contains a precipitate of phosphates and carbonates, which may give rise to the formation of calculi. Occasionally nervous disturbances appear, such as muscular wasting, tremor, spasm, exaggerated tendon-reflexes, and neuritic symptoms. Osteomalacia almost always pursues a chronic course, extending at least over several months, but generally over several years. Often remissions and exacerbations occur repeatedly, the latter generally in connection with renewed pregnancy. Death results at times in consequence of progressive exhaustion, while at other times it is the result of bronchial catarrh, pneumonia, or weakness of the heart-muscle. Diagnosis. The recognition of osteomalacia is exceedingly difficult at the commencement of the disease, and it is possible with certainty only when deformity of the bones has developed. Even then, however, confusion with multiple osteomyelomata is scarcely to be avoided. The latter disease is still rarer than osteomalacia. Prognosis. The prognosis of osteomalacia is grave, because permanent recovery rarely takes place. Women are exposed to dangers of especial magnitude in the act of parturition in consequence of pelvic contraction. Anatomic Alterations.-The bones have occasionally become so soft that they yield and can be cut with a knife, like artificially decalcified bones, or, at any rate, can be readily broken. At times the long bones are so thin as to have acquired an intestine-like character. The bones present abnormal dilatation of the medullary and Haversian canals. In the spongy bones the osseous trabeculæ are often absent, so that large spaces filled with bone-marrow result. The bone-marrow in the early stages appears red and rich in blood, but subsequently it acquires a rather yellowish, then a grayish, color, and it undergoes atrophy. On microscopic examination of the bones the marked dilatation of the medullary spaces and the Haversian canals is likewise conspicuous. In the immediate neighborhood the osseous tissue has lost its calcium-salts, stains therefore with carmine, and exhibits a striated appearance. Often the bone-corpuscles have undergone degeneration. The medullary spaces and the Haversian canals exhibit numerous diverticula in the bones (Howship's lacunæ) in which myeloplaques are situated. The bones are unusually light, and contain little inorganic matter, particularly lime-salts. bone-fluid is said occasionally to possess an acid reaction. The presence of lactic acid in the bones has also been reported, and this is thought to effect solution of lime-salts. Other physicians, it is true, attribute the solvent action to carbon dioxid, which probably accumulates in excessive amount in the vascular medullary tissue. The Treatment. The treatment is similar to that for rachitis (p. 305). I have as vet been unable to convince myself with certainty of the usefulness of phosphorus. The patients should be admonished of the danger of falling, and women, particularly, of that of renewed pregnancy. Recently both ovaries have been removed in desperate cases-thus castration performed. DEFORMING ARTHRITIS. Etiology.-Deforming arthritis generally avoids early life, and develops as a rule after the fortieth year. The disease occurs most frequently in the poorer classes of the community, so that it has been designated also the arthritis of the poor. Among the causative factors exposure to cold is mentioned, emphasis being placed upon the fact that moldy and moist dwellings and working in the damp favor the development of the disorder. An unfavorable influence is ascribed, also, to traumatism. Occasionally the alterations in the joints develop after antecedent infectious diseases. Finally certain diseases of the nervous system are believed to be of etiologic significance, particularly hysteria and chronic diseases of the spinal cord. Symptoms.-The disease generally sets in insidiously, and involves at times but a single joint or many joints, in the latter event often exhibiting a strikingly symmetric distribution. The monarticular variety of deforming arthritis occurs with especial frequency in the hip-joint, is attended with pain, stiffness, and, finally, immobility. The condition is known as senile disease of the hip-joint, and is much feared. Polyarticular deforming arthritis involves with preference either the large or the small joints, although simultaneous involvement of the most varied joints is not uncommon. The patients complain generally at first of pain, which is not confined alone to the affected joint, but extends throughout an entire extremity, and is frequently aggravated by change in the weather and after exposure to cold. The pain is increased on pressure and on movement. The joints gradually become the seat of enlargements of bony hardness and of deformities, which render movement progressively more difficult, and eventually result in ankylosis. Movement of the joints is not rarely attended with palpable and audible grating and crackling. These alterations are unattended with fever and symptoms of local inflammation in the joints. Should numerous joints be involved the patients become rigid, immobile, and helpless, and are forced to seek the aid of others. Peculiar distortion and deformities occur in the fingers and the toes. In the hands, the thumb and the little finger often are uninvolved, while the remaining fingers become markedly flexed upon the palm at the interphalangeal joints, and luxation toward the ulna occurs in the metacarpophalangeal joints, so that the fingers are superimposed upon one another like the shingles of a roof (Fig. 54). A number of other displacements of the fingers also occur. Often small, hard nodules. -so-called Heberden's nodes—are encountered between the middle while the peripheral portions exhibit hyperplasia, in which, also, the articular extremities of the bones are involved. The articular capsule often is the seat of thickening, and even of calcification, and its inner surface presents hyperplasia of the articular villi, which likewise are often in part ossified. Occasionally some villi have become detached, and lie in the articular cavity as free bodies. Treatment.-Potassium iodid (5.0: 200-75 grains: 63 fluidounces; 15 c.c.-1 tablespoonful-thrice daily) especially has been recommended in the treatment of deforming arthritis. Salicylic acid, sodium salicylate, salol, salophen, salipyrin, antipyrin, and phenacetin usually afford little relief to the articular pain. Massage of the joints with salicylated ointment (salicylic acid, 10.0-21 drams; wool-fat and lard, each, 25.0-3 ounce) and enveloping the joints in salicylated cotton may be recommended. The symptoms are usually mitigated also by means of hot baths. Well-todo patients may be sent during the summer to indifferent thermal baths or to sulphur-baths, saline baths, peat-baths, or mud-baths. Sand-baths and the local employment of hot air are also in good repute. Nothing can be accomplished with electricity (local application, galvanization of the sympathetic). The patient should be guarded against exposure to cold and wetting of the body, should always avoid damp dwelling-rooms, and should wear flannel clothing next to the skin. Those who are favorably situated will do well to spend the cold and changeable period of the year in a uniformly warm climate, as, for instance, on the Riviera or, still better, in Egypt. PART X. INFECTIOUS DISEASES. INFECTIOUS DISEASES OF TYPICAL I. ACUTE INFECTIOUS EXANTHEMATA. TYPHUS FEVER. Etiology.-Typhus fever is a highly contagious disease, to which nurses and physicians in the pursuit of their avocation have often fallen victim. The infective material is not known, but it is believed to be some form of lower organism. Infection may take place by transmission through the air, through personal association, through the intermediation of a third person, and through articles in common employ. Typhus fever still occurs in endemic distribution in Ireland, Russia, Galicia, Hungary, and Italy. The disease is often conveyed from these countries through emigrants, peddlers, laborers, and vagrants, and it has repeatedly been possible to demonstrate that it has appeared in all places that have been visited in their travels by individuals infected at home. Only recently typhus fever was conveyed to cities in Northern Germany, in which extensive epidemies occurred. The circumstance is especially favorable for the transmission of the disease that infected persons are infective at a period when they feel tolerably well and are capable of travelling. All places in which they sleep over night are constituted sources of infection for those who follow them, and accordingly experience demonstrates that epidemics of typhus fever frequently originate from certain lodginghouses of low and uncleanly character. Police-stations and prisoners also are not rarely infected through vagrants, and from these sources the disease may be widely disseminated. In earlier times typhus fever was more frequently encountered than at the present day, because little importance was attached to measures of isolation and disinfection. The disorder occurred with especial fre |