miliary in form. 4. Gummata are always yellow or white, never transparent like miliary tubercle. 5. Until softening takes place gummata are of more equal consistence than tubercles, and if they soften do not break down, wholly owing to the capsule. Histologically, there is no difference in structure." Gummatous formations may be found on the pericardium and heart and in the thoracic and abdominal walls. Clinically, the most important pathological feature is that large districts of healthy lung are interposed between the affected districts; this is not so in ordinary phthisis.

Bronchial Lesions.-The syphilitic like the scrofulous are predisposed to catarrhal inflammation, and this may spread down the bronchial tubes, giving rise to a general bronchitis; a coexistent laryngitis may or may not exist. Enlargement of the bronchial glands is frequently combined with the syphilitic pulmonary process. When the glands are enlarged they present a firm pigmented character, varying in size from a hazelnut to an egg, and the connective tissue surrounding them is usually infiltrated. Subsequently, owing to the pressure of the mediastinal growths, the bronchi are narrowed and more or less occluded; the same effects are occasioned in the smaller bronchi by the pressure of the new growth which develops along their lumen. The effects of bronchial narrowing or occlusion produce serious mischief in the lungs proportioned to the degree of obstruction. By the retention of the bronchial secretions the air-supply to the vesicles is interfered with; emphysema with or without asthmatic symptoms or atelectasis may ensue. Further, the results of bronchial narrowing affect the circulation through the lungs, and in combination with atelectasis very intractable local bronchitis may be developed; and, with or without atheroma, hemorrhagic infarctions may occur, with a form of pneumonia which has been described by Fuchs as apneumatosis. The narrowing of the bronchial tubes in specific fibroid. phthisis affords a means of differentiating this disease from non-syphilitic fibroid phthisis, in which the tubes are widened. Cases have been reported of nodules of syphilitic new formations in the mucous membrane of the superior and inferior extremities of the trachea and larger bronchi. The nodules ulcerate, and in healing cicatricial bands of fibrous tissue are formed which cause contraction of the tracheal tube transversely or diminish its length. These lesions resemble tuberculous ulceration, but they differ in the nature of the initial neoplasm by the formation of cicatricial tissue and by the tendency to stenosis of the tracheal tube. The cutaneous syphilides, mucous patches, the exostoses of the bones of the cranium help to demonstrate the connection of the marked cachexia with syphilis rather than scrofula.

SYMPTOMATOLOGY.-As the pathology of syphilitic pulmonary processes is intertwined with the pathology of many other forms of phthisis pulmonalis, so the symptoms must be common to those obtaining in other forms of pulmonary disease. They are insidious and gradual in their development, and may be classified as the subjective, the physical signs, and the objective phenomena. The subjective symptoms may be present without noticeable departure from an appearance of health. There may be difficult respiration with more or less dyspnoea, especially in the mornings and evenings, besides a sense of heaviness and oppression in the chest, with a feeling of inability to inflate the lungs. These symptoms may be increased on exertion, respiration becoming wheezing, with imperfectly-developed asthmatic attacks. Hoarseness, with varying degrees of aphonia, more or less dysphagia or unequal pupils, may be present. Nearly all of these symptoms may be accounted for as indicative of mediastinal pressure or irritation of the pneumogastric nerve by the enlargement of the bronchial glands. The catalogue of phenomena may be present in whole or in part, and the intensity of their manifestations may vary from time to time in the history of a single case. If the bronchial glands are much enlarged, a sense of discomfort, oppression, and uneasiness

at the root of the neck may be experienced, which increases until actual pain is felt, located in the back between the scapulæ, but sometimes radiating through the intercostal nerves around the chest. Cough, as a rule, is an early symptom, usually dry, paroxysmal, and associated with dyspnoea, or there may be bronchial catarrh, with a relative amount of expectoration. Syphilitic disease of the larynx may occur coequal with the pulmonary trouble, and some of the above symptoms may be thus explained and many others added. Rheumatic and nervous symptoms, including sleeplessness and deterioration of the blood-crasis, may testify to the syphilitic infection of the blood.

When a physical examination of the chest is instituted, thickening of the head of the periosteum of one or both clavicles, substernal tenderness, thickening of the tibial periosteum, are usually detected. Prominent among the physical signs are the evidences of enlargement of the bronchial glands. According to Guéneau de Mussey, percussion over the spinous processes of the cervical vertebræ in the course of the trachea reveals in a healthy subject a distinct tubular sound down to the point of bifurcation of the trachea at the level of the fourth dorsal vertebra. Opposite the fifth and downward we get the lower-pitched pulmonary resonance. When the tracheal and bronchial glands are enlarged, the tubular sound over the upper dorsal vertebra is replaced by dulness, which may contrast sharply above with the tracheal and below with the vesicular resonance.

The respiratory murmur will be feeble in volume and limited to inspiration, especially over the interscapular region. Over one or the other bronchus the respiratory murmur may be more high pitched than in health, and slightly exaggerated on one side or at the base of the chest. The rhythm is often jerky and paroxysmal; the paroxysms are more or less constant, but are liable at times to increase.

The additional physical signs in syphilitic phthisis, unassociated with gummata, are those shared by other forms of fibroid phthisis, and do not require particular description here, as increasing dulness, varying degrees of bronchial breathing, and bronchophony. A peculiar alveolar rustle, resembling the sound produced by the rumpling of wall-paper, has been alluded to as

characteristic.

Inspection or palpation sometimes reveals changes in the contour of the chest, with displacement of the movable thoracic viscera, as in fibroid phthisis. When cavities occur, the physical signs necessarily correspond to those of other varieties of phthisis at this stage.

When a gumma is large enough to be recognized by physical examination, one finds dulness or flatness on percussion, confined to a section of the chest, and not occupying its semi-circumference, as in pleural effusions. The vocal fremitus is suppressed in proportion to the size of the gumma. The respiratory murmur is abruptly cut off over the area of flatness, but it may be only distant bronchial breathing. The vocal resonance is absent or is distant bronchophony. Around the gumma the respiratory murmur is usually very feeble or scarcely audible, generally without râles unless they are due to neighboring congestion. The percussion resonance is good or exaggerated. Proportionate vicarious functional activity prevails in the opposite lung. If the gumma be large, the heart's impulse may be displaced to the left or right, and dyspnoea may occur as in case of pleural effusions. In this stage, owing to irritation of the bronchial mucous membrane, there may be expectoration of a tough, glairy mucus, or as a gumma softens the expectoration may become purulent.

The objective phenomena vary: the chest is often well developed, the body fairly nourished, and constitutional symptoms of a severe character may be wanting. The patient may be capable of hard physical labor, even though a

considerable part of the lung be affected. Moxon relates a case of a man "employed in carrying sacks of grain who was suddenly killed, and who had fibroid infiltration of a great part of the left lung and part of the right, and besides scars in his liver and testes." But in some cases the complexion is pallid and waxy, indicative of cachexia associated with digestive disorders, with night-sweats, and a variable but low thermometrical record. Usually, the progress of the disease is slower in syphilitic than in tubercular phthisis, but when the systemic poisoning is grave and many other organs are coincidently involved, the progress is more rapid; but the process peculiar to syphilis is often past, and the patient suffers from simple catarrhal phthisis with formation of cavities and softening gummata. Diarrhoea and nightsweats are said to be less frequent than in ordinary phthisis, and the pulse is slower. Haemoptysis occurs infrequently, because the process in the lungs is chiefly fibroid; but it is possible through the rupture of newly-developed blood-vessels in the new formation in the lung or hemorrhagic infarction through the rupture of atheromatous vessels.

DIAGNOSIS. This depends mainly on the history of the cases, the prior or coexisting syphilitic lesions, especially laryngeal processes, cutaneous syphilides, exostoses, perforation of the palate, substernal tenderness, and the thickening of the tibial periosteum or that of the head of one or both clavicles. Family immunity from phthisical tendency, recovery from lesions usually incurable if they have any other than a specific origin, are suggestive of pulmonary syphilis. If a patient retains flesh and strength beyond the natural expectation considering the serious lesions of the langs, the fact is of relative importance when considered in connection with the other diag nostic features. The distribution of specific lesions is variously located by different authors. Grandidier found induration affecting the middle lobe of the right lung in 27 out of 30 cases believed by him to be specific phthisis; the surrounding lung contained large areas free from disease. This tendency to localization in portions of the lungs, leaving large areas free from disease, is of value in diagnosis.

PROGNOSIS. The prognosis is involved in the discovery of syphilis as the cause of the disease and on the subsequent appropriate treatment. Grave and important specific lesions, according to some authors, have yielded to the resources of art. Fournier has recorded a case where “dulness at the summit of the left lung was extensive and signs of a cavity distinct. After six weeks of antisyphilitic treatment recovery was almost complete. In this case the presence of a phagedenic ulcer of the foot was the only sign that suggested syphilis, the symptoms of the pulmonary affection being identical with those of tubercular phthisis." The principles presiding over the prognosis of the various stages of pulmonary diseases in general are applicable to syphilitic pulmonary processes.

TREATMENT. When a case of pulmonary lesion presents itself, unless the existence of tuberculosis be demonstrated, we must ascertain if the symptoms can possibly be due to syphilis, and the line of treatment indicated in any single case must be based upon an estimate of the prominence of the specific process. The ravages of syphilis, however, often produce such loss of substance in the lung that the lesions are irreparable, and therefore we cannot always accomplish the brilliant results which usually attend an antisyphilitic treatment. If there is evidence of enlarged bronchial glands, in addition to other measures local counter-irritation is useful by means of the biniodide of mercury ointment, 16 grains to the ounce, and applied for a continued period, or a preparation of iodine with croton oil may be tried. In the main, the general principles of treatment correspond with those recognized in similar forms of pulmonary disease of a non-specific etiology.

PNEUMONOKONIOSIS.

BY EDWARD T. BRUEN, M. D.

DEFINITION. A generic term applied to pulmonary diseases due to the inhalation of particles of irritating dust.

SYNONYMS AND CLASSIFICATION.-The synonyms and classification of pneumonokoniosis have been based upon the character of the dust inhaled, using such terms as anthracosis (Opa, coal), disease due to coal-dust; siderosis (topos, iron), due to metallic dust; chalicosis (zát, gravel or pebbles), due to mineral dust; tabacosis, due to tobacco-dust; and byssinosis (5, cotton), due to cotton fibre and dust. A more imperfect classification has been derived from the avocations of the sufferers; for example, miners' phthisis, Sheffield grinders' rot, potters' consumption and asthma, freestonehewers', masons', or millers' lung.

HISTORY.-From the early experiments of Cruveilhier, who injected mercury into the system and subsequently noted the pulmonary changes, down to the experiments of the present day, evidence has accumulated to show that inorganic irritant materials are capable of exciting inflammatory new formation in the lungs. The difference between the changes produced in the lungs by experimental processes and those occurring after the inhalation by artisans of inorganic materials consists in degree rather than in essential character. In pneumonokoniosis the pulmonary processes are gradually developed, and consequently the ensuing changes in the tissues represent those usually associated with the more chronic forms of pulmonary lesions, and may not only occasion phthisis, but during years of life may cripple the sufferer by engendering chronic catarrhal processes in the mucous membranes, complicated by emphysema or asthma.

ETIOLOGY.-Predisposing Influences.-Atmospheric dust is composed of organic and inorganic matter, and both have been demonstrated by many admirable experiments to be very widely diffused in the air we breathe. In most instances the injurious action of inorganic dust is augmented by the conditions of imperfect ventilation under which it is inhaled, because the amount of dust deposited in the lungs is thereby increased. Illustrations of this fact can be found in various avocations, particularly among miners. The injurious action of dust inhaled when there is imperfect ventilation is increased in proportion as there is deprivation of sunlight, both conditions tending to lower the vitality of the artisan. Again, the rigor of confinement of parents engenders a sickly or scrofulous constitution which is transmitted to their offspring, causing great mortality among the children of artisans, especially where they, in turn, are subjected to unfavorable environment.

When work is performed in constrained or stooping positions, or when proper inflation of the chest is not secured, the liability to pulmonary disease is increased.

The foregoing conditions having been considered, the injurious action of dust upon the lungs is in proportion to the quantity deposited in them. The

entrance of dust is, however, physiologically opposed by the action of the pulmonary cilia, although the resistance is frequently ineffectual. This inefficiency may be owing to the quantity of dust inspired or to deficient tissueintegrity in general upon which the ciliary action depends in inverse ratio. Exciting Causes.-These vary materially in different avocations. The most injurious industries are those in which the various forms of grindstones are used, or those trades which necessitate labor in an atmosphere loaded with particles of steel, iron, or flint. In London, where millstones are made from French burr, a peculiarly hard flint quarried on the Marne to the east of Paris, and more liable to chip from its hardness and dryness than flint quarried in other places, the mortality among the artisans is said to be very much increased. Peacock, who has investigated this subject, asserts that in certain manufactories of this class the average age of those engaged is very low: of 23 apprentices the average age was twenty-four, and the longest period during which the occupation could be followed was thirteen years. The same author has also demonstrated the presence of silicious particles in the lung-tissues. In the pottery districts of England the death-rate from pulmonary diseases is greater among those who work at that avocation than among the other inhabitants.

The study of the effect upon the lungs of the inhalation of coal-dust is very important. In the coal-mining region of Cornwall the deaths from chest diseases among miners is double that of males in the community at large; the mortality of those working in lead-mines is also very great.

The black spit of pitmen, examined under the microscope, is seen to consist of mucus enclosing finely-divided particles of coal, frequently presenting the special bands of the particular coal in which the subject of the disease may have worked. The fact that coal-dust may enter the lungs in the act of breathing is corroborated by Rindfleisch, who, reporting for Traube a post-mortem made in 1860, found in the fluid expressed from the parenchyma of the lung "one of the dotted cells of coniferous wood entirely carbonized, in which he was able to count seven pores close together. This particle of charcoal-dust equalled half the diameter of an alveolus." Inhaled particles of dust first penetrate the bronchial tubes and infundibula, and, entering the alveolar parenchyma, mix with the general current of extravascular fluid, together with which they ultimately tend to reach the lymphatic vessels. On their way they must occasionally meet with corpuscular elements which have the power of permanently adopting small solid particles into their protoplasm: foremost among such elements are the stellate corpuscles of the connective tissue, next the migratory amoeboid cells, which are found in the connective tissue of the lungs as well as elsewhere, and which carry the black pigment with them wherever they go. The residual portion which escapes, being arrested by cells on its way through the lymphatic system, is carried to the root of the lung and enters the lymphatic glands of the mediastinum; here the granules meet an obstacle to their further progress, for the countless lymph-corpuscles with which the glands are stored are ready to take up as many of the charcoal particles as can by any possibility be accommodated in their protoplasm. We may conclude that the influence of inhalations of coal-dust varies in different cases, but may be considered as prominent among the exciting causes of pneumonokoniosis.

The charcoal-grinders and carriers, chimney-sweeps, moulders, iron and glass polishers, and the workers in mother-of-pearl, all suffer more or less. from destruction of lung-function. Deposits of oxide of iron have been found in the lungs of operators who have for years used this substance as a polishing pigment. Merkel reports the case of a man who was employed to clean the surface of oxidized iron by scrubbing it with sand: his expectoration was grayish-black, and was found to contain small grains of magnetic.