A Manual of Dissection and Practical Anatomy founded on Gray and Gerrish. By Wm. T. Eckley, M.D., Professor of Anatomy, and Corinne B. Eckley, Demonstrator of Anatomy in the Medical and Dental Departments of the University of Illinois. In one octavo volume of 400 pages, illustrated with 220 engravings, 116 of which are colored. Cloth, $3.50 net. Lea Brothers & Co., publishers, Philadelphia and New York.

As an adjunct to a complete work on practical anatomy, a manual on dissection has its peculiar sphere. It presents a detailed guide for dissection and offers a ready opportunity for the student and physician to quickly grasp a comprehensive knowledge of the anatomy of any region. This manual was designed to fully meet all requirements that may be exacted of a book intended for the purpose for which this was prepared, and it gives explicit and clear directions for dissecting and identifying the various structures of the body, Its usefulness is increased by the fact that it has been developed along the lines of regional anatomy, thus adapting it to the needs of the surgeon and the pathologist. The illustrations are especially good, and the engravings, of which there are a number, deserve particular commendation.

The American Text-Book of Obstetrics. In two volumes. Edited by Richard C. Norris, M.D.; Art Editor, Robert L. Dickinson, M.D. Second edition, thoroughly revised and enlarged. Two handsome imperial octavo volumes, of about 600 pages each; nearly 600 text-illustrations and 49 colored and half-tone plates. Per volume, cloth, $3.50 net; sheep or half morocco, $1.00 net.

Of recent contributions to the text-book literature on obstetrics, this new edition of the American Text-book of Obstetrics deserves special commendation. It is one of the most up-to-date works on this subject that can be found. This new edition has been rewritten in its entirety, and the work as now published represents the science and art of obstetrics in its most latter-day aspects.

The Medical News Visiting List for 1903. Weekly (dated, for 30 patients); Monthly (undated, for 120 patients per month); Perpetual (undated, for 30 patients weekly per year); and Perpetual (undated, for 60 patients weekly per year). The first three styles contain 32 pages of data and 160 pages of blanks. The 60-patient Perpetual consists of 256 pages of blanks. Each style in one wallet-shaped book, with pocket, pencil and rubber. Seal grain leather, $1.25; thumb-letter index, 25 cents extra. Lea Brothers & Co., publishers, Philadelphia and New York.

Of the various visiting lists, this is one of the best known to the medical profession. It improves each year, and is constantly receiving additions which render it all the more valuable.

Essentials of Histology. By Louis Leroy, B.S., M.D., Professor of Histology and Pathology, Vanderbilt University, Medical and Dental Department; Pathologist to the Nashville City Hospital, etc. Second edition, thoroughly revised and greatly enlarged. 16 mo. volume of 263 pages, with 92 beautiful illustrations. Philadelphia and London: W. B. Saunders & Co., 1902. Cloth, $1 net.

Dr. Leroy is well known to the physicians of the South and Southwest, and his little work on histology, the first edition of which appeared some months since, has added not a little to his reputation as a teacher of this branch of medicine. In this second edition of his excellent work, he has added much in the way of new original illustrations and rewritten many of the chapters. Dr. Leroy's book will be found a most excellent guide to the worker in the field of histology.

THE NATURE AND TREATMENT OF THE
DYSPEPSIA IN CONSUMPTIVES.*

BY PAUL PAQUIN, M.D.
ASHEVILLE, N. C.

Member American Medical Association; Mississippi Valley Medical Association;
North Carolina Medical Association, etc., etc., and Honorary Member of
St. Louis Medical Society.

In a paper recently read before the Mississippi Valley Medical Association I attempted to give a general outline of digestive disorders in consumption, and suggest measures of management. Today I will endeavor to give a brief, practical description of the nature, symptoms and treatment of such affections, leaving my audience to investigate more thoroughly the points I shall present, by consulting the authorities on the diseases of the digestive apparatus.†

Three forms of dyspepsia have been described as appertaining to consumption of the respiratory organs: one preceding it; one at the beginning of its symptomatic manifestations; one accompanying it. This distinction, as I have held before today, does not seem to me warranted. In the light of long observations and studies, I have arrived at the conclusion that they are mere divisions of the same malady at different stages

Read by invitation before the Tri-State Med. Assn. (Miss. Ark. & Tenn.), Memphis, November 12, 1902.

†Saltau Fenwick, Ewald, Hutchinson, Brinton, Du Jardin Beaumetz, etc. Vol. 23-5

59

of it. And then, too, there is to be considered other forms of dyspepsia seemingly different and yet simulating the so-called consumption kind, and occasionally seen with it. What we term dyspepsia preceding phthisis, probably occurs after the tubercular infection has begun its insidious ravages, but before its recognition by the patient or physician. I have watched certain dyspeptics many years, finding by the tuberculin test the existence of tuberculosis that no physical sign present could positively reveal, except as such dyspepsia could suggest. When the physical signs of tuberculosis did appear in them the dyspepsia had become worse, and during the course of the disease became more intractable. So strikingly have my observations of many years impressed me, that I now look with grave suspicion upon all cases of dyspepsia of any kind, exhibited without symptoms of tuberculosis, and make it a point to search closely for the existence of tubercular infection somewhere in the system. I must then, with this proposition in my mind, necessarily discuss the so-called dyspepsia of consumptives as an entity, exhibiting various and variable symptoms at different stages of its pathology and duration.

PATHOLOGY: At the onset of the dyspepsia of consumptives organic changes are not found in the stomach or intestinal structure. These changes develop slowly, and it is in advanced cases that their phenomena appear. Then, they sometimes become so serious and radical that the stomach, liver, pancreas, intestines and glandular system cannot properly perform their functions. The greatest degree of structural changes of the digestive organs occurs during the stages of destruction of the lungs, becoming often irreparable during caseation processes. These conditions, as well as some special lesions, such as "mammillation," which consists of small elevations closely besetting the mucous membrane of the stomach; the honeycombed pitting of the mucosa; its punctiform hemorrhagic points; certain of its ulcerations and erosions are all due more or less directly to an interstitial inflammation involving the whole of the gastro-intestinal tract. This inflammation seems to be indeed the essential feature of the disease. In the stomach its first results consist of "a slight infiltration of round cells into intertubular connective tissues;" this infiltration, as

it increases, compresses the tubules until they can no longer secrete sufficiently. Gradually various forms of tissue alterations and degenerations take place and the gravest organic damages result. At last it is not uncommon to find cirrhosis of the mucous membrane. The intestine suffers more or less in a similar manner, particularly the duodenum. The glandular system also becomes involved in pathologic developments, particularly the parotids and the pancreas. These usually reach, in chronic cases, various stages of fibrous transformation. It is possible, if not probable, that some glands of the system, as the parotids and lymphatics, begin to suffer at the very onset of tubercular bacterial poison in the circulation. A gross change in the digestive system, one which appears sometimes very early and affects more or less possibly 50 per cent. of the consumptives, is dilatation of the stomach, which means thinning, or atrophy or hypertrophy of its walls, with all of their consequences on the processes of digestion. (Figs. 1 and 2.)

ETIOLOGY: Considerable has been said about the etiology of the dyspepsia of consumptives, but the question remains unsolved. My own theory is, as already suggested, that there is no dyspepsia truly and wholly pretubercular bearing a direct causal relationship to tuberculosis. In this expression, I maintain in part a prior opinion of Saltau Fenwick. I believe that the dyspepsia manifested before the appearance of specific symptoms of consumption depends on more than one factor, the chiefs of which are, first, natural deficiency of structure in the digestive tract, and subsequently the early tubercular poisoning of the cellular organization, resulting in interstitial inflammation with the pathologic cellular infiltration mentioned above. If we realize that a very large percentage of persons, never exhibiting any symptom of tuberculosis, are nevertheless infected with a mild form sufficiently active to react to the tuberculin test, we can conceive of the tubercular poison generated in the system and circulating in the blood being sufficient to induce changes in susceptible tissues. There are, however, many reasons to believe that the gastro-intestinal dyspepsia of consumptives is often made worse by physical causes, and perhaps sometimes ushered in by them. I have

seen this result from the abuse of alcohol, creasote and other drugs; also from injudicious force feeding.

SYMPTOMS: In the dyspepsia that precedes consumption (as well as in the dyspepsia which seems to usher it in and accompany it), two varieties are recognizable: one which is atonic and one which is of an irritant kind. But in certain cases both seem to be present at the same time. The first attacks females more commonly than males, particularly between the ages of 13 to 25 or 26, and are not infrequently the seeming sequelae of some specific fever, such as typhoid, scarlet fever, diphtheria, measles, having just occurred. There is pain at the epigastrium, sometimes very severe; there is nausea, vomiting, thirst (which is sometimes very great), loss of appetite, with other more usual signs of subacute gastric catarrh. These symptoms may appear abruptly and persist irrespective of the usual treatments for indigestion. They recur and recur, vomiting resulting after a meal day after day without any apparent reason. Food ferments on the stomach, gas and acids are formed, and these increase the distress. A well-authenticated fact is that many dyspeptic persons, who afterward exhibit tuberculosis, had during this so-called pretubercular dyspepsia exhibited great antipathy for meats. Such patients sometimes abhor beef, mutton and pork, especially the fats of the two first mentioned. They are perhaps a little more partial to poultry.

Generally the intestines become involved in fermentation and flatulency occurs. Listlessness, despondency, mental depression, appear and disappear. The least physical exertion produces weariness and tired limbs. Sudden perspiration, particularly toward morning, is a common thing. Armpit sweatings are also associated with the disease sometimes; and, too, cold and clammy feet and irregularly flushed cheeks. The face, however, is usually pale, sometimes pinched and thin. The tongue may be large and red or pale and flabby. The breath is generally sour and otherwise offensive. The teeth decay readily. Constipation almost always exists; in fact this dyspepsia is rarely without it at the beginning. The pulse is feeble and slow, and the temperature, particularly in the morning, is generally subnormal, i. e., 98°F., 97°F., and even lower.