During this time he has suffered with severe cough; has had a temperature which, as you see by the chart, has oscillated markedly, ranging from 99° or 100° F. in the morning to 104° or 105° F. in the evening, and has lost strength and flesh rapidly. No previous history of value can be obtained, for his mother, who is a prostitute, left him to the tender mercies of chance friends, and knows little or nothing about him. He comes before you now, presenting a miserable spectacle. His face is pinched, and shows the imprint of severe illness. The lips are cracked and ulcerated, marking great impairment of nutrition, a fact still further manifested by the wasted thorax and limbs. From the latter all the flesh seems to have disappeared, and the investing skin hangs about the bones in loose inelastic folds. The abdomen alone appears to be unaffected by the general wasting, and by its prominence stands in marked contrast to the emaciated frame.

The general symptoms may be stated in a few words. They are fever, profuse night perspirations, harassing cough, accelerated breathing, rapid and feeble pulse, impaired appetite, thirst, and irregular bowels. There is no cedema, the conjunctivæ are pearlywhite, and the urine is unaltered in composition.

To begin the physical examination with the lungs, as the cough and quickened respiration point to them as the seat of the disease, you perceive that there is greatly impaired resonance on percussion over the upper third of the right lung, and auscultation reveals the signs of a small cavity immediately below the clavicle, with broncho-vesicular respiration, and subcrepitant râles over the rest of the dull area. Over the remainder of the right and the whole of the left lung there is hyperresonance on percussion, and exaggerated puerile breathing on auscultation. The heart, beyond rapidity of action, presents nothing abnormal.

Passing next to the abdomen, note that while the whole region projects markedly, the greatest bulging is at the upper half. In this position the fingers of the palpating hand distinctly detect a solid, smooth mass beneath the integument, which extends upwards to the costal border and downwards to the level of the umbilicus. The lower border is somewhat hard to find, as it seems to fall away from the parietes, but on careful manipulation it can be grasped by the fingers, and is rounded and soft. On tracing this from right to left, one can distinctly mark out an outline exactly

resembling that of the right lobe of the liver; while here, a little to the left of the meridian line, is the notch between the right and left lobe, and still more to the left, the margin of the left lobe. To further prove that this mass is an enlarged liver, the dulness over it is continuous with the usual liver dulness, and the upper margin of the latter extends nearly an inch higher than in health. The abdomen below the tumor gives the ordinary tympanitic note on percussion, and is soft and flexible to palpation. There is no enlargement of the spleen. It is particularly to be observed that during the whole of the abdominal exploration the child has evinced no signs of pain nor tenderness. Now, all of these features are characteristic of fatty infiltration of the liver.

The case before you, therefore, is one of tuberculosis with associated fatty liver.

The pulmonary disease undoubtedly antedated and induced the hepatic enlargement, and I think you will be able to trace this etiological factor in the majority of cases occurring among children. curring among children. The causes, however, may be divided into two classes,-first, the over-use of farinaceous food, which induces a physiological and transitory infiltration of the liver, the excess of hydrocarbons supplied from without being deposited in the cells in the form of fat; second, chronic wasting diseases, such as tubercle, scrofula, rickets, caries of bone, chronic intestinal catarrh, and syphilis. Here the fat is absorbed from the subcutaneous and other fatforming tissues of the body, and the process is pathological.

The rational symptoms, as exemplified in the present instance, belong usually to the causal affection rather than to the hepatic disease. In fact, the latter has no especial symptoms, except disturbance of the functions of the stomach and intestines due to obstruction of the portal circulation; the features of associated fatty changes in the heart and kidneys, that so often direct attention to, or confirm the existence of, similar lesions of the liver in adult life, being of rare occurrence in childhood. Symptoms, therefore, are little to be relied on.

The physical signs so readily elicited today are, on the contrary, quite characteristic. Unfortunately, they are fully developed only in well-matured cases. For, while uncomplicated fatty infiltration of the liver is always. attended by an increase in bulk, we may fail to detect a moderate alteration on account of the tendency the organ has, from its softness, to fall away from the abdominal wall.

Understand, then, that the presence of this disease may be absolutely asserted when a tumor, having the outline of the liver, can be felt in the abdomen; when this tumor has a blunted edge, is soft and painless; when the percussion-dulness over it is continuous with the normal liver-dulness; and when there is neither enlargement of the spleen, ascites, nor jaundice. Without these features there must always be uncertainty, and sometimes the lesion is not even suspected until the viscus is exposed on the post-mortem table.

The diagnosis between fatty and amyloid liver is best tabulated as follows:

AMYLOID LIVER.

Increase in size; the lower margin of right lobe often extending down to brim of the pelvis.

Tumor smooth but very hard.

Edge sharp and prominent, often pushing forward the parietes in a visible ridge.

No pain nor tenderness. Spleen enlarged and hardened.

Vomiting and diarrhoea from amyloid degeneration of the mucous membrane of the gastro-intestinal tract.

Urine albuminous, with hyaline tube-casts from amyloid degeneration of the kidneys.

Anæmia and sometimes oedema of feet and ankles. No ascites.

No jaundice. Usual cause: protracted suppuration.

In very exceptional cases, jaundice and ascites are met with in both forms of disease. They depend upon enlargement of the glands in the fissure of the liver, due in the one case to caseous or tubercular, and in the other, to amyloid degeneration.

The prognosis depends upon the cause. If the enlargement be caused by an excess of farinaceous food, regulation of the diet soon produces a reduction in bulk, but when it occurs during the course of a protracted wasting disease, dangerous impairment of nutrition is indicated.

As already stated, then, when fatty liver depends upon dietetic causes, proper feeding is all that is required for its removal. In other cases, the only successful treatment is one directed against the originating disease. So

far as the liver itself is concerned, the plan of management is to exclude all starch and fat from the food; to insist on warm clothing, fresh air, and sunlight; to correct dyspeptic symptoms by the administration of alkalies with bitters; to relieve constipation by mild laxatives; and to restore the crasis of the blood in anæmia by the use of some acceptable preparation of iron.

2. Amyloid Degeneration of the Liver.-The little patient before you is 8 years of age. He has been an inmate of the Children's Hospital for over three years, and during this time has been treated for suppurative disease of the right hip-joint. He is very anæmic and much emaciated, suffers from attacks of vomiting and diarrhoea, has slight oedema of the ankles and feet, and his urine is highly albuminous and contains numerous hyaline casts. The abdomen is, as you see, very prominent, and on physical examination the liver is found to be immensely enlarged, the lower edge of the right lobe extending quite to the brim of the pelvis; the spleen is also greatly increased in size, and both organs feel firm and dense to the palpating fingers. There is no jaundice. nor ascites, and no pain nor tenderness over the liver. There can be no question that this is a case of amyloid degeneration of the liver, with associated amyloid disease of the spleen, kidneys, and gastro-intestinal mucous membrane.

The albuminoid or amyloid liver occurs as a factor in general amyloid degeneration, and is not infrequently met with in childhood. The disease consists in a complete or partial infiltration of the liver-cells by a peculiar translucent, refracting substance, possessing the property of fixing iodine, and assuming a mahogany-brown color, which, upon the application of sulphuric acid, changes to blue, green, violet, or red. This infiltration begins in the hepatic arterioles and capillaries, and at first is limited to the middle zone of the lobules; it then extends to the periphery and centre, destroying the normal elements of the cells, and converting them into irregularlyshaped, glassy-looking masses; with this condition fatty infiltration is sometimes associated.

There is uniform enlargement of the liver; its density is increased; the color is yellowishgray; the peritoneum is smooth and shining, and the edges are thin and well defined. On section, dry, homogeneous, glistening surfaces are exposed.

The spleen, kidneys, and lymphatic glands are frequently similarly altered, and at times,

also, the mucous membrane of the stomach and intestines.

Amyloid degeneration of the liver is always produced by some chronic disease, attended by suppuration and purulent discharge. Suppurative diseases of the bones and joints, scrofulous abscesses, empyema with a fistulous opening in the chest-wall, dilated bronchi with copious muco-purulent expectoration, chronic pulmonary tuberculosis, and constitutional syphilis are the most frequent causes. It may occur at any age, but is more frequent after the fifth year, and in boys than girls.

The rational symptoms are those of the originating disease. There is no pain nor tenderness in the hepatic region; there is absence of jaundice, distention of the superficial abdominal veins, and ascites. If, however, the glands in the fissure of the liver be at the same time enlarged by waxy deposit, the pressure exerted upon the portal vein and bile-duct will cause jaundice, distention of the superficial abdominal veins, and ascites. The patient may complain of weight in the hypochondrium, and is always weak, wasted, and anæmic, with pale, sallow skin, clubbed fingers, and oedematous feet and ankles. If the kidneys be involved, the urine is increased in quantity, has a low specific gravity (about 1014), is light lemon-colored, and contains albumen, and at times hyaline tubecasts. The dropsy of the lower extremities is due in great measure to this complication, and when the intestinal tract becomes involved there is a tendency to vomiting and diarrhoea.

The physical signs are characteristic: the abdomen is prominent, especially over the upper third, and both percussion and palpation show the liver to be very greatly and uniformly enlarged.

The upper margin of dulness is higher by an inch or more than is normal, while the lower edge of the right lobe is somewhat blunted, but perfectly well defined, and can often be felt below the level of the umbilicus, even, as in the present case, at the brim of the pelvis. The portion uncovered by the ribs feels very dense and firm, and perfectly smooth, except where broken by the natural fissures.

The spleen can often be detected projecting from beneath the left costal border. The absence of splenic enlargement is, however, no proof against the existence of amyloid changes in that organ, as in some few cases there is no appreciable alteration in size.

The course of the disease is chronic.

The diagnosis is not difficult, and is readily made from the physical signs furnished by the liver and spleen, the absence of jaundice and ascites, the previous history of cachexia and suppuration, the character of the urine, the anæmia, and the gastro-intestinal symptoms.

Congestion of the liver, with consequent enlargement, has an entirely different history, rarely occurring in cachectic or anæmic cases. A fatty liver, while large, is soft and yielding to the touch, and is unattended by increase in the size of the spleen or albuminuria.

The prospect of ultimate recovery is better in children than in adults, for, provided the cause of the degeneration can be removed, it is quite possible for the liver to return to its normal dimensions and to an apparently healthy condition, through the active reparative power always present in early life. Nevertheless, amyloid change in the liver adds greatly to the danger of the originating disease, and is fatal in most cases.

In the matter of treatment it is hardly necessary for me to say that attention must first be given to the amelioration or removal of the cause. It is more difficult to cure the disease when once developed than to prevent it by checking chronic suppuration, removing carious bone, healing diseased joints, energetically treating constitutional syphilis, and building up the health in cachectic subjects.

To combat the disease itself, the diet must be as nutritious as possible, taking care that the powers of digestion be not overtaxed, and a moderate quantity of alcoholic stimulants must be taken daily. The child must be clothed so as to prevent all chilling, and must live as much as possible in the sunlight and open air, or, if confined to the house, in a bright, airy room. Alkalies, iron, and iodine are the most useful drugs. Of alkalies, the chloride of ammonium is the best, and it may be given in combination with a bitter. The following prescription answers very well in these cases:

R Ammonii chloridi, zii;

Infus. gentianæ comp., fiii. M. S.-One teaspoonful four times daily; for a child six

years old.

It is often well to combine iron with the ammonium salt; for example:

B Tinc. ferri chloridi, fzi;
Ammonii chloridi, zii;

Infus. calumbæ, q.s. ad fiii. M.
S.-One teaspoonful three times daily.

Tinc. ferri chloridi, fzi;
Acidi acetici dil., fziss;
Liq. ammonii acetatis, fzx;
Elix. aurantii, fzv;
Syrupi, fi;

Aquæ, q.s. ad fzvi. M.

S.-One tablespoonful four times a day.

When there is kidney complication with oedema, this formula is particularly useful. Iodine is most efficient if there be a syphilitic taint. It may be given in the form of iodide of potassium, 5 grains or more three times a day, with a bitter infusion, or liquor iodinii comp. can be employed in doses of 2 drops, well diluted, three times a day.

The complications must be met as they arise. Vomiting, by ice, Apollinaris water, bismuth, and counter-irritation of the epigastrium; diarrhoea, by the vegetable astringents, combined with small doses of opium ; and dropsy, by diaphoretics and diuretics.

DIET IN FEBRILE MALADIES.*

BY PROFESSOR DUJARDIN-BEAUMETZ, Paris, France.

ENTLEMEN :-If I were to attempt to give a full history of the subject of which I am to speak to-day, one lecture would hardly suffice for all the details, or even to indicate the various phases through which this vexed question of hygienic therapeutics has passed. I shall, then, call your attention only to the principal points of historical interest connected with the dietetics of fevers.

For long ages the medical world followed scrupulously the rules pertaining to diet in febrile diseases so remarkably set forth by the Father of Medicine. In the treatise which he has devoted to this subject, Hippocrates expresses himself thus: "Doubtless in cases where there is much enfeeblement, resulting from pain and acuteness of the malady, it is great mistake to give the patient large quan-" tities of drinks, ptisans, or alimentary substances, with the idea that the debility is due to the emptiness of the vessels, but it is a mistake, also, to lose sight of the fact that a fever patient is weak by inanition, and to make his state worse by starving him." He adds, with much good sense and discernment, "If, under such circumstances (where the patient has been subjected to a starvation diet), some friend or

* A lecture on Alimentary Therapeutics.

comes in and recommends nourishing food and drinks, despite the doctor's orders, he will often greatly benefit the patient, and may even get the credit of a cure. It is such cases as these that bring reproach upon the physician, the new man who prescribes food, whether a physician or a layman, receiving praise for having wrought an astonishing cure."+

Galen, Celsus, Etius, Paulus of Ægina, followed rigidly, with comments of their own, the precepts of Hippocrates, which were summed up in these words: "When you have deal with, you must treat it by a rigorously an acute inflammatory or febrile disease to low diet." At the same time complete abstinence was not enforced, for physicians of Hippocrates's school were in the habit of administering in the acute stages of disease a plentiful supply of infusion of ground barley, which has given to ptisans their generic name (Toán, ground barley). The medical men of antiquity rarely broke through these traditional rules. One of the most curious of these infractions is that of Petronius, who allowed febricitants meat, for which Galen bitterly reproached him.

But towards the end of the eighteenth century (in 1780), when Brown gave to the world his "Elementa Medicinæ," which was destined to revolutionize medical practice, the doctrine of Hippocrates relative to the dietetic treatment of fevers underwent modification. Re

garding almost all acute febrile diseases as asthenic affections, the Scotch reformer coun

selled in their treatment a stimulant and tonic regimen in which food played an important. part. These views found a fitting soil in England; they were welcomed also in Scotland, and long afterwards we find Graves successfully defending Brown's doctrine, and showing the danger of abstinence in fevers. He, in fact, considered this position which he had taken respecting diet in fevers as such an important factor of his medical career that he is said to have desired to have this inscription on his tombstone: "GRAVES FED FEVERS."

In France for many years the doctrine of Brown found few partisans; Broussais's physiological system was in fashion, and opposed an invincible barrier to it. Considering all febrile diseases as dependent on gastro-intestinal irritation, the ardent reformer of Val de Grâce, more severe than Hippocrates, condemned his fever patients to absolute ab

Hippocrates, "On Regimen in Acute Diseases."

stinence. Ignorant of the fact that at the terminal periods of continued fevers the nourishment which these patients at that time require provokes a physiological fever (febris carnis), as Bordeau had before observed, Broussais would rigorously remand to low diet or entire abstinence the poor patients who experienced the least febrile return as result of the first ingestion of food, and it may now be affirmed, without fear of contradiction, that this practice, as judged by its fruits, was most disastrous.

When, at length, the medical profession in France had advanced sufficiently to throw off the yoke imposed by the school of Broussais, more rational views as to the dietetic treatment of fevers began to prevail; the starvation regimen of Broussais was repudiated, and, despite the earnest endeavors of Forget, who took a vehement stand against these "fever-feeders," as he called them, and who naïvely wrote that there was something better to do than to feed fevers,—namely, to cure them, the great majority of physicians recognized the dangers of abstinence in febrile maladies; the bed-sores so often witnessed in typhoid patients, with other untoward incidents, were laid to the charge of poverty of alimentation,-i.e., were attributed to the abstinence to which the patients had been subjected.

The contest was carried on with ardor by such men as Marotte, Trousseau, and Herard, and in a remarkable discussion which was held almost thirty years ago (in 1857), at the meeting of the Society of the Hospitals, all present were agreed in acknowledging the necessity of feeding persons suffering from febrile affections. If Trousseau, by the eloquence of his teaching, by the charm of his manner, and his personal magnetism, was the most popular advocate of this new mode of alimentation, it must be remembered that it was Monneret who the most boldly carried it out. He was in the habit of ordering broths, vinous lemonade, wine of quinine, and Bagnol's wine for his typhoid patients, and would make them take as much as six quarts a day of nutrient and stimulating drinks.

Note, also, that several years before the prize Corvisart was awarded to a work of Duriard on abstinence in acute diseases, the conclusion of which was as follows: Abstinence has no influence on the progress of acute diseases; it neither modifies their march nor their manifestations." Thus far only clinical observation had been invoked in favor of or in opposition to a generous ali

mentary regimen in febrile disorders; but latterly new means of investigation have been put in exercise, and we shall presently see what support these have furnished to either the one or the other of the conflicting views. which the medical world has entertained.

To give method to my exposition, I shall first examine the modifications which the febrile process effects in the functional operations of the digestive tube, and in nutrition. As far as the functions of the digestive tube are concerned, all observers are agreed that typhoid fever profoundly modifies the secretions of the alimentary canal. In experiments made on individuals, the subjects of a gastric fistula, it has been again and again remarked that one of the first symptoms of this fever was marked diminution of the secretion of gastric juice, and even a decided change in the composition of this fluid. It is the same with the other secretions of the digestive tube.

But the most important point is that when you examine the condition of the intestinal mucous membrane in certain fevers, as typhoid fever, the modifications in the functions of this mucosa are still more pronounced. In this disease, in fact, the entire net-work of lymphatics is affected; the mesenteric glands are inflamed, so that the functional operation of the lacteals is profoundly perturbed, and the absorption of emulsified fatty substances and of peptonized albuminoid aliments cannot be effected in the greater part of the small intestine and in the large intestine. Drinks only ean penetrate the economy by the venous plexuses of the portal

vein.

The question of nutrition is also one of prime importance. I cannot here enter into a general description of the phenomena which characterize fever. Suffice it to say that we know by the examination of the urine on the one hand, and that of the gases of respiration on the other, that the febrile hyperthermia results either from a more active disintegration of the organism, with diminution of the combustions, or from an exaggeration of the combustions. The first theory is held by those who take for their basis the cellular theory of nutrition, and who consider urea as a breaking up of albuminoid substances; the second is held by those who accept as true the views of Liebig, and who regard urea as the direct result of organic combustions.

We have, moreover, a direct proof when we examine the loss of weight of fever patients. In a very interesting thesis, unfortunately in