Chapter LXVIII: Part 68

DEFINITION.--Lymphangitis may be either simple or septic. As a rule, the disease is localized, but may, especially when induced by some septic poison, be widely diffused, implicating extensive areas of lymphatic tissue and extending to contiguous structures.

Simple lymphangitis may be either reticular or tubular. In the former the fine capillary network or plexus is involved; in the latter the trunkal vessels are inflamed. Very frequently both forms exist at the same time.

ETIOLOGY.--Simple lymphangitis may be either idiopathic or traumatic. It is, however, rarely spontaneous. External irritation, such as solar rays, pressure, and friction, may set up a superficial inflammation, though usually there is some form of injury--a wound, scratch, sprain, contusion, abrasion, prick, or sting of an insect. The graver forms are caused by neighboring inflammation, suppuration, and ulceration. The products of these morbid changes are absorbed and conveyed along the vessels. The inflammation may be continuous along the course of the vessel, or separated from the origin of the morbid product by an area of intervening healthy tissue. Absorption of the secretions and parenchymatous fluids of inflamed parts is an active and frequent agency in the causation of lymphangitis. It may also be caused by contiguous inflamed tissue and by obstruction of the current of the lymph. Lymph-thrombosis, from whatever cause produced, may excite inflammation at the locality of formation, which is usually in the immediate vicinity of a valve, or the thrombi may disintegrate or undergo puriform liquefaction, and thus extend and diffuse the inflammation.

Slight pricks, scratches, and abrasions, which in themselves are so trifling as not to attract attention, may admit irritating substances from without. This is a frequent cause among medical men, whose hands and fingers are constantly exposed to irritating and ichorous discharges.

Localized lymphangitis is frequently set up by specific kinds of irritation. The adenitis and periglandular inflammations in cases of scarlet fever and diphtheria are familiar illustrations. The indurated glands in syphilis and suppurating buboes in chancroid exhibit the different effects of the virus of these forms of disease. The lymphatics of the solid viscera are often inflamed when the organ is the seat of disease. Pelvic cellulitis, if not in itself a lymphangitis, may be the starting-point of a severe and extensive inflammation of the absorbents, occasionally involving both the superficial and deep-seated vessels along one or both thighs.

Age and constitution are recognized factors. Lymphangitis is more frequent in the young, and is much more easily excited in the strumous and persons in a low state of health. Unhygienic conditions predispose to its development.

{987} Lymphangitis may also find its cause in excessive exercise of function, paralysis of vessels, mechanical obstruction to the lymph-stream, lodgment of particles of cancerous or tuberculous matter in the vessels, compression from cicatrices, indurated connective tissue, tumors, diseased glands, stasis in large veins, and regurgitant heart affections.

SYMPTOMATOLOGY.--Reticular lymphangitis is characterized by rapidly-increasing localized redness, attended with a burning, throbbing pain, and usually quickly implicates the skin and its capillaries. Oedema to a greater or less extent may soon ensue, which, when present, increases the pain. Fever may or may not be present, depending in some measure upon the extent, intensity, and cause of the inflammation and upon individual peculiarities. Erythema usually represents a reticular lymphangitis with hyperæmia of the skin and its capillaries, and erythema nodosum is the same associated with lymphatic oedema. Any trivial injury may induce this form of inflammation, such as a prick or the sting of an insect, which in extent, duration, and intensity will vary with the cause, nature of the poison introduced, location, and susceptibility of the sufferer.

Tubular lymphangitis is usually a much more serious form of the disease. When the vessels of the superficial set are involved, wavy or straight irregularly reddened lines are seen along the course of the vessels, extending from the point of beginning to a single gland or ganglion, which is usually tender and enlarged. These lines feel like hard, knotted cords. The inflammation may be limited by the first tier of glands, or it may extend to one or more distant ganglia. From the inflamed gland the disease may be conveyed along the connecting branches of the deeper set of vessels, and both sets may become involved. The inflammation may also extend through the intervening tissues from the superficial to the deeper-seated vessels. When both sets are involved, the disease assumes a graver form and the symptoms are aggravated. The pain becomes more acute, and the swelling is greatly increased and more diffused. Fever may or may not be present, and is usually moderate when the inflammation is confined to the superficial vessels, but when the deeper set is implicated it often commences with a rigor and is usually considerable. When the deeper set is alone affected the red wavy, knotted lines cannot be seen, but may, unless the oedema is great, be felt. The parts are swelled, indurated, and stiffened, due in the acute stage to increased saturation of the tissues, and in the chronic stage to hypertrophy of the connective tissue. When the oedema is great the covering integument presents a glossy, shining appearance.

PATHOLOGY AND MORBID ANATOMY.--In lymphangitis the adventitia of the vessels and surrounding connective tissue are chiefly affected. The external coat is thickened, injected, and infiltrated with cells. The intima becomes opaque and is stripped of its endothelium. The lymph coagulates in the interior of inflamed vessels and blocks up the channel. These thrombi may become organized and permanently obliterate the lumen of the vessel, or they may liquefy or suppurate. Their products may enter the circulation and cause septicæmia or pyæmia. In a few instances the clots have undergone calcareous degeneration. In some instances coagula are found independently of any disease of the coats of the vessels. In such cases the coagulation has been caused by the entrance of some foreign material into the lymph-stream. The thickening and relaxation of the coats of the vessels lead to dilatation, and consequently to slowing of the current and stasis of lymph. From this may result the serious consequences of an extensive lymphangiectasia, which may involve either or both the superficial and deeper vessels of a large area or an entire extremity. In such cases enormous development of the adipose tissue usually takes place, not infrequently associated with rupture of the dilated radicals and exhaustive periodic discharges of lymph. In most of the {988} cases of lymphangiectasia and lymphorrhagia the fluid, which either accumulates in the affected area or is discharged through the ruptured orifices, presents the physical characteristics and appearance of chyle, due to the quantity of fat it contains. In some cases the fluid at first discharged is serous, and gradually changes, as the flow continues, to a chylous or milk-like fluid. In these cases there is also a tendency to frequently-recurring attacks of an erysipelatous or elephantoid inflammation. This predisposition is traceable to the structural changes produced by the previous inflammation, traumatism, or thrombosis. Inflammation and lymph-thrombosis are the pathological processes which usually cause circumscribed narrowing or complete occlusion of lymph-channels; and within the area from which the narrowed or occluded vessels originate there is lymph-stasis, dilatation of trunkal vessels, and oedema of the tissues. Lymphangitis may also cause adhesion of the internal surfaces of the vessel, fibroid transformation or calcification of their coats, and suppuration.

The alterations which take place in the lymph consist chiefly of an increased proportion of fibrin, the addition of numerous cell-elements, not unlike endothelial cells, white and occasionally red blood-corpuscles, lymphoid cells, granular matter, and a varying quantity of albumen and fat, which in a measure must owe their presence to pathological processes affecting the intima and to transformation of the inflammatory products.

All forms of inflammation of the lymphatic vessels exhibit a tendency to extend to the connective tissue. Cellulitis is almost a constant accompaniment of lymphangitis. In other cases the inflammation and consequent thrombosis and obstruction of the lymph-stream produce oedema and saturation of the tissues. Hyperplasia and sclerosis of the connective tissue follow.

Adenitis is characterized by swelling, congestion, and hardness. If resolution takes place, as is usual in all forms of simple lymphangitis, the gland or ganglion will be restored to its normal condition, though not infrequently some enlargement and firmness will remain for a considerable time, which favor recurrences from very trivial causes. It often happens, however, that structural changes occur. Exudation and suppuration may take place. Suppuration begins in the centre, and sooner or later the whole gland-structure is converted into a pus-cavity. Buboes are usually associated with periglandular abscesses. In fact, the latter are very frequently present when the glands do not suppurate, but have assumed a condition of chronic or subacute inflammation, which subsides very slowly and is subject to recurring acute exacerbations from some continuous or repeated irritation. Glands may be devastated or rendered wholly or partially impermeable, thus forming permanent and irremediable obstacles to the lymph-stream. Inflamed and swollen glands are not necessarily impermeable, but the flow of the lymph through them is undoubtedly impeded. The subacute or chronically inflamed glands may become adherent to and imbedded in a mass of indurated connective tissue, and may finally undergo calcareous or caseous degeneration.

Lymphangitis sometimes extends by contiguity of tissue to the synovial membrane of joints, most frequently the knee-joint. So likewise may synovitis and other joint affections set up a lymphangitis. In either case the tendency to suppuration is imminent.

DIAGNOSIS.--The diagnosis of the forms of simple lymphangitis is very easy. The red, wavy, corded, and irregularly-knotted lines following the course of lymphatic vessels readily distinguish it from phlebitis. These lines lead to a gland, which soon also becomes tender and swollen. Oedema soon takes place. An inflamed lymphatic vessel is much smaller and more tender to the touch than an inflamed vein, and usually lies between the injured locality and an inflamed gland. Fever is more constantly present and higher than in phlebitis.

{989} Reticular lymphangitis is usually a circumscribed inflammation, with more or less oedema, located in the region of a lymphatic network. It invades the integumental structures. It is not necessary to distinguish it from an erythema, for the latter can scarcely ever be present without implication of the lymphatic radicles. Tubular lymphangitis and lymphangiectasia, which are so frequently associated conditions and attended with oedema, present objective appearances very similar to those present in oedema from phlebectasis. Phlebectasis is excluded by the absence of pain, of dilatation of the superficial vein, and of changed color, and of a single hard cord along the course of the varicose vein; by the non-appearance of oedema in the neighborhood of the ankle and on the dorsum of the foot during the earlier stages of the disease, and its gradual extension upward. The infiltration in phlebectasis results from increased transudation in consequence of increased blood-pressure in the venous radicles, and their dilatation, or from interrupted venous circulation. The accumulated fluid is consequently watery, poor in solid constituents, and the resulting swelling presents all the characteristics of ordinary oedema. Absorption may be normal or perhaps increased, and with rest of the limb the intumescence will probably diminish or disappear. In consequence of the poverty of the transuded fluid the changes in nutrition are very slow, and the enlargement partakes more of the nature of an anasarca than of an hypertrophy; and, finally, phlebectasis is usually connected with some constitutional affection or distant local disease, and attacks the most distal parts, where the circulation is least supported by the muscles. Lymphangiectasis is most often found in circumscribed localities where the networks of lymph-capillaries are most numerously distributed. The swelling is more diffused, and is not in the form of single hard cords. It is more resistant, and the color of the surface is unchanged. It usually extends downward, and is not so much influenced by continued rest and posture. The accumulated fluid results from diminished absorption or interrupted lymph-circulation, and consists of the normal pre-existing parenchymatous fluids, the nutritive juices continually conveyed thither, and the fluids consumed by the functions of the parts saturated with organic débris. It is, however, more abundantly supplied with organic elements from both progressive and retrogressive metamorphosis. It also contains more albumen and fibrinous substances than the accumulated fluid in phlebectasis and ordinary oedema. The swelling or enlargement is formed of more consistent, coagulable, and partly organizable material, possesses greater consistence, and is nearly compact to the touch, which increases as the fluid undergoes the changes due to its retention in the parts. The development is peculiar, and not altogether unlike phlegmasia. The pus-formations which sometimes ensue partake of the nature of cold abscesses, and are located in the connective tissue. The pus-formations in phlebectasis usually begin in the venous thrombi within the dilated and enlarged veins, are associated with acute symptoms, and result, usually, in purulent absorption.

In view of later anatomical and pathological researches, it must be admitted that phlegmasia dolens is occasionally a lymphangitis, having its origin in inflammation of the vessels or areolar tissue. Some pathologists have advanced the theory that, as seen in lying-in women, it is a parametritis commencing in the cellular tissue in the immediate vicinity of the womb and extending to remoter parts. The writer saw recently, in consultation with J. Taber Johnson, a case of puerperal pelvic cellulitis associated with a firm, resistant, diffuse, painful, and tender swelling involving the inner aspect of both thighs, and extending from the groin on each side downward below the middle third of the thigh. The pelvic inflammation appeared first in the left iliac fossa, and was associated with the swelling before described on the thigh. This subsided, and was immediately followed by a similar condition {990} in the right iliac fossa, accompanied by a precisely similar intumescence on the right thigh. At no time could any enlarged, hard, or corded veins be discovered. The swellings presented the usual objective and tactile characteristics of those inflammatory affections so frequently supervening within areas abundantly supplied with lymph networks, in communication with the original lymphangitis and lymph-thrombosis. In this case the swellings were located in a region specially rich in lymph capillary networks. With the subsidence of the pelvic cellulitis the thigh intumescence on either side gradually disappeared.

Tubular lymphangitis is readily distinguished from erysipelas by the presence of the knotted and corded lymphatic vessels. Reticular lymphangitis is characterized by fine, closely-arranged red lines limited to a circumscribed area, and is usually associated with and starts from some injury. In erysipelas the redness is uniform. It does not follow the course of the lymphatic vessels, nor extend from a wound in the direction of and to a gland or ganglion of glands. The fever is usually higher and of longer duration. The inflamed surface is marked by the appearance of blebs.

PROGNOSIS.--Simple lymphangitis is usually unattended with danger unless complicated with suppurating arthritis. The disease, as a rule, runs a rapid course to recovery. It is more favorable the nearer the inflammation lies to the surface.

TREATMENT.--The treatment is both constitutional and local. The first indication is to remove the cause. The wound should be cleansed and disinfected. For this purpose solutions of carbolic or acetic acid may be employed, or it may be cauterized with caustic potash or chloride of zinc. The fever should be controlled by the employment of antipyretics. One or more full doses of the sulphate or hydrochlorate of quinia, administered at shorter or longer intervals according to the quantity given at each dose and the intensity of the fever, may be sufficient. Antipyrin is a very valuable remedy. It will reduce the fever more speedily and decidedly than the salts of quinia. If the fever is reduced and kept under control by the judicious administration of this remedy in moderate doses, the tendency of the inflammation to extend is very greatly diminished, and may be arrested. Its antipyretic effect is, however, less durable than that of the salts of quinia, but is unattended with the cerebral disturbances usually associated with the employment of quinia salts. The bowels should be kept solvent by the use of saline cathartics. The diet should be restricted during the pyrexial stage. After the acute stage has passed, tonics and improved diet may become necessary; especially will this be the case in those previously debilitated. In healthy, robust subjects it is not probable, under proper and prompt treatment, that the disease will continue long enough to endanger convalescence by serious exhaustion. When needed, iron, cod-liver oil, and the salts of quinia may be resorted to. But, after all, a good appetite and a sufficient supply of nutritious and easily-digested foods constitute the best and most available tonics. Rest of the affected part is very important, and the posture should be such as to remove pressure and relieve tension.

In the beginning of the acute stage cold applications may be employed, but, as a rule, the local treatment should be confined to the assiduous application of hot soothing and emollient fomentations, to which opium or belladonna may be added. By these means the tension of the swollen and inflamed parts, and consequently the pain, are assuaged. It is rarely necessary to employ internally any anodyne to relieve the pain; but in occasional cases, occurring in persons keenly susceptible to pain, an opiate or some less powerful anodyne may be administered. Some advise the local abstraction of blood by leeching, but it is admissible only when the pain is very acute and confined to a limited and defined area. After the subsidence {991} of the fever and acute inflammatory stage the remaining oedema and indurations may be treated with the local application of the tincture of iodine, inunction with mercurial ointment, bandaging, massage, and rest.

For the oedematous condition, which is sometimes very persistent, pressure is the most available and potential remedy. This should be secured by systematic bandaging either with a flannel or an elastic bandage. In such cases passive movement and massage or kneading of the part constitute an important and valuable auxiliary to pressure.

To allay itching, which is sometimes almost intolerable even after the acute inflammation has subsided, the part may be painted with a solution of nitrate of silver or collodion. If these fail, an alcoholic solution of benzoic acid, twenty grains to the ounce, may be employed.

If suppuration takes place, the abscess should be promptly and effectually incised. It should be thoroughly evacuated and dressed antiseptically. When this occurs a more or less tonic and supporting treatment is necessary. Iron, cod-liver oil, quinia, and stimulants may be, according to circumstances, administered. The devastating effects of suppurating cavities should be controlled by the liberal use of the appropriate remedies to arrest exhaustion and to rebuild waste.

In occasional instances the initial stage, consentaneous with the receipt of the injury, such as the sting of an insect, is marked by violent shock and threatening collapse. The writer has witnessed two such cases occurring in robust, healthy men stung by honey-bees on the forearm, where great exhaustion and alarming collapse, with violent retching, profuse diarrhoea, and agonizing pain, were accompanied by rapidly-developed inflammation and swelling at the locality of the puncture. In such cases the free administration of alcoholic stimulants seems imperatively demanded.

The general plan of treatment of acute simple lymphangitis is antiphlogistic, by the employment of remedies to reduce inflammation and promote resolution. The danger of suppuration should not be overlooked or underestimated. A single suppurating focus may widely diffuse disease and impair the entire organism. A single and apparently trivial inflammation of lymphatic tissue may be the initial stage of a fatal pyæmia or septicæmia.

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INDEX TO VOLUME III.

A.

Abdominal aneurism, 821
viscera, lesions, in catarrhal pneumonia, 358

Abscess, diffuse splenic, 962
embolic, of spleen, 963
of the lung, 296
of the mediastinal space, 861
termination of croupous pneumonia in, 311, 332

Abscesses, seat and nature, in suppurative endocarditis, 604

Accidents during tracheotomy, 156

Acephalocysts, expectoration of, in pulmonary hydatids, 469

Aconite, locally, in chronic laryngitis, 127
use, in exophthalmic goitre, 767

Acupuncture, use, in thoracic aneurism, 820

Acute general diseases, resemblance of croupous pneumonia to, 317
miliary tuberculosis, 472

ADDISON'S DISEASE, 939
Definition, synonyms, and history, 939
Diagnosis, 947
Duration, 941
Etiology, 939
Morbid anatomy, 942
Nervous system, lesions, 944
Spleen, lesions, 943
Suprarenal capsules, lesions, 942, 943
Pathology, 944
Theories regarding origin, 945-947
Symptoms, 940
Anæmia and hemorrhages, 940
Bronzing of skin, seat and characters, 940
Dyspnoea, 941
Gastro-intestinal disorders, 941
Nervous symptoms, 941
Pain, characters and seat, 941
Pulse in, 941
Urine, condition, 941
Treatment, 948

Adductors of vocal cords, paralysis of, 81

Adenitis, in lymphangitis, 988

Adherent pericardium, 785

Adhesions, pericardial, seat and characters, 785

Adults, grave form of catarrhal pneumonia in, 360

Adventitious products of the heart, 637

Ægophony, significance, in pleurisy, 510

Aërial fistula, following tracheotomy, 163

After-treatment of tracheotomy, 159

Agaricus, use, in pulmonary phthisis, 438

Age, influence on aortic obstruction, 655
on causation of acute catarrhal laryngitis, 93
of acute miliary tuberculosis, 478
of angina pectoris, 759
of aortic regurgitation, 655
of asthma, 190
of bronchitis, 157
of cardiac thrombosis, 722
of catarrhal pneumonia, 353
of croupous pneumonia, 314
of exophthalmic goitre, 764
of fatty degeneration of the heart, 613
of fibroid phthisis, 441
of fibro-serous pleurisy, 492
of gangrene of lung, 301
of hæmoptysis, 275
of hay asthma, 212
of Hodgkin's disease, 922
of laryngismus stridulus, 70
of leukæmia, 909
of mediastinal tumors, 871
of mitral regurgitation, 671
of mitral stenosis, 666
of pernicious anæmia, 899
of phthisis, 396
of pneumothorax, 576
of pseudo-membranous laryngitis, 101
of purulent pleurisy, 540
of simple lymphangitis, 986
of thoracic aneurism, 802

Air, compressed, use, in bronchial asthma, 208
moist, use, in acute catarrhal laryngitis, 97
rarefied, exhalation into, in emphysema, 246

Albuminoid expectoration following thoracentesis, 535

Alcohol, abuse, influence on causation of chronic laryngitis, 121
of the caisson disease, 858
influence on causation of fatty cardiac degeneration, 612
use, in acute miliary tuberculosis, 481
in bronchial asthma, 205
in catarrhal pneumonia, 370
in croupous pneumonia, 348, 349, 351
in endocarditis, 651
in gangrene of the lung, 305
in parenchymatous degeneration of the heart-muscle, 611
in pseudo-membranous laryngitis, 108
in pulmonary phthisis, 435

Alcoholism, influence on causation of chronic myocarditis, 607
of pleurisy, 493
of croupous pneumonia, 314

Alkalies, use, in pseudo-membranous laryngitis, 105
in rheumatic pericarditis, 783
in prevention and treatment of pulmonary embolism, 389, 390

Alkaline sprays, use, in chronic laryngitis, 125, 127

Allen's nasal forceps, 54

Altitude, influence on causation of hæmoptysis, 277, 278

Alum, use, in laryngismus stridulus, 73

Ammonium, carbonate, use, in cardiac thrombosis, 745
in croupous pneumonia, 349
in prevention of pulmonary embolism, 389
and chloride of, use, in catarrhal pneumonia, 370, 371
chloride, use, in chronic laryngitis, 124, 125

Amphoric respiration in pulmonary phthisis, 417

Amyl nitrite, use, in angina pectoris, 760
in bronchial asthma, 204
in chronic endarteritis of the coronary artery, 830
in fatty cardiac degeneration, 616

Amyloid degeneration of heart-muscle, 616
of suprarenal bodies, 949

ANÆMIA, 887
Albumen, continuous loss of, influence on causation, 887
Blood, changes in, 890, 891
Bone, spleen, lymph-glands, enlargement of, and relation to
production of blood-corpuscles, 888-894
Hemorrhage, influence on causation, 887
Inanition, influence on causation, 889
Toxic causes of, 889

Anæmia in Addison's disease, 940
in exophthalmic goitre, 763
in pulmonary phthisis, 406

ANÆMIA, PROGRESSIVE PERNICIOUS, 898
Course, 903
Definition and history, 898
Diagnosis, 905
Etiology, 899
Age and sex, influence on causation, 899
Hygiene, bad, influence on causation, 899
Loss of blood, chronic discharges, etc., 900
Mental worry and anxiety, 900
Pregnancy and parturition, 900
Morbid anatomy, 904
Bones, changes in, 905
Lymph-glands, changes in, 905
Spleen, changes in, 905
Pathology, 905
Prognosis, 906
Symptoms, 900
Blood and blood-corpuscles, changes in, 901
Gastro-intestinal disorders, 903
Hæmic heart-murmurs, 902
Hemorrhages in, 901-903
Oedema in, 901
Onset, mode of, 900
Skin, changes and color of, 901
Temperature, 903
Urine, changes in, 903
Treatment, 906
Arsenic, use, 907
Diet in, 907
Iron, use, 907
Milk, injection of, 908
Transfusion of blood, 907

Anæmic necrosis of heart-muscle, 610

Anæsthesia of larynx, 65

Anæsthetics, use, in laryngismus stridulus, 73

Anatomy of tracheal region, 146, 147

ANEURISM, ABDOMINAL, 821
Diagnosis, 822
Symptoms, 821
Treatment, 822
Compression of aorta, good results of, 822

Aneurism, diagnosis of, from mediastinal tumors, 876

ANEURISM, THORACIC, 801
Definition, 801
Diagnosis, 814
From abscess, 814
From tumors, 814
Duration, 815
Etiology, 802
Age and sex, influence on causation, 802, 803
Occupation, influence on causation, 803
Syphilis and gout, influence on causation, 803
Morbid anatomy, 801, 802
Symptoms, 803
Auscultation in, 811
Bone, signs of pressure upon, 807
Bruit, characters, 811
Cyanosis and oedema, 807
Dysphagia in, 806
Dyspnoea in, 805
Frémissement cataire, frequency, 808
Inspection, 807
Localization of tumors, 812
Myosis in, 805
Of varicose form, 813
Oral whiff of Drummond, significance, 812
Pain, characters, 804
Palpation in, 808
Percussion in, 812
Physical signs in, 807
Pressure signs, 804-807
Pulse, peculiarities of, 808-810
Thrill in pulse, 809
Veins, signs of pressure upon, 807
Voice, modifications of, 806
Terminations, 815
Treatment, 816-820
Acupuncture, use, 820
Barwell's operation of ligation, 818, 819
Ergotin, hypodermic use, 816
Electrolysis, method of applying, 819, 820
Opiates, use, 817
Potassium iodide, 818
Pressure, use, 816
Starvation method, 816
Tufnell's method of rest and diet, 816, 817
Wire, introduction of, into sac, 816

Aneurism of the coeliac axis, 841
of the coronary artery, 830
of the heart, 636
of the hepatic artery, 840
of the interior mesenteric artery, 839
of the superior mesenteric artery, 836
of the pulmonary artery, 833

Aneurismal form of hæmoptysis, 284

Angina, in anæmic necrosis of heart-muscle, 610

ANGINA PECTORIS, 755
Death, cause of, 760
Definition, 755
Diagnosis, 757
Etiology, 758
Morbid anatomy, 758
Prognosis, 759
Symptoms, 755-757
Treatment, 760
Amyl nitrite, use, 760
Chalybeates, use, 760
Digitalis and nux vomica, 761
Opium and morphia, use, 760
Preventive, 760
Stimulants, 760

Angina pectoris in aortic regurgitation, 661

Anginoid attacks in chronic myocarditis, 608, 609

Anomalies, congenital, of heart and great vessels, 687
of blood-vessels of tracheal region, 147
of suprarenal bodies, 949

Ante-mortem heart-clots, character, 737

Anthracosis, appearance of lungs in, 458

Antimony, use, in bronchitis, 179, 180
in croupous pneumonia, 347

Antipyrin, use, in acute miliary tuberculosis, 480, 481
in simple lymphangitis, 990

Antiseptics, use, in croupous pneumonia, 352

Antispasmodics, use, in functional heart disease, 754
in laryngeal oedema, 116
in laryngismus stridulus, 73
in spasm of the glottis, 74

Anxiety, in cardiac thrombosis, 731

Aorta, atheroma of, 800
disease of, influence on causation of hypertrophy of the heart, 620
diseases of, 800
occlusion of, 824, 825
perforation of, 824
rupture of, 823
stenosis of, 825

Aortic arch, localization of aneurism of, 812
conus, defects of, in cyanosis, 708
obstruction, 654
regurgitation, 659
stenosis and regurgitation, treatment, 683
trunk, narrowing, in cyanosis, 708
and mitral orifices, defects of, in cardiac malformations, 690

Aortitis, acute, 800

Apex-beat, in dilatation of the heart, 634
in hypertrophy of the heart, 625, 627
normal position of, 654
significance of position of, in diagnosis of functional heart
disease, 750

Apex of lung, tendency to tuberculous deposit in, 408

Aphonia, in paralysis of adductors of vocal cords, 82
in pulmonary phthisis, 403

Apomorphia, use, in catarrhal pneumonia, 371
in acute catarrhal laryngitis, 97, 98

Apoplexy of suprarenal bodies, 949
pulmonary, 293

Appetite, impaired, in pulmonary phthisis, 406

Arch of aorta, localization of aneurisms of, 812

Arsenic, use, in acute miliary tuberculosis, 482
in Addison's disease, 948
in atrophic nasal catarrh, 49
in bronchial asthma, 207
in carcinoma of larynx, 131
in chronic congestion and enlargement of the spleen, 959
in chronic laryngitis, 125
in dilatation of the heart, 636
in Hodgkin's disease, 931
in leukæmia, 921
in pernicious anæmia, 907
in pulmonary phthisis, 436

Arterio-sclerosis of the coronary artery, 828
of the pulmonary artery, 833

Artery, coronary, diseases of, 828
hepatic, aneurism of, 840
pulmonary, diseases of, 833
inferior mesenteric, diseases of, 834
superior mesenteric, diseases of, 836

Arytenoideus, paralysis of, 84

Aspiration in pericardial effusion, 776, 780
of the pleura, dangers of, 596
history, etc., 593-596

Aspirators in thoracentesis, varieties, 530, 532

Asthenic pneumonia, treatment, 351

ASTHMA, BRONCHIAL, 184
Definition, 184
Diagnosis, 198
From dyspnoea of bronchitis and cardiac disease, 198
of laryngeal affections, 199
From embolism of pulmonary artery, 200
From emphysema, 198
From spasm of diaphragm, 199
Duration, 189
Etiology, 190
Age and sex, influence on causation, 190
Cold and damp, influence on causation, 192
Enlarged bronchial glands, 191
Heredity, influence on causation, 190
Pollen of plants, vapors, gases, etc., 192
Uterine, nasal, and stomachic irritation, 193
History, 184
Morbid anatomy, 197
Pathology, 193-197
Prognosis, 200
Sequelæ, 189
Synonyms, 184
Symptoms and course, 185
of intervals, 184
paroxysms, description, frequency, and time of onset, 185-187
heart-circulation, state of, during, 188
physical signs of, 187, 188
Physiognomy of asthmatics, 186, 190
Treatment, 201
Hygienic and dietetic, 206
Locality, change of, 206
Of intervals, 206
Of paroxysms, 201
Use of arsenic, 207
of belladonna and stramonium, 203
of chloroform, 202
of cigarettes, medicated, 203, 207
of compressed air, 208
of electricity, 205
of emetics, 204
of lobelia and tobacco, 204
of morphia and chloral hydrate, 201, 202
of nitrite of amyl, 204
of nitro-glycerin, 208
of potassium bromide, 204
iodide, 207
nitrate, 203
of stimulants, 205

Asthma complicating emphysema, 239
hay, 210

Astringents, use, in chronic laryngitis, 125, 126
in laryngeal oedema, 116

Atelectasis, influence on causation of bronchial dilatation, 228

Atelectasis. See _Lung, Collapse of_.

Atheroma of the aorta, 800
of the coronary artery, 828
of the pulmonary artery, 833

Atmospheric causes of goitre, 977

Atomizer, use, in hyper- and paræsthesia of the larynx, 64

Atresia of the pulmonary artery, 702

Atropia, use, in profuse expectoration of bronchiectasis, 231
in pulmonary phthisis, 438
in the caisson disease, 858

Atrophic form of chronic nasal catarrh, 47
lobar emphysema, 248

Atrophy of suprarenal bodies, 949
of the heart, 618

Auricles of the heart, hypertrophy of, 627

Auriculo-ventricular orifice and tricuspid valve, defects of, 689
rings, condition, in cardiac dilatation, 633

Auscultation during paroxysm of asthma, 187
of mediastinal tumors, 874
in bronchial dilatation, 229
in bronchitis, 170-174
in cardiac malformation, 710, 711
thrombosis, 728
valvular disease, 657, 663, 668, 673, 675, 677, 680
in catarrhal pneumonia, 359, 360, 362, 363
in collapse of the lung, 253
in croupous pneumonia, 335, 337, 338
in emphysema, 238
in endocarditis, 648
in fibro-serous pleurisy, 507-510
in hydrothorax, 572
in mediastinal abscess, 862
in pericarditis, 775
in pneumothorax, 579
in pulmonary phthisis, 412-418
in purulent pleurisy, 543, 544
in pyo-pneumothorax, 545
in thoracic aneurism, 811

Auscultatory percussion in fibro-serous pleurisy, 503

Auto-laryngoscopy, 29

Axillary glands, enlargement of, in Hodgkin's disease, 926

B.

Bacelli's sign of pleurisy, 510, 517, 543

Bacillus tuberculosis, relation of, to acute miliary tuberculosis, 477
to hæmoptysis, 279, 280
to pulmonary phthisis, 398

Balfour's treatment of aneurism, 818

Balsams, use, in chronic bronchitis, 182

Bandage, use, in phlegmasia dolens and lymphangitis, 848, 991

Barrel-shaped chest of emphysema, 237

Barwell's operation for cure of thoracic aneurism, 818

Basedow's disease. See _Exophthalmic Goitre_.

Baths, cold, use, in bronchial asthma, 206
in croupous pneumonia, 349
hot, use, in laryngismus stridulus, 73

Belladonna, use, in pulmonary phthisis, 438
and stramonium, use, in bronchial asthma, 203

Bellocq's canula, use, in epistaxis, 52

Benign form of pulmonary embolism, symptoms, 382
growths of the larynx, 128
tumors of the trachea, 140

Benzoin, use, in chronic laryngitis, 124, 126

Bilious pneumonia, 334

Binaural stethoscope, use, in auscultation, 412

Black sputa of pitmen, 455, 459

Blaud's pills, use, in chlorosis, 896

Bleeder families, 933

Bleeding in heart disease, question of, 686

Bleedings, seat and amount, in hæmophilia, 935

Blisters, use, in acute myocarditis, 606
in capillary bronchitis, 180
in chronic phlebitis, 848
in pericardial effusion, 784
in pleurisy, 521
in thoracic aneurism, 817

Blood changes in, in croupous pneumonia, 313
in hæmoptysis, 287
in Hodgkin's disease, 924
in leukæmia, 911, 915
in pernicious anæmia, 901
condition of, in chlorosis, 894
in hæmophilia, 936
diseases of the, 882

Blood-corpuscles, changes in, in pernicious anæmia, 901
relation of spleen, lymph-gland, and bone-marrow to production, 890,
891

Blood-glandular system, diseases of, 882

Bloodletting, local and general, in pulmonary congestion and oedema,
263, 264

Blood-vessels, pulmonary, changes in, in emphysema, 243
relation of, to miliary tubercles, 474, 475

Bone-marrow, hyperplasia of, in anæmia, 892
influence on blood-formation, 885
lesions, in leukæmia, 916
in pernicious anæmia, 905

Bones, pressure upon, in thoracic aneurism, 807

Bowditch's connection with history of thoracentesis, 591-595

Brain, lesions, in croupous pneumonia, 313
in pernicious anæmia, 905
and membranes, lesions, in catarrhal pneumonia, 358
in leukæmia, 918

Breath, fetid, in chronic pharyngitis, 122

Breathing, in collapse of lung, 252

Bright's disease, complicating phthisis, 407
influence on causation of pericarditis, 771
of congestion and oedema of the lungs, 259

Bromides, use, in exophthalmic goitre, 767

Bronchi, diseases of, 164

Bronchial asthma, 184
breathing, in pleurisy, 508
catarrh, complicating emphysema, 247
influence on causation of collapse of lung, 251
glands, enlargement of, in croupous pneumonia, 313
lesions, in bronchitis, 175, 176
in catarrhal pneumonia, 357
in pneumonokoniosis, 457
lesions of syphilis of the lungs, 451
respiration in croupous pneumonia, 337

BRONCHIAL TUBES, DILATATION OF (Bronchiectasis), 227
Definition, history, and etiology, 227
Diagnosis and prognosis, 230
Morbid anatomy, 230
Symptoms, 228
Treatment, 230

BRONCHITIS, 164
Definition, 164
Diagnosis, 176
From phthisis, 177
From pneumonia, 176
Of chronic form, from emphysema, 177
Etiology, 164
Age and sex, influence on causation, 165
Cold and damp, season, etc., 166-168
Exciting causes, 168
Predisposing causes, 165
History, 164
Morbid anatomy, 175
Mortality, 165, 177
Prognosis, 177
Synonyms, 164
Symptoms--acute form, 169
Capillary form, 171
Cough, characters, 171
Dyspnoea in, 171
Physical signs of, 171
Chronic form, 174
Cough and expectoration, characters of, 174
Mechanical form, 170
Pseudo-membranous form, 173
Rheumatic form, 172
Treatment, 178
Of acute and capillary forms, 178-180
Antimony, use, 180
Counter-irritation, 178
Emetics, 180
Expectorants, 179
Quinia, use, 179
Venesection, 178
Of chronic form, 181
Alteratives, 182
Change of climate, 183
Compressed air, 183
Diet, 181
Inhalations, 182
Iron, use, 182
Of pseudo-membranous form, 180
Of rheumatic form, 180

Bronchitis and pneumonia, influence on causation of phthisis, 394
complicating emphysema, 239
tracheotomy, 162
of acute infectious diseases, influence on causation of catarrhal
pneumonia, 354

Broncho-vesicular respiration, characters and significance of, 412

Brown atrophy of heart-muscle, 616
induration of lungs, 256

Bruit, in thoracic aneurism, 811

C.

Caffeine, use, in dilatation of the heart, 635

CAISSON DISEASE, 854
Definition, 854
Duration, 855
Etiology, 857
Morbid anatomy, 855
Pathology, 855
Symptoms, 854
Headache, vertigo, and coma, 855
Nausea and vomiting, 854
Pain, seat and characters, 854
Paralyses, 854, 855
Treatment, 858
Atropia, use, 858
Compressed air, 859
Ergot, use, 859
Morphia, use, 858
Of paralysis, 859

Calcareous degeneration of the heart-muscle, 616

Calcification of the vein, 852

Calcium sulphide, use, in acute phlebitis, 846

Canulas, tracheotomy, 151, 152

Cancer of adrenals in Addison's disease, 943
of the heart, 639
of the lungs, 460
of the pericardium, 792
of the pleura, 583
of the veins, 853

Capillary bronchitis, 171
emboli of lungs, effects, 385
vessels, relation to miliary tubercles, 475

Caput Medusæ, 849

Carbolic acid, danger of, in injections into pleural cavity, 561
use, in abscess of lung, 300
in gangrene of lung, 305
injections, in goitre, 980
and iodine, injections, in pericardial effusions, 795

Carcinoma of the larynx, 128
of the mediastinum, seat and characters, 869
of the nasal passages, 55
of the thyroid gland, 978
of the trachea, 141

Cardiac action, irregular, in fatty degeneration of the heart, 615
disease influence on causation of chronic splenic enlargement, 957
hæmoptysis, symptoms, 285
hypertrophy, relation to adherent pericardium, 786
murmurs, relation to valvular disease, 651
sedatives, use, in hypertrophy of the heart, 630

CARDIAC THROMBOSIS, 718
Complications and sequelæ, 733
Definition, 718
Diagnosis, 740
From dyspnoeic uræmia, 742
laryngeal affections, 743
nervous shock of acute endocarditis, 744
pulmonary embolism, 743
Duration and terminations, 732
Etiology, 721
Age and sex, influence on causation, 722
Mechanical causes, 723
Vital or pathological causes, 724
Endocarditis, influence on causation, 725
History, 719
Morbid anatomy and pathology, 734
Of ancient clots, 737
cadaveric and terminal clots, 735
Physical characters of clots, 735-740
Prognosis, 744
Synonyms, 718
Symptoms, 726
Blowing murmur of Bouillaud, significance, 730
Dyspnoea, 730
Mental condition, 731
Pain, 730
Physical signs, 727
Physiognomy in, 730
Pulse, characters, 729
Syncope, 730
Treatment, 745
Alkalies, as solvents, use, 745
Ammonium carbonate and liquid ammonia, use, 745
Counter-irritation, 746
Digitalis and nux vomica, use, 746
Intravenous injections of ammonia, 745
Rest, value, 746
Sodium bicarbonate, use, 745
Stimulants, use, 746

Cardicentesis, 798

Caseated morbid products, influence on causation of pulmonary phthisis,
400

Caseous pneumonia following pleurisy, 514
pus, influence on causation of acute miliary tuberculosis, 473

Casts of bronchi, in pseudo-membranous bronchitis, 176

Catarrh, chronic nasal, 42

Catarrhal pneumonia in children, symptoms, 359
relation of, to collapse of lung, 354, 355
tendency, influence on causation of hæmoptysis, 275

Catheterization of larynx in true croup, 107

Cavernous form of hæmoptysis, 284

Cavities, diagnosis of, in pulmonary phthisis, 416
tubercular, injection of, 439, 440

Cell-walls, changes in, as a cause of emphysema, 334

Cerebral anæmia, in aortic obstruction, 656
disturbance in functional heart-disease, 749
hyperæmia in tricuspid regurgitation, 649

Cerebral symptoms in cardiac thrombosis, 731
of croupous pneumonia, 329
of pericarditis, 774

Chest, alterations of, in pleuritic effusions, 497, 498
changes in, in emphysema, 236, 237

Cheyne-Stokes breathing in fatty degeneration of the heart, 615

Children, catarrhal pneumonia in, 359

Chills in croupous pneumonia, 320
in pleurisy, 494
in purulent pleurisy, 542

Chloral hydrate, use, in bronchial asthma, 202
in catarrhal pneumonia, 372

Chlorides, diminution of, in croupous pneumonia, 330

Chloroform, use, in bronchial asthma, 202

Chlorosis, 894
Definition and etiology, 894
Morbid anatomy, 894
Symptoms, 895
Treatment, 896

Chondritis of the larynx, 117

Chorea of the larynx, 76

Chronic bronchitis, 174
influence on causation of bronchiectasis, 228
congestion and enlargement of the spleen, 956
endarteritis of the coronary artery, 828
of the pulmonary artery, 833
interstitial pneumonia, 391, 440
lobular emphysema, 233
myocarditis, 607
pericarditis, 784
phlebitis, 848
purulent pleurisy, symptoms, 342

Cigarettes, medicated, use, in bronchial asthma, 203, 207

Circumscribed pleurisies, 545

Cirrhosis of the liver, influence on causation of splenic enlargement,
957
of lung, displacement of heart by, 603

Classification of hay asthma, 221
of pleurisy, 454
of pneumonokoniosis, 454
of pulmonary embolism, 373

Climate, change of, in acute laryngitis, 96
in chronic bronchitis, 183
influence on frequency of hæmoptysis, 277

Climatic treatment of pulmonary phthisis, 427

Clothing, proper, for phthisical patients, 433, 434

Clots, ancient or ante-mortem, of heart, characters, 737
cadaveric, in cardiac thrombosis, 735
terminal, in cardiac thrombosis, 735

Clubbing of fingers in cyanosis and cardiac malformations, 711

Cocaine, use, in chronic laryngitis, 127
in coryza, 42
in epiglottic ulceration, 112
in hyper- and paræsthesia of the larynx, 65
in morbid growths of the larynx, 131

Codeia, use, in bronchitis, 180, 182
in cough of miliary tuberculosis, 480

Cod-liver oil, use, in acute miliary tuberculosis, 482
in atrophic nasal catarrh, 49
in chronic bronchitis, 182
in chronic laryngitis, 125
in pulmonary phthisis, 434
in purulent pleurisy, 549
in ulceration of trachea, 139
in vesicular emphysema, 245

Coeliac axis, aneurism of, 841
diseases of, 841

Coffee, use, in bronchial asthma, 205
black, use, in cardiac thrombosis, 746

Colchicum, use, in rheumatic bronchitis, 181

Cold applications in epistaxis, 51
influence on causation of congestion and oedema of the lungs, 258
of pericarditis, 770
of perichondritis and chondritis of larynx, 117
use, in catarrhal pneumonia, 371
in pericarditis, 783
in reduction of temperature in croupous pneumonia, 349
in simple lymphangitis, 990
and damp, influence on causation of asthma, 192
of bronchitis, 166
of croupous pneumonia, 315
of fibro-serous pleurisy, 491
and moisture, influence on causation of acute catarrhal laryngitis,
93

Collapse of lung, 250

Color of ante-mortem heart-clots, 739

Columnæ carneæ, lesions, in chronic myocarditis, 607

Communicability of pulmonary phthisis, 396

Complications after tracheotomy, 161
of acute coryza, 41
of cancer of the lungs, 464
of cardiac thrombosis, 733
of catarrhal pneumonia, 364
of emphysema, 239
of fibro-serous pleurisy, 512
of mediastinal abscess, 864
of pulmonary phthisis, 400

Compressed air, use, in bronchial asthma, 208
in chronic bronchitis, 183
in emphysema, 245

Compression in treatment of abdominal aneurism, 823

Congenital anomalies of the heart and great vessels, 687
malpositions of the heart, 601

Congestion, acute, of spleen, 953
and enlargement of the spleen, chronic, 956
and oedema of the lungs, 258

Congestive form of hæmoptysis, 283

Contagiousness of acute miliary tuberculosis, 472
of pseudo-membranous laryngitis, 102
of pulmonary phthisis, 396-400

Conus arteriosus dexter, obstruction with open ventricular septum in
cyanosis, 703

Convallaria, use, in dilatation of the heart, 635

Convulsions, in croupous pneumonia, 329
in pseudo-membranous laryngitis, 102

CORONARY ARTERY, DISEASES OF, 828
Chronic Endarteritis (Arterio-sclerosis; Atheroma), 828
Diagnosis and prognosis, 829, 830
Etiology and symptoms, 828
Pathology, 829
Treatment, 830
Aneurism of, 830
Embolism of, 831
Embolism and thrombosis of, 831
Obliterating endarteritis of, 830
Occlusion of, 831
Rupture of, 833
Thrombosis of, 832

Corpuscles of the blood, changes in, in Hodgkin's disease, 924
in leukæmia, 912
in pernicious anæmia, 901

Coryza, acute, 41

Cough in acute catarrhal laryngitis, 94
in asthma, 188
in bronchial dilatation, 228
in capillary bronchitis, 171
in cardiac malformations and cyanosis, 710
in catarrhal pneumonia, 358-361, 363
in chronic bronchitis, 174
pharyngitis, 122
in croupous pneumonia, 322
in emphysema, 236
in fibro-serous pleurisy, 495
in hydatids of pleura, 585
in laryngismus stridulus, 71
in mitral regurgitation, 671
stenosis, 667
in morbid growths of the trachea, 140
in pseudo-membranous laryngitis, 102
in pulmonary congestion in oedema, 260
phthisis, 400
treatment, 436
in purulent pleurisy, 542
in thoracic aneurism, 806
nervous, 71

Counter-irritation in acute bronchitis, 178
in atelectasis, 255
in cardiac thrombosis, 745, 746
in catarrhal pneumonia, 369
in croupous pneumonia, 347
in pericarditis, 783

Course of anæsthesia of the larynx, 67
of cardiac thrombosis, 732
of fibro-serous pleurisy, 510
of hyperæsthesia of the larynx, 163
of hypertrophy of the heart, 621
of laryngismus stridulus, 71
of leukæmia, 818
of pernicious anæmia, 903
of pulmonary congestion and oedema, 261

Crepitant râle of croupous pneumonia, 335

Crico-arytenoid muscles, hysterical paralysis of, 83

Cricotomy, 148, 156

Critical phenomena in croupous pneumonia, 331

Croup, false. See _Laryngismus Stridulus_.

Croupous pneumonia, 307

Cubebs, use, in chronic laryngitis, 124

Cyanosis, admixture theory of origin, 712
congestive theory of origin, 714
in cardiac malformation, 709
in fibroid phthisis, 442
in fibro-serous pleurisy, 496
in mitral regurgitation, 671
and congenital anomalies of the heart and great vessels, 687

Cysts, fibrinous, in cardiac thrombosis, 738
hydatid, of lungs, number and seat, 467
of suprarenal bodies, 949
of the heart, 637

Cystic goitre, 978

D.

Dangers of thoracentesis, 534

Death, cause of, in angina pectoris, 760
in croupous pneumonia, 345
in leukæmia, 919
in pericarditis, 783
in pulmonary embolism, 380, 381
in thoracentesis, 536, 537
in valvular heart disease, 681
mode of, in cardiac thrombosis, 732
in Hodgkin's disease, 929

Decubitus in fibro-serous pleurisy, 495

Definition of acute miliary tuberculosis, 472
of Addison's disease, 939
of angina pectoris, 755
of anæsthesia of larynx, 65
of bronchitis, 164
of bronchial asthma, 184
dilatation, 227
of brown induration of lungs, 256
of cancer of the lung, 460
of cardiac thrombosis, 718
of catarrhal pneumonia, 353
of chronic laryngitis, 121
nasal catarrh, 42
of collapse of the lung, 250
of congestion and oedema of lungs, 258
of croupous pneumonia, 307
of dilatation of the heart, 630
of endocarditis, 639
of emphysema, 232
of epistaxis, 50
of gangrene of the lung, 301
of hæmophilia, 931
of hæmoptysis, 266
of hæmothorax, 582
of hay asthma, 210
of Hodgkin's disease, 921
of hydrothorax, 570
of hyperæsthesia of the larynx, 62
of hypertrophy of the heart, 619
of laryngeal oedema, 112
of leukæmia, 908
of lymphangitis, 986
of mediastinal tumors, 864
of morbid growths of larynx, 128
of trachea, 139
of pericarditis, 169
of perichondritis and chondritis of the larynx, 117
of pernicious anæmia, 898
of pleurisy, 483
of pneumonokoniosis, 454
of pneumothorax, 573
of pulmonary abscess, 296
embolism, 373
hydatids, 466
phthisis, 391
of purulent pleurisy, 539
of simple tracheitis, 133
of spasm of the glottis in adults, 74
of stenosis of trachea, 142
of syphilis of the lung, 447
of the caisson disease, 854
of thoracic aneurism, 801

Deflected septum in chronic nasal catarrh, 44

Degenerations of heart-muscle, 609-616
of the suprarenal bodies, 949
of the veins, 852

Dermoid cysts of the mediastinum, 870

Delirium in croupous pneumonia, 329

Dentition, influence on causation of laryngismus stridulus, 70

Depressing influences, influence on causation of croupous pneumonia,
315

Diagnosis of abdominal aneurism, 823
of abscess of the lung, 299
of acute and chronic bronchitis, 176
of acute catarrhal laryngitis, 95
of acute congestion of spleen, 955
of acute miliary tuberculosis, 480
of acute myocarditis, 606
of acute phlebitis, 846
of Addison's disease, 947
of adherent pericardium, 788
of anæsthesia of larynx, 66
of aneurism of the coeliac axis, 842
of angina pectoris, 757
of aortic obstruction, 657
regurgitation, 664
of asthma, 198
of atrophic emphysema, 249
of bronchial dilatation, 230
of cancer of the lung, 464
of the pleura, 584
of cardiac thrombosis, 740-744
of catarrhal pneumonia, 365
of chronic congestion and enlargement of the spleen, 958
endarteritis of the coronary artery, 829
laryngitis, 124
myocarditis, 609
of collapse of the lung, 254
of coryza, 41
of croupous pneumonia, 339
of cyanosis, 709
of dilatation of the heart, 634
of echinococcus of the spleen, 969
of embolic splenic abscess, 964
of embolism of the coronary artery, 832
of the superior mesenteric artery, 838
of endocarditis, 650
of epiglottic affections, 109-112
of exophthalmic goitre, 763
of fatty cardiac degeneration, 615
infiltration of the heart, 612
of fibroid phthisis, 443
of functional heart disease, 749-752
of gangrene of the lung, 304
of hæmophilia, 937
of hæmoptysis, 289
of hæmothorax, 582
of hay asthma, 221
of hemorrhagic pleurisy, 568
of Hodgkin's disease, 929
of hydatids of the pleura, 585
of hydrothorax, 572
of hyperæsthesia and paræsthesia of the larynx, 64
of hypertrophic lobar emphysema, 243
of hypertrophy of the heart, 627
of interlobular emphysema, 249
of lardaceous spleen, 967
of laryngeal oedema, 115
of laryngismus stridulus, 72
of leukæmia, 919
of mediastinal abscess, 863
tumors, 876
of mitral regurgitation, 674
stenosis, 669
of morbid growths of the larynx, 130
of the trachea, 141
of paralysis of adductors of vocal cords, 83, 85
of tensors of vocal cords, 85, 86
of pseudo-membranous laryngitis, 103
of pericardial effusion, 778
of pericarditis, 776
of pernicious anæmia, 905
of pleurisy, 514
of pneumonokoniosis, 459
of pneumothorax, 580
of pulmonary apoplexy, 294
congestion and oedema, 262
embolism, 387
hydatids, 469
phthisis, 410
regurgitation, 677
stenosis, 676
of purulent pleurisy, 543
of simple lymphangitis, 988
tracheitis, 134
of spasm of the glottis in adults, 75
of stenosis of the aorta, 827
of the trachea, 142
of syphilis of the lungs, 453
of thoracic aneurism, 815
of thrombosis of the coronary artery, 832
of tricuspid stenosis, 677

Diaphoretics, use, in laryngeal oedema, 116
in pulmonary abscess, 264

Diaphragm, displacement of, in pleurisy, 497, 498, 507

Diaphragmatic pleurisy, 563

Diarrhoea in Hodgkin's disease, 925
in leukæmia, 910
in pernicious anæmia, 903
in pulmonary phthisis, 406
treatment, 439

Diathesis, the tubercular, 477

Diet after tracheotomy, 161
in acute miliary tuberculosis, 481
in Addison's disease, 948
in bronchial asthma, 206
in cardiac valvular disease, 683, 685
in catarrhal pneumonia, 369, 370
in croupous pneumonia, 348
in collapse of the lung, 256
in endocarditis, 651
in fatty degeneration of the heart, 616
in hay asthma, 224
in pericarditis, 783
in pernicious anæmia, 907
in pseudo-membranous laryngitis, 108
in simple lymphangitis, 990
restricted, in thoracic aneurism, 817

Dietetic treatment of pulmonary phthisis, 431

Digestive disorders in functional heart disease, 749
influence on causation of pernicious anæmia, 900

Digitalis, use, in acute myocarditis, 606
in angina pectoris, 761
in aortic disease, 684
in chronic endarteritis of the coronary artery, 830
in croupous pneumonia, 349
in dilatation of the heart, 635
in exophthalmic goitre, 767
in fatty degeneration of the heart, 616
in functional disease of the heart, 754
in hypertrophy of the heart, 630
in mitral disease, 685
in pericarditis, 783
in pulmonary congestion and oedema, 263
in vesicular emphysema, 247, 248

Dilatation of the pulmonary artery, 833
of the bronchial tubes, 227
of the heart, 630
of the trachea, 143
of the veins, 849

Diphtheria, influence on causation of anæsthesia of the larynx, 66
paralysis of the larynx, 80
of the trachea, 136

Displacement of adjacent organs in pleurisy, 504
of the heart in pneumothorax, 577

Displacements of the heart, 601-604

Disseminated form of catarrhal pneumonia, lesions, 357

Diverticular dilatation of trachea, 143

Double pleurisy, 562
pneumonia, prognosis, 343

Drainage of pleural cavity, methods of, 552-562

Dropsy in aortic regurgitation, 661
in mitral regurgitation, 672
of emphysema, treatment, 247
time of appearance in tricuspid regurgitation, 679

Drummond's oral whiff in aneurism, 812

Ductus arteriosus Botalli, defects of, in cardiac malformation, 691

Duration of anæsthesia of the larynx, 67
of asthma, 189
of cancer of the lungs, 463
of cardiac thrombosis, 732
of catarrhal pneumonia, 368
of fibro-serous pleurisy, 511
of Hodgkin's disease, 929
of laryngismus stridulus, 71
of life in cardiac malformations and cyanosis, 711
of mediastinal abscess, 863
tumors, 875
of pulmonary phthisis, 424
of stenosis of the aorta, 825
of the caisson disease, 855
of thoracic aneurism, 815

Durham's tracheotomy canula, 151

Dysphagia in chronic pharyngitis, 122
in hysterical affections of the glottis, 83
in inflammation of the epiglottis, 110
in laryngeal oedema, 114
in mediastinal tumors, 872, 873
in morbid growths of larynx, 129
in perichondritis and chondritis of the larynx, 118
in thoracic aneurism, 806

Dysphonia in morbid growths of larynx, 129
in perichondritis and chondritis of the larynx, 118
in pulmonary phthisis, 408

Dyspnoea in acute catarrhal laryngitis, 94
in Addison's disease, 941
in angina pectoris, 756
in aortic regurgitation, 661
in cardiac thrombosis, 730
in catarrhal pneumonia, 359, 360, 363
in chronic pharyngitis, 122
in croupous pneumonia, 321
in cyanosis and cardiac malformation, 710
in dilatation of trachea, 144
in fatty infiltration of the heart, 612
in fibro-serous pleurisy, 493, 495
in Hodgkin's disease, 925
in hydatids of pleura, 585
in hydrothorax, 571
in hypertrophy of the heart, 626
in laryngeal oedema, 114
in leukæmia, 913
in mediastinal tumors, 872
in mitral regurgitation, 671
stenosis, 667
in morbid growths of the larynx, 129
in paralysis of abductors of vocal cords, 88
in pernicious anæmia, 903
in pneumothorax, 578
in pulmonary embolism, 379-381
in stenosis of the trachea, 143
in thoracic aneurism, 805

E.

Echinococcus of the spleen, 968

Effects of cardiac hypertrophy, 626
of pulmonary embolism, 383

Effusions, characters, in purulent pleurisy, 540, 541
of fibro-serous pleurisy, 487-491
of pericarditis, 772

Elaterium, use, in hydrothorax, 572

Electric illuminator, use, in laryngoscopy, 24

Electricity, use, in anæsthesia of the larynx, 68
in angina pectoris, 761
in bronchial asthma, 205
in paralysis of the larynx, 90

Electrolysis, use, in goitre, 980
in thoracic aneurism, 819

Embolic abscess of the spleen, 963

Embolism and thrombosis of coronary artery, 831
of pulmonary artery, 835
complicating cardiac thrombosis, 733
from aortic obstruction, 656
influence on causation of gangrene of the lung, 302
of inferior mesenteric artery, 839
of pulmonary artery distinguished from asthma, 200
of superior mesenteric artery, 836
relation to acute myocarditis, 604
symptoms of, in endocarditis, 647

Emetics, use, in acute catarrhal laryngitis, 97
in catarrhal pneumonia, 371
in collapse of the lung, 255
in pulmonary congestion, 263
in pseudo-membranous laryngitis, 106

EMPHYSEMA, 232
Definition and history, 232
Varieties, 232
_Interlobular or Extra-vesicular Emphysema_, 249
_Vesicular Emphysema_, 232
Acute lobular form, 232
Symptoms and treatment, 233
Atrophic lobar form, 248
Symptoms and treatment, 248, 249
Chronic lobular form, 233
Hypertrophic lobar form, 233
Complications, 239
Diagnosis, 243
Duration, 242
Etiology, 234
Changes in alveolar wall, influence on causation, 234
Expiratory and inspiratory theories of causation, 235, 236
Heredity, influence on causation, 234
Morbid anatomy, 242
Prognosis, 244
Symptoms, 236
Cough and dyspnoea, 236
Chest, shape of, 237
Physical signs, 236-238
Respiration, peculiarities of, 238
Treatment, 245
Cod-liver oil, use, 245
Compressed air, use, 245, 246
Digitalis, use, 247
Expectorants, use, 246
Expiration into expired air, 246
Iron, use, 245
Potassium, iodide, 246
Quinia hydrobromate, hypodermatically, 247
Strychnia, use, 245

Emphysema after tracheotomy, 162
distinguished from asthma, 198
following asthma, 189

Empyema, pulsating, 596
See _Pleurisy, Purulent_.

Enchondroma of the mediastinum, 871

Encysted pleurisies, 545, 546

Endarteritis, obliterating, of the coronary artery, 830
of the pulmonary artery, 833
of the superior mesenteric artery, 839

ENDOCARDITIS, 639
Definition, 639
Diagnosis, 649
From aortitis, 650
From pericarditis, 649
Etiology, 645
Acute and chronic Bright's disease, 646
Acute rheumatism, 645, 646
Pyæmia, puerperal fever, the specific fevers, etc., 646
History, 639
Morbid anatomy, 640-645
Of acute exudative form, 640
Of interstitial form, 643
Of ulcerative form, 642
Prognosis, 650
Symptoms, 646
Dyspnoea, 647
Mitral murmurs, frequency and characters of, 648
Of exudative form, 647
Of interstitial form, 647
Of ulcerative form, 647
Pain in, 647
Physical signs, 648, 649
Physiognomy, 647
Pulse, characters, 647
Tricuspid and aortic murmurs, characters, 649
Treatment, 650
Iron, use, 651
Opium, use, 651
Rest, value, 651
Stimulants, use, 651

Endocarditis, influence on causation of cardiac thrombosis, 725
ulcerative, influence on causation of splenic infarction, 961

Engorgement stage of croupous pneumonia, 308

Enlargement of the spleen, chronic, 951, 956
in lardaceous disease, 967
in syphilis, 971

Epigastric pulsation in mitral disease, 672
in tricuspid disease, 679

Epiglottis, erosion of, 110
treatment, 111
inflammation of, 109, 110
ulceration of, 111
symptoms and treatment, 112

Epistaxis, 50-52
in croupous pneumonia, 331

Ergot, use, in epistaxis, 51
in embolism of superior mesenteric artery, 839
in hæmophilia, 938
in hæmoptysis, 291
in morbid growths of larynx, 131

Ergotin, use, in aneurism, 816
in exophthalmic goitre, 766
in hæmoptysis of heart disease, 685
in hæmothorax, 583
in pulmonary phthisis, 437

Erosion of epiglottis, 110

Eruptive fevers, influence on causation of pericarditis, 771
of pleurisy, 493

Erysipelas of the trachea, 136

Ether, use, in pneumothorax, 582