especially in the vicinity of the ankle. Though a frequent parasite, only the female is known. In the mature condition it is nearly uniformly cylindrical, and ranges from eighteen inches to three or four feet in length and less than a line in thickness. The head end is rounded and furnished with a little papillate plate, in the centre of which is situated a minute oral aperture. The caudal end is conical and incurved. The intestinal canal is atrophied and without an anal aperture. The coelum is mainly occupied by a capacious uterus filled with free embryos. A generative aperture appears also to be absent, and the young can only escape by rupture of the parent.

Experiments made about a dozen years since in Turkestan by Fedschenko, at the suggestion of Leuckart, have shown that when the embryos of the Medina-worm are introduced into water containing the familiar little crustacean cyclops, they penetrate into this, and within it undergo transformation into the larval stage. The subsequent history of the larval worms remains unknown, but from what we have learned of the history of many parasitic worms it is reasonable to suppose that if the infested cyclops is swallowed in drinking-water, it may explain the presence of the mature worm in the human body. The young worms, liberated from their crustacean host by digestion in the stomach, probably enter the intestine, and thence migrate to their destination. In the young condition, advancing to maturity, the worms have been found in all parts of the body except within the cranium and eyeball. They appear to migrate in the course of the least-resisting connective tissues, along the route of the principal blood-vessels, until they reach the surface of the body.

Usually, a single worm is found in a person, though cases occur where several, to a dozen or more, are present. Commonly, the parasite is solitary, though two or three may be associated together. When deeply seated the Medina-worm ordinarily produces but little discomfort, though in some cases its movements are accompanied with more or less severe pain. It also gives rise to inflammation and the formation of an abscess, in the purulent matter of which the worm lies bathed. The removal of the worm, when accessible, by the proper surgical aid is followed by complete relief.

It is evident that filtration of the drinking-water would be a certain prophylaxis for the Medina-worm.

FILARIA SANGUINIS.—SYNONYMS: Filaria sanguinis hominis, Lewis; F. sanguinolenta; F. Bancrofti, Cobbold.

Another species of Filaria, a more dangerous parasite of man and indigenous to the tropics, is of frequent occurrence, though of comparatively recent discovery. It has been observed in India, Africa, Brazil, and the West Indies. It is commonly seen in the embryonic condition, living in the blood of patients affected with elephantiasis and certain other diseases, and is also found in the urine. In this early condition it is a minute worm, scarcely more than the ¹/100 of an inch in length, and occurs together in immense numbers.

In the sexually mature condition the female filaria is a white hair-like worm three or four inches in length, living in the lymphatic vessels distally to the glands, especially in those of the lower limbs and scrotum. The embryos after leaving the parent pass into the lymphatic stream, and thence into the circulating blood. According to recent observations of Manson, they enter the blood in the evening and increase in number until midnight, after which they decrease and disappear by morning, from which time during the day they remain absent from the circulation. The investigations of the same authority have shown that when the blood of infected persons is sucked by mosquitoes these insects also imbibe the embryos, which subsequently undergo transformation in the mosquitoes into the larval state. In this condition the filariæ may be transferred to water, by drinking which man may become infected with the parasites. The larvæ introduced into the stomach appear thence to make their way to the lymphatics, within which they undergo further development to maturity, and thus remain a long time.

The presence of the worms in the lymphatics, with their numerous brood in the circulating blood, gives rise to hæmaturia and chyluria. As results of the obstruction of the lymphatic currents, the parasites induce inflammation, suppuration, lymphatic abscesses, buboes, lymphangiectasis, oedema, ascites, chylous hydrocele, elephantiasis,³ and certain cutaneous affections.

³ Several years since, with the view of ascertaining the presence of parasitic worms, the writer examined the blood of a case of elephantiasis under the charge of T. G. Morton, but none were detected. From what we have since been informed of the habits of Filaria sanguinis, the absence of the parasites may have its explanation in the circumstance that the blood examined was withdrawn in the daytime.

TREATMENT.—While the treatment of the affection induced by the Filaria sanguinis is varied and uncertain, the prophylactic measures are obvious and certain. Under favorable conditions of bright light, high temperature, and abundant food the stagnant waters of tropical countries are especially prolific of the minute forms of animals which harbor parasites. It hence becomes evident that all such waters, whether obtained from puddles, ponds, tanks, or cisterns, should be filtered before being used for drinking. Boiling is also effectual in destroying all the animal life of waters, and thus rendering them innocuous so far as parasites are concerned.

Several other species of Filaria have been found in the human body, but are little known and very rare in their occurrence.

FILARIA LOA.—This species occurs in Western Africa, on the Gaboon River, and is perhaps more frequent than now commonly supposed. It is an active worm, little more than an inch in length, and is usually found beneath the conjunctiva of the eye. It probably also occupies other positions, and a missionary on the Gaboon informed the writer that he had extracted one from the back of one of his own fingers. Its presence produced an intense burning pain. The negroes are reported to extract the worm by means of a thorn. The worm has also been observed in Brazil and the West Indies.

FILARIA RESTIFORMIS.—Under this name the writer recently described a large Filaria reported to have been withdrawn from the urethra of a man in West Virginia. It was obtained by C. L. Garnett, and sent, together with an account of the case, to the Army Medical Museum of Washington, where it is now preserved. It was a red cylindrical worm, twenty-six inches in length, tapering at the head, and thick, incurved, and obtusely rounded at the tail end.⁴

⁴ Proceedings of the Academy of Natural Sciences, Philada., 1880, p. 130.

FILARIA OCULI HUMANI; FILARIA LENTIS.—A few cases are on record of the occurrence of little worms in the aqueous humor and crystalline lens of the human eye, to which the accompanying names have been applied.

FILARIA TRACHEALIS.—Recently some minute worms found by Rainey in the trachea and lungs have been described under this name.

In conclusion, the writer acknowledges his indebtedness for much of the information of this article to the articles on "Intestinal Parasites" and "Diseases from Migratory Parasites" in Ziemssen's Cyclopædia of the Practice of Medicine, and to Glazier's Report on Trichina and Trichinosis.

DISEASES OF THE LIVER.

BY ROBERTS BARTHOLOW, A.M., M.D., LL.D.

I. FUNCTIONAL DISORDERS.

Biliousness.

DEFINITION.—The term biliousness is used to signify a disturbance of the gastro-intestinal digestion, with coincident excess in the production of bile. According to the popular conception, both lay and medical, the excess of bile is the cause of the symptoms; but when the whole subject is carefully examined it will be found that biliousness is made up of several factors, and that the hepatic disorder, if it exist at all, is a mere incident.

PATHOGENY.—From the time of Galen biliousness has been regarded as a morbid entity and the liver as the organ affected. Stoll, amongst moderns, first revived the Galenical doctrines. Abernethy¹ was amongst English physicians the most conspicuous advocate of the condition called biliousness, and was the apostle of blue pill and black draught. Copland in his great dictionary² more distinctly formulated the views of the English school—especially that portion of it influenced by the results of Indian practice—than had been previously attempted, and hence his work best represents the opinions and practice of the time amongst the English-speaking peoples. In this country the great Rush first promulgated the notions of biliousness which have since so dominated the medical opinion of this continent. A large part of the United States has proved a fruitful soil for the cultivation of theories of biliousness, since the condition known under this name is a frequent accompaniment of malarial poisoning. To this fact must be attributed the preponderating importance of biliary derangements in the practice of the physicians of India also.

¹ Surgical Works, London, 1811, vol. i. p. 36.

² A Dictionary of Practical Medicine, vol. ii. p. 723.

It is a fact which will be hereafter more fully developed that malarial infection may, and often does, derange the hepatic functions without producing fever. The malarial poison irritates the liver, and thus more bile is produced, but the quality deteriorates with the increase in quantity. The functions of the liver are more disturbed during an access of intermittent fever: the organ is swollen, the skin is muddy, the eyes yellow, the tongue coated with a thick yellow fur, and the urine is deeply tinged with bile-pigment.

Many of the metals employed as medicines and as poisons, as gold, silver, antimony, arsenic, phosphorus, etc., irritate the liver both in their entrance and in their exit from the organism, and cause biliousness; and the same fact is true of some vegetable alkaloids and animal poisons. The liver excretes many of these substances, and in their passage out from the blood the hepatic cells are irritated and an increased production of bile is a result. Improper food, indulgence in fats, sweets, condiments, and all kinds of fermented and alcoholic liquors, intestinal indigestion arising from any cause, and gastro-duodenal catarrh, are the most usual and obvious pathogenic factors. In respect to food and indigestion as etiological factors there are several points requiring more explicit statement. When nitrogenous elements (albuminoids) are in excess in quantity or as respects the power to digest and convert them, immature products, of which uric acid is the chief, accumulate in the blood. When the fats, sugars, and starches are in excess of the requirements of the organism or are imperfectly disposed of in the small intestines, a local irritation of the mucous membrane is produced, and various complicated, immature products enter the blood. With these troubles and faults of intestinal digestion a gastro-duodenal catarrh is usually associated. Without the production of catarrhal jaundice, gastro-duodenal catarrh, with the forms of indigestion accompanying it, keeps up a reflex irritation of the liver. Just as the presence of normal chyme induces the flow of bile, so the unhealthy products of intestinal indigestion excite an irritation of the liver. The continued operation of this cause maintains an abnormal activity of the liver, and more bile is produced than is easily disposed of.

SYMPTOMS.—The condition of biliousness, as now understood, is made up of derangement of the gastro-duodenal mucous membrane, with bile-production in excess and bile-absorption probably delayed. The symptoms are the product of these complicated conditions. The complexion is muddy; the conjunctivæ are yellow; the tongue is heavily coated with a yellowish-white fur; a bitter taste persists in the mouth; the breath is heavy in odor, even fetid; the appetite may be keen or there may be complete anorexia; a sensation of nausea, of heaviness, and fulness of the stomach is experienced, especially after eating; the bowels are confined usually, but occasionally the movements are relaxed, bilious in appearance, and cause heat and irritation about the anus; headache is constantly present to some extent, and there is a sense of fulness with more or less dizziness, and singing in the ears; vision is rather blurred, and there is a hebetude of mind; the urine is high-colored, high in specific gravity, and deposits lithates abundantly on cooling. When these symptoms are conjoined with hemicrania, nausea, and vomiting, the case is called bilious sick headache, and when diarrhoea supervenes, the discharges apparently containing much bile, it is bilious diarrhoea. The symptoms which above all others give the character to the morbid complexus are the muddy (bilious) complexion, the yellow-coated tongue, the yellow conjunctivæ, and the high-colored urine. The first departure from the normal may be scarcely observed. Gradually, owing chiefly to errors of diet, to climatic changes, or to malarial influences, or to these several factors combined, the affected person drifts into the condition of biliousness above described. Besides the general malaise, he experiences no little despondency, inaptitude for exertion, and indeed actual weakness. Finally, he is unable to apply himself to business, relinquishes the effort, and seeks advice.

COURSE, DURATION, AND TERMINATION.—Those who are accustomed to experience attacks of biliousness suffer from them at certain intervals which may be tolerably regular—at intervals of a few days, two, three, or four weeks—when the cause is uniform; but they may happen very irregularly when the conditions producing them are variable. The duration of an attack is from two days to a week or more, according to the severity of the symptoms and to the character of the measures instituted for relief. The termination is in a return to the normal state. If the conditions which produced it continue, when one attack is ended the preparations for another begin at once, and at length sufficient derangement of the organs concerned arises to constitute the morbid complexus of biliousness.

TREATMENT.—Prophylaxis has great importance, since the causes of the malady are to a considerable extent, at least, preventable. Errors of diet in respect to the use of condiments, fats, meat, pastry, etc. must be corrected. When there is pronounced gastro-duodenal catarrh and acid fermentation in the duodenum, the saccharine, fatty, and starchy elements of the food must rather be excluded and lean meats allowed. Abundant exercise, bathing, and an open-air life in general should be directed. Whenever a malarial infection is causative a change of climate becomes imperative. Heredity cannot, of course, be excluded, but the tendency to hepatic derangement can be rendered inoperative by an abstemious life.

The remedial management includes the dietetic as well as the medicinal treatment. When the distress has reached sufficient proportions to justify such an extreme measure, the patient should be restricted to a diet exclusively of skimmed milk, of which he is directed to take a gill or more every three hours. This serves a double purpose, as aliment and as a depurative agent, for this considerable quantity of fluid promotes the urinary excretion and the elimination of waste products. If the case is not severe enough to allow of such an expedient, the diet should in any event be restricted to skimmed milk hot, milk and hot water, hot lemonade, a little chicken or mutton broth, a bit of dry toast, etc. As a rule, although not so palatable, hot drinks are more beneficial than cold, but if the preference is decidedly for cold, they may be allowed. After the more severe symptoms have subsided a little lean meat broiled may be added, and as the cure proceeds the succulent vegetables and acid fruits may be permitted. Abstinence from potatoes, hominy, cracked wheat, and oatmeal should be enjoined during the convalescence of those who suffer from habitual attacks.

Medicines may not be necessary to those who have the resolution to adhere to skimmed milk for several days or who can abstain from food altogether for a day. Many experienced sufferers, especially through the South and West and in England, procure rather prompt relief from a blue pill of ten to fifteen grains or from one to five grains of calomel at night, followed by a Seidlitz powder, Rochelle or Epsom salts, or phosphate of soda on the following morning. Such patients find that no other treatment is as serviceable. They get relief from other measures, it is true, but neither as promptly nor as satisfactorily. It is held by the advocates of this practice that the mercurial acts on the liver—that the surplus bile is carried off; and they point to the peculiar stools and to the relief experienced in evidence of the truth of this theory. Without entering on the argument, which would occupy too much space, it must suffice here to state that calomel and blue pill do not increase bile-production,³ but they do stimulate the intestinal glands and increase excretion from them. The peculiar greenish stools produced by these mercurials do not owe their characteristic appearance to the presence of bile, but rather to the chemical transformations of the mercury itself and to the waste products excreted by the intestinal glands. Since the researches of Rutherford have been published, euonymin has been much prescribed in cases of biliousness. From three to five grains are taken at the bed-hour, and a mild laxative in the morning. In the same group of cholagogues are ipecac, iridin, sanguinarin, and especially podophyllin; but the serious objection to their use is that they stimulate the liver when this organ is in an irritable state. As calomel and blue pill have a sedative rather than a stimulant action on the liver, they are more useful in biliousness than are the true cholagogues. It should be borne in mind that one-half of a grain of calomel will have a distinct purgative action on many persons, and that one grain will rarely need to be exceeded.

³ That calomel, the type of a mercurial purgative, does not increase the discharge of bile has been demonstrated on dogs by Röhrig and Rutherford, and confirmed by observation of the effects of 20 grains on Westphalen's case of biliary fistula in man—a case in which, for a time, all the bile escaped externally, and none apparently entered the intestine (Deutsch. Archiv f. klin. Med., 1873, Band xi. pp. 598 and 600).

In general, notwithstanding the unquestionable utility of the mercurial, it is better to relieve cases of biliousness by less objectionable measures. A saline which acts at the same time on the intestines and kidneys, as Rochelle salts, is usually effective in bringing relief. A bottle of solution of magnesia citrate, of Saratoga water (Congress, Hathorn, or High Rock), and of Blue Lick, the famous sulphurous laxative of Kentucky, may remove the disorder in mild cases if at the same time a suitable diet is enjoined. Phosphate of soda in laxative doses, with or without Vichy water, is also a good remedy, if somewhat slow. The warm purgatives, rhubarb, colocynth, aloes, etc., are useful when there is pronounced constipation.

Lithæmia.

DEFINITION.—By the term lithæmia is meant a condition of the system in which uric (lithic) acid is produced in excess, and in which certain derangements occur in consequence of the accumulation of this material in the blood. Uricæmia was the term first suggested by Flint, Sr.,⁴ to express this state, and subsequently lithæmia was employed by Murchison.⁵ The latter has been more generally accepted. In one of the most recent and valuable contributions to this subject by DaCosta⁶ lithæmia is the term used to designate the complex of symptoms produced by uric acid in excess.

⁴ The Principles and Practice of Medicine, Philada., 1882.

⁵ Clinical Lectures on Diseases of the Liver, 2d ed., p. 565.

⁶ The Medical News, vol. ii., 1883.

PATHOGENY.—The ultimate product of albuminoid substances in the organism prepared for final excretion is urea. That this substance is finally formed in the liver, to be excreted by the kidneys, seems now well established.⁷ In acute yellow atrophy of the liver, with the disappearance of the proper structure of the organs urea ceases to be produced, and instead leucin and tyrosin are excreted. In certain states of the system characterized by deficient oxidation urea is not sufficiently formed, and instead uric acid, a lower grade of oxidation and a product of the disintegration of albuminoid substances, results. An excess of urates is not always pathological. Their excretion seems to be in a certain sense a safety-valve function. When albuminoid matters are taken in excess of the power of the system to convert them, or when the supply of oxygen to the blood is deficient from any cause, urea is not formed, but uric acid and urates are abundantly excreted by the urine.⁸ Imperfect digestion of the albuminoids when they are not taken in relatively too large an amount, and limitation below the normal of the oxidation process when the supply of oxygen is not insufficient, will have the same effect: in place of urea, uric acid and urates will be formed and excreted. One of the early results of the persistent presence of an excess of uric acid is the production of lithæmia, the morbid complexus of which this excess is at once the cause and the proof.

⁷ This proposition is not universally accepted. Valmont (Thèse de Paris, Étude sur les Causes des Variations de l'Urée dans quelques Maladies du Foie, 1879) has carefully studied the excretion of urea in several diseases in which the proper structure of the liver is damaged—in atrophic cirrhosis and in cancer. As in these maladies not all the secreting portion of the organ is destroyed, the argument is so far weakened. His conclusions are as follows: "1. Patients with cirrhosis or cancer of the liver who eat little excrete but little urea. If they eat and do not absorb, or vomit or have diarrhoea, the result is the same. When they partake largely of nitrogenous aliment the proportion of urea rapidly increases. 2. In a cachectic or simply anæmic patient the urea falls, apparently in proportion to the state of the general nutrition and of the work done by the organic functions. 3. Absolute immobility of the patient seems to have an influence on the amount of urea excreted. 4. In sclerosis or cancer the quantity of urea falls rapidly on the occurrence of ascites or oedema, when a notable quantity of urea is found in the fluid. 5. The digitalis often used in the treatment also contributed to the loss of urea." If these conclusions are verified, the formation of urea must depend on some other function.

⁸ Genevoix, Essai sur les Variations de l'Urée et de l'Acide urique dans les Maladies du Foie, Paris, 1876.

The persons who suffer from lithæmia are usually those who indulge in the pleasures of the table and habitually consume much meat, pastry, and highly-seasoned and rich food of all kinds. The idle, luxurious, and indolent, literary men of sedentary habits, men who have led active lives, but on retiring from business have continued to indulge in a full diet, are apt to suffer from this malady. Women are less disposed to it, but if subjected to the same conditions may also be similarly affected. Especially do those suffer from lithæmia who indulge in malt liquors or in alcoholic drinks of any kind. These substances act by deranging digestion, and thus preventing the proper conversion of the albuminoids, by inducing congestion of the liver, and also by interfering with the process of oxidation.

SYMPTOMS.—The symptoms of lithæmia include derangements of the digestive organs and of the liver, of the circulation, and of the nervous system. As these subjects suffer from gastric and gastro-duodenal catarrh, they present the usual symptomatology of these affections, as a sense of weight and oppression at the epigastrium, acidity, pyrosis, a capricious—sometimes voracious, sometimes good—appetite, a coated tongue, a bitter taste, etc. The bowels are irregular, sometimes constipated, occasionally relaxed, with scybalæ. The stools may be liquid, almost black or light-yellow and grayish. The motions are apt to be offensive, and a good deal of offensive gas is discharged with them. Hemorrhoids are often present, and there may be heat and irritation about the anus, and not unfrequently intolerable itching. After meals there is much depression, and often an insupportable drowsiness. Irregularity in the rhythm, even intermissions, of the pulse are not infrequent.

The nervous symptoms, as DaCosta has lately insisted on, are the most important and pronounced. The connection between oxaluria and mental despondency has long been known, but the nature of the relation remains undetermined. Headache, frontal and occipital, especially the former, dizziness, tinnitus aurium, suffusion of the eyes, ecchymoses of the conjunctiva, are usually present. Not unfrequently the subjects of this affection experience sudden attacks of vertigo, accompanied by dimness of vision and intense headache, and are supposed to have some organic lesion of the brain. They are irritable, despondent, and often intensely hypochondriacal, almost suicidal—are subject to neuralgic attacks, and have aching in the limbs, a sense of weariness, and more or less burning in the palms and soles.

The skin is rather dry and the complexion muddy. Urticaria is of frequent occurrence, and sudden attacks of nausea, vomiting, and intestinal pain coincide with the appearance of the eruption on the skin.

The urine is usually rather increased in amount, its color heightened, its acidity above normal, and floating in it, usually visible to the naked eye, are reddish masses composed of uric acid. More or less pain in the back, referable to the situation of the kidneys, and sometimes extending along the course of the ureters, is common. The bladder is rather irritable, and the passage of the urine produces heat and scalding. The testicles are apt to feel sore and are somewhat retracted. On standing, the urine may deposit uric acid and the urates copiously, or the acid may be seen to form a cloud which slowly subsides.

COURSE, DURATION, AND TERMINATION.—The course and duration of lithæmia are much influenced by the habits of life of the person affected. When unopposed by treatment and no change is made in the conditions producing it, a gradual increase in the various disturbances takes place. After a time structural changes occur in the liver; the organs of circulation early undergo atheromatous degeneration; various cerebral disorders due to degenerative changes arise; and acute intercurrent affections may terminate life. Amongst the secondary maladies due to lithæmia are gout, diabetes, renal calculi, and nephritic colic. If the cases are subjected to appropriate treatment, curative results may be certainly obtained. The prognosis, then, will be influenced materially by the moral strength of the patient. If he is one who can surrender his appetites and live abstemiously, a cure may be promised. The case is far different with those who will continue the use of malt, vinous, or alcoholic drinks, and will persist in indulging in the pleasures of the table.

DIAGNOSIS.—The differentiation of lithæmia from other affections offers no special difficulties. From gastro-duodenal catarrh it is separated by the excess of uric acid in the urine only, the other symptoms being for the most part the same. The cerebral symptoms—the vertigo, headache, etc.—are to be distinguished from the same due to actual disease of the brain by the previous history, by the absence of changes seen on ophthalmoscopic examination and of other signs of brain disease, and by the subsequent behavior. Cases of cerebral mischief producing such effects would rapidly develop into serious states, whereas in lithæmia there are great fluctuations, but no apparent progress in many months. In lithæmia also there are no changes in the fundus oculi, whereas in brain diseases choked disk, hemorrhage into the retina, white atrophy, etc. are often discovered. Further, in lithæmia there are no disorders of sensibility, of motility, or of intellection, whilst these are ordinary evidences of cerebral mischief.

TREATMENT.—Attention to diet is of the first importance. As uric acid is an intermediate product in the metamorphosis of albumen, it might be supposed that to diminish the quantity of this constituent of the food would be sufficient. In some cases this suffices, but usually attention must be given to the peculiarities of digestion characteristic of each patient. More frequently trouble arises from indulgence in the starchy and saccharine constituents of the diet; in some a very considerable gastro-duodenal catarrh exists, and the mucus, acting as a ferment, sets up an acetic fermentation in the starchy and saccharine substances, with the necessary production of much carbonic acid gas. If the fats disagree, the butyric fermentation also takes place, and very irritating fat acids result. In these cases there is usually much gas formed in the stomach and intestine, and an immediate ratio appears to exist between the degree of mental despondency and the quantity of gas in the intestinal canal. It follows, then, that in cases of lithæmia the saccharine, starchy, and fatty constituents of an ordinary diet should be omitted from the food of such subjects. Bread should be partaken of very sparingly, and the foods containing starch, sugar, and oil ought not to be partaken of at all. The succulent vegetables, as lettuce, spinach, celery, cole-slaw, tomatoes, etc., ought to be substituted. Lean fresh meats, poultry, game (plainly cooked), fresh fish, oysters, eggs, etc. should constitute the basis of the diet. On the other hand, there may be those who do better on a diet of vegetables and fruit, excluding meat. In such we may suppose the fault lies in the stomach digestion, where the albuminoids are converted into peptones, the intestinal digestion being active and normal. All kinds of wine and malt liquors should be prohibited. Coffee and tea must also be relinquished. Without the carefully-regulated diet medicines can accomplish but little; hence he who would obtain curative results must give careful attention to every dietetic detail.

As deficient oxidation is an important factor in developing lithæmia, active exercise must be enjoined. The amount of exercise must be determined by the condition of the individual and the time, regulated as far as may be by the period after meals. As when the food prepared for assimilation is entering the circulation oxygen is needed to perfect the final changes, it seems clear that exercise should be taken three or four hours after the process of digestion has begun. Walking exercise is better than any other for this purpose, but it should not be carried to the point of exhaustion from fatigue. Sea-air and sea-bathing are oxidizing agents of considerable value, and are especially useful to the subjects of lithæmia suffering at the same time from malarial infection.

Medicines are administered with the view to accomplish two purposes: to correct the disorders of digestion, to promote oxidation. One of the most useful remedies is nitric acid, five to ten minims of the official diluted acid being given before meals. It is more especially effective when there is an excessive production of acid. The fermentation which produces acid and the diffusion of acid-forming materials from the blood are alike prevented by it. The injunction to administer it before meals must be borne in mind when these purposes are to be subserved. Nitric acid, as well as the other mineral acids, but in a greater degree, promotes the flow of bile. This well-known clinical fact has been confirmed by experiments. Under the use of nitric acid, as above advised, uric acid and the urates disappear from the urine, being excreted as urea, and hence this remedy accomplishes both of the objects for which medicines are administered in this disorder. No other mineral acid can fill its place in this connection.

Alkalies possess very decidedly the power to promote oxidation. The soda salts are objectionable, for, combining with uric acid, they form the insoluble urate of soda. The salts of potash and lithium, on the other hand, form soluble combinations, and they also increase elimination. Much depends on the time at which they are administered, as Bence Jones,⁹ and since Ralfe¹⁰ especially, has shown. To increase the alkalinity of the blood and urine, they must be taken after meals, for then the acid materials of digestion are pouring into the blood. For the same reason, if alkalies are administered to neutralize the acidity of the intestinal canal, they must be given after meals. The most useful alkaline remedies are liquor potassæ, bicarbonate of potash, Rochelle salts, citrate of lithium, etc. The effervescing preparations of potash and of lithium are elegant and palatable forms in which to administer these remedies. They may also be taken dissolved in Vichy water, in our Saratoga Vichy, or in Carlsbad or Bethesda. When the use of mineral waters is not contraindicated in the state of the digestive organs, great good is accomplished by the persistent use of Vichy, foreign or domestic, of Carlsbad, and the alkaline waters of Wisconsin.

⁹ Lectures on Pathology and Therapeutics, by H. Bence Jones, London, pp. 90, 280.

¹⁰ Physiological Chemistry, by Charles Henry Ralfe, London, 1883.

The so-called cholagogues are unquestionably useful, but they become less and less necessary according to the success achieved in the dietetic course. Phosphate of soda is one of the most effective of this group of medicines. As it acts as a compound, and not as a salt of soda merely, it does not come within the prohibition against the use of soda salts. It promotes the flow of bile and appears to remove the catarrhal state of the mucous membrane. A teaspoonful three times a day is the quantity usually required. Under some circumstances it may be advantageously combined with arseniate of soda. Mercurials were formerly almost universally used, but they have been largely supplanted by podophyllin, euonymin, baptisin, etc., and by the phosphate of soda above mentioned. Podophyllin is indicated when constipation is a symptom. An efficient mode of giving it is in the form of granules, but it must be continued without intermission for some time or during the existence of the lithæmia. The quantity given should be sufficient to maintain the evacuations in a soluble state. Good results are obtained from a combination of podophyllin with extracts of physostigma, nux vomica, and belladonna. When distinct torpor of the liver without constipation exists, euonymin, combined with physostigma, may be advantageously used. For the vertigo and hypochondriasis no remedy is more beneficial than arsenic (Fowler's solution) in small doses kept up for some time, and it is also distinctly curative of the catarrhal state of the mucous membrane. When malarial infection is the cause of lithæmia, quinine becomes indispensable.

Topical agents in some cases render important aid to the other curative measures. A daily sponge-bath, the water made more stimulating by the addition of sea-salt, is very useful in the absence of sea-bathing. Friction of the hepatic region with the official ointment of the red iodide of mercury unquestionably stimulates the hepatic functions. General faradization and faradic and galvanic excitation of the chylopoietic system promotes activity of the digestive apparatus and of the organic functions in general.

Hepatic Glycosuria (Temporary).

DEFINITION.—By the term hepatic glycosuria in this connection is meant a temporary glycosuria due to excessive formation of glycogen. The liver, unduly stimulated, produces more glycogen than can be disposed of, and hence it is excreted by the kidneys as grape-sugar.

PATHOGENY.—In the normal condition it is supposed that the glycogen produced by the liver is converted into grape-sugar, and soon oxidized and thus consumed. One theory of diabetes maintained that in some way the conversion of glycogen into grape-sugar was excessive and beyond the oxidizing power of the blood, and hence this substance was discharged in the urine. The recent discovery by Pavy¹¹ of glycogen in considerable amount in the blood of all parts of the body renders it certain that there are peculiar conditions necessary to the formation of grape-sugar in sufficient quantity to constitute diabetes. It is tolerably certain that an excess of acid in the intestinal canal, diminishing thus the alkalinity of the blood, will have as a symptom sugar in the urine. Persons disposed to the accumulation of fat, and eating freely of sugar and starchy food, are apt to have intestinal indigestion, and the acid produced by the fermentation of these substances will, after its absorption, hinder the conversion of any food-sugar. In such subjects also there may be an increased conversion of the glycogen of the blood into sugar under the same conditions. Such a glycosuria must necessarily be temporary and a purely functional disorder.

¹¹ The Lancet, vol. ii., 1883.

SYMPTOMS.—The subjects of the malady under consideration are of full habit, even obese. They habitually consume considerable quantities of malt liquors and a diet composed largely of the starchy and saccharine foods. If not in malt liquors, they at least indulge freely in bread, potatoes, pastry, cakes—in all forms of farinaceous food, fats, and sweets. They have a keen appetite, eat largely, and drink freely of fluids. As a rule, these subjects are but little disposed to physical exercise and lead rather sedentary lives. Indulgence in such a mode of life tends to increase the accumulation of fat, weakens the muscles, and with them the heart-muscle, and slowly induces a gastro-intestinal catarrh accompanied by stomachal and intestinal indigestion. At first, heaviness, oppression, and drowsiness after meals are experienced; then acidity, pyrosis, and eructations follow; and ultimately the evidences of intestinal indigestion—flatulence, pain, irregular and unhealthy evacuations, etc.—come on. Meanwhile, the appetite is not usually impaired, and the disposition to drink fluids increases; the amount of urine voided is greater, and to rise during the night for the purpose of emptying the bladder comes to be a fixed habit. The urine under these circumstances is copious, high-colored, acid, and deposits on cooling abundantly of uric acid and urates. The amount passed in twenty-four hours will reach sixty, eighty, or more ounces, and the specific gravity will range from 1025 to 1035. On testing in the usual way, traces of sugar, more or less distinct, will appear,¹² but not constantly, and hence repeated examinations are necessary to determine the quantity. As a rule, the evidence of the presence of sugar in small amount is satisfactory.

¹² In testing for sugar, when the urine contains the urates in such abundance there is danger of error. In using Trommer's, Fehling's, or Moore's test, on heating, the urates will effect a reduction of the copper or bismuth. It is necessary, therefore, to separate them before applying the test. This is accomplished as follows: The urine is evaporated to dryness on a water-bath; the sugar in the evaporated residue is dissolved out by absolute alcohol, and then an aqueous solution is prepared, to which the test is applied. An experienced operator will not need to take such precautions, for, familiar with the reactions, he can readily judge of the results.

Various affections of the skin appear in the subjects of this malady, and urticaria, prurigo, eczema, and boils are the forms most usual.

COURSE, DURATION, AND TERMINATION.—Slow in developing, this temporary glycosuria is also slow in its course. It remains nearly stationary for months, even years. Meanwhile the degenerative changes associated with it slowly develop on all sides. The quantity of sugar does not greatly increase, for its amount, being apparently dependent on the quantity of acid entering the blood from the intestinal canal, must continue nearly at the same standard. It is comparatively rare for true diabetes to develop out of this state, although such a termination must be regarded as a natural outcome. One reason, it may be, why such a conclusion is not often reached is because of intercurrent maladies. It is an important fact that acute serous—less often parenchymatous—inflammations are very apt to occur during the existence of even temporary glycosuria. Under appropriate management this disorder is readily amenable to treatment. Hence the prognosis will be favorable or not according to the skill exhibited in its treatment.

DIAGNOSIS.—This malady offers no special difficulty in diagnosis. From gastro-duodenal catarrh and from lithæmia it is distinguished by the saccharine condition of the urine. From diabetes it is separated by the rate of progress, by the protracted duration of the case without any distinct advance, and by the temporary and fugitive character of the glycosuria.

TREATMENT.—To carefully regulate the diet is the first consideration. The traces of sugar and the excess of urates rapidly disappear when the starches, sugar, and fats are withdrawn from the diet. Indeed, the rule as to alimentation must be as rigidly enforced as in true diabetes, but after the gastro-intestinal catarrh has subsided the ordinary mixed diet—that before the disturbance began—may be returned to gradually. Active exercise must be enjoined under the same conditions and for the same purpose as in the treatment of lithæmia. In these obese subjects, unaccustomed to movement, exercise must be cautiously undertaken; beginning with short excursions, it must be gradually increased. Horseback riding is an excellent expedient, but should not take the place of walking.

The merely medical measures have a twofold direction: to remove the gastro-duodenal catarrh; to promote oxidation of the sugar in the blood or prevent the conversion of glycogen into grape-sugar. Vichy water, the potash salts, and alkalies generally serve to accomplish the latter, and phosphate and arseniate of soda, tinctures of nux vomica, and of physostigma, bismuth, and carbolic acid, relieve the former. Small doses of Fowler's solution (two drops ter in die), and a minim three times a day of a mixture in equal parts of tincture of iodine and carbolic acid, are effective remedies in gastro-duodenal catarrh.

Jaundice (Icterus).

DEFINITION.—The term jaundice has its origin in the French word jaune, yellow. Icterus, which has come to be a more technical word, is of uncertain Greek origin, and is much employed by French writers as ictère. The common German name is Gelbsucht, a highly expressive designation. Jaundice signifies a yellow discoloration of the skin caused by the presence of bile. It is a symptom rather than a disease. As a symptom it will receive much consideration in the pages to follow, but there is also a functional disorder—a jaundice due to a disturbance in the biliary functions, without evidences of structural change—which must be discussed here. This preliminary statement of our present knowledge of jaundice will facilitate the comprehension of it as a symptom, and will render unnecessary explanations that will be merely a repetition of previous ones.

CAUSES.—The theories of the causation of jaundice may be reduced to three: 1, that it is due to a disorganization of the blood in which the coloring matter is set free, and hence is known as hæmatogenous; 2, that the materials of the bile, which it is the office of the liver to remove from the blood, are not so disposed of; 3, that the bile, after being formed by the liver, is absorbed into the blood because of an obstacle to its escape, and hence this is called hepatogenous jaundice.

The modern view of hæmatogenous jaundice had its origin in the supposed discovery of the identity of hæmatoidin with bilirubin. If the pigment of the blood has the same composition as the pigment of the bile, hæmatogenous jaundice will be produced whenever hæmatoidin is set free in the blood. Virchow¹³ was the first investigator to show the close resemblance between these two pigments. Since his observation was made an identity of hæmatoidin and bilirubin has been maintained by Zenker, Valentiner, Kühne, and others, and as strenuously denied by Städeler, Preyer, Young, and others. At the present time it appears to be established that although the blood- and bile-pigments are closely related, they are not identical.¹⁴ Nevertheless, a hæmatogenous jaundice is still admitted to exist by Leyden,¹⁵ Immermann,¹⁶ Gubler,¹⁷ Ponfick,¹⁸ and some others. The existence or non-existence of this form of jaundice is, however, of little importance in this connection, since, if it ever occur, the malady of which it is a symptom is not an affection of the liver, but of the blood, as phosphorus-poisoning, pyæmia, etc.

¹³ Archiv für path. Anat., etc., Band i. p. 370, 1847.

¹⁴ Legg, J. Wickham, On the Bile, Jaundice, and Bilious Diseases, p. 243.

¹⁵ Beiträge zur Pathologie des Icterus, Berlin, 1866, p. 6.

¹⁶ Deutsch. Archiv für klin. Med., Band xii. p. 502.

¹⁷ Union médicale, 1857, p. 503.

¹⁸ Ziemssen's Cyclopædia, vol. ix. p. 24.

The second theory, that the bile is preformed in the blood and separated by the liver, and that jaundice results because of the failure of the liver to perform this office, is no longer entertained, although largely held down to within a very recent period. As the bile acids and bile-pigments are not to be found in the blood, chemistry lends no support to the theory of jaundice by suppression of the hepatic function. As they do not exist in the blood and are found in the secretion of the liver, there can be no other view held than that they are formed by this organ.¹⁹