THE SCIENCE OF THERAPEUTICS, ACCORDING TO THE PRINCIPLES OF HOMCEOPATHY, BY BERNHARD B^HR, M. D. TRANSLATED AND ENRICHED WITH NUMEROUS ADDITIONS FROM KAFKA AND OTHER SOURCES. BY CHARLES J. HEMPEL, M. D. VOL UME I. NEW YORK: BOERICKE & TAFEL, No. 145 GRAND STREET. 1875. Entered according to Act of Congress, in the year 1869, by BOERICKE & TAFEL. In the Clerk's Office of the District Court of the Southern District of New York. CAXTON PRESS OF SHERMAN & CO., PHILADELPHIA. FREE A. C E. The work which is here presented to the public is a work of no ordinary merit. It is to take the place of the late Hart- mann's Acute and Chronic Diseases; but in point of scientific value and practical usefulness it is as far superior to the former as the present status of Homoeopathy is above that of Hart- mann's time. BEehr is a man not only endowed with great scientific accomplishments, but he is likewise a man of large experience. It is our opinion that this work will be read with pleasure and profit by every physician, and we recommend it to all students of medicine who are anxious to obtain a more elevated perception of Homoeopathy. We have incorporated in this work large sections from Kafka, so that this author is also presented in these two volumes. We have likewise introduced on suitable occasions the new remedies, and have made valuable additions from our Journals and drawn upon our personal records. It is with infinite pleasure that we commend this highly useful work to our colleagues generally; we have devoted much time and persevering labor to its translation. Most respectfully, CHARLES J. HEMPEL, M. D. Grand Rapids, March, 1869. CONTENTS OF THE FIRST VOLUME. Page Preface. Introduction 1-55 1 The Proving of Drugs on the healthy organism 2 2. The law of Similar.ty . 1^ 3. Diagnosis of the Natural Disease 28 4. Single Remedies 39 5. Size of Dose 41 6. Preparation, Repetition, etc., of Medecines 48 7. Diet 51 FIRST SECTION. Diseases of the Brain, the Spinal Cord, and the Nervous System Generally 57 A. Diseases of the Brain ................................................................ 57 Hypersemia of the Brain and its Membranes 57 Anaemia of the Brain 65 Cerebral Apoplexy 70 Inflammatory Affections of the Brain and its Membranes 86 1. Meningitis 86 2. Encephalitis. Cerebritis . 94 8. Tubercular (granular) inflammation of the meninges. Hydrocephalus acutus 99 Hydrocep.ialus, [stricte sic dictus.] 109 B. Diseases of the Spinal Marrow 110 Inflammation of the Spinal Cord and its Membranes 110 Meningitis Cerebro-spinalis, Cerebro- pinai Meningitis, Spot- ted Fever 130 Spinal Irritation. Neuralgia Spinalis 135 C. Diseases of the Nervous System 139 1. Epilepsy 139 2. Eclampsia 154 a. Eclampsia Infantum 154 b. Eclampsia Parturientium 163 3. Chorea ....: 170 4. Catalepsy 177 5. Tetanus and Trismus 178 6. Paralysis 183 7. Hysteria 190 8. Hypochondria. Hypochondriasis, Spleen 207 V VI Contents of the First Volume. SECOND SECTION. Pago Diseases of the Head 218 A. Diseases of the Scalp 218 Cephalhematoma, Bloody Tumor of the Scalp 218 B. Diseases of the Cephalic Nerves 220 1. Cephalalgia, Headache 220 Hemicrania or Megrim 221 2. Neuralgia Tricemini 227 Fothergill's Prosopalgia ; Tic douloureux ; Prosopal- gia, Face-ache 227 3. Spasmus Nervi Facialis. Tic Convulsif. Spasm of the Facial Nerve 234 C. Diseases of the Eye .................................................................... 235 1. Conjunctivitis Catarrhalis 237 2. Conjunctivitis Blennorhoica 242 a. Acute Blennorrhcea 242 b. Chronic Blennorhma 243 3. Conjunctivitis Scrofulosa 249 D. Diseases of the Ear 257 1. Otitis Interna 258 Internal inflammation of the Ear 258 2. Otitis externa 261 E. Diseases of the Nose 263 1. Coryza, Catarrh, Cold in the He id 263 2. Inflammation of the Nose, Nasitis 268 3. Epistaxis, Bleeding at the Nose 269 THIRD SECTION. Diseases of the Mouth, Fauces and Oesophagus 272 1. Stomatitis . 273 2. Thrush, Aphthae of Infants 279 3. Angina 281 a. Angina Catarrhalis, Sore Throat 281 b. Angina Tonsillaris, Tonsillitis, Amygdalitis, In- flammation of the Tonsils. Quinsy 284 4. Retropharyngeal Abscess 294 5. Diphtheritis, Diphtheria 296 6. Noma, Cancer Aquaticus 307 7. Glossitis, Inflammation of the Tongue 311 8. Parotitis 314 a. Parotitis, Inflammation of the Parotid Gland, Mumps, Angina Parotidea 314 b. Parotitis Maligna 317 9. Salivatio, Ptyalism 319 Contents of the First Volume. VII Page 10. Scorbutus 322 Scurvy of the Gums 322 11. Ranula 324 12. Oesophagitis, Dysphagia Inflammatoria, Inflammation of the Oesophagus 326 13. Odontalgia, Toothache 328 FOURTH SECTION. Diseases of the Stomach, Intestines, and Peritonaeum 334 A. Diseases of the Stomach 334 1. Catarrhus Ventriculi Acutus. Acute Catarrh of the Stomach 334 2. Catarrhus Ventriculi Chronicus, Chronic Catarrh of the Stomach 350 3. Gastritis, Inflammation of the Stomach 361 4. Ulcus Perforans Ventriculi seu Rotundum. Chronic Ul- cer of the Stomach 368 5. Carcinoma Ventriculi, Cancer of the Stomach 375 6. Haematemesis, Hemorrhage from the Stomach 383 7. Cardialgia, Spasm of the Stomach 391 B. Diseases of the Intestinal Canal 404 1. Catarrhu; Intestinalis, Intestinal Catarrh 404 a. Simple Intestinal Catarrh 406 b. Cholera Sporadica seu Nostras, Cholerine 408 c. Catarrhus Intestinalis Chronicus, Chronic Intes- tinal Catarrh, Chronic Diarrhoea, Cholera In- fantum, Summer Complaint 413 d. Febris Gastrica Catarrhalis, Mucosa et Biliosa; Gastric Fever 422 2. Enteritis, Inflammation of the Bowels . 435 3. Typhlitis, Perityphlitis, Inflammation of the Caecum... 440 Catarrhal Inflammation of the Rectum, Proctitis 445 Cellulitis 451 Inflammation of the Cellular Tissue of the Intes- tinal Canal 451 4. Dysenteria, Dysentery 455 a. Catarrhal Dysentery 455 b. Dysenteria Epidemica, Dysentery Proper 457 5. Enteralgia, Colic 468 6. Stenosis of the Bowels, Occlusion, Obstruction of the Bowels 479 7. Hemorrhoids, Piles 485 8. Helminthiasis, Worms 492 C. Diseases of the Peritoneum 503 Peritonitis, Inflammation of the Peritoneum 503 VIII Contents of the First Volume. FIFTH SECTION. Page Diseases of the Liver, Spleen and Pancreas 520 A. Diseases of the Liver 520 1. Hyperaemia of the Liver 522 2. Hepatitis, Inflammation of the Liver 528 a. Hepatitis Acuta, Acute Inflammation of the Liver 529 b. Perihepatitis, Inflammation of the Capsules of the Liver, Capsular Hepatitis 531 c. Pylephlebitis, Inflammation of the Vena Porta 532 3. Hepatitis Chronica, Chronic Inflammatory Affections of the Liver 537 4. Icterus, Aurigo, Jaundice 554 5. Colelithiasis, Biliari Calculi 564 6. Carcinoma Hepatis, Cancer of the Liver 569 B. Diseases of the Spleen 572 Splenitis, Inflammation of the Spleen 573 G. Diseases of the Pancreas . 578 SIXTH SECTION. Diseases of the Uropoetic System 580 A. Diseases of the Kidneys 580 1. Nephritis, Inflammation of the Kidneys 586 2. Morbus Brightii, Bright's Disease of the Kidneys 596 3. Hemorrhage in the Kidneys 609 4. Renal Calculi, Gravel 614 5. Diabetes Mellitus, Melituria, Glycosuria 617 B. Diseases of the Bladder 625 1. Cystitis, Inflammation of the Bladder 625 2. Hematuria, Bloody Urine 629 3. Enuresis Nocturna, Wetting the Bed 631 4. Cystospasmus, Spasm of the Bladder 632 5. Cystoplegia, Paralysis of the Bladder 634 INTRODUCTION. Hartmann's attempt to apply the doctrines of Homoeopathy to special Pathology has, so far, remained solitary and alone in the literature of our school; that is, if we do not include in the list popular publications or such as only refer to one part of Pathology. However strange this may seem to any one who is not familiar with Homceopathy, yet this absence of all pathological treatises after the example of Hartmann, is in perfect accord with the spirit of this doctrine, as we shall show by-and-by. A system of special Therapeutics never was, nor ever will be, a necessary, scientifically founded requisite of our doctrine, but will always depend upon the necessity of mediating between us and our therapeutic antipodes and opponents. In this way they will find it easier to institute clinical experiments with our system of treatment, and to form correct opinions concerning its scientific value. Starting from this stand-point it becomes indispensable, as a preliminary step, not only to explain the general principles of Homceopathy, but likewise to show in what manner this new system of treatment affects the science of Pathology. In this respect our general system of Therapeutics must necessarily differ from that of other therapeutic manuals; our position in the domain of medicine, which is still of a polemic character, compels us to touch certain questions which, though not necessarily included within the range of Therapeutics, yet are of essential importance to ourselves. Among these questions, the question, What is Homoeopathy ? What is its aim and object ? occupies a prominent place. But few physicians who are not homoeopaths, will be able to answer this question satisfactorily. Let us hasten to add that this is in a great measure the fault of the homoeopaths themselves. Rashly and improperly the unessential points are made prominent points of doctrine; the essential points are pressed into the background. U nder these circumstances, we cannot wonder that our opponents should imitate our example, and, worse still, should charge upon us the most nonsensical fables and absurdities. In many respects, 1 2 Introduction. Hahnemann, the founder of our ddetrine, furnishes them the au- thority for their conduct; and many of his successors have been but too anxious to multiply the reasons for their justification. In the course of this introduction we shall have an opportunity of laying bare the mistakes that have been committed by our own adherents. First, let us answer the question: What is Homoe- opathy ? It is the doctrine of the effects of drugs upon the animal organism as applied, according to an uniformly valid law, to the doctrine of the morbid changes of the organism. As such, it is not antagonistic to Medicine considered as a scientific whole; on the contrary, it constitutes a necessary completion of this science, inas- much as the homoeopathic system establishes one part of Medicine, which had hitherto been abandoned to the crudest empiricism, upon a scientific basis. Accordingly, it shares with the ancient science of Medicine all the suppositions necessary to a knowledge of pathological changes, and is distinguished from that science only by the mode in which it leads to a knowledge of the remedial agent, and brings this knowledge in union with the curative object. This is accomplished in accordance with two fundamental principles, the principle of proving drugs on the healthy organism and the thera- peutic law : Similia similibus curantur. In order to perceive very fully and clearly how far this principle exerts an influence upon the arrangement of our Materia Medica, we shall have to examine, in the first place, the manner in which a knowledge of drugs has been obtained hitherto, and is still sought to be obtained. Casting a retrospective glance at the beginning of Medicine, we have to admit that the first physicians obtained their knowledge of drugs from the people to whom, while using them for their com- plaints, accidental experience revealed some of their virtues. By partaking of a plant or fruit indiscreetly, vomiting or diarrhoea was caused; the same substance was afterwards employed for the pur- pose of exciting similar evacuations. In performing such thera- peutical experiments, it was likewise found by mere accident that, together with these troubles, certain other affections for which the medicine had not been administered, disappeared simultaneously, on which account the same medicine was afterwards employed for these incidental affections. Thus it was that, gradually, a whole series of facts was collected which were utilized by physicians as a 1. The Proving of Drugs on the healthy organism. Introduction. 3 fountain-head of Therapeutics. We need not attempt to show the gaps which must disfigure a knowledge of drug-effects thus ob- tained ; what was particularly injurious was that all that was known of a drug was its relation to some particular morbid condi- tion, without any corresponding knowledge of the kind of action which the drug really exerted. This crude empiricism was not only peculiar to the most remote periods, but it has continued even to the present period, although in a somewhat different form, care being had, by resorting to systematic forms, an adequate nomencla- ture, and other little artifices, to clothe this empiricism in a more scientific garment. All that was known was a series of exceedingly equivocal facts whose connection was so little ascertained and which very often seemed to contradict each other to such an extent that they gave rise to the most insane hypotheses. Experiments on the sick organism did not yield any more satis- factory results. The boldness, or, if we did not know that physi- cians had acted in good faith, we might even say, the want of conscientiousness, with which, even to this day, therapeutic experi- ments are instituted with substances of whose virtues really nothing is known; the extraordinary perseverance with which these experi- ments are conducted; the numerous victims that have been sacri- ficed, ought to have been crowned with better success than the creation of a Materia Medica which is of no use to anybody. This may seem an exaggeration ; yet that it is not, can be shown very easily. If the employment of an unknown drug in a given case of disease is to have a definite result, a preliminary knowledge of this case, in every direction, is indispensable. What disease is there which we can diagnose so surely, or, even if this were at all possi- ble, whose course we can predict with so much positive certainty, that this knowledge should enable us to deduce the effects of the drug with mathematical accuracy ? And even if we had the means of obtaining this knowledge in single cases; even if we had observed the same effect in a hundred cases, who guarantees to us that the one hundredth case will run the same course? May we not have to consider a variety of circumstances which cannot be determined in advance? For instance, is not one patient more sensitive to medicinal influences than another? Are there not indeterminable idiosyncrasies which we are in the habit of de- spatching under this name? Does not the influence of the weather, and of other external agents, act an important part ? If any one is disposed to deny this, let him read attentively our medical journals. 4 Introduction. We will quote a recent example. A French physician hits upon the idea-how he was led to it we are not informed-to employ Ipecacuanha for intermittent fevers; he treats two hundred cases, one hundred and sixty of which with good success. He concludes that this drug is a panacea for intermittent fever, and urges its employment accordingly. Some dozen physicians, imitating his example, suddenly raise a cry against his assertion, not having had any success with Ipecacuanha. Who is right ? In our judgment both parties are right, for the reason that Ipecacuanha only cures one class of intermittent fevers. How far is the Materia Medica benefited by this kind of experimentation? The same course is pursued with Arsenic in the same disease, and with other drugs in other diseases. Who is to be believed ? The only way to obtain certainty would be to repeat all these experiments. Is there no danger in random experimentations with large doses ? Does it not argue a want of conscientiousness to experiment upon patients who expect from us either a mitigation or a cure of their sufferings ? Beside the real or apparent curative results, we likewise find such drug-effects recorded as manifested themselves simultaneously with the curative results. Is a deception in regard to these new symp- toms or drug-effects much more probable than in regard to the curative results ? How are we to decide whether these results were not exclusively due to the peculiar course of the malady or to individual circumstances ? It is true that in this manner a number of fixed facts have been obtained, but in proportion to the number of drugs, more particularly as regards single drugs, these facts are too few to enable us to assert that we are fully acquainted with a single drug in every direction of its therapeutic range. Read the article Opium in some of the more important works on Materia Medica. There is scarcely a drug with which experiments have been multiplied as with Opium; yet there is no drug concerning which our Materia Medicas are as full of absurd contradictions as concerning this agent. The necessity which is becoming more apparent from day to day, of obtaining a more correct knowledge of our drugs before using them in the treatment of disease, has led long ago to experiments upon animals; so far, a vast number of dogs, cats, frogs, etc., have fallen victims to pharmacological investigations. But even in this respect the gain has been inconsiderable. The reasons for this are quite obvious. The organism of the beast differs from that of man in many essential particulars; even the organisms of many classes Introduction. 5 of animals differ among themselves. A dog frequently bears sub- stances which are decidedly hostile to man; whereas other sub- stances develop violent reactions in the canine organism. This being the case, how is it possible to draw reliable conclusions from experiments on dogs or other animals regarding the human organ- ism ? But, supposing even that such a proceeding is not entirely absurd, the profit which it yields is exceedingly small. The animal is unable to indicate subjective sensations according to their form, locality or intensity ; we only become acquainted with objec- tive changes. These changes have their value, but even they are generally obtained in an improper manner. They are sought to be obtained rapidly and fully developed by means of large doses of the drug, which, after all, only produce phenomena of the coarsest character. The most we learn is the maximum effect of a drug, nothing of the less marked, and yet so essential, shades of its action. How far do such coarse experiments advance our knowledge of a drug in its capacity as a remedial agent ? Only a very little. Moreover, this kind of experimentation exposes us to great decep- tions, for most drugs, when administered in 'large quantities, pro- duce effects very different from those which are produced by con- tinued small doses of the same drug. By what means do we obtain a knowledge of the latter effects which are our sole proper guide in determining the therapeutic uses of a drug? We are far from denying the value of experiments upon animals; but this value is limited, and acquires a certain importance only when judged in connection with other experiments. The same remarks apply to cases of poisoning observed on human beings. The circumstances which render such accidents less in- structive, or ill-adapted for the purposes of a scientific Materia Medica, are the following: In the first place, the poisoning is not under our control. Accident may furnish a number or none at all, within a limited space of time; a hundred may be furnished by a single drug, whereas a hundred other drugs may not furnish one. We possess the history of a large number of cases of poisoning with Arsenic, but of how many cases with Gold? This depends upon the degree of accessibility of a poisonous substance to crime or indiscretion. Moreover, in every case of poisoning of a human being, the re- sults are necessarily more or less obscure, since we are obliged to employ every means of saving or relieving the patient. What symptoms are, in such cases, chargeable to the poison, what other 6 Introduction. symptoms to the action of the antidote? These two series of symptoms are very frequently mixed up with a good deal of reck- lessness. How many cases of poisoning are recorded in our journals, as having been occasioned by a single substance, whereas they were really caused by two or three! How much can we learn from such cases for the benefit of our patients ? Finally, the same objection occurs to us here that has already been mentioned, when speaking of experiments upon animals. Large doses of a poisonous substance only furnish the massive Outlines, not the finer shades of a drug-picture. However, we should commit the most crying injustice against the tendency of our scientific opponents, if we were to assert that they have contented themselves with the above-mentioned partially accidental and partially unreliable means of building up their Materia Medica. This is not the case. Other sources of knowledge have sometimes been sought and employed with an amazing energy and great sagacity. We may mention Chemistry, from which, to this day, the most important yield has been expected for the Materia Medica. Without wishing to lessen the importance of chemical investigations, we must nevertheless confess that Materia Medica is under very slight obligations to Chemistry. It is well to know the constituents of vegetable substances; but to use this knowledge for the purpose of determining approximatively their effects upon the sick, seems a hazardous enterprise, and has never yet led to favorable results. The speculations based upon Chemistry have likewise engendered many errors in theory and practice. We mention the use of Iron in chlorosis. Iron does not always cure chlorosis, and, where it does cure, often entails a disturbed diges- tion. We admit that Chemistry has shed light upon the nature and connection of a number of facts, but a Materia Medica can never be created by chemical analysis. As a rich and memorable source of a knowledge of drugs in the domain of ancient Medicine, we have to mention Homoeopathy. Not only have many drugs, especially recently, been taken from the store-house of Homoeopathy, and applied to the cure of diseases, often, it is true, in a very wrong way, but the very road upon which the homoeopath arrives at a knowledge of drugs, has been pursued by old-school physicians. Such a course, it is true, has only been pursued by a few, most systematically by Schroff, of Vienna. This is not the place for a more particular examination of his labors; they contain a great deal that is good, but too little of it when Introduction. 7 compared to the immensity of his efforts. His effort to obtain a powerful medicinal effect as rapidly as possible, is the cause owing to which his labors have produced such inadequate results. By and by we shall point out the road that has to be pursued by those who are desirous of obtaining a large yield of drug-effects by means of pure experiments; those who take an interest in such matters are invited to contrast our views with Schroff's method of investigation, in order to find out what we censure in his pro- ceedings. By employing the means and ways above mentioned, the present science of Medicine has been perfected in the course of centuries. Upon examining it more closely we only find the most striking, because most massive and crudest effects of drugs, recorded on its pages; the more delicate shades of the drug-picture are wanting. In accordance with these coarse drug-effects, drugs were divided into classes, the names of which indicated the leading effects of the drugs enumerated in each class. What such classifications, in the gross, amount to, can easily be seen by comparing certain manuals with each other, where the same drug is found recorded under the most diversified heads. How embarrassing it must be for a con- scientious physician who wishes to employ a narcotic, and has to hunt it up among thirty or more other drugs, without having a single point of support to lean upon in the selection of his special agent. This is simply a blind-catching process, not a conscious act in accordance with a rational motive. It is indeed remarkable that modern Medicine which has been so active in investigating physiological and pathological processes, seems to have utterly neglected a corresponding investigation of the curative sphere of drugs. The subtle diagnosis of modern pathologists is certainly not adequately responded to by an exceed- ingly general random selection of a remedial agent. The defects of the Materia Medica exert even a pernicious reaction upon the diagnosis. To a scientific physician, the diagnosis cannot be suffi- ciently accurate; but from the moment he abandons the practical side of diagnosis, he becomes content with the vaguest diagnostic generalities, for the reason that they are sufficient to secure the selection of a remedial agent. Thus it is that science and practice have become sharply divided in Medicine, to the detriment of physicians, still more than to that of patients. Quite recently we have heard a Viennese physician exclaim, how strange it was that, in their lectures, Skoda and Oppolzer should despatch a 8 Introduction. whole lot of drugs against a given case of disease, with the utmost contempt and with a pitiful smile; whereas, at the bedside of patients, they prescribe quantities of these despised drugs. Does the fault rest with the physicians, or with the drugs? Is it be- cause the drugs are powerless, or is it rather because the physicians do not know how to employ them? This latter question we have to answer in the affirmative, for we have the evidence of it in our hands, and shall exhibit it to our readers in the course of this work. Hahnemann was the first who endeavored consistently and per- severingly to obtain a knowledge of the effects of drugs, and to apply it to practical uses in accordance with a definite law. He found the sources of remedial agents, which had been valid up to his time, either insufficient or deceitful and false, and he set up the doctrine that a knowledge of the true effects of drugs could only be obtained by experimenting upon the human organism, and that these experiments must be instituted upon the healthy organism; since the organism in disease develops and substan- tiates too many illusory views and perceptions. His extraordi- nary energy gave birth to the Materia Medica Pura, a work to which the most censorious mania cannot deny the tribute of admiration in spite of the isolated defects with which this noble work is tainted. When did a single human being ever succeed in treading a new path without committing a single mistake, or making a single false step? Let it suffice that so far nobody has ever produced greater results by entering upon a new road of in- vestigation. Provings upon the healthy constituting the very central point of Homoeopathy, which could not exist without them, we shall ne- cessarily have to submit the manner in which such provings are conducted to a more rigorous examination. In the first place, we have to inquire how the provings are con- ducted, and, in the second place, how the results of these provings are improved for the benefit of the Materia Medica. Only such persons are fit for the business of proving who enjoy physical and mental health, and are possessed of a capacity to de- scribe their sensations with clearness and precision. In opposition to this first requisite, it may be said that perfectly healthy in- dividuals are very scarce ; an assertion which is certainly not ex- aggerated. By the term " health" we do not mean to designate the absolute harmony of the physiological processes, but the existing Introduction. 9 equilibrium of the organic activity of the body. While proving, the bodily functions of the experimenter should not be disturbed in any respect, and, in order to obtain the greatest possible certainty on this point, it may be well to subject the prover to a careful ex- amination. The physicians themselves are always the best pro vers. If the provings are instituted by other parties, the physician should never cease to exercise strict control in order to prevent unes- sential symptoms from being assigned a prominent place in the list, or essential symptoms from being described too superficially. . In order that a proving should yield a complete list of symptoms, it has to be conducted by as large a number of individuals as pos- sible, of different ages, sexes, social positions and habits. This con- dition need not be dwelt upon any further; it is of self-evident necessity. We will add that even children may be included among the list of provers. However, they have to be watched much more carefully, for the reason that they are much less capable of de- fining the subjective symptoms developed by the drug. Shortly before, and even during the whole course of the trial, even some time after the last dose of the drug had been taken, the prover should observe a simple and regular conduct. All medi- cinal substances have to be avoided ; likewise every exposure by which the bodily equilibrium might be disturbed, such as excessive bodily or mental exertions, violent emotions, too much or too little sleep, irregular eating or drinking. Such articles of diet which we know to have an injurious influence upon his bodily health, have to be avoided with particular care. If possible, the mode of life which we have to lead during the trial, should be commenced some time previous to the beginning of the trial, so much more since, in order that we might pursue a correct mode of living, habitual dishes or beverages have to be discontinued; otherwise many changes which originate in this very circumstance, might be charged to the action of the drug. It is likewise necessary, before the trial commences, to examine the beats of the heart, the quality of the pulse, the quantity of the urine, as well,as the temperament and other peculiarities. Of the drug to be proved, we must make sure of obtaining a reliable preparation. It is best to employ it in form of a tincture or of triturations with sugar of milk, in case it should not be feasible to take the drug in substance. This mode is preferable for the reason that tinctures and triturations constitute the leading preparations of drugs in homoeopathic practice. The dose to be proved, has to 10 Introduction. vary. A commencement may be made with the smallest doses, even with the thirtieth attenuation, from which we may gradually descend to the stronger and more substantial preparations. The doses should not be repeated in too rapid succession; it is best to first allow all the morbid phenomena of one dose to pass away before a second dose is taken. If no effects are produced, the dose is progressively increased and repeated more frequently. These pre- cautions concerning the dose are of essential importance, for the reason that the susceptibility to medicinal impressions varies ex- ceedingly in different individuals, and it is impossible to determine beforehand how large or feeble the dose should be in order to elicit the smallest possible medicinal symptoms. A good deal depends upon these feeble beginnings; they serve as starting-points in ac- counting for subsequent more marked phenomena of drug-action. It is a good plan to let every prover take the same preparation of the drug; in order to prevent also in this respect the possibility of a mistake. The best time to take the drug is undoubtedly before breakfast, for the reason that we are better able to observe the symptoms manifesting themselves in the first hours subsequent to taking the drug; and that the medicine is moreover introduced into an empty stomach. However, it is likewise advisable to swallow a dose of the drug some evening before bedtime, in order to observe possible differences of action. Finally, special rules are required in order to regulate the conduct of the pro ver, with reference to the medicinal symptoms that may become manifest. Above all things the prover should attentively observe all changes in his feelings, without watching himself on that account with anxious solicitude; what is most particularly to be avoided are fanciful illusions. If the prover is a physician, it is well that he should remain ignorant of the drug he is proving. All changes in the ordinary condition of the patient, even the least and most insignificant, are to be noted down. This should be done as soon as the symptoms are perceived. Accessory circumstances should be carefully recorded. The period of the appearance of the symptoms, their duration, aggravating or ameliorating circum- stances, locality and quality of the sensations, etc. These written reports have to be revised by the physician as often as possible, in order that he may have an opportunity of completing defective records by appropriate questions, of clearing up obscure statements, adding objective symptoms, etc. It is more particularly objective symptoms which render a physician's control during the trial in- Introduction. 11 dispensable. It is well known how wrongly objective symptoms are sometimes described by lay-provers upon their own persons, such as efflorescences upon the skin, changes of the tongue, al vine discharges, urine; on which account great injury is often done to the provings, since it is precisely these objective symptoms that are the most important, because they do not admit of deception. The physician should moreover accompany the symptoms with annotations referring to circumstances, which either confirm the medicinal symptoms or cast a doubt upon them. If the prover, for instance, is disposed to catarrhal affections of the Schneiderian membrane, and he should be attacked with such an affection during the trial, the physician has to institute inquiries in order to find out whether he has to deal with a medicinal symptom or not; and if a doubt should prevail, he has to mark this symptom with a note of interrogation. As a general rule, the physician should apply to an investigation of the drug-disease all the means of diagnosis that he brings to bear upon an investigation of natural maladies. The changes in the different secretions, especially in the urine, are par- ticularly noteworthy. A systematic arrangement of the symptoms elicited by such provings constitutes the basis for a full picture of the drug-disease. We say, intentionally, the basis, for an exhaustive proving can never be instituted on a human being, since it is impossible to in- crease the doses of a drug to the point of poisoning ; at any rate it is only with a very small number of drugs that we shall dare to saturate the system, so as to develop their medicinal effects in all their intensity. These provings are to be considered as a basis for the additional reason that, starting from them and by them, it becomes possible for us to apply to practical uses whatever else we may be able to learn of the drug in question through other chan- nels. Experiments upon animals, comparatively valueless, without corresponding provings upon human beings, show us, by the objec- tive symptoms which they develop, how a variety of phenomena in men have to be interpreted, both according to their origin, as well as according to their final course; and conclusions by analogy, from animals to men, can now be made without any great danger of being deceived, since we are now in possession of the most positive points of departure. For these reasons, experiments upon animals are really of decided benefit and importance only to homoeopaths. Starting from the above-mentioned basis, the poisonings of human beings, with which our toxicological treatises are replete, 12 Introduction. obtain their true value, yea, they become important contributions to our Materia Medica. Poisonings which do not terminate too rapidly in death, and whose characteristic symptoms are not effaced by the intensity of their course, are particularly instructive. Poisons which produce fatal results too rapidly are of but trifling importance even for the toxicologist, inasmuch as their toxical re- sults only denote in almost every case the symptoms of a violent local irritation. In other respects, cases of human poisoning, even if we do not draw any conclusions from analogy or expose our- selves to the danger of deception, as we have to do in making experiments upon animals, furnish us an explanation why the alterations obtained by our provers with small doses should have a definite significance, and why the effects of small doses should, in their turn, shed light in many cases upon the effects of poisonous doses. Of particular value are likewise the material post-mortem changes, which alone render it possible in many cases of a most subtle pathological diagnosis to determine what drug- diagnosis corresponds to it very fully. In cases of poisoning, we should, of course, observe the greatest caution, in order to preserve the distinction between the toxical symptoms and the effects of such antidotes as may have been administered in the case, and the symptoms of a previously existing disease, for which purpose the symptoms elicited by provings on healthy persons will again fur- nish us a safe standard of comparison. In other respects the relation of the toxical to the pathogenetic symptoms is best ascer- tained by comparing the toxical symptoms, caused by one of our well-proved drugs, with the symptoms recorded in our Materia Medica. It is but seldom that a symptom will not be found re- corded in the latter; on the contrary, it will be found that the toxical symptoms constitute a drug-picture, whose sharp features are reflected by the drug-pictures elicited by our provings in dimmer and more shadowy outlines. And finally, upon the basis of the pathogenetic series, clinical experience can be made available for the benefit of our Materia Medica, although only conditionally. This experience either con- sists in the observation of new symptoms not belonging to the disease, which manifest themselves after the administration of the remedial agent, or in the changes which existing morbid symptoms undergo, either for the better or the worse. The former category is of less importance; in many cases it furnishes a valuable confir- mation of our provings on healthy persons, and, which is of the Introduction. 13 utmost importance, makes us acquainted with the doses that have to be employed in order to effect a cure without aggravating the symptoms of the disease. However, the custom of incorporating these new incidental symptoms in the pathogenetic series, and which has been practised in more than one case, should be aban- doned. The second category, in so far as it refers to an aggravation of existing morbid phenomena, yields a further basis for the determination of the proper dose which is capable of effecting curative results, without any precursory aggravation of the symp- toms. The homoeopathic doctrine of dose rests exclusively upon such observations. When reaching the question of dose, we shall again revert to this subject. Our observations concerning the curative action of remedial agents, by confirming the principle in accordance with which the cure was effected, constitute the true system of homoeopathic Therapeutics. They show us by the practi- cal result what drug-effects are of real use in determining the cura- tive indication. In a previous paragraph we have already alluded to the deceitful character of clinical observations, and have to apply this remark likewise to observations made in accordance with the principles of Homoeopathy. We should add, however, that Homoe- opathy has done every thing that can possibly be done to diminish uncertainties and to avoid deceptions. If the experience obtained of the effect of a medicine is applied in every case, in accordance with the same principle, the results must necessarily be more homogeneous, than they could be imagined under any other therapeutic proceeding. It is from the different sources that have been indicated so far that the Homoeopathic Materia Medica has obtained its material, and, in accordance with this origin, it alone is justly entitled to the attribute of physiological. Viewed in its integrity, from its origin throughout its whole development, it is a working represen- tative of progress in the domain of Medicine in the presence of the great improvements which have been effected in other departments of this science; ignorance alone can deny it the character of a perfect scientific structure. Nevertheless, in so far as a want of completeness is a necessary attribute of every science which can never be conceived as a perfect whole, no longer capable of a progressive development, and which, in reality, only becomes a science through an unceasing and system- atic struggle after a more perfect form; our Materia Medica is neither a perfectly rounded, nor, in its present shape, a complete and 14 Introduction. faultless whole. As a closed science it could only be considered in case it should contain every thing that can be used as medicine, a thing that is utterly inconceivable. It would only be a closed and perfect science if every medicinal substance had been so completely and so exhaustively investigated, and determined in the different directions of its therapeutic efficacy, that nothing could be added to the domain of its usefulness. This likewise is inconceivable. Inde- pendently of these extreme requisites of completeness, we have to point out defects, which we shall subject to a short discussion in the present place, because an equally suitable opportunity may not present itself at a subsequent stage of our work. It would be un- reasonable to entirely omit a consideration of these defects, since it is isolated defects that so readily frighten beginners away from the study of Homoeopathy, and furnish points of attack to our oppo- nents. In the following paragraphs, unless special quotations are made, we refer exclusively to Hahnemann's Materia Medica Pura, and to his Chronic Diseases; if we introduce subjects in this discus- sion with which every one familiar with Homoeopathy has been perfectly acquainted for a long time past, our excuse must be that this Introduction is not so much written for the accomplished practitioner, as for those who are only now becoming initiated into our science. In his Materia Medica, Hahnemann gives us the results of his own provings as well as those of other provers. He only furnishes the final results, saying nothing of the manner in which they were obtained, nothing of the material which has yielded these results. This constitutes the main, perhaps the only defect of his Materia Medica, since all its other defects spring from this one. In the shape in which Hahnemann has left us the results of his great labors, they are like a dense, large forest. Upon first entering it, it seems impossible to find one's way through it; he who is ac- quainted with the forest, finds his way without any difficulty. The symptoms are pressed into a certain scheme, to accommodate which the symptoms are torn into fragments and numbered without any connection. We are far from censuring this scheme, which, in spite of all the criticisms that have been passed upon it, has after all proved the best possible arrangement; even the splitting of the symptoms for the purpose of accommodating them to this scheme, would do no harm provided Hahnemann had left us the key to it, that is, a record of each single proving that has been made use of in the list of symptoms. This defect is exceedingly grave, and, Introduction. 15 what is worse, cannot be remedied satisfactorily. Re-provings have helped out in the case of single remedies, and, in many places, very satisfactorily; but to institute a re-proving of every drug that has been proved by Hahnemann, is an enormous task of very difficult solution. It is incomprehensible that Hahnemann, in spite of his accustomed sagacity, should have committed this sin of omission. It seems as though he had fallen into one extreme, in order to avoid the opposite one; he was opposed to every kind of generaliz- ing in Medicine, and, for fear lest he should give rise to it, he omitted reports of his provings, in consequence of which he made it much more difficult for his successors to follow his example. As a matter of course the effects of a drug, in accordance with their importance, their origin and course of manifestation, can only be learned by studying the record of each single proving; by this means a knowledge of drugs is obtained very easily. In this way we become acquainted with the starting-point of drug-diseases, what organs and systems are first acted upon by the drug, and what disturbances of the general organism arise from these begin- nings ; and, in order to obtain a reliable knowledge of drug-diseases, it is just as important that we should be acquainted with the origin and succession of the morbid changes as in any other nat- ural malady. The defect becomes still more serious in conse- quence of our remaining unacquainted with the individual condition of the provers, their sex, age, temperament, etc., how long a time the drug required to develop its effects, what quantities it took in order to produce them. The remarks which Hahnemann has added to single symptoms, and which often have the appearance of being snatched from an adventurous fancy, can only be accounted for by a knowledge of the different provings; it was expecting too much that his successors should accept all such statements upon the faith of their master. That Hahnemann did not arrange his Materia Medica without critical judgment is evident from similar remarks, and from his introduction to some of his drugs; never- theless it was wrong that he should have cut off his successors from the possibility of an independent criticism, and should have placed his work before them with the apodictic authority of an ipse dixit. Lastly we are unable to decide what symptoms in the list of Hahnemann's provings belong to the respective drugs as constant and hence characteristic symptoms, since it is only exceptionally that we are told whether a symptom was observed by all the provers, or only by a few, or by one alone. All these defects of the 16 Introduction. Materia Medica Pura are still more salient in the Chronic Diseases, where even new ones appear in addition to the former. The circum- stance that in this last-mentioned work the medicines were proved almost exclusively with small doses, has occasioned a certain uni- formity which cannot possibly be justified in a scientific point of view, and diminishes the number of the objective symptoms, upon which, however, the selection of a remedial agent principally de- pends. A number of symptoms are moreover taken from observa- tions on the sick; this course might appear justifiable, if all such symptoms had been designated as such. But this has never been done. Nor can we pass silently by the fact that the quotations in both the above-mentioned works are disfigured by great mistakes, erroneous interpretations and defective rendering of the original text. In spite of these defects, Hahnemann's work remains one of unusual importance and significance. A human work can scarcely be found anywhere that does not bear more or less the imprint of human imperfection. It is the duty of subsequent generations to remedy these defects. Many efforts have been made with occa- sional success to perfect Hahnemann's work; but a good deal remains yet to be done; only a partial reform has as yet been achieved. We need not show in this place what has already been accomplished, and refer to such works as those of Hirschel, (Die Homoeopathic, eine Anleitung zum Selbststudium,) where a correct statement of these new reforms can be found. Beside the efforts to render Hahnemann's Materia Medica more accessible, and to purge it of all defects, a good deal has been done in the way of proving new drugs, either by individual provers or by Pro vers' Unions. These new provings have been conducted so as to avoid Hahnemann's faults entirely. This is not the place to discuss these new efforts ; wre have to consider the results of such efforts rather than their history. These results are found recorded in journals, in essays, and exceptionally in larger works, like Hering's, but at all events in a very scattered form. This scattered mode of publication entails great injury. If any one should ask us where he might obtain a complete Homoeopathic Materia Medica, we should not know what to say to him, except giving him the names of a whole list of publications. We do not yet possess a complete collection of provings, on which account the study of our Materia Medica is rendered much more difficult. The labor of collecting all these provings would undoubtedly be a gigantic enterprise ; if it has not yet been undertaken, it is undoubtedly Introduction. 17 because new additions are continually expected. When will the period arrive when our Materia Medica shall be completed? As long as we are deprived of the means of studying our Materia Medica from original sources, we have to content ourselves with works whose object it is to lay the symptoms elicited by our prov- ings before us in a more concise form, that can be easily looked over and comprehended. Among these works, the following oc- cupy the first rank: Jahr's Symptomen Codex, and Noack and Trink's Materia Medica, both, however, of too remote a date not to omit a multitude of new facts, and being, moreover, adapted to the necessities of the practitioner rather than to those of a mere student. What road had better be pursued in studying Materia Medica cannot well be pointed out more clearly than has been done by Hirschel, in his above-mentioned publication, to which we refer the reader. An example of a model-proving, in accordance with the principles of Homoeopathy, is furnished by Watzke in his treatise on Colocynth, in the first volume of the " Oesterreichische Zeitschrift," where the difficulties of producing a complete proving are likewise laid bare. At the same time, this treatise will likewise satisfy any reader of the tendency of true homoeopaths to elaborate the science of Pharmacology from a genuinely scientific stand- point. Having thus far enumerated a variety of defects in our Materia Medica, we now have to show how far, in spite of all these defects, it surpasses the Materia Medica of the dominant School in practical usefulness. The existing material enables us to obtain a thorough knowledge of a large number of drugs; those that are proved less perfectly, give us a tolerable picture of their leading properties. We admit that such a study requires a great deal of labor and per- severance ; but by this means we are placed in possession of the great advantage of becoming acquainted with the instruments with which we have to operate in the sick chamber; of learning to ex- amine critically their noxious as well as their saving properties, and of being protected against the possibility of inflicting direct injury where help was expected at our hands. Let us now examine the law according to which' we have to prescribe the medicine of whose therapeutic virtues we have acquired a correct knowledge. Previously, however, we will here record a piece of advice that has been frequently given, but cannot be repeated too often. We have shown that Homoeopathy, or rather Materia Medica itself, rests upon the proving of drugs upon healthy individuals; as a 18 Introduction. matter of course it is the duty of every partisan of this doctrine to complete and perfect it by proving drugs upon himself and others. Those who wish to obtain a knowledge of Homoeopathy should regard it as an indispensable condition to prove at least one drug upon themselves. Only he who has made such a proving upon himself is capable of obtaining a complete and familiar knowledge of Materia Medica; a proving upon one's self facilitates a compre- hension of the provings of others a great deal. This is an undis- puted and an indisputable truth, for whose sake we warmly urge the above-mentioned advice upon every lover of our doctrine. 2. The Law of Similarity. Before defining this law, we cannot refrain from casting a glance at the laws prevailing in the domain of Medicine, or the rules that have to be observed if we wish to effect the cure of a disease by artificial means. An examination of this kind is necessary in order to comprehend to some extent the position of Homoeopathy in opposition to the other methods of cure, and in order to show that the law of similarity alone has claim to a more general validity and completely responds to all scientific demands. The therapeutic methods of the ancient systems of Medicine can be ranged, without resorting to any forcing process, in the follow- ing categories: 1. The disease is cured by removing the cause that produces it. Whenever this method can be pursued, it is undoubtedly the simplest and generally the safest, which, for the matter of that, no physician will neglect. But how small is the number of diseases whose causes we are able to trace with positive certainty 1 and, among this small number, how few diseases are there the known causes of which we are able to remove 1 Considering, moreover, that in many cases the disease, even after the cause is removed, still continues to exist as an affection that has acquired an independent existence, we must confess that such causal treatment can never acquire an uni- versal validity. 2. The disease is removed by exciting an artificial condition directly contrary to the natural malady, in other words: Contraria contrariis curantur. At first sight, this principle seems to be re- markably applicable to all cases; but a closer examination compels us to admit that it cannot be applied in every case to the treatment of diseases. A disease is a complex of various functional disturb- ances of the organism; it is only in very few cases that we meet Introduction. 19 with diseases confined to only one organ. How can we manage to apply the above-mentioned principle to a complex of phenomena, such as occurs in pneumonia or typhus? Individual symptoms or groups of symptoms can be treated in accordance with such a prin- ciple ; but their removal does not imply a cure of the whole disease. Constipation can be momentarily removed by a purgative; but this does not secure a cure of the disturbance which engenders the con- stipation in its course, and keeps it up. Nevertheless, diseases are treated in most cases in accordance with this maxim, but the cure is generally only apparent, for, in the present condition of the Materia Medica, it is next to impossible to find a contrarium for every disease. In the same manner as the authors of Materia Medica have endeavored to range drugs in certain general categories, depending upon a few single massive drug-effects: upon the same basis physicians resort to these categories, for the purpose of con- ducting a totally symptomatic treatment by opposing these coarse drug-effects to isolated prominent symptoms of the pathological dis- ease. Owing to this gross method of treatment, such irrational gen- eralizations have been introduced in Old-School Therapeutics, as we see them embodied in the history of any case of disease. Thus it is that the maxim " Contraria contrariis" is not only defective and insufficient in the treatment of diseases, but it has become decidedly hurtful to pathological science. 3. The disease is sought to be extirpated by alterations excited in non-affected organs or systems by artificial means, the revulsive method. This method of treatment is an imitation of the mode in which Nature herself often seeks to remove diseases. It cannot be denied that a cure is often achieved by pursuing this method; but we are as yet without a guide for such therapeutic imitations, since we are as yet unable to determine, with any thing like certainty, the connection in consequence of which one organ exerts a certain definite influence upon the other. This knowledge has not even been fully acquired with reference to the normal organism ; much less are we acquainted with the changes which morbid derange- ments cause in the relation of one organ or system to another. What is known on this subject are isolated observations which are partially utterly unreliable and certainly illy adapted to founding a law of universal validity. It is the more impossible to pursue such a road to a cure, the more the whole organism is affected by the disease. 4. More recently the more perfect development of organic Chern- 20 Introduction. istry has given rise to a new method of treating many morbid conditions medicinally. One or the other organic constituent was either found diminished or increased, and it was supposed that the disease could be counteracted by supplying deficiencies or by re- moving the excess by neutralization or some other proceeding. It is undoubtedly true that in some cases this method has proved successful, but in most cases this chemical method of treatment was soon found to have no higher value than that of a speculative theory, and that it is not sufficient to introduce the required con- stituent into the organism, but that, in order to produce a favor- able effect, the constituent has to be introduced in such a form and quantity as the organism requires for its special use. It is likewise self-evident that the curative attempts depending upon chemical indications can only be applied to a small number of diseases. A system of Therapeutics, based upon such doctrines as we have described, would be tolerably perfect, provided the methods men- tioned in the preceding numbers should coalesce in such a manner that one of them would help where the others leave us in the lurch. Such a mutually completing process docs not, however, take place, and a tolerable number of morbid affections remain against which we have to proceed upon the basis of the purest empiricism, where every species of treatment is no better than a bold attempt at curing without any fixed principles whatsoever, except perhaps a few morbid conditions for which tolerably fixed remedies have been discovered that are designated as specific remedies without any apparent reason. This appellation is erroneous for the reason that these remedies are not specifically curative of a definite species of diseases, which, as specific agents, they should be. For this reason, we declare such a system of Therapeutics defective, without any scientific basis. In opposition to these vague and defective doctrines, Hahnemann first set up a maxim alike applicable to the treatment of every kind of disease: Similia similibus cur ant nr, the law of similarity: in other words, a disease is cured most safely, speedily and easily by a drug which, when acting upon the healthy organism, produces all the symptoms of the disease in their greatest possible similarity. It is well known that Hahnemann was first led to conceive the possibility of such a law by observing that Cinchona is capable of developing on persons in health all the symptoms of intermittent fever. In order to change a mere possibility into certainty, he commenced to make a trial of all kinds of drugs upon persons in Introduction. 21 health, and to employ them for purposes of cure in accordance with the maxim he had started. The uniform success obtained by this method of treatment satisfied him that this maxim had all the dignity of a natural law. We, too, might content ourselves with referring to thousands of cures as a proof of the validity of this law, without troubling ourselves about any further explanation. But inasmuch as cures can be disputed, and such testimony is not within everybody's reach, we prefer showing, a priori, why such a law must necessarily be of universal applicability. The literature of Homoeopathy is replete with attempts to explain the law of similarity, from Hahnemann down to the present period. We cannot possibly undertake an enumeration of all these different views and opinions, more particularly since they would not possess any essential interest in this place. If anybody desires more special information on this subject, he will find it in the above- mentioned work by Hirschel. A brief record of the leading views will be sufficient in this instance; independently of all support de- rived from experience, the main point is, that the homceopathic law should prove universally valid in practice. Even if Hahnemann could have been reproached, with an appearance of justice, with having abstracted a natural law from a single fact, this reproach can no longer be applied to the Homoeopathy of the present day, which might very justly abstract a law from facts of universal and re- peated occurrence, even if it were impossible to account for this law by a priori arguments. Hahnemann himself explains the law of similarity by accepting a natural and an artificial disease, the latter of which, being the stronger, annihilates the natural malady, whereas itself is hushed up by the vital forces. This explanation is not satisfactory, more particularly for the reason that it is founded upon hypotheses which cannot possibly be proven. Who can prove the superior force of the medicinal disease, an essential condition upon which Hahnemann's explanation rests? What a hazardous hypothesis to suppose that the natural malady is annihilated by the vital forces, for no better reason than because, after the natural malady is cured, the drug- disease is no longer perceptible 1 Does it not seem as though this extinction of the drug-disease ought to take place simultaneously with that of the natural malady ? It is undoubtedly wrong to base one hypothesis upon a number of others. Hahnemann's view has indeed been abandoned, and has given rise to the most decided opposition. In order to overcome the difficulty that a similar disease 22 Introduction. is overcome by a similarly acting drug, it was said that a drug occasions in the sick organism opposite effects from what it does in the healthy. This mode of arguing simply substitutes one diffi- culty for another; such a behavior on the part of the drug can only be accounted for by an entirely wrong conception of the pri- mary and secondary effect of a drug. This designation of primary and secondary has led to many embarrassments, not only in this particular explanation but in Homoeopathy generally, by diverting our attention from the conception of drug-action as a morbid process progressing in accordance with an inherent law of necessity, and setting up an arbitrary separation of drug-effects which can never be carried out in practice. Nor can we admit another view as correct according- to which the drug excites the sound portion of an organ against its diseased portion, occasioning by this means an elimination of the disease. This explanation does away with the idea of similarity. For if the effects of the drug- and those of the disease are similar throug-h- out their whole course, the medicine must necessarily have affected the same organs and parts of organs as the disease, since without such a supposition the law of similarity cannot be thought of. How does it happen that, in effecting a cure, the medicine suddenly excites the sound parts into action? We know nothing of an action upon the latter. Nevertheless we shall show by-and-by, that, with a slight variation, this explanation has a good deal of probability in its favor. The supposition of a special predisposition to disease which is hushed up by the medicine, is likewise an unproven or, at any rate, a hazardous hypothesis. How do we understand that by extir- pating the predisposition the disease must necessarily be cured ? To account for a cure upon the basis of a chemical neutralization is likewise too hypothetical. If the greatest possible similarity between the disease and the drug-action proves, as it undoubtedly does, their mutual affinity; even if they neutralize each other after the fashion of bodies between which chemical affinity prevails, we shall have to inquire by way of following up the simile, what becomes of the product of neutralization? For the action of two agents upon each other can certainly not result in a nothing. This explanation, like many others, is faulty in this respect that it regards the disease as an entological entity in the organism. In our opinion, the following explanation comes nearest to the truth, for the reason that the suppositions which it implies are few Introduction. 23 in number, and the most probably correct. The medicine stimu- lates certain organs or systems, and, by acting upon sound parts, necessarily produces morbid phenomena, whereas, by acting upon the diseased organ, it produces the stimulation requisite for a cure. This explanation does not imply a contrary action, but the effect remains the same, only that in its union with the morbid action it gives rise to a different product from what it does when acting upon sound tissues. This view likewise renders it possible to account for aggravations occasioned by too large doses. Our view of accounting for the modus operandi of homoeopathic agents, leads us to an explanation of the law of similarity, which seems to us, more than any other, to satisfy the demands of logic and the necessary thoroughness in deducing it from known physio- logical facts. This explanation was originated by Wislicenus, and may be found in his work entitled: " Entwicklung eines wahrhaft physiologischen Heilverfahrens." Leipsic, 1860. In stating the fact that the object of this work is to show the correctness of the law of similarity in a series of logical deductions, we can only mention the chief points of this work in a few concise passages. For this reason many a proposition will necessarily appear disconnected and prob- lematic, because the intermediate links are omitted, and many of our readers may find our short extracts insufficient: So much the more we invite all, in the warmest manner, to read this book. The necessary consequences of the law of similarity, so far as the prac- tical business of the physician is concerned, are moreover so fully developed in this work from the leading maxims of Homoeopathy that the book is not only invested with a purely scientific but a directly practical interest. In order to be correctly understood, we have to premise certain statements of physiological facts that con- stitute an integral portion of our argument. Health depends in every organic being upon an inherent endeavor to preserve the equilibrium of its organic functions. This endeavor is designated by physiologists as an organic tendency of persistence, or as a physiological antagonism, or as an organic power of reaction. By virtue of this reactive power the organism equalizes the noxious influences acting upon it from without. As long as this equaliza- tion is continued regularly and imperceptibly, we call the organism healthy. But if the disturbances are too powerful to be at once and imperceptibly conquered by the reactive force of the organism, in other words to be equalized, we call the organism sick. In pro- portion as the struggle between these two factors is more or less 24 Introduction. violent, more or less extensive, we call the disease acute, sub-acute or chronic. The triumph of the reactive power over the disease is designated as a cure, the triumph of the disease leads to death. If the transition to recovery or cure is marked by tumultuous phe- nomena, we designate it as a crisis ; if the process of equalization is gradual, without any violent symptoms, we call it lysis. In so far as the organic reaction is engaged in a struggle with the disease, it is termed the vis medicatrix naturae. Like any other organic ac- tivity, it is based upon the nervous system, without which it can- not exist. But inasmuch as the disease is not a strange something that becomes mixed up with the tissues; inasmuch as it is simply the consequence of a change in the reciprocal relations and func- tions of organs, disease can likewise not exist without involving the nervous system, a derangement of the nervous functions being the starting-point in every disease. Every disease arises from the action of some external noxa upon the organism, the difference of one noxa from another, together with the peculiarities of the organ- ism, determine the different forms of diseases, and, inasmuch as these two factors may differ from each other in a variety of ways, it follows that there must be a variety of forms of disease. Disease is only recognized by the phenomena it presents to our senses. It is only from these phenomena that we can draw conclusions regard- ing the morbific agent and the opposing endeavors of the reactive force. Hence it becomes necessary to investigate every trifling cir- cumstance in the picture of the disease in order to obtain a knowl- edge of its true character, and to use it for the purpose of becoming acquainted with the road which Nature follows in order to free itself from the derangement of its functions, and likewise of obtain- ing light, by an analysis of the external phenomena, regarding the internal processes which these phenomena reflect. This result can only be obtained if each case of disease is placed before us as a sepa- rate individual case; for it is only in this way that we learn to know how far the organism is capable of equalizing the disturbance of its functions by its own unaided efforts, and when it becomes necessary to assist it in this endeavor. Experience shows that in many cases the organism is capable of throwing off the disease without any external aid, whereas in many other cases the reactive energies of the organism are insufficient and the disease triumphs over the former. It likewise shows that, if the morbific agent acts upon the organism with great intensity, the elimination of the morbific agent takes place slowly and with Introduction. 25 great difficulty. The desire of accelerating this natural curative process, of facilitating it or bringing it about, induces us to institute a search after remedial agents capable of answering this purpose, and all such remedial agents are called medicines. We have shown in the preceding chapter how we have to proceed in order to obtain a correct and full knowledge of their effects ; all we have to do here is to inquire how we have to apply the drugs with whose effects we have become acquainted, to the actual treatment of diseases. It is an old rule, which cannot be followed too strictly, that a physician should be the servant, not the master of Nature, mivister, not magister Naturae. If, as such, he means to help the organism, he is under an obligation to examine above all things the road which Nature pursues wThen endeavoring to free itself from disease; he is bound to try to effect a cure by means of the organic reaction which he has to reinstate into possession of its lost superiority over the morbific agent. Moreover, in order to act with as much directness as possible and to effect a cure as speedily as possible, he has to affect that portion of the nervous system which is the seat of the organic reaction in the present case, likewise in the direction which the curative effort of Nature is disposed to take. But, as the process of every natural cure is governed by an universally valid law, so should the medicinal influence upon the nervous system likewise be regulated by a law of universal and admitted validity. This must be the law of similarity as Wislicenus shows indirectly by his refutation of other methods of treatment, and afterwards directly by the following mode of reasoning: Our drug-provings have shown that a medicine produces a characteristic drug-disease peculiar to itself. If this drug-disease resembles a natural malady in all its essential points, it must necessarily proceed from the same essentially similar processes in the interior of the organism. If, in addition to the natural malady, we excite an essentially similar drug- disease, the former experiences an addition as regards quantity, and likewise ■ an extension as regards quality; for the question is not whether the morbid processes are equal but similar. In the same manner, by adding the medicinal disease, the existing reactive efforts are not simply heightened but qualitatively extended and in- creased, in consequence of new reactive endeavors characteristic of the medicine having been excited, which, however, are necessarily intimately connected with the existing reaction of the organism. Experience teaches that the drug-disease, when caused by a moderate quantity of the drug, is easily overcome by the organism 26 Introduction. which, even after the disappearance of the original disturbance, oscil- lates in the direction of the opposite medicinal phenomena, which may be regarded as a remnant of the natural curative endeavor directed against the drug. For by this union of the medicinal and natural diseases, the excess of the reactive endeavor of the drug- disease must necessarily go to the credit of the natural disease, since in both the drug-disease and the natural malady the reaction bears upon the same portions of the organism. This cannot take place where the drug-disease and the natural malady are not similar, consequently are deprived of the numerous and essential points of contact existing in case of similarity. From the foregoing remarks we infer that it is only the after-action by the drug which deter- mines the cure, for it alone represents the reactive endeavor of the organism that we have to call into play. In as far as a disease can only continue as long as the organic reaction remains too feeble to control it, and must disappear as soon as the reactive force becomes superior to it, and in as far as we are capable of securing such a superiority by the most similarly acting remedy: just so far the law of similarity precludes the idea of an incurable disease, provided we are able to discover a similarly acting remedial agent. We have it in our power to acquire this knowledge; all we have to do in order to accomplish this object is to continue our provings with persistent energy and correctness, and to unceasingly increase the number of the drugs to be proved. All this shows that the law of similarity necessarily requires the most careful proving of drugs ; for it alone enables us to contrast the most comprehensive diagnosis of a natural disease with an equally comprehensive diagnosis of drugs, which, after all, is the main requisite to a cure. The law of similarity invests every apparently insignificant drug-effect with a degree of importance, since it becomes an clement in our thera- peutic series. On the other hand, the preceding statement regarding the necessity of instituting careful and comprehensive provings likewise argues in favor of the law of similarity, which alone renders it possible to use all the results of our provings for therapeutic purposes. This explanation of the law of similarity likewise facilitates the explanation of an idea that has heretofore been used very improperly by many .physicians: we allude to the expression of specific. If the old system of Medicine applies the term specific to such drugs as had been found to be specially curative against certain morbid processes in a manner that it was beyond the power of analysis or Introduction. 27 observation to investigate: all that such an appellation accomplishes is to cause us to condemn, a priori, every investigation of the causes of therapeutic results as useless ; the thing has been given a name, this is all. We know very well that this name has no meaning, and that it does not designate a constant curative effort. There are no specific remedies for entire genera of diseases. If we content ourselves with the definition that a remedy is specific with reference to a cer- tain form of disease; if it exerts under all circumstances a curative influence upon the disease, our previously developed explanation gives us the privilege of applying the term specific to the similarly or rather to the most similarly acting drug. At the same time our explanation shows that there are specific remedies only for.indi- vidual cases of disease, not for whole categories, and that the so-called specific remedies of the Old School are specific only in so far as they correspond, under the application of the law of similarity, with individual cases in the category. It is only by accepting this explanation of the term specific that Homoeopathy can be called the doctrine of specific remedies, the specific curative method. Speaking of names, we may as well add a few words concerning the term Homoeopathy. More recently as well as years ago, at- tempts have been made to alter this name. It matters not, and we need not inquire whether this name is in strict accord with the rules presiding over the formation of words; but we doubt whether another name can be found indicating the distinction between the homoeopathic and other curative methods. The term Homoeopathy has become fixed by usage, and will only disappear with the princi- ples of this doctrine. If this name is either erroneously or mali- ciously associated with notions that have rendered it somewhat odious, we need not concern ourselves about this, provided we en- deavor to do the name honor, and do not expect the name to confer honor upon us. We have already stated in previous paragraphs that an explana- tion of the law of similarity has only a purely scientific value with- out influencing the practical treatment of diseases, although it does exert such an influence in many respects. In conclusion, let us now present a point of view which must satisfy every one of the import- ance of our law without any further demonstration. If we are called upon to treat an affection of a certain organ or system, it is evidently of the first importance that we should find a remedy which acts adequately and definitely upon the diseased organ or system, and more particularly upon the parts where the morbid pro- 28 Introduction. cess is going on. Setting aside the modus operandi^ the law of similarity alone can reveal to us the existence of such a drug. Con- sidering for the present every kind of treatment as empirical, and imagining ourselves restricted to clinical cases, we must admit that so far we are not acquainted with a single method that leads so surely to the knowledge of a drug exerting a definite action upon a definite locality as the law of similarity based upon physiological provings of drugs. It is with the remedy thus found that we shall have, at all events, to attempt a cure. The correctness of the pro- ceeding may afterwards be deduced from the result, in case oppo- nents should neither be willing nor able to concede this correctness, a priori. From this point of view it would seem as though any one who professes to be a physician must consider it as a matter of conscience to try the homoeopathic method of treatment. Let us now consider the consequences resulting, with more par- ticular reference to practice, from the two cardinal maxims that have been discussed in the preceding paragraphs. These conse- quences are, in the first place, the mode in which the disease has to be diagnosed; and, secondly, the manner in which the remedial agent has to be applied to the treatment of any given case of disease. 3. Diagnosis of the Natural Disease. Here too we quote as literally as may be Hahnemann's views as he has expressed them in his Organon, in order afterwards to ex- plain what changes they had to undergo in the course of time. Hahnemann says: " It may readily be supposed that every dis- ease presupposes a change in the interior of the organism. These changes, however, as far as they are revealed by the morbid symp- toms, (and these are the only data by which we can be guided in non-surgical diseases,) can only be apprehended by the understand- ing obscurely and at the risk of being mistaken. The essence of these changes cannot possibly be recognized in its inmost nature, nor can it be recognized at all without fallacious conclusions. The totality of the symptoms is the only aspect of the disease laid open before the eyes of the healing artist; this is the chief part of the disease which he can know and need know for purposes of curing. The physician may be aided in his work by a knowledge of the probable circumstances that induced the acute disease, or by an investigation of the most significant points of interest in the his- tory of a chronic malady, and finally by a study of the constitution of the patient so far as it is amenable to observation, a knowledge Introduction. 29 of his character, business, mode of living and habits, his social posi- tion, age, sexual functions, etc. This externally reflected image of the internal essence of the disease is the chief and only channel through which the disease can indicate the remedy it requires for a cure, the only means of determining the selection of the proper remedial agents. From this truth we infer with absolute certainty that the totality of the symptoms in every individual case of disease is the only indication by means of which the true remedial agent can be found out." We will add to this quotation the maimer in which a patient should be examined : " The individualizing examination of a ease of disease, for which I here give only general directions, and of which the examiner may use whatever he may require for a present case, demands of the healing artist nothing but presence of mind and sound senses, at- tention in observing phenomena, and fidelity in drawing the image of the disease." " The patient describes the history of his troubles; his family relate his complaints, his conduct, and whatever has come within the range of their observation ; the physician sees, hears and notices through his other senses whatever unusual changes have taken place in the patient. He records every thing in the same language in which the patient and his friends have described his trouble. Without saying a word he allows them to finish their statement; he only interrupts them if they lug in unessential trifles, (for such interruptions disturb the mental process of the relator;) all he does is to request slowness of speech in order that he may be able to note down the statemens of the speaker while he utters them." " With every new statement of the patient or his friends he com- mences a new paragraph, for the purpose of obtaining a successive list of the symptoms in detached series. In this way he is enabled to make subsequent additions to that which at first seemed to him vague but afterwards was stated more clearly." "After the parties have said all they intended to say of their own accord, the physician then seeks to obtain more precise definitions of their statements by instituting the following proceeding: He peruses each symptom that has been described to him, and inquires in regard to each symptom in particular: When did this symptom appear? Previous to his taking the present remedy? While he was taking it ? Or only a few days after discontinuing it ? What kind of pain, what sensation was it, which was experienced at this spot? (These pains and sensations have to be minutely described.) 30 Introduction. What was the precise spot ? Did the pain occur in isolated, inter- mittent paroxysms, at different times? Or was it continued, not intermittent? How long did it last? At what time of the day or night and in what position of the body was it worse, or did it in- termit entirely ? Give an exact statement of this or that symptom or circumstance as it did occur or was felt." " In this manner the physician elicits a more circumstantial description of every single statement, without, however, suggesting an answer at the same time that the question is asked, so that all the patient would have to do is to either answer yes or no; other- wise he might be induced to state that which is either false or only partially true, or to give an affirmative or negative answer, which- ever might seem to suit the views of the questioning physician; all of which would lead to an incorrect delineation of the disease and suggest improper remedies for its cure." "If, in making these voluntary statements, nothing was said regarding several parts or functions of the body or the condition of the mind, the physician then inquires what has to be stated with respect to these parts and functions, and likewise with reference to his mental and moral condition; but all such inquiries have to be couched in very general terms, so as to compel the respondent to express himself in very definite and precise language." "After the patient, who is, after all, chiefly to be trusted with respect to his sensations, except in diseases where he naturally seeks to dissimulate, has furnished all proper information to the physician by these voluntary and indirectly suggested statements, and has completed the image of the disease with a tolerable degree of accuracy, the physician, if he should be satisfied that he is not sufficiently informed of the condition of his patient, may then address more special and definite questions to the latter, such as: How often have the bowels been moved? What was the nature of the stools? Did the whitish stool consist of mucus or faeces? Was the evacuation attended with pain or not ? What kind of pains and where? All the other symptoms have to be more pointedly examined in a similar manner." " If the physician has recorded all these statements, he then notes what he himself has observed in his patient, for instance: How the patient has acted during the physician's visit; whether he was peevish, quarrelsome, hasty, whining, etc.; whether he was soporous or wide awake; how he talked; what was the color of Introduction. 31 his skin, tongue, etc., and inquires how far these conditions differ from-what they were in health." "In chronic diseases an investigation of the above-mentioned and all other morbid symptoms has to be conducted with particular care and circumstantial detail, even to the minutest particulars, partly because in chronic diseases the symptoms are of a more peculiar, strange character, are least like the symptoms of diseases running a rapid course, and, if a cure is to be successful, cannot be noticed with sufficient care, partly because patients become so accustomed to long suffering that they pay little or no attention to lesser, incidental symptoms which, however, are often very signifi- cant and characteristic, and even decisive in the selection of a remedial agent. Trifling deviations from the normal equilibrium are even regarded by such patients as a part of their necessary con- dition, even as a state of health, the true perception of which a suffering o/ fifteen or twenty years duration has caused to be for- gotten ; they scarcely imagine that these trifling symptoms, these smaller or greater deviations from a state of health, have any con- nection with their main affection." Except a few unessential omissions which we may discuss in sub- sequent paragraphs, we have here given an outline of Hahnemann's ideas concerning the diagnosis of diseases, and how he intended it should be carried out. We here feel bound to subject his views to a brief critical examination from the present stand-point of medicine. Let no one imagine that, by offering this criticism, we intend an insult to Hahnemann or mean to underrate his labors. If we consider the time when the above-stated rules were laid down; if we consider to what extent, at that time, Medicine was lorded over by speculative theories, we must wonder that Hahne- mann, in opposition to the tendency of the age, did not go over to the crassest empiricism. Since then, a good many changes have taken place: in diagnostics the most powerful levers have been set in motion with the greatest success; hence a good deal will have to be modified in Hahnemann's instructions. The first point we have to examine is the assertion that the physician has only to deal with the externally reflected image of the disease. At Hahnemann's time this proposition seemed per- fectly correct. The progress of Medicine has divested it of all such pretensions. Physiology, pathological Anatomy, Chemistry, and even Physics, have furnished us so many points of support by means of which the externally reflected phenomena lead us on the 32 Introduction. road of rational deductions, very frequently with absolute cer- tainty, to a knowledge of the inner process, that, by neglecting these diagnostic resources, we would commit an equally great wrong as that with which we reproach our opponents for neglect- ing our diagnosis of drug-effects. With reference to present claims on Homoeopathy we have to formulate the above-quoted passage from Hahnemann's instructions far differently, as we shall show by-and-by. In discussing Hahnemann's doctrine of psora, we shall show that he was not so very serious in trying to limit our knowledge of disease to a mechanical delineation of its outward image. The second point is Hahnemann's assertion that, in examining the patient, the physician requires only presence of mind, sound senses and attention. These requisites may have been entirely sufficient in his time, but in our own time they are utterly insuffi- cient. We assert that, without a knowledge of the above-men- tioned collateral sciences, it is impossible to institute a thorough examination of the patient or to obtain an exhaustive diagnosis of his disease. An incoherent juxtaposition of symptoms is not what is required ; we have to inquire into their origin, combination, etc.; we should endeavor to have a clear view of the internal pathological process upon which all external symptoms depend, as well as of the laws according to which this process, if there is no interference on our part, will develop itself, and either expand or become ex- tinct. It behooves us, by every known means at our command, to find out what symptoms are the more important and characteristic of the disease, since it is after all upon these symptoms that the determination of the true remedial agent will depend. Where the existing means of diagnosis are not sufficient, it becomes our duty as much as that of any other physician to procure new sources of information or to complete those we have. Hahnemann's proposi- tion must therefore encounter a decided condemnation at our hands. His doctrine of psora shows most conclusively how little import- ance Hahnemann attached to a rigid adherence to his views of disease, or rather, how deeply sensible he was of the defects of his own teachings. Chronic diseases had driven him, in some meas- ure, into a strait; anxious to solve the knot, he at most made the attempt in cutting, but he failed in accomplishing his purpose. The language in which the deep thinker reveals his invention to Introduction. 33 the world has a peculiar sound about it; we quote the passage referring to it from the Organon. " Heretofore syphilis had been known to some extent as a chronic- miasmatic disease, that, unless cured, only becomes extinct in death. Sycosis, which, unless cured, is equally unconquerable by the vital force, was not known as an internal chronic-miasmatic disease, sui generis; it was supposed that a cure consisted in destroying the cutaneous excrescences; the internal malady, which continued its course, remained unobserved." "Of immeasurably greater extent and importance than these two chronic miasms, is the chronic miasm of psora. Whereas the former miasms reveal their internal malady, one by the venereal chancre, the other by cauliflower-excrescences: the psoric miasm, after having infected the whole internal organism, reveals its exist- ence by an intolerable, titillating, voluptuous itching, and by a specific odor. It is this miasm which constitutes the fundamental cause and fountain-head of the numerous, or rather innumerable forms of disease, which, under the names of nervous debility, hys- teria, hypochondria, mania, etc., figure in pathological treatises as idiopathic, independent diseases. It took me twelve years to find out the source of an incredible number of chronic affections, to investigate and substantiate this great truth that had remained un- known to our ancestors, as well as to our contemporaries, and, at the same time, to discover the anti-psoric remedial agents which, together, will in most respects prove a match for this hydra- headed monster of disease in its diversified forms and manifesta- tions." This quotation may suffice, since everybody may learn from it what Hahnemann intended to accomplish. By contrasting this quotation with the above-mentioned propositions, their contradiction must appear self-evident to everybody. In these propositions we are told that the phenomenal image of the internal disease is our only object of cure, and that after its extirpation, health must remain ; whereas, in the above quotation, the opposite is presented to us as the truth, moreover with a feeling of ostentation, and as the fruit of a persistent labor of twelve years. Hahnemann sets up the boldest and most unfounded hypothesis in order to get over a difficulty which he had prepared for himself. Practice soon showed that Hahnemann's view of diagnosis of disease caused prac- titioners who sought to cure chronic diseases of every kind, to stumble upon difficulties; that something more was required than 34 Introduction. the possession of sound senses and a practised hand; that it was necessary to investigate the internal nature of the malady, espe- cially in cases that had but a few symptoms: all these difficulties were to be remedied by .the authoritative assumption of a secret morbific agent, for which purpose the itch, whose true nature was still enveloped in mystery at Hahnemann's time, proved a welcome expedient. We should scarcely deem it worth our while to pur- sue this subject any farther, except to show Hahnemann's inconsis- tencies, if psora did not continue to play an important part with many homoeopaths, not by any means to the advantage of our doc- trine. Our own opinion of the itch will be stated when we come to treat of this disease. In this place we will simply ask the question v hy the itch, after all its morbid manifestations are removed, should still continue in the organism as a disease, and why, upon the same pi inciple, a flea-bite, which likewise causes an efflorescence upon the skin, should not continue to flourish as a secret malady? Does an explanation of the peculiar processes of chronic diseases render the supposition of the existence of a secret agent at all necessary? Tins we cannot believe ; and, in order to substantiate our belief, we fall back upon our explanation of the law of similarity. Consequently we accept the proposition that, in a therapeutic point of view, disease is an aggregate of the sensually perceptible morbid symptoms, and that, where no symptoms are seen, a disease does not exist. To these sensually perceptible symptoms belong the results obtained by means of auscultation and percussion, or by any other means of physical diagnosis, as well as by the aid of Chemistry. Besides we should endeavor, by means of this external knowledge, to determine the internal processes upon which the perceptible phe- nomena depend as their generating cause. That this is not possible in all cases, and never will be altogether, is a defect with which all human knowledge is tainted. So far as it is possible, we are bound to initiate our reason into the internal processes of disease. Speak- ing of individual affections, we have shown that it is owing to the light which pathological Anatomy has shed upon internal changes, that we have become enabled, in many diseases, to pursue the cor- rect road to a cure, to prove which we refer the reader to our chapters on apoplexy, acute hydrocephalus, affections of the spinal cord, as illustrations of our statement. Accordingly we give it as our opinion, that, together with Hahnemann's requisites, an exhaustive diagnosis of disease implies an intelligent knowledge of the physiological connection of the individual phenomena. Introduction. 35 This is not favoring hypothesis; Physiology rests upon facts to which alone it is indebted for its very existence. The phys- iological connection of the symptoms is the means of arriving at a diagnosis of chronic diseases, without having to lug in invisible, impalpable, incomprehensible morbific agents; this connection not only demands an investigation of the present malady, but likewise, and as an absolute condition of success, a consideration of previous diseases, of peculiar conditions in life, habits, abnormal mental phenomena and characteristics, of all causative, favorable or unfavorable, ameliorating or aggravating circumstances, peculiar local conditions, etc. Nobody will probably wish to deny that such a deeper investigation of the malady must be of great value in practice. If Hartmann informs us in his in- troduction that the modern science of diagnostics avails the homoe- opath only in so far as it enables him to arrive at a speedier and more certain cognition of diseases, but is of no avail in the treat- ment of diseases, since no definite plan of cure can be suggested by it, until provers apply these modern diagnostic contrivances in their provings, and mark fhe internal changes caused by the drug: he contradicts himself to some extent, since he does not accept the proposition that the sensually perceptible phenomena constitute the sole image of the disease. Besides, he errs if he insists upon a cor- responding drug-proving, before such diagnostic resources can be made available for purposes of cure. We admit that it would be desirable, and that it is necessary to a complete elaboration of our Materia Medica, that our modern diagnostic contrivances should be applied to our drug-provings, but we cannot admit for all that, that our present Materia Medica is not adequate to an exhaustive diag- nosis of the natural disease. For in the drug-disease we lay no less stress upon the physiological connection of the symptoms than in the natural disease. In the drug-disease, likewise, we have to pos- sess a lucid apprehension of the relative value and significance of the symptoms, of their origin, succession, final tendency, in short, of ah the circumstances a knowledge of which we have to acquire in the case of a natural disease. Though a good deal may still be wanting, yet such a want should not deter us from doing our duty as far as possible. It is very probable that we may make many mistakes, but it is likewise certain, that by pursuing the road we have pointed out, we shall err much less frequently than those who strictly adhere to Hahnemann's course. Errors committed by fol- lowing our own plan have this advantage, that we acquire a lucid 36 Introduction. perception of the defects in our Materia Medica so far as the what and the wherefore are concerned, whereas Hahnemann's method leads but too easily to a perfect stagnation in the investigation of drug-effects. The history of Homoeopathy has shown this to our perfect satisfaction. As regards the diagnosis of disease, the following proposition is the only one that we can recognize as correct: Investigate by all possible means and contrivances all the changes developed by the disease with reference to their cause, form, origin, course, connec- tion, and succession; in a like manner investigate the symptoms and changes of the drug-disease, and you will be in possession of the two conditions necessary to achieve a cure by remedial agents. The less perfectly these two conditions are fulfilled, the less sure can we be of effecting a cure. It is readily seen that this proposition includes all covering of symptoms, but in addition requires something else. It cannot be denied that in the present condition of our remedial resources it may often happen that we shall have to select a remedy exclusively according to the similarity of symptoms without any knowledge of their connection or origin, and that such a course will likewise lead to favorable results. However, it would be a mistake, if from a few favorable results of this kind we would draw conclusions re- garding all possible cases of disease, and jump at the inference that we must treat diseases exclusively upon the basis of symptomatic similarity; for where a disease manifests itself only with a few morbid phenomena, the selection of the remedial agent can be de- pended upon as certain and infallible, if the symptoms are strongly marked and characteristic; not otherwise. Covering the symptoms can only lead to a cure by way of exception, not as a rule; in addition to the uncertainty involved in the selection of a remedial agent, such a proceeding is, moreover, highly unscientific. Our demands relative to a complete and practically reliable diag- nosis of disease can only be satisfied in accordance with our pre- vious statements, if the diagnosis remains purely individual, in other words, confines itself to the case in hand, without regard to other similar cases that may have occurred before, or without re- gard to a general similarity with other cases of the same category. Therapeutically speaking, the homoeopath knows of no categories of diseases, of no classifications based upon individual phenomena were they ever so essential, of no names such as are used in Pathology for the purpose of attaching to them equally general therapeutic rules. 37 Introduction. Generalizing is the enemy of every correct treatment, more particu- larly when conducted in accordance with the principles of Homoe- opathy. It would be going too far if we would condemn all patholo- gical forms. So far as the study of disease is concerned, great benefit is derived by starting from the general phenomena and combining with them the more special symptoms which are pecu- liar to the individual case. Pathology, for instance, reveals to us the characteristic symptoms peculiar to all cases of pneumonia, but not by any means the symptoms by which one case is distinguished from another, and which are of the utmost importance in practice. The fact pneumonia suggests to us a whole series of drugs, all of which may be useful in this disease; but it does not, at the same time, inform us what remedy may be the best in the present case. Our Therapeutics cannot, therefore, either be united with, or applied to the commonly received Pathology. As it enjoins upon us a rig- orously individual diagnosis and selection of remedial agents, so should a manual of Therapeutics, rigorously speaking, occupy itself with individual cases of disease; it should really be a collection of single cases, and yet, in spite of all its completeness, it would even then be only fragmentary, and would, moreover, be such a bulky and unmanageable fragment, that nobody might feel anxious to wade through it. Such a work could not possibly be perfected by one man; it w'ould have to engage for a long time the energies of a number of co-laborers, and even then it would not answer the de- mands of a really scientific work. Inasmuch as with an exhaustive diagnosis of disease, and a complete knowledge of drug-effects, we are placed in possession of all the requisites of Therapeutics, we might really do without any special system of this science. Up to this time we have not yet reached this point. We are neither in possession of the means to complete our investigations of disease, nor are we thoroughly acquainted with the effects of drugs. This last point we have endeavored to explain in a former paragraph; the former does not require .any further argument to demonstrate its correctness. This fragmentary knowledge compels us to avail ourselves in many cases of disease of such knowledge of the action of drugs as we have obtained from their clinical use; conse- quently, it is this kind of knowledge that has to constitute the chief contents of a manual of homoeopathic Therapeutics, for the reason that it completes the knowledge in which we are as yet deficient. At this stage another difficulty meets us that cannot be over- come. A knowledge of practical results can only be obtained from 38 Introduction. a collection of complete, carefully recorded cases of disease, which we have to search for in the literature of our School. In surveying the whole field of our literature we cannot help confessing that it contains but very little material available for our purpose, more particularly if we consider that a sure conclusion can only be drawn from a large number of homogeneous facts. Upon the whole, all cases of disease recorded in our literature show, with not very numerous exceptions, a want of complete diagnosis, and, for this reason, cannot safely be depended upon, more especially in morbid conditions which, without a rigorous diagnosis, would lead to the most momentous misapprehensions. By way of example we mention the following three conditions which are very different and yet so often resemble each other symptomatically: meningitis, acute hydrocephalus, and typhus. In the sequel we have never failed to direct the reader's attention to such defects. In conclusion we have to explain the points of view starting from which this work has been composed. The object of the work, to serve beginners in Homoeopathy as a guide in the treatment of diseases, rendered it necessary to follow up a strictly pathological system, and to range, in parallel series with the pathological catego- ries, a whole number of remedies that occupy the first rank in the treatment of diseases. To those who may consider the number too small, we have to reply that too much material confuses the beginner, without doing much good to those who are thoroughly conversant with Homoeopathy. In order to satisfy the claims of Medicine regarding diagnosis, we have deemed it necessary to describe diseases as completely and accurately as possible, so much more as, in this respect, Homoeopathy is as yet guilty of many sins of omission. Most likely many will blame us for having done too much in this direction. The therapeutic chapter contains but sel- dom a list of individual symptoms; such lists are only furnished in cases where the symptoms seemed to have a special value, or where a splitting of the symptoms in the Materia Medica might have given rise to a wrong apprehension of their import. In mentioning single remedies, their relation to the disease in point has been described in a very general manner, to which we have added various items that are not found in the Materia Medica and which have been derived from the usu in morbis. By this means we be- lieve we have made it impossible for any one to imagine that the statements made in any given case of disease are sufficient for prac- tical treatment. What we intended to accomplish was, to furnish Introduction. 39 a guide to a knowledge of the Materia Medica, on which account we have indulged in as few special indications as possible, in order that everybody should be obliged to study the special symptoms in the Materia Mcdica, which is really the true Therapeutics of Homoeopathy. In order to facilitate such a study by means of a comparative arrangement of the materials, we have endeavored, instead of adopting the classification of other writers, and more particularly the confused and confusing classification of Hartmann, to follow the plan of the Materia Medica and to adapt to it our arrangement of particular diseases. In this way a comparison of the different drugs among each other bearing upon one and the same anatomical locality, is very much facilitated. As to the dose, it has been mentioned only now and then in the special part of this work. We shall discuss our views concerning this subject in this introduction, in order afterwards to avoid giving offence, on this account, in view of the great divergency of opinions on this subject. 4. Single Remedies. Next to the two leading maxims of Homoeopathy, this subject is undoubtedly the most important. We generalize as follows: Every drug must be administered without the admixture of any other medicinal substance. If Hahnemann had done nothing: further than to start the previously expressed proposition, more particularly at such a time as he lived in, he would not only deserve our grati- tude, but likewise our admiration. It is undoubtedly this law which has exerted the greatest influence upon Medicine generally. In proof of this it is well known that apothecaries have heaped upon Hahnemann their bitterest curses for introducing this reform. We do not consider it necessary either to defend or to explain this law any further. This law is an inevitable consequence of the law of similarity. We might be answered that mixed drugs might be proved and employed accordingly. In reply to such an objec- tion we suggest that it would be improper to prove mixtures, whereas so many single drugs still remain unproved, and to employ mixtures where single remedies are sufficiently curative. And then, definite mixtures that have been proved would be like single remedies, since they would have to be prescribed in every case in the same identical combination. So far as we are concerned, we regard medicinal mixtures with a great deal of disfavor; we believe that we do not assert too much, if we maintain that the mixing of drugs has been the main reason why Old-School Therapeutics has 40 Introduction. not progressed or been improved. We even go so far as to assert that every physician who has an eye to practical results, must be- come a homoeopath from the moment he binds himself as by a law never again to prescribe a mixture of drugs. It is only by pursu- ing this course that he will be able to obtain results from which he can draw conclusions for himself and others, and upon which he can erect the edifice of experience. It is impossible to comprehend that even homoeopaths could have sinned against the doctrine of a single remedy; alas, it has been done, and is even done at the present time in two different ways. In the first place two homoeopathic medicines have been mixed together with a view of obtaining in this manner a simillimum, one part of the symptoms being arbitrarily separated from the other part in order to decide upon the proper remedies. We need hardly show that this proceeding is contrary to the laws of our system of treatment; it has but few apologists. The custom of administering two remedies in alternation is much more common and widespread, especially with our English colleagues. Much may be said in its favor, still more against it; nor do we share Hartmann's opinion when he calls the alternation of drugs an improvement in our system of Therapeutics. The method of alternating drugs can be excused under certain circum- stances, but can never be defended as scientific. We very fre- quently meet with cases where it is difficult to at once hit upon the right remedy on account of the inherent difficulty of establishing a correct diagnosis; nevertheless the imminence of the danger may require prompt help. In such a case the use of two drugs in rapid alternation may be excused until our diagnosis is satisfactorily cleared up. Croup may serve as an example. As soon as our diagnosis is perfectly certain, there is no further reason to excuse the alternate employment of drugs ; after this it becomes a mistake that weighs so much more heavily, since it renders our observations obscure and unreliable. In cases where we have to depend upon written reports for a selection of drugs, we may be excused for em- ploying two drugs in alternation, but only until we obtain a correct knowledge of the disease. What we have said shows that the alternate use of drugs is either a forced or self-indulgent palliation of a want of knowledge either of the drugs or of the diseases, or is even a matter of conve- nience. As a general rule we shall find that homoeopaths who are equally well versed in Materia Medica and Pathology do not favor Introduction. 41 an alternation of drugs. We more especially warn beginners against adopting this custom ; it will render their path much more difficult since they cannot place any reliance upon an experience derived from such a source. 5. Size of Dose. No subject has been discussed by homoeopaths with more invet- erate and even bitter persistence, and no subject has furnished our opponents so many opportunities for scientific and unscientific attacks as this subject of the size of the dose. In setting up this subject as the fifth cardinal maxim of Homoeopathy, we may at the same time indicate thereby the rank which this maxim holds in relation to its four predecessors. We omit quoting Hahnemann, whose teachings concerning the size of the dose have never acquired any general validity, and are, moreover, couched in language that would require a commentary for its proper elucidation. We will briefly state that Hahnemann, observing that the employment of large doses of similarly acting drugs aggravated the disease for which the medicine was pre- scribed, diminished the size of his doses more and more, by which means he was led to the discovery that a quantitative diminution of the drug did not necessarily involve a corresponding diminution of its curative power. Starting from the idea of a so-called homoeo- pathic aggravation, he finally hit upon a dose which would be suffi- ciently powerful for curative purposes, but too weak to occasion any medicinal aggravations. For all that it was a mistake to announce the thirtieth potency as a normal dose, as we shall shortly endeavor to show. The question of dose is a purely practical question, whose solution can only be approximated and achieved by thousands of experi- ments ; for the action of a medicinal substance upon the human organism is not regulated by a uniform law, but depends upon a number of accessory circumstances. We cannot expect ever to derive the same effect from the same dose, either among sick or healthy individuals. These modifying circumstances are of three different kinds, according as they are founded in different degrees of susceptibility to medicinal impressions, or in differences of the morbid conditions, or of the remedial agents. The difference in individual susceptibility to medicinal impres- sions is shown by every proving that is instituted on different individuals, and likewise by the number, be it ever so small, of 42 Introduction. observations on the sick. We cannot form an a priori judgment regarding the degree of susceptibility, even if experience should have satisfied us that certain points may be regarded as fixed. Ex- perience has shown that children, nervous and irritable natures, and men who live as nearly as possible in accordance with the laws of Nature, and with strictness and regularity, are more susceptible to medicinal action than those who pursue an opposite course; that the susceptibility decreases in proportion as the general reactive energies of the organism diminish, in consequence of the persistent use of large quantities of medicinal substances, etc. Daily experience likewise points to the fact that the size of the dose depends upon the peculiar character of the pathological pro- cess. We see that affections of the nervous system do not require such large doses of medicine as affections of the circulatory organs; that contagious or miasmatic diseases require larger doses, etc. Everybody may likewise see that different drugs, when admin- istered in the same dose, do not manifest the same degree of inten- sity of action. A grain of Arsenic, of course with reference to the effects peculiar to this poison, acts more powerfully than a grain of the Nitrate of Potash or of Mercury; a drop of Belladonna more powerfully than a grain of Chamomile. Looking at the subject from these three points of view, a normal dose, be it small or large, is an assertion that cannot be proved-a mere theory that can never be substantiated by practice. If many of our homoeopaths still continue to adhere to a normal dose, we have to regret so much tenacity as a damaging mistake, as a direct violation of the spirit of Homoeopathy. Upon the same principle that Homoeopathy demands the strictest process of individualization in diagnosing a disease; that it even insists upon a rigorous indi- vidualization of drug-effects: upon this same principle it likewise demands as a strictly logical consequence, that the dose shall be rigorously individualized in every case by adapting it to the nature and the special circumstances of the case in hand. To meet these requirements we have an universally valid law in Homoeopathy, which we shall discuss more particularly in the subsequent para- graphs. Every cure which a physician is expected to perform is to be conducted in accordance with the principle: Tuto, cito et jucunde curare. In other words: Every conscientious physician will see to it, without impairing the certainty and rapidity of the cure, that, in addition to the existing complaints, the medicine employed in the Introduction. 43 case, shall not cause additional sufferings to the patient. By pre- scribing a tolerably large dose of a drug in accordance with the law of similarity, we shall almost always develop a more or less consid- erable exacerbation of the symptoms, the so-called homeopathic aggravation. Everybody can easily satisfy himself that such an aggravation is not an imagination or vague theory; on the other hand, it is certainly an imagination, if many homoeopathic physi- cians profess to see an aggravation after every dose below the omin- ous thirtieth potency, remaining in this respect much too literally the faithful followers of Hahnemann. The fear of a homoeopathic aggravation led Hahnemann to the great mistake of setting up the thirtieth potency as the normal dose. It is certain that the obser- vations of his successors have not confirmed the statements of their teacher. Now, inasmuch as a homoeopathic aggravation-although if it does not manifest itself with too much violence, it is generally a proof of the correctness of our choice of the true remedy in the case-yet is not altogether in accordance with the requirement of "jucunde curare," we are bound to avoid the aggravation by les- sening the dose, and to continue this lessening process until we reach a point where the fullest possible curative action of the drug is no longer followed by an aggravation of the symptoms, even if this course should lead us to the thirtieth and even higher potencies. Beside the homoeopathic aggravation, we observe from large doses purely medicinal effects, that is to say, effects that are caused by the medicine outside of the range of the natural pathological symptoms. This medicinal aggravation only sets in after propor- tionally large doses, whereas the homoeopathic aggravation may occur after very small doses. That such an aggravation may some- times be excited by very small doses, in individuals endowed with an extraordinary sensitiveness to medicinal action, is a welcome proof of their efficacy. We have treated a very sensitive lady, in whom the sixth attenuation of Mercury always excited profuse, though short-lasting ptyalism, accompanied with a metallic taste. The patient, of course, never knew what medicine she was taking. Evidently a purely medicinal aggravation is more than any other opposed to the "jucunde curare," and should, therefore, be avoided with the greatest care. According to what we have said, the dose should be determined in accordance with the following rule: The dose should be of a size not to develop any medicinal symptoms while the healing process 44 Introduction. is going on, nor, if possible, any homoeopathic aggravation. We use the term " if possible," because it is impossible to avoid a homoeo- pathic aggravation in every case, which, after all, deserves our attention only in case it should set in with much violence. It must be evident to every one that the rule which we have ex- pressed regarding the dose, cannot be applied without any further thought in every disease, since both the homoeopathic and the medicinal aggravations depend upon the above-mentioned relative conditions of the patient, the disease, and the medicine. Practical observation has su^^ested a few more or less definite and fixed rules bearing upon this subject, which we shall at once proceed to point out. Previously, however, we will briefly explain how it is possible that such small doses as are employed in homoeopathic practice, do at all manifest any curative virtue. Regarding this point a whole legion of explanations has been furnished, which we could not possibly discuss without being carried too far. We avoid such a discussion so much more readily as all explanations of this point never lead to any convincing result. We have already stated in a previous chapter that the small doses of Homoeopathy have been suggested by the purest empiricism, and we here add that it is only the practical ex- periment that can furnish evidence of their efficacy. If any one can- not or will not believe in the efficacy of these small doses-and we do not blame any one for it-let him try them in practice, and ob- tain practical evidence concerning a subject that seems incredible to his abstract understanding. In view of the tendency now prevailing to observe the course of diseases without the use of drugs, we deem it much more natural and conscientious to find out with how little medicine cures can be effected than to determine how much medicine a patient can bear without being injured or killed by it. If, with reference to the question of dose, the old system of Medicine is in direct opposition to Homoeopathy, no unprejudiced person can doubt to what party the palm of discretion and conscientiousness should be adjudged. We know that most diseases terminate in recovery even without our aid;-if this be so, is it not a piece of unscrupulous boldness to operate with large doses of powerful drugs?-We ho- moeopaths are entitled to backing up our mode of administering drugs by the experience of thousands of cases and practitioners; but who is justified, without instituting a final trial, in arrogating to himself an apodictic judgment concerning things which he rejects for no better reason than because he is unable to comprehend them Introduction. 45 with his purely human imperfect understanding ? The actual ex- periment establishes the belief in small doses much better than a purely theoretical explanation. Are the small doses of Homoeopathy the sole thing in Nature which surpasses our comprehension ? Should we deny results for no better reason than because we marvel at the road upon which they have been reached?-As we have stated, it is useless to undertake to argue against those who are not willing to believe; we prefer repeating to them Hahnemann's words: " Imitate my example, but imitate it correctly 1 " We pity those whom mere prejudice prevents from trying small doses; they do not injure Homoeopathy, only themselves and the patients who confide themselves into their hands. In other respects, general propositions are best attached to each of the following truths which experience alone has taught us: 1st-Every medicine which is administered in accordance with the law of similarity, has to be administered in proportionally small doses. In order that this proposition should be clearly understood, we have to determine in the first place what we understand by large and small doses. The term small can only be understood with refer- ence to the doses that are generally employed in Medicine; hence we might state the case in this way, that medicines prescribed according to the law of similarity can never be given in the same quantity as the same medicines are prescribed according to any other law of cure. If small is to be understood with reference to Homoeopathy, the rule then is worded in this wise: The dose should never be large enough to develop either a medicinal or homoeopathic aggravation. The proportionate smallness of our doses is founded in the totally different views that guide us in the use of drugs. What we intend to accomplish by means of the drug is to excite the reaction, not to divert the reaction from its natural course. Inasmuch as we intend to excite this reaction within the limits of the parts affected by dis- ease, we do not prescribe the medicine in such a large dose that, in addition to the existing symptoms of the disease, it is able to de velop its own inherent drug-effects ; this would envelop other organs and symptoms within the range of the pathological process. That only small doses are necessary to excite the reaction, is not only taught us by practice, but we are led to such a conclusion a priori, since a diseased organ is much more sensitive to the action of an artificial stimulus than the same organ in health. 2d-The limit up to which the dose of a remedy prescribed in 46 Introduction. accordance with the law of similarity can be diminished, without being divested of its curative power, has not yet been fixed up to this time. Hahnemann had decided in favor of the thirtieth potency as the dose sufficient in all cases ; finding even this dose too strong in some cases, he was led to the notorious custom of causing patients to smell of the prescribed drug. Most of his successors have decided in favor of the lower potencies, employing the thirtieth potency only- in exceptional cases. Another not altogether insignificant party has carried the potentizing process much higher than Hahnemann. If the partisans of the high potencies profess to have obtained bril- liant curative results from the two thousandth or even the ten thousandth potency, those who think differently are certainly not authorized to deny these results without further proof; it is just as rash to brand such curative results as absurd, as it would be rash on the part of the high potentialists to reject as improper the more material doses of their opponents. We admit that high potencies exert a curative influence. But there is no evidence that they act better than the lower potencies up to the thirtieth. It is certain that a remedy in a lower potency, which is unable to overcome a disease, will not overcome it any more if given in a higher. Inas- much as no one can pretend having seen the thirtieth potency pro- duce a homoeopathic, much less a medicinal, aggravation, which must necessarily determine the degree beyond which a medicine need not be attenuated, we cannot comprehend why the immense labor of manufacturing high potencies'should be undertaken. Since they do not yield any advantages worth mentioning, this innovation, which carries the " mysticism" of Homoeopathy to the utmost ex- treme, had better be abandoned. For this reason, we can neither invite nor encourage the trial with high potencies. On the other hand, if we adhere to Hahnemann's scale up to the thirtieth as the normal series, we deem it inconsistent and unscientific for any one to use the first numbers of this scale and to reject the higher num- bers nolens nolens as absurd. The practical trial being alone capable of deciding, every one should satisfy himself by actual experiments whether high or low potencies are preferable. This is the only way of arriving at a final and conclusive result. It may suffice in this place to say that we consider it proven that the thirtieth potency is still capable of effecting decidedly curative results. 3d-We consider it an established fact that the lower potencies show a more rapid, momentarily more intense, but less persistent, Introduction. 47 effect than the higher potencies, which develop their effects more slowly and gradually, but more persistently; and that, for this reason, the lower potencies are more suitable where rapid aid is required-the higher potencies, on the contrary, where the effect can be awaited without any great hurry. We have purposely avoided lugging in, in this proposition, the idea of acute and chronic diseases. Such a separation is always more or less impractical, since we shall always have transition-forms which it might be very difficult to classify, so much the more as the question of dose would have to be settled in accordance with such a classification. Moreover we have acute affections where higher potencies may be more useful than lower, and, vice versa, there are chronic affections where lower potencies will prove more beneficial than higher. The former class, for instance, comprehends all dis- eases running a definite course, such as typhus, contagious exan- thems, or such chronic affections as frequently show an acute ex- acerbation of the symptoms. It is our opinion that in selecting a drug we should be guided by the urgency of the reaction to be obtained, and we prefer this more general definition to special rules which it is impossible to furnish for all cases ; in pursuing this course we shall of course be guilty of many sins of omission. 4th-The more similar the chosen remedy to the disease, the more surely may we expect curative results even from the smallest dose. This proposition is easily explained by what we have said before in explanation of the law of -similarity ; it likewise accounts for a fact which is common to all homoeopathic practitioners: that is, the more familiar they have become with the Materia Medica, the more correct their knowledge of the curative virtues of our drug's, the more habitually they prescribe smaller doses. This shows that in selecting a drug, its similarity to the natural disease is the first and most important condition, and that the quantity of the dose plays an entirely subordinate part. 5th-In determining the dose, the peculiar nature of the drug demands special consideration. In a previous section already we have shown that this point is somewhat essential. We have many medicinal substances that do not display their therapeutic power until they have been commi- nuted. This number includes all inorganic substances that are in- soluble either in water or alcohol. These it is which the process of trituration has first to convert into remedial agents; it is therefore 48 Introduction. impossible that such drugs, when prescribed in material doses, should manifest any curative power. In the case of soluble inorganic and of vegetable substances we have likewise to consider the intensity of the effect. Corrosive Sublimate, for instance, or Phosphorus, Nux vomica or Ignatia can never be given in as large a dose as Chamomile or Sambucus, comparatively large quantities of which can be administered without any injurious effect. In this place we cannot well classify drugs with reference to these inherent differ- ences of medicinal power, and therefore refer the reader to the Materia Medica. 6th-The peculiar nature of the sick individual requires to be carefully considered in the selection of a drug. This point has likewise been alluded to before; here we add the following to our previous remarks. It is always difficult, when taking charge of a new patient, to determine a priori the degree of reaction against medicinal impressions he may be endowed with. In such cases we have to proceed with a great deal of caution, the more so the younger the patient. It is only a protracted observation of individual peculiarities that can afford us a more or less certain basis for a correct j udgment. We believe that the foregoing general propositions have ex- hausted the question of dose as far as this is possible in the present position of our science. We have intentionally omitted every thing that might convey the suspicion of party-predilections. We deem it just as wrong on the part of those who prefer the lower potencies to deny the efficacy of the higher, as on the part of those who prefer the higher potencies to condemn the lower as though they only produced toxical results. The former generally pronounce judgment without having made sufficient trials, the latter condemn under the influence of a pitiable one-sidedness. It is therefore fortunate that the dispute about doses which was formerly carried on with so much foolish zeal and repulsive vehemence, has yielded to a temporary armistice. Let both parties first gather up good material, after which they may wage a war of annihilation. Under this head we range various points of subordinate import- ance, which, however, with reference to practice, cannot remain unnoticed. In his instructions for the preparation of the different medicines we likewise are led to admire Hahnemann's great practical tact. 6. Preparation, Repetition, ere., of Medicines. Introduction. 49 He considered it a physician's duty to prepare all his own medicines, and, in order to do this, the preparation of drugs had to be a very simple affair. Hahnemann's rules in this respect have undergone but few alterations, indeed only such as have been suggested by our superior knowledge, particularly of inorganic substances or by a difference in our views concerning doses. Particulars may be found in Jahr and Gruner's Homoeopathic Pharmacopoea, (New York: Wm. Radde.) The following are the general rules to be followed in the preparation of drugs. Organic substances in as fresh a condition as they can be obtained, are extracted by means of concentrated alcohol. This yields us the mother-tincture. One drop of this tincture shaken up with nine drops of alcohol, gives the first attenuation, (potency or dilution;) one drop of this first attenuation diluted in a similar manner, gives the second attenuation, and so on. This is the decimal scale which is now in almost general use. Hahnemann followed the centesimal scale, where one drop of the tincture is shaken up with ninety-nine drops of alcohol. Many prefer this scale as superior, doubtless with- out any sufficient reason. The decimal scale yields evidently a more exact, a more uniform attenuation of the drug, and the differences of the single numbers of the series are of less consequence. The centesimal scale is more suited for one who always uses the same potency in his treatment of diseases. Inorganic substances are best attenuated by trituration. To this end one grain of the chemically pure and, if possible, amorphous substance is rubbed up for one hour in a mortar with nine grains of sugar of milk. This yields the first trituration, one grain of which, rubbed up in the same manner with nine grains of sugar of milk, yields the second trituration, etc. The triturating process is usually continued only up to the third or sixth potency, after which liquid attenuations are prepared by mixing one grain of the triturated substance with ninety-nine grains of diluted alcohol. Some drugs have been triturated up to much higher numbers ; this practice has not been generally applied to all drugs. Organic substances, that can only be imperfectly extracted by alcohol or not at all, have likewise been triturated; likewise such vegetable substances as can only be obtained dry. Soluble, inorganic substances, on the contrary, are prepared in a liquid form at the outset. For convenience sake-and it is asserted on account of their better preservation-small globules of sugar have been moistened 50 Introduction. with a few drops of an attenuation, which are afterwards allowed to dry again. These globules are excellently adapted to pocket- cases ; however, there is no reason why they should be preferred to the liquid form. Medicines may be administered to the sick in form of drops or powder, or in the shape of globules, or dissolved in distilled water. There are no fixed rules with regard to this point. These statements show at once Low simple and yet how bulky such a preparation of our drugs must be. Inasmuch as it is impos- sible to exercise any control over the intrinsic value of the attenua- tions, it is evident, that they either have to be prepared by the physician himself, or by a reliable apothecary. From this dilemma the bitterest struggles have arisen for Homoeopathy, for it involves the necessity of self-dispensation for every physician who cannot avail himself of the services of a reliable apothecary. This is not the place for an elaborate discussion of this subject; let it suffice that we deem it of the utmost importance and advantage for every physician to dispense his medicines to the patient directly, even if he should have a reliable pharmacy to fall back upon. As regards the repetition of drugs, Hahnemann advises not to repeat the dose until the former has exhausted its action. This sounds simple enough, but is of very difficult application in practice. At all events, in chronic affections nothing is lost by waiting a reasonable length of time ; in acute affections, on the contrary, such waiting is very often out of place, and would only be admissible if we could always be sure of the simillimum, and in possession of sure signs by which we could decide when the medicine ceases to act. Let every one ask himself whether he can be certain of this in a given case; we do not believe it, and look upon Hahnemann's rule as a correct theory that cannot be carried out in practice. Nor was Hahnemann quite as indisposed to repeat the dose as it might seem; if he prescribes a tablespooniul of the same solution in frequent doses, this too is a repetition of the medicine. As a general rule all practical homoeopathic physicians act upon the principle ot repeating the dose the more frequently the more intense the disease. In violent attacks of croup or cholera, for instance, the medicine may be repeated every ten minutes; it is even well to do so. In affections which, although acute and very intense, run a definite and more extended course, a less frequent repetition of the dose is perfectly appropriate. In chronic affections where no great changes Introduction. 51 take place, one or two doses a week generally advance the cure more than frequently repeated doses. Frequent changes of medicines are contrary to the spirit of Homoeopathy. In acute affections where the life of the patient is in imminent danger, it may be both necessary and pardonable to resort to a rapid change of medicine, since, after all, we are not mathematically certain of having chosen the right remedy; in affections running a less rapid course our best plan is to select a remedy with great care and afterwards to give it a fair trial by continuing it for some time. We should always keep in mind what we intend to accomplish with our remedies; this will induce us to persevere in the proper use of one drug. What we intend to accom- plish is to assist the organic reaction and to enable it to restore the equilibrium of the disturbed functions by a normal process; we do not intend to expel the disease from the organism by violent means. This has to be considered more particularly where the disease has developed morbid products of some magnitude, or has produced other material alterations. A pneumonic exudation, an apoplectic effusion, a considerable deposition of pus, etc., cannot possibly be removed within twenty-four hours; it might even be injurious to the organism if it should develop such an extraordinary reactive activity. If we desire to proceed truly physiologically in such cases, we must not indulge in frequent changes of medicines. 7. Diet. The so-called homoeopathic diet such as it was insisted upon in former times, has not been of particular advantage to Homoeopathy. In the first place it has deterred a number from adopting homoeo- pathic treatment; the fear of the rigid homoeopathic diet is still haunting the public mind; in the next place it has furnished the opponents of Homoeopathy a handle they are even now making use of for the purpose of denying the efficacy of our drugs. Experience has shown that these two disadvantages are not by any means counter-balanced by adequate gains. It is perfectly absurd to attempt to furnish stereotyped rules of diet, as is sought to be ac- complished by our notorious diet-papers. As we allow Physiology full swing, in all other medicinal injunctions, so we should in diet which should likewise be rigorously adapted to the necessities of individual cases. This kind of dietetic individualization requires us to consider the circumstances in which the present generation lives. If we would 52 Introduction. change our mode of living even approximatively to a natural system, we should change our whole surroundings, our occupations, our mental and bodily labor. Such a dietetic Utopia is and will remain a religious desire the fulfilment of which is not even looked for by those who entertain it. Habit is a wicked tyrant and yet so ami- able that, in spite of our better judgment, we are unable to shake off his yoke. What wine-bibber would want to renounce his wine? what woman her coffee ? what smoker his cigar ? Before opposing such habits, we had better inquire first how far they are an ob- stacle to a cure, and whether it is not possible to attain our object in spite of them. In most cases we shall certainly be able to do so. The so-called obnoxious habits are not hurtful or at least equally hurtful for everybody; with many they constitute a necessity resulting from the conditions of life. Persons who are constantly occupied mentally, and whose nervous system is bad, require coffee as a stimulant; if they are deprived of it, they feel quite sick. For a state of mental and bodily depression, wine is a perfect panacea; physicians know this perfectly well by their own personal ex- perience. What shall we say of tobacco? Are we not compelled to put up with it, unless we wish to make tobacconists as well as druggists our mortal enemies? Many habits can easily be put off, but it is best not too suddenly. Among them we range for instance the use of a number of spices, a want of exercise, too warm cloth- ing. Such habits have to be changed, but very cautiously; as regards other habits, they had better be left unchanged at the be- ginning of the treatment. Our remedies act in spite of them, and, we believe just as well, unless the habit should happen to antidote the medicine, such as coffee the vomic nut. Our advice therefore is, do not prescribe a set diet, and do not prohibit too many things in order to secure a more perfect obedience to our positive demands; this may not seem very consistent, but of what avail is all consistency against a secretly sinning patient? In treating of the different diseases, we have generally indicated the proper diet, and cannot indulge in any further details in this place. We repeat, Physiology gives us sufficient hints what rules we ought to adopt in regard to diet, and likewise points out the reasons why we cannot deem a strictly homoeopathic diet necessary to the successful action of our remedial agents. The maxims of Homoeopathy which have been discussed so far, show that in the treatment of diseases this science pursues an en- tirely different road from that pursued by the Old School. Let us Introduction. 53 now briefly inquire whether under certain circumstances it may not be necessary or possible that Homoeopathy should approximate to or coalesce with other curative methods, and what, in general, is the relation of each curative method to Homoeopathy. We hear it said very frequently that more recently the views of homoeopaths and non-homceopaths approximate to each other more and more. This can be admitted with great propriety, since all physicians simplify their prescriptions more and more, and, some of them at least, diminish their doses. Homoeopathy cannot make any concessions if it means to remain what it is. Hence it is absurd to suppose that a physician can treat a patient homceo- pathically at one time or by some other method at some other time. A physician who pursues this course is either a mere beginner in Homoeopathy or a common impostor. We do not mean to assert that we alone are able to achieve a cure; we admit that a cure may be wrought in some other way; what we claim for Homoe- opathy is, that it achieves at least as much as any other curative method, and in most cases assuredly more. Hence we are not under the necessity of seeking help elsewhere; all we require to do is to use earnestly and consistently what we possess. Of course our op- ponents will never admit this, but what matters it ? As regards surgery, it stands to reason that necessary surgical operations are likewise indispensable to homoeopaths; yet it cannot be denied that the number of necessary operations has been very much circumscribed by Homoeopathy. There are very many affec- tions which it is not necessary to treat surgically, since they can be managed just as well and better by internal means; such are various kinds of swellings, incarcerated hernia. Nor will we have to decline the use of external, indifferent auxiliary appliances. Cold and warm fomentations, compresses, etc., are indifferent things in a medicinal point of view, but of sufficient importance for the allevia- tion of many sufferings to deserve the consideration of homoeo- pathic practitioners. These auxiliary means are likewise very fre- quently used by us homoeopaths differently from what is generally the case. Balneo-therapeutics promises in time to become a curative means of great importance. For the present we are confined with few exceptions to the narrowest empiricism, and it would be desirable if homoeopathic physicians were less anxious to subject their patients to a cure whose indications and results are so uncertain. In this matter fashion has unfortunatelv enforced her behests and has 54 Introduction. caused many a one to forget that a medicine should not be em- ployed before we are well acquainted with its physiological effects. As regards artificial mineral waters, all we can say is that they belong in the category of medicinal mixtures, consequently are in diametrical opposition to the spirit of Homoeopathy Of particular importance to homoeopaths is the hydropathic system of treatment. Its successes are sufficiently striking to ex- cite universal attention. It would be well if physicians could only learn from this method of treatment that it is not always and per- haps never necessary to attack diseases with an excessive quantity of substances that are inimical to the body, and that these diseases are removed much more easily by careful nursing and an awakening of the reactive energies of the organism. Watercure treatment aims in general at what Homoeopathy seeks to accomplish by more special means, leading the organic reaction back to its normal condition. For this reason we regard the former treatment as of special importance to Homoeopathy, cold water being the only truly constitutional remedy which is not antagonistic to any of our medi- cines. Our literature furnishes abundant evidence that the value and importance of water as a curative agent have been recognized and appreciated by homoeopaths at a very early period. However, we would warn our readers against imitating the extravagances of the modern hydro-therapeutic treatment. Equally important to a homoeopath as the watercure treatment is the movement-cure. If we cannot hesitate to admit that gym- nastic exercises are of incalculable importance to the preservation of the normal condition of the body, we must infer from this as a necessary consequence that methodical exercises must exert a power- ful influence upon the restoration of the physiological equilibrium. In employing this treatment we have likewise to caution the patient against excesses, especially in diseases that do not admit of an in- creased acceleration of the circulation. Gymnastic exercises do not merely feed the muscular powers, but likewise exert an all-powerful influence upon the nervous system generally as well as upon diges- tion. The Swedish movement-cure possesses the undoubted advan- tage of rigidly circumscribing the mechanical treatment within proper limits, and concentrating its effect upon definite and separate portions of the muscular system. The treatment by electricity is still so recent that it is as yet im- possible to decide for what affections it may prove useful. The experiments which are as yet being made with electricity are more Introduction. 55 or less empirical; even if it is not otherwise directly antagonistic to Homoeopathy, yet so far it is too little founded upon a rational basis to enable homoeopathic practitioners to derive positive advantages for their patients from the electro-therapeutic treatment. We have endeavored to show by this short survey that there are many remedial methods which, though not borrowed from Homoe- opathy, yet are not contrary to it in any shape or manner. We repeat, however, that no homoeopath should ever avail himself of any remedial agent the use of which cannot be justified upon the principles of Homoeopathy. Every therapeutic experiment is justified before the tribunal of reason, which is founded upon a knowledge of the remedial agent, and is instituted with all the precautions necessary to render it a standard rule, be the dose otherwise ever so large or ever so small. Experiments without a principle should always be repudiated with becoming energy. FIRST SECTION. Diseases of the Brain, the Spinal Cord, and the Nervous System Generally. A. DISEASES OF THE BRAIN. Hypersemia of the Brain and its Membranes. Even up to a recent period, doubts have been entertained whether a true hypersemia of the contents of the skull is possible or not, and a number of reasons were well calculated to favor such doubts. Recent physiological experiments, however, have shown satisfactorily that the volume of blood within the skull may differ, and we will refrain from taking sides in this purely pathological question, except so far as to pronounce in favor of the opinion according to which hypersemia of the brain is not only possible but likewise of frequent occurrence. By hypersemia of the brain we understand a condition of this organ where the cerebral vessels contain more blood than the nor- mal quantity. This abnormal increase of the volume of blood may be occasioned by three different causes. In the first place, the flow of blood from the brain being normal, a larger quantity of blood returns to the brain. In the next place, the flow of blood from the brain may be abnormally diminished, whereas it may be returned in a normal quantity. Finally, the cause may be located in the brain itself, the cerebral parenchyma may become atrophied or softened, or the capillaries of the brain may become enlarged. Hyper semi a of the brain is either confined to a limited locality, or extends throughout the whole organ. It will scarcely ever be found possible to establish, during the life of the patient, a sure diagnosis regarding the special seat and the extent of the hyperse- mia, for the reason that congestions of limited extent frequently excite much more striking symptoms than more extensive conges- tions. So far as Therapeutics is concerned, such a diagnosis is 57 58 Diseases of the Brain. scarcely ever of much importance. Even a post-mortem inspection does not always show hypersemia with absolute certainty, since a sanguineous engorgement is often supposed to exist where there is not any, and, on the other hand, localized or apparently not very marked stagnations are often overlooked. In this respect the meningeal membranes are very apt to lead one into error. On the contrary, the post-mortem signs become much more apparent in consequence of a frequent recurrence of the congestion, since this causes a dilatation of the vessels. By this means the vessels of the meningeal membranes are made to look like varicose veins, having a strongly marked serpentine course, while the substance of the brain, on its cut surface, exhibits more or less numerous bloody points, and even assumes a reddish tint. It often happens that the most unmistakable signs of a high degree of cerebral hyperaemia have been present during life, without any corresponding alterations being discovered after death. The most important terminations of cerebral hyperaemia, which impart to it a higher significance in practice, are: Sudden death from paralysis of the brain in consequence of excessive pressure of the blood; dilatation of the vessels, especially the capillaries, by which the tendency to congestion is increased; exudation and extravasation. The causes of cerebral hyperaemia are various and important in a practical point of view, since in most cases they determine the selection of the suitable remedy. These causes are of two kinds, causes which affect the brain directly, and indirect causes, by which, through the operation of influences that are partially unknown to us, the brain becomes involved in an affection more or less remote from the brain. Among the direct causes affecting the brain, the most prominent are: Concussions of the head by a fall, blow, etc., continued, persevering and excessive mental exertions, emotional excitement, exposure to excessive heat of the sun (insolation, coup- de-soleil) or to artificial heat, likewise to excessive cold, more par- ticularly if the influence of cold is suddenly succeeded by the action of intense heat. In the second category we may range, according to circumstances, almost all kinds of febrile affections, since almost all of them may be associated with cerebral hyperaemia; in this place we will content ourselves with mentioning pathological processes where cerebral congestions are almost always present; they are: Erysipelas of the face, angina, parotitis, inflammatory affections of the eyes and ears, irregularities of the teething process. Hyperaemia of the Brain and its Membranes. 59 Among the more or less chronic affections that may be mentioned in this connection as causal circumstances, the most prominent in the list of those that impede the flow of blood from the brain are: Defects of the right heart, emphysema, tumors on the neck; in the list of those that occasion a general increase in the impulse of the circulation: Anomalies of the left ventricle, suppression of habitual losses of blood, (menses, piles.) In this last category we likewise range, without doing any great violence to the natural order, the cerebral hyperaemias occasioned by the abuse of alcohol or of other narcotic substances, such as Opium. Without doubt, there like- wise exists a tendency to cerebral congestions, in which case they may take place without having been excited by any perceptible pathological alteration. This tendency is identical with the so- called apoplectic habitus, but cannot be recognized with any certainty, a priori, by definite diagnostic signs, but has to be deter- mined in most cases, a posteriori, by the actual fact; it is a certain fact that it is not alone indicated by a thickset frame and a short, thick neck. On the other hand, the idea of a probable occurrence of cerebral hyperaemia suggests itself, a pri'on, in the case of individuals who, while consuming quantities of nourishing food, do not take bodily exercise in a corresponding ratio, and in whom this mode of living develops a condition that may be justly termed plethora. We have already stated in a former paragraph that the frequent repetition of attacks of hyperaemia leads to a dilatation of the vessels, which increases the disposition to renewed attacks. Generally speaking, the prognosis in this affection is favorable, since a fatal result need not be apprehended unless some other com- plicating affection should supervene. In one respect it depends upon the age of the patient. Whereas, in persons of middle age, the danger is not very serious ; it is, on the contrary, much greater in the case of children and old people. In the case of children, death takes place very frequently in consequence of the cerebral paralysis occasioned by the hyperaemia; in old people, the vessels are gener- ally so fragile that they readily tear, and their contents become effused upon the brain. The apparent violence of the hyperaemia is no adequate criterium of the danger caused by it. On the other hand, the more frequently the congestion occurs, the more dangerous it becomes. Where it depends upon pre-existing derangements, the prognosis depends almost exclusively upon the character of these derangements. The symptoms by which hyperaemia manifests itself vary proba- 60 Diseases of the Brain. bly according as one or the other locality of the brain is the seat of the affection, and according as the pressure upon the brain is more or less violent. The head feels heavy, confused, or as if encircled by a tight band ; the headache, which is scarcely ever wanting, is almost always throbbing, and is aggravated by stooping, unusual exercise and every mental effort. Buzzing in the ears, sensitiveness of the eyes, even seeing of sparks and obscuration of sight, are generally present. Vertigo is seldom wanting; if arising from anaemia, a characteristic sign of this kind of vertigo is to become aggravated by stooping, but more especially by looking up, by which, for that matter, any other complaint in the head is made worse. Generally the patient feels drowsy, without, however, being able to sleep, or else the sleep is anxious, disturbed, full of drcams. The patient feels very languid, and his gait is rendered insecure by a want of firmness of the lower limbs. The pulse may continue normal, and, if the congestion sets in as an idiopathic disease, febrile phenomena arc entirely absent. This mildest form is combined in other cases with a prevailing disturbance in the emotive sphere, characterized by constant rest- lessness and gloomy ideas; sleep is disturbed by anxious dreams, which, in the more violent cases, do not even entirely disappear while the patient is awake; they even assume the character of hallucinations, and, if the trouble continues without being checked, a permanent mental derangement will not unfrequently result. Palpitation of the heart, ill-humor, distrust, total indisposition to work, fitful mood, are almost always present. This form of hyperae- mia mostly befalls individuals who, while indulging in good cheer, take little bodily exercise, but perform a large amount of mental labor. The foregoing symptoms are almost characteristic of hyper- femia consequent upon suppression of certain forms of haemorrhage. The trouble is much more dangerous if it sets in as an acute affection, and, although very violent at first, continues to increase in intensity until it terminates in death. In such cases the face looks dark-red, the eyes are injected, the vessels of the head and neck pulsate violently, the pupils are almost always contracted, the organs of all the senses are very sensitive, the headache is madden- ing. Furibond delirium is apt to supervene. This type is most prominent in hyperaemia occasioned by sunstroke, and, not unfre- quently, is an accompaniment of mental derangement. Not very unfrequently the above-described symptoms are sud- Hyperaemia of the Brain and its Membranes. 61 denly succeeded by all the signs of apoplexy, regarding which the diagnosis cannot be established with any positive certainty until the proportionally rapid course and the sudden disappearance of the symptoms of paralysis have satisfied one that no extravasation of blood can have taken place, since the fluid could not have been reabsorbed so soon. In this category belong most likely all the cases that are said to have been cured so rapidly. Cerebral hypers mia may likewise, though erroneously, be supposed to exist during: an epileptic attack; here the course of the attack alone gives us perfect certainty concerning its true nature. Among children hyperremia is an almost habitual accompaniment of all febrile affections, and not unfrequently conceals the symptoms of the true primary affection, for the reason that the course of the hypereemia is marked by the more violent symptoms. In every considerable congestion convulsions of one or the other kind almost always supervene; they are accompanied by drowsiness even to sopor, delirium, excessive restlessness and anxiety, and vomiting is almost always present. However threatening such a condition may seem at first sight in almost every case, yet it passes off speedily and without leaving a trace behind, so that the hypersemia seldom lasts longer than thirty-six hours, and generally abates already after the lapse of twelve hours. Treatment. Belladonna.-Among all the remedies of our Materia Medica there is not one which, in its physiological action upon the organism, reproduces the image of cerebral hypersemia in all its degrees and forms as completely as Belladonna. It is of importance to refer to the many evidences of Belladonna-poisoning where a post-mortem examination reveals a more or less considerable sanguineous engorge- ment in the vessels of the brain. If nowhere else, it is certainly in cerebral hyperaemia that Belladonna is calculated to show the correctness of the homoeopathic method of cure, since, in most, especially uncomplicated cases of this affection it affords relief with wonderful rapidity. It would be useless to detail, in this place, a list of the principal symptoms of this drug, for the reason That their vast number and physiological differences render it necessary that the provings of this drug should be subjected to a special and most careful study. However, it may be of import- ance to place a few more general points of view more promi- nently before the reader. As regards temperaments, the sanguine temperament is more especially adapted to our drug. Plethoric 62 Diseases of the Brain. constitutions, disposed to rush of blood, together with a nervous system, endowed with a high degree of sensitiveness, likewise child- hood and the female organism, constitute the more special sphere of action for Belladonna. The greater the tendency to cerebral congestions, and the more frequently the patient has been attacked by them, the more Belladonna will be found suitable. Hence, it will be found particularly useful in the more important periods of development of the body, during dentition and the period of pubescence, but likewise during the critical period. The more the congestion sets in like an independent disease, the more surely it will yield to Belladonna ; by which proposition is not to be under- stood that, if the congestion depends upon other primary affections, such as angina or scarlatina, for which Belladonna is the truly homoeopathic remedy, such affections impair the homoeopathicity of our drug to the symptomatic congestion. • Having thus indi- cated, in a few leading traits, the general views that determine the selection of Belladonna as the remedial agent in the case, we do not mean to convey the impression that other temperaments and constitutions are not likewise accessible to the action of Belladonna ; such a teaching would be in direct antagonism to the experience of our practitioners. Among the special symptoms, we quote more particularly the delirium which, in the case of Belladonna, is gen- erally furibond, and the characteristic excessive sensitiveness of the organs of sense. Contraction of the pupils does not counter-indicate Belladonna, dilatation of the pupils not being a constant effect of this drug, although much more common than the opposite. Bailor of the face, or even deficient redness, are more reliable counter- indications. Where there is doubt whether Aconite or Belladonna should be given, I have always found that a disposition to perspire constitutes, creteris paribus, a valuable indication in favor of the latter drug. Aconite, in its action upon the organism, is so closely related to Belladonna that it is sometimes very difficult to choose between the two agents. I have just now indicated a distinctive sign, that has never deceived me. Practically, we have found that a genuine hypenemia of the brain does not constitute the true field for the action of Aconite. The case is different where the cerebral hyperae- mia is a mere symptom of a disturbance of some other organ; in such a case, the hypereemia does not contra-indicate Aconite, among whose symptoms those of cerebral congestion hold a prominent place. According to Hartmann, Aconite is the best remedy for Hvperaemia of the Brain and its Membranes. 63 cerebral congestions that have been caused by violent emotions, such as fright or mortified feelings. This somewhat specific effect may be accounted for by the fact that in such conditions the action of the heart is peculiarly excited, and that Aconite, as we shall show more particularly by-and-by, exerts a remarkably calming influence upon cardiac excitement. Hyoscyamus and Stramonium, in their relation to the brain, are closely related to both Belladonna and Aconite, especially the former ; we think that it will be sufficient to merely indicate them in this place. Opium is a more important remedy than either of the two last- mentioned drugs, and its action upon the brain is much more cor- rectly delineated. Judging from the scantiness of our clinical records, it would almost seem as if very little use were made of it in congestion of the brain ; yet it deserves special commendation, as any one may see, even from a superficial survey of its pathogenesis. The following symptoms constitute characteristic indications for the employment of this drug: Continual sopor, with insensibility of all the senses ; dark redness of the face, with paleness and coldness of the rest of the body; slow pulse, slow respiratory movements, stertorous breathing. Such phenomena indeed do not often occur in simple hypersemia of the brain; they occur more generally in hyperaemia constituting the commencement of more intense affec- tions of the brain. We must not forget to mention two drugs whose employment as therapeutic agents is limited, in consequence of their being so commonly used as articles of daily consumption, but which acquire importance from the fact that their habitual use is very apt to induce cerebral congestions. These drugs are coffee and tobacco. The effects of coffee upon the brain are much better known than those of tobacco ; nevertheless, the use of tobacco causes, in many individuals, the most obstinate congestions, from which they can only be freed by renouncing their habit, which is supposed to be harmless. This may, likewise, show the necessity that, in the presence of habitual congestions, which we are called upon to remove, the use of such agents should be strictly forbidden. For such congestions as are very apt to attack sensitive individuals, in consequence of some joyful event and which generally last some time, Hartmann recommends a few dessert-spoonfuls of ordinary coffee, provided the patient is not an habitual coffee-drinker, in which case Coffea cruda should be given. However, it may be 64 Diseases of the Brain. doubtful whether Coffea cruda has any effect upon coffee-drinkers any more than a drop of Tabacum has any effect upon habitual smokers. Nux Vomica.-This agent will scarcely be suitable in simple hyperaemia, but is important in such hypersemias as are caused by a sedentary mode of life, excessive mental labor, and more espe- cially by the frequent use of spirituous beverages. In such cases, the selection of the remedial agent will depend upon the digestive de- rangements with which such patients are always afflicted. It is only at the commencement of the trouble that Nux will render good service; whereas, if the cerebral affection manifests itself at a later period, as a more independent disease, Sulphur and Natrum muriaticum will prove more efficient aids, to which remedies we therefore direct the reader's particular attention. Arnica is admitted to be the best remedy for hyperaemia conse- quent upon concussion of the brain by a fall, blow, etc., or by other mechanical impressions. So far as the wounded locality is con- cerned, it may be well to apply Arnica externally, but this will not be of any special benefit to the congestion. [After exhibiting Belladonna for twenty-four to thirty-six hours, giving a dose of the third attenuation every half hour or hour, without any perceptible improvement, Kafka resorts to the Sul- phate of Atropine, third trituration, giving it in the same manner as Belladonna. If this agent produces no favorable result within twenty-four or thirty-six hours; if the patients start or cry out frequently and suddenly during their slumber; if they are tor- mented by a variety of frightful optical illusions, which cause anxiety and trembling; if symptoms of incipient compression of the brain, such as sopor, apathy, slight reaction to light and sound, etc., begin to show themselves, and the determination of blood to the head still continues, Kafka has seen happy results from Apis 3, in solution, giving a dose every hour or two hours ; and, if an active delirium predominates, attended with sleeplessness, rest- lessness, disposition to escape, violent throbbing of the carotids, great heat in the head, G-lonoin 3, in the same dose and form, is recommended by this author. Apis is particularly recommended when symptoms of cerebral depression prevail; Glonoin, on the contrary, for symptoms of cerebral exaltation. Veratrum viride is one of the most powerful remedies for cerebral hyperaemia. It is extensively used by American physicians for this condition, both in private and hospital practice. The symptoms Hyperaemia of the Brain and its Membranes. 65 which call for Veratrum viride are almost the same as those that indicate Belladonna: fulness and heaviness of the head, violent headache, heat and throbbing in the head, violent throbbing of the carotids, sensitiveness to sound and light, flushed countenance, heavi- ness, and a tingling or prickling sensation in the lower limbs, and the preliminary symptoms of apoplexy generally. Regarding the dose, it is the general experience of our physicians that a compara- tively large dose, say a few drops of the strongest tincture, in half a tumbler of water, is necessary to develop its therapeutic effects. Gelsemnium Sempervirens, or the Yellow' Jessamine, is appropriate in hyperemia during dentition. In hypenemia from sunstroke, applications of ice to the head, and frictions with ice along the spine and extremities, are indispensable to reawaken the paralyzed reaction of the organism, after which Aconite, Gelseminum or Belladonna may have to be given. II.] Among the other remedies the following deserve particular attention: Agaricus, Baryta, Ignatia, Rhus tox., Staphysagria and Veratrura. Regarding the general conduct of such patients, we shall offer but few remarks, since the diet is easily agreed upon. The local application of cold of course affords momentary relief to the patient, but if the cold is applied too energetically and persistently, it may prove hurtful rather than useful; the case is the same in this re- spect as with the general or local sanguineous depletions. If the application of cold affords great relief to the patient, he may apply for a short time cold-water compresses which, however, should never be left too long, and should be renewed quite frequently. If the patient is not confined to his bed, derivation by the application of warmth to the feet should never be attempt el. Foot-baths are de- cidedly out of place. As a matter of course, the stomach should not be overcrow'ded -with food, for the reason that even in the normal condition of the organism, the digestive process is attended with a certain degree of congestion. On this account it is highly im- portant that, where there is a tendency to congestion, a horizontal position or sleeping immediately after a meal should be strictly avoided. Anaemia of tlie Brain. In treating of this affection we shall pursue the same course as in hypersemia of the brain, and, without discussing the admissibility of the hypothesis of a diminished flow of blood to the brain, we shall take this for granted as a fact. In most cases cerebral anaemia 66 Diseases of the Brain. is not such a separate affection as to require a separate chapter. This, however, may find its excuse in the great importance that attaches to it in consequence of the ease with which it is confounded with other affections, and of the dangerous consequences based upon a correspondingly erroneous treatment. Cerebral anaemia either consists in a diminished volume of blood in the brain, or in a supply of blood to the brain destitute of red globules. In the former case it is caused by constriction or com- pression of the arteries through which the blood courses toward the brain, and by any other circumstances in consequence of which the space within the skull is narrowed; in the second case all the causes of anaemia come into play, whereas the deficiency of blood consequent upon sanguineous losses will have to be counted in both categories, since it is not only the quantitative decrease of the volume of blood, but likewise, and perhaps still more, the qualita- tive alteration of the blood that determines the anaemia. And finally there is no doubt that circumstances with which we are not yet perfectly acquainted, probably changes of a spasmodic nature, may induce a sudden decrease of the volume of blood in the brain, a lesser degree of which we may very frequently observe in con- sequence of powerful mental excitement. The symptoms of cerebral anaemia differ a good deal according as it develops itself more or less rapidly. In the former case we have the most perfect image of syncope: consciousness, the sensus communis, voluntary muscular movements are suspended, most generally amid slight convulsions, and both the breathing and the pulse are slower. This condition is most prominently seen during metrorrhagia in confinement. Evidently such accidents are attended with great danger to life.-If the anaemia sets in more slowly, the sinking of the cerebral activity is always preceded by symptoms of stimulation which are almost always similar to the phenomena of. hyperemia. Here as well as in hyperaemia we have violent head- ache, great irritability of the organs of sense, buzzing in the ears, obscuration of sight, vertigo, and it is only from the course and the etiology of these phenomena that we obtain light regarding their probable cause. At a subsequent and more or less remote period symptoms of paralysis supervene. Such conditions are most readily misapprehended in the case of children, where they often set in in consequence of exhausting diarrhoea. They are likewise very apt to deceive when they occur in the further course of morbid pro- cesses involving a rapid loss of animal fluids, in which case they Anaemia of the Brain. 67 are but too easily mistaken for an entirely new and more recent affection of the brain. It is characteristic of most cases of anaemia that the symptoms either abate or disappear in the horizontal posi- tion, and that the inhibition of food or stimulating substances causes an improvement.-That syncope is generally determined by a suddenly arising anaemia of the brain, and not, as is generally supposed, by a semi-paralysis of the heart, results even from the great resemblance of syncope to anaemic phenomena, and is more- over confirmed by the fact that the same remedies are applicable in either case. The course and duration of this disorder depend of course upon the determining pathological processes, upon which the prognosis likewise depends. What is certain is that the appearance of pheno- mena of cerebral anaemia is always a very bad symptom, especially in the case of children. 7reatment. Inasmuch as in subsequent chapters we shall have to revert more than once to cerebral anaemia, and more particularly in the general chapter on Anaemia where this subject is more specially treated of, we should have to indulge in useless repetitions, if we would furnish particular descriptions of every variety and modification of cerebral anaemia. For this reason we refer the reader to that chapter, contenting ourselves in this place with men- tioning the most prominent remedies for anaemia of the brain when manifesting itself as an independent, and more particularly in the form of an acute disease. Ammonium carbonicum. Notwithstanding its decisive action upon the brain, this remedy has not yet been employed to any very great extent in affections of this organ, more particularly for the reason that its cerebral symptoms have been falsely interpreted. These symptoms resemble in a very high degree those of hypersemia, whereas a comparison of all the phenomena shows most emphat- ically that they characterize a condition of anaemia. As far as we know, no special accessory indications have as yet been enumer- ated for this agent which, at all events, is deserving of special consideration. Camphora. This medicine shows a great contrast between exalta- tion and depression of the cerebral functions, the last-named con- dition being the most permanent symptom. Even a superficial view of the pathogenesis of this drug must satisfy everybody that it is remarkably suitable for anaemia. The effect of Camphor setting in and passing away again very rapidly, we shall have to .depend upon 68 Diseases of the Brain. it more commonly in cases where anaemia takes the form of syncope, more particularly when consequent upon sanguineous losses. An essential condition for its employment is that the organic reaction should not yet he extinct; on the contrary, that it should still be very active. It being known that the action of this medicine is of short duration, the doses should be given in rapid succession. Ipecacuanha, as a cerebral remedy, is particularly suitable for children and after rapid losses of animal fluids, if symptoms of con- vulsion are present, together with more or less complete coma. In haemorrhages it is likewise recommended by a number of practi- tioners ; hence such accidents would not counter-indicate the use of this agent. Secale cornutum deserves particular notice in the metrorrhagia of parturient females, and the resulting anaemic phenomena; here it acts in a twofold direction, against the haemorrhage itself and, as is shown by a comparison of its physiological effects, against the symptoms emanating from the brain and the spinal marrow; upon both these organs it acts in a very marked manner. Cuprum is only suitable in cases where the whole process is de- veloped gradually, and is more especially characterized by spasmodic phenomena. It would hardly be applicable in cases of genuine anaemia; in general, excessive losses of animal fluids do not come within its range. Other remedies deserving special consideration in this disorder are: Arsenicum, Calcarea carbonica, Colchicum, Digitalis, Tartarus emeticus, Veratrum, Zincum, Silicea. Some of these remedies have been mentioned as suitable for hyperaemia, a circumstance that may seem singular. This is in the first place partly owing to the fact that the pathogenesis of such drugs is not sufficiently distinct, and, in the second place, to this other fact that the same drug may mani- fest its action in two opposite directions, like Arsenic for instance, which not only occasions extraordinary symptoms of reaction, but likewise a complete prostration of all vital energies. In both these directions Arsenic can be used with great effect, which is likewise true of other medicines the successful application of which, in a variety of different pathological processes, shows that the whole series of pathogenetic phenomena, even the so-called phenomena of alternation, may serve as guides in selecting a remedy. In simple syncope medicinal interference will scarcely ever have to be resorted to, except where its frequent recurrence is owing to the existence of some other affection against which the treatment will have to be Anaemia of the Brain, 69 directed in such a case. A perfectly horizontal position is the simplest remedy against syncope, by which the attack is always considerably shortened; at the same time this may serve as evidence that the abnormal distribution of the blood is most generally the cause of syncope. This is the most appropriate place to speak of a condition which is of importance to a practitioner for the reason that it is exceedingly troublesome and sometimes obstinate: it is vertigo. It is not our intention to give a list of the different kinds of vertigo and the numerous causes from which it may arise; we will confine ourselves to the vertigo about which old people so frequently com- plain, and which most generally seems such an isolated symptom that it is difficult to decide what causes occasion it. Under all cir- cumstances it is a certain fact that it only emanates from the brain; but whether it is caused by hyperaemia or anaemia, is often as diffi- cult to decide as it is on the other hand essential to do so, since such a decision exerts a most important influence upon the selection of the most efficient remedial agent. In order to arrive at such a decision, the most trifling symptoms are to be observed with the utmost care, and the circumstances under which the vertigo makes its appearance are to be considered with the most scrupulous atten- tion. This course will show that the trouble arises from cerebral amemia much more frequently than from hyperaemia. In such a case the former results from a defective condition of the cerebral arteries, in consequence of which the supply of blood is impeded, and the cerebral parenchyma is deprived of its proper nourishment, owing to which it may even become atrophied. This explains that anaemia may cause attacks of cerebral congestion, since atrophy of one portion of the brain deprives the other portion of the power to offer a normal resistance to the afflux of the blood. W e will here mention a few of the distinctive diagnostic signs. The hyperaemic vertigo is seldom present early in the morning, is made worse by eating a little more than usual, particularly after the use of such stimulants as wine, coffee, etc.; it abates by persevering exercise, patients have to sit in a half-recumbent position; mental labor and excitement aggravate the vertigo, open air diminishes it, and it is generally accompanied by a slight headache. Anaemic vertigo, on the contrary, generally makes its appearance in the morning, is caused, or at any rate increased by exercise, particularly in the open air, is improved by the use of food and stimulants and likewise by exciting mental labor, and very soon disappears in a quiet recumbent 70 Diseases of the Brain. position; it is very seldom attended with headache, nor need the patient exhibit any pallor of countenance. The remedies for hyper- semic vertigo are generally the same as those that have been men- tioned for cerebral hyperaemia. At the head of the list we have Belladonna, which alone will remove it in most cases, beside which we have Arnica, Nux vomica and Lachesis. For anaemic vertigo the best remedies are: Silicea, Baryta carbonica, Graphites;-Lycopo- dium, Ambra and Fluoris acidum likewise deserve our attention.-• After what we have stated it is self-evident that a suitable diet is a matter of course. In hyperaemic vertigo all overloading of the stomach and the use of stimulating substances have to be strictly forbidden, and habitual exercise has to be enjoined ; while in anaemic vertigo a nourishing diet, the use of moderate quantities of wine, and mental and bodily rest are indispensable.-The fear of an apo- plectic attack which is fully justified during the presence of hyper- aemic vertigo, could only lead to false measures during the presence of anaemic vertigo, the employment of which would entail so much more injury as the apprehensive solicitude of the patient, which is already very troublesome, would be uselessly increased by such a proceeding. [Aconite is suitable for hyperaemic vertigo, with nausea; the patients have sallow, dark complexions, or are plethoric indi- viduals with flushed faces. Digitalis is excellent in vertigo, with slow, intermittent and irregular pulse. IL] We apply this name to a condition of the brain where, in conse- quence of some cause or other, an extravasation of blood takes place from the cerebral vessels into the substance of the brain. That such an extravasation can only take place from the arteries or capillaries, will not be doubted by any one who takes the laws of the circula- tory process into consideration. The influences occasioning the apo- plectic extravasation must always be of such a nature as to bring about an overpowering impulse of the sanguineous current over the resistance of the walls of the arteries, since it is only in this manner that the rupture of the blood-vessel is possible. In this respect we have to consider four points of view.-The structure of the blood- vessel may have become altered in consequence of its walls having lost their elasticity and having become brittle by the atheromatous process. In the next place the cerebral substance surrounding the vessel may have become altered in its consistence, so that the Cerebral Apoplexy. Cerebral Apoplexy. 71 counter-pressure exerted by the brain may have become diminished or partially suspended, and resistance against the current of the blood is exclusively confined to the walls of the blood-vessel. This condition of things takes place in softening of the brain, and in apo- plectic effusions undergoing the process of resorption. An entirely analogous condition exists in the atrophy of the brain peculiar to persons of an advanced age, and may constitute as frequent a cause of apoplexy as the atheromatous process. A third cause is the inherent weakness of the walls of the vessels that cannot be reco<r- nized by any peculiar diagnostic signs, and in consequence of which the vessel is lacerated' by the violent impulse of the sanguineous current. Finally as a fourth cause may be viewed an alteration in the blood itself, this fluid becoming so thin that its principal constit- uents penetrate the walls of the vessels. This arrangement is most distinctly noticed in purpura where the petechue form upon the skin without any laceration of the vessels. Even if this last-men- tioned form of extravasation does not constitute apoplexy in the rigorous acceptation of the term, yet, for the sake of analogy, this seemed the most suitable place to mention it. The extravasation at times takes place from one, at other times from several, at times from smaller, at other times from larger vessels, is more or less considerable, and sets in with more or less suddenness. The quantity of effused blood generally, but not always, corresponds to the size of the blood-vessel. In accordance with these circumstances we distinguish two kinds of apoplectic effusion. The first kind is capillary apoplexy where the blood is effused from the finest vessels. In this form the apoplectic centres are generally present in larger number, are very small like ecchy- moses, and scattered over a large surface. If they are so closely crowded together that they seem to constitute a single apoplectic locality, they form an apoplectic focus. The second kind of apo- plexy is termed the apoplectic insultus, where a considerable quantity of blood is effused into the cerebral parenchyma from one or more larger vessels. The larger the vessel which pours out the blood, the more rapid the haemorrhage, which is checked in proportion as the brain is capable of resisting the effusion of the blood. More blood is poured out where the brain is atrophied, or its volume had become lessened by contracting cicatrices remaining after former apoplexies; whereas, with a normal size of the cerebral mass, the flow of blood is arrested much more speedily. The haemorrhage may likewise take place by fits and starts, so that a large coagulurn 72 Diseases of the Brain. may be gradually formed by the blood discharged from a vessel of proportionally small size. The changes which the cerebral mass undergoes in consequence of the extravasated blood, do not differ in degree merely. If the apoplectic coagulum is small, the fibres of the brain may retain their normal structure, and are only pressed asunder by the blood; in such a case a complete restoration of the af- fected portion of the brain may be considered certain as soon as the coagulum has been absorbed. But the more considerable and the more sudden the apoplectic attack, the more the affected portion of the brain becomes more or less completely disorganized, so that the cere- bral fibres project into the coagulum as so many shapeless shreds or are mixed up with it in the form of a shapeless pap, (so-called red softening of the brain.) Such apoplectic coagula are surrounded by a more or less extensive infiltration of blood and ichor. If death does not take place immediately or very soon after the apoplectic effusion, the effused fluid undergoes certain definite changes. Either - and this is of more frequent occurrence -the blood is gradually absorbed except its solid constituents, the apoplectic coagulum be- comes smaller and finally forms only a cicatrix of a yellowish or brownish tint, several of which are often seen in the same individual in different stages of development. Or else the portion of brain surrounding the effused blood reacts so powerfully that it becomes inflamed, and the exudation proceeding from it coniines the blood as within a capsule. In such a case, likewise, a gradual metamor- phosis of the blood takes place, leading to the formation of a cyst filled with a clear serous liquid. As a third possible result which is of the least frequent occurrence, it may happen that the irritating action of the extravasated blood develops an inflammation which, instead of leading to the formation of a cyst, causes suppuration, in which case all such causative influences come into play as will here- after be mentioned when we co ne to treat of encephalitis. Death either takes place in consequence of the pressure exerted by the extravasated blood upon the brain, or, even if the pressure is pro- portionally slight, in consequence of paralysis of such portions of the brain as are absolutely necessary to the preservation of the vital functions. Although apoplexy may take place in any portion of the larger as well as the smaller brain, yet it occurs most frequently in the large brain, and here again more particularly on the confines between the white and gray substance. As causes of cerebral apoplexy we may regard, in a general sense, the same as those that have been mentioned under cerebral hyper- Cerebral Apoplexy. 73 semi a; in addition to which another very frequent cause is the change caused in the texture of the cerebral vessels by the atherom- atous process. From the circumstance that apoplexy is not of sufficient occurrence to justify the belief in epidemic apoplexy, we are authorized to draw the conclusion that atmospheric influences favor such accidents; however, it is not, by any means, certain what kind of atmospheric impressions are favorable to apoplexy, although we are pretty well satisfied that a low range of the barom- eter is a marked indication of the presence of such influences. Hence it has been observed that most apoplexies take place about the time of the equinoxes. Since cerebral haemorrhages may take place in every age, no age can be regarded as exempt from such dangers, though small children are very seldom attacked. It occurs most frequently in persons beyond the age of fifty, and its occur- rence becomes more frequent in proportion as they advance in years beyond this period. This is naturally owing to the above-mentioned changes in the vessels of the brain, and in the cerebral mass itself. We have purposely devoted more space to the pathological por- tion of this section than the object of this work required. We have done this for the purpose of opposing Hartmann's own peculiar views, (vol. II., page 311, &c.) In accordance with the formerly pre- vailing views about apoplexy, he adopts four kinds of this disease, apoplexia sanguinea, nervosa, serosa, and gastrica, starting at times from the cause and, at other times, from the effect as a principle of classification, whereas the pathological process in the brain is, after all, the same.-That nervous apoplexy is possible, may be admitted, though not in Hartmann's sense, but we need not care from what cause it arises,-(it is said to have been observed to take place in consequence of crushing mental emotions;)-since, on account of the suddenness of the fatal result, it can never become an object of cure. The other divisions are equally valueless in a therapeutic point of view, especially when the treatment is conducted in ac- cordance with homoeopathic principles, since under this treatment the determination of the pathological process in the brain implies an examination of all the exciting and co-operating circumstances with a view of selecting the proper remedy. If we would enumer- ate corresponding categories, they would be almost endless. The symptoms by which an attack of apoplexy manifests itself differ a good deal. In many cases the attack is preceded by well- marked precursory symptoms of various kinds, very much like the symptoms denoting cerebral hyperamiia. Very frequently abnormal 74 Diseases of the Brain. precursory symptoms are entirely absent, unless we mean to regard, as such, symptoms that are peculiar to the age of the affected per- son. If the haemorrhage sets in suddenly, the activity of the brain is suddenly paralyzed, the patient falls down without uttering a sound, is unconscious, insensible, partially or totally paralyzed, so that stool and urine pass off involuntarily; the breathing is ster- torous, slow, the expirations are characterized by the blowing move- ments of the mouth; the pulse is at times full, hard, and slow, at times so feeble that it can scarcely be felt; the pupils are at times dilated, at others contracted, sometimes quite normal, the eyes are staring and glassy; speech is suspended, and one corner of the mouth is drawn down paralyzed. Not unfrequently there is vomit- ing; the face may neither be flushed nor hotter than usual.-If the extravasation is proceeding slowly, the patients first complain of headache, or even only of a disagreeable sensation in the head, they feel languid and indisposed to any thing, they sometimes have to vomit. They are not yet deprived of the power of motion. Soon, however, according as the extravasation is more or less extensive, symptoms of paralysis set in, with which all the above-described symptoms may become associated. How long it may take before the attack is complete, has been shown me even a short time ago. It was the case of a man who experienced the first symptoms early in the morning; about noon he called at my office, after having walked .a long distance. One arm was already semi-paralyzed, and it was late in the night when the whole of one side became para- lyzed.-If the quantity of effused blood is small, the symptoms often consist only in paralysis of one side of the body, especially of the tongue or of one arm; or the brain is deprived of the faculty of performing a certain function of the mind, so that the patient has to stutter or is unable to find single words or his memory is lost. These changes often happen to old people who often retire in the evening in good health, and wake in the morning partially paralyzed. If the patient was not struck with death at the outset, the attack runs a very slow course, such as must necessarily be expected con- sidering the nature of the pathological process. Small effusions are re-absorbed without leaving any perceptible derangements, and the symptoms of paralysis which they had superinduced often disap- pear again with surprising rapidity. If the effusion of blood is con- siderable, the paralysis can only disappear partially, for the reason that the destruction of the fibres of the brain causes an unavoid- Cerebral Apoplexy. 75 ably incurable paralysis; months may elapse before the cure reaches its highest point. As a general rule, it is at the commencement that the progress in the improvement is most distinct, and con- tinues so, as long as those portions of the brain which surround the coagfulum, continue to divest themselves of their infiltration. which takes place in a proportionally rapid manner. At the commencement of the attack, it is very difficult to give a satisfactory prognos's. Although it is true, as a general rule, that the danger to life is greater in proportion as the paralysis ex- tends, beside involving the mental functions, over a larger portion of the body, and that it is greatest if the respiratory and circulatory organs are involved in the paralysis, yet it not unfrequent ly hap- pens that patients who seem to have been struck beyond all chances of recovery, recover their consciousness and a proportional restora- tion of the bodily functions, whereas other cases of much more favorable appearance terminate fatally. If the patients live through the first twenty-four or forty-eight hours without any increase of the symptoms, their restoration may be expected so much more certainly. Frequent recurrences of an apoplectic attack render the prognosis of each following attack more dubious; patients who have been attacked once, have constantly to be on their guard against a recurrence of the attack. Treatment. Before giving a more circumstantial account of the remedies that may be advantageously employed in apoplexy, it behooves us in the first place to answer the question what effect we expect of the remedies prescribed and what expectations we may entertain of their curative action.-Apoplexy of itself is no disease in the same sense as the idea of disease is generally conceived; it is only the last link, at least in the larger number of cases, of a chain of pathological alterations that are made manifest by the prelimin- ary stage. It is only in a very small number of cases that these preliminary symptoms come within the range of professional ob- servation, for the reason that they generally seem unimportant, often last only a short time, and still more frequently are of such a nature that even the physician is unable to recognize them with positive certainty as the precursory symptoms of apoplexy. Most generally the physician is sent for when the apoplectic effusion is in full tide of progress or has even reached its limits. In the former case we have to determine whether the causes of the attack are still in operation, with a view of meeting them and arresting the continuance of the haemorrhage. In the second case our inquiries 76 Diseases of the Brain. have to be confined to what remedies will bring about the absorp- tion of the extravasated blood in order to free the brain from this pressure. It is of the utmost importance that this result should be reached as soon as possible, inasmuch as the probability that the disabled parts of the brain will again resume their functional activ- ity, depends in a great measure upon the speed with which their deliverance from the abnormal pressure is accomplished; if this should take place too slowly, we have to apprehend atrophy of these parts, and the number of the paralyzed parts remains much larger than if the extravasated blood had been reabsorbed more speedily. This is one of those cases where the existing symptoms are not sufficient to determine the proper remedial agent, but where the internal process with whose nature we are acquainted from analogous cases, must necessarily serve as our guide. For this reason it is perfectly useless to undertake to cure paralysis of years' standing, that had remained after apoplexy; such paralysis is, and will always remain incurable, since we cannot well expect to re- place material tissues that are lost, by internal treatnient. Although discussions about the results of other methods of treat- ment are not within the province of this work, yet we cannot re- frain from offering a few words of comment upon the favorite remedy in apoplexy, local or general sanguineous depletion. Al- though in latter years important authorities among our therapeutic opponents have pronounced against blood-letting in apoplexy, yet this expedient is still so generally resorted to by physicians and so devoutly worshipped by laymen that genuine courage is required to criticize. And yet it can be shown a priori that its effect can only be injurious; in no case its employment has as yet resulted in an undeniable cure, whereas, on the contrary, it is highly probable,- we have not the means of saying absolutely certain,-that deple- tion does not diminish the apoplectic extravasation and subsequently facilitates a more rapid resorption.-In one respect the effect of every sanguineous depletion is of short duration, since the impulse of the current of blood is depressed only for a few hours. Viewed from this point, blood-letting may seem an excellent remedy for an apoplectic effusion of blood. But in another respect the loss of blood causes a decrease of the solid constituents of the blood, with- out occasioning a corresponding decrease of the fluid constituents whose loss is repaired very rapidly. Hence the fluidity of the blood increases, and the blood not only exudes or extravasates much more easily, but it loses the faculty of coagulating and arresting the Cerebral Apoplexy. 77 haemorrhage by the formation of clots in proportion as more blood is drawn oft* by the artificial depletion. Even if the process of ex- travasation should still be going on, the usefulness of depletion is, to say the least, counter-balanced, if not outweighed, by the previ- ously mentioned disadvantages. If this were not so, why should not sanguineous depletions have been resorted to for the purpose of arresting other haemorrhages, from the uterus, for instance; in a case of this kind the ancient theory of blood-letting might either easily be confirmed or else demonstrated as mischievous and absurd. Even if in some or even many cases the patient experience a mo- mentary relief, a short suspension of the haemorrhagic process, this apparently favorable result is abundantly neutralized by the usually considerable reaction succeeding the brief period of rest. The same thing takes place here as in pneumonia, where the depletion, gener- ally speaking, is likewise followed by an abatement of the symp- toms, which is very soon succeeded by a so much more considerable aggravation. Resorting to such evanescent expedients implies not only a deception of one's own judgment, but likewise a disappoint- ment of the poor patient's expectations. But, we will ask in con- clusion, docs not blood-letting favor the resorption of the extra- vasated blood? To effect resorption a certain amount of vascular activity is undoubtedly required. That resorption is not favored by a loss of animal fluids; that it is efleeted most rapidly in the normal condition of the organism ; that it becomes slower and more insufficient in proportion as the patient is more enfeebled : is noticed in so many cases more immediately accessible to observation, that we may conclude with certainty the action of the brain is similarly affected. Under all circumstances the whole body is weakened by a loss of blood which depresses vascular activity and acts in opposi- tion to the very conditions upon which a rapid resorption depends.- The reasons we have mentioned seem to us sufficient to reject a resort to sanguineous depletion in every case of apoplexy. Even if we were willing to concede to blood-letting in this affection an ap- pearance of usefulness or even of active aid, after all it would only be against the hypersemia that accompanies and as it were occasions the apoplectic attack. Where the apoplexy is an accomplished fact, blood-letting seems to us like a crime. All the previously men- tioned reasons derive a higher significance from the circumstance that the individuals who are struck with apoplexy are generally very far advanced in years, in whom the functional equilibrium, if once disturbed, is restored much more slowly than in young people. 78 Diseases of the Brain. We have already stated that the preliminary stage generally presents the symptoms of a more or less violent cerebral hyperagmia, on which account we may content ourselves with referring for the treatment of this stage to our statements concerning the treatment of hyperagmia. The other functional derangements with which the preliminary symptoms may be complicated, present such a great variety that it is impossible to furnish even an approximative enumeration of all imaginable cases; in such cases which rank un- doubtedly among the more serious, the study of the Materia Medica itself can alone come to our aid. The remedies mentioned under hyperagmia have such an extensive range of action that it is only in rare cases that one of them will not be found available; in order to be convinced of this fact, all that we shall have to do, will be to institute a careful comparison of the special symptoms. If, in the following paragraph, we repeat some of the remedies that have been mentioned for hyperemia, it is because in every case of apo- plexy it may still be necessary to first act against the hyperaemia that may continue to exist; it is less important to aim at a resorp- tion of the fluid that has already become effused than to prevent a further spread of the extravasation. Belladonna. There is scarcely one case of apoplexy where this remedy is not suitable and sometimes has a magic effect. What we have stated above regarding the constitutions that are a suitable sphere of action for Belladonna points to apoplexy. But inasmuch as the symptoms of hyperaemia are much more characteristic of Belladonna than the subsequent symptoms of apoplexy, it will be found more particularly indicated in cases where the apoplectic effusion is still attended with violent symptoms of congestion. Belladonna is more particularly indicated by the following syipp- toms: red and injected conjunctiva; sparkling, glistening eyes; greatly dilated pupils; diplopia; excessive restlessness of the ex- tremities ; great anxiety; illusions of the senses. It is not likely that this remedy will have any direct influence over the extra- vasated blood itself, and will therefore have to be given within the first twelve hours of the attack. But inasmuch as, according to our previous remarks, the extravasated blood may, according to circumstances, excite a powerful inflammatory reaction, Belladonna will, although rarely, come into play even in the further course of the attack. In this last-named condition it competes with Aconite, which we do not think possesses any special power in hyperaemia or apoplexy, but which is in its place, and preferable to Cerebral Apoplexy. 79 Belladonna, if a process of exudative inflammation should have to be overcome. This alone shows that it is only in a few cases of apo- plexy that Aconite will be found indicated. Of Coffea, Hartmann says that it deserves especial notice in cases of apoplexy that have been caused in very sensitive individuals by a variety of violent emotions. According to this author the effect of Coffea is evanescent and only palliative. This remedy is partic- ularly suitable in cases characterized by extreme irritability of the organs of sense and of the nervous system generally, sad and whin- ing mood, sleeplessness on account of excessive mental and bodily excitement, frequent flashes of heat in the face, anxiety and a head- ache as if the brain had been bruised, or vertigo, with a sensation of heaviness in the head, excessive sensitiveness of hearing on the days preceding the attack. Opium is undoubtedly a remedy of particular importance in most cases of apoplexy. We do not think that the characteristic indi- cations for this remedy in apoplexy can be given with more precision than by copying the essential parts of Hartmann's own statement: " Opium corresponds to all those forms of apoplexy whose symp- toms resemble those that we notice in drunkards. This drug is of great use were it for no other reason than because in apoplexy the vital force is so much depressed that even the most appropriate remedies do not excite any organic reaction and hence remain with- out any effect whatever. Opium possesses the important and peculiar faculty of supplying this deficiency of reactive power in very many cases and rousing; the vital forces from their lethargic condition. In order to attain this object a single small dose is often sufficient; sometimes more than one dose is required. Since Opium has a limited sphere of action and seems to exert a beneficial influence only in cases of recent origin, it is evident that its exhibition in apoplexy must not be delayed too long if we expect to derive benefit from its employment. The following symptoms are in every case characteristic indications for its use: Comatose sopor, with stertorous and rattling breathing, and depression of the lower jaw; impossi- bility to rouse the patient; or he can at most only be roused enough to cause him to gaze around unconsciously without answering a single question; the face is flushed, bluish-red, bloated ; the patient moans, groans, moves his lips continually as if he were talking; the pulse is large and slow, the breathing oppressed and anxious; the face is covered with a profuse and cold sweat; the head feels 80 Diseases of the Brain. heavy; if the patient attempts to raise it, it immediately sinks back upon the pillow ; the temporal arteries pulsate strongly and visibly." In real apoplexy Hyoscyamus may not often be found suitable; Hartmann mentions as a characteristic sig-n of this drug-: suddenness of the attack, the patient falls down at once with a violent cry, fol- lowed by convulsive motions, and rattling and snoring. The patient looks wild and livid. Laurocerasus. Without contradiction no poisonous agent, in its physiological as well as toxical effects, exhibits so much similarity to apoplexy as this one. In the lesser grades of poisoning with Laurocerasus a very marked hyperaemia of the brain is one of the most constant phenomena; in the higher grades this hyperaemia in- creases until paralysis results from it. A post-mortem examination almost always shows a copious extravasation of blood in the cra- nium. There is scarcely a more characteristic image of apoplexy to be found anywhere. Neverthele s, our literature does not furnish any evidence that this drug is used much in apoplexy, certainly much less frequently than it ought to be. Special characteristic indications are nowhere to be found. In Hartmann's recommen- dation that the drug should be used if the attack sets in suddenly, without any precursory symptoms, and the patient is struck down suddenly as if dead, there is scarcely any thing characteristic to be seen; moreover such cases are very rare, nor do we see why the signs of cerebral congestion that necessarily precede the extinction of nervous activity, should be entirely overlooked in such cases. The effects of Prussic acid, on the contrary, give us the image of a peculiar form of apoplexy ; we subjoin a description of these effects for the reason that this knowledge will facilitate a determination of the cases where this remedy will prove suitable. As soon as the poison is swallowed the individual experiences a sensation of ex- cessive and unconquerable muscular debility, vertigo, stupefaction, inability to stand. The pupils become dilated, the visual power is extinct, the patient is seized with violent anguish and palpitation of the heart. The skin becomes cold, moist, insensible, the pulse can scarcely be felt. At this stage convulsions frequently set in, the more readily, it would seem, the smaller the quantity of the poison that had been swallowed; these convulsions affect more particularly the muscles of the face or represent peculiar rotatory movements of the trunk; trismus is almost always present, in some rare cases opisthotonos. Very frequently, however, all convulsive symptoms are absent, and the poisoned individual is struck down as by the Cerebral Apoplexy. 81 hand of death a few seconds after the poison had been swallowed, and without uttering a cry. This concise picture contains a few symptoms that are undoubtedly calculated to determine the choice of this agent; they are the following: palpitations of the heart while the pulse is almost imperceptible; a cold and moist skin, trismus, convulsions of the facial muscles. Coma consequent upon poisoning with Prussic acid has this peculiarity that it completely resembles a deep, very quiet sleep. By these symptoms it would seem we might easily decide where this drug is suitable or not in a case of apoplexy. Nux vomica. If we include this drug in the list of remedies for apoplexy, it is not because we place much reliance upon it in this affection, but in order to satisfy the numerous recommendations of other practitioners. Except the paralytic depression of the lower jaw, no symptom is indicated that would justify the selection of this agent. Its being suitable to wine-bibbers and coffee-drinkers is probably mere theory. Considering the totality of its toxicological effects they do not point to apoplexy, but, on the contrary, to simple hypersemia. The following drugs are likewise worthy of mention in this place: Ipecacuanha, Cocculus, Veratrum and Phosphorus. For a chronic disposition to apoplexy, with danger of a frequent recur- rence of the attack, Kafka likewise recommends Glonoin. We shall now turn to the remedies that have to be employed against the apoplectic effusion in order to effect or rather accelerate its resorption, or to oppose the excessive reaction of the organism. Many who are as yet unacquainted with the practical results of Homoeopathy, will scarcely be willing to admit, on account of all sorts of theoretical reasons, that the resorption of the extravasated blood can be affected at all by such small doses of internal remedies. We shall not attempt to refute their theoretical arguments by other theories, but we claim the full right to refer to our practical results. It is true that in apoplexy these results can scarcely ever be pre- sented as incontrovertible facts, since opponents can fall back upon the expedient of attributing all such cures to the healing powers of Nature. But if in other cases of exudation, the existence of which can be demonstrated by physical investigation, the effused fluid has been re-absorbed under the influence of small doses of internally administered medicines, we have a right to conclude from analogy that, in a case of apoplectic extravasation, the internal employment 82 Diseases of the Brain. of medicines is not only founded in reason, but must likewise lead to successful results. Among all the medicines belonging to this category, Arnica oc cupies the first rank. Even in the Old-School Materia Medica it is recommended as an excellent remedy for apoplexy. To a homoeo- pathic physician its physiological effects reveal its important action upon the brain, since these effects contain all the signs of violent congestion ; moreover we are justified in concluding from what we witness of the action of Arnica in injuries complicated with external sanguineous extravasations, that this agent possesses an extraordi- nary power of determining the re-absorption of the extravasated blood. It is most suitable for individuals not too far advanced in age, with a full habit and vigorous frame, and it is rather im- portant, if we wish to secure a favorable result from this drug, that its employment should not be delayed beyond the period when the process of extravasation in the brain may be considered terminated. The presence of slight febrile reaction constitutes an additional in- dication for Arnica in persons of that descri; tion. As a matter of course no immediate improvement can be expected after its employ- ment, hence it will be well to continue its use for some time before other remedies are resorted to. Sulphur comes into play in apoplexy where the action of Arnica terminates. This statement defines very exactly the relative posi- tion of Sulphur in the list of remedies for such an accident. Hence It is applicable in the subsequent stages of the apoplectic effusion. Its employment in apoplexy is sufficiently justified by its extraordi- nary effects in other depositions of long standing. The remedies that compete with Sulphur, and are of special importance in cases where, from reasons that we are unable to account for, this agent remains without effect, are Silicea and Baryta carbonica. The latter is particularly suitable for old people. Hartmann relates a brilliant instance where Baryta caused a great improvement in the organs of speech. lodium is not indicated in simple, uncomplicated apoplexy; at any rate it yields the palm to the other remedies that have already been mentioned. If the reaction becomes so marked that it has to be regarded as depending upon an inflammation of those parts of the brain that surround the extravasated coagulum, Sulphur comes into play. We shall revert to this subject when speaking of meningitis to which we refer. These remarks likewise apply to Mercurius. None of the remedies that we have named are capable of healing Cerebral Apoplexy. 83 an apoplectic attack where a good deal of blood has become extra- vasated and a portion of the brain is destroyed, so that the func- tions of the brain will be completely restored. Isolated symptoms of paralysis will remain, the removal of which we may pronounce a very questionable task, but which, especially in cases of some- what recent standing, we ought not to give up without trying all proper means of effecting a cure. In many cases we have often suc- ceeded, contrary to our expectations, in removing such derange- ments either totally or at least partially. The medicines upon which we shall have to depend in such cases have not so much any immediate connection with apoplexy as with the subsequently remaining paralysis. Causticum here occupies very properly the first rank. Although this drug has been regarded with suspicion, especially in former times, and although many homoeopaths continue to regard its action as questionable and problematical when judged from a purely theor- etical stand-point, yet its practical results are so surprising that this fact alone compels us to believe in its efficiency. In cases of par- alysis belonging to this range, Causticum, even after every other drug has been tried in vain, will still show good results which, it is true, are often enough confined only to a very slight improve- ment. It is most suitable in paralysis of the extremities, especially when complicated with muscular contraction; it is less suitable in paralysis of the organs of the head, such as the tongue, pharynx, eyelids. Among the derangements of the mental functions it is an inability to select the proper words, for which this remedy may be prescribed. Zincum is particularly indicated in cases where the senses remain disturbed after the attack; complete paralysis does not come within the therapeutic range of this drug; it is even doubtful whether any thing can be done for the hemiplegia when manifested by con- stant involuntary movements. Cuprum. Everybody knows how constantly paralysis is present in poisoning with copper. It has this peculiarity that the motor power is extinct and the paralyzed part grows thinner, while the nerves of sensation preserve their normal functional power. Copper does not affect the functions of the senses in the least, the mental functions remain undisturbed; total or partial paralysis of the tongue, on the other hand, occurs very frequently, and shows itself by a stuttering or deficient speech. In accordance with these in- dications it will be found easy to determine the cases where copper 84 Diseases of the Brain. is indicated. We may add that violent, almost unyielding contrac- tions or chorea-like paroxysms and automatic movements constitute additional indications for the use of this a^ent. Plumbum is still more characteristic in its effects than the pre- viously mentioned drug. We believe that we can do no better than to give a connected list of the principal symptoms of lead-poisoning, by which means they will become much more comprehensible than by a perusal of their scattered record in our ordinary treatises on pathogenesis. We have obtained the symptoms from various cases of poisoning which are described with marked accuracy in some of our journals. We have: hypochondriac, peevish, indifferent, de- sponding, apathetic mood; the consciousness is blunted, dull, not wanting altogether ; loss of memory, complete absence of volition ; the speech is impeded and interrupted ; single syllables are omitted, or the patient is unable to combine syllables which he had spelt, into words; mimic spasms of the mouth and face when speaking; trembling of the tongue when it is put out; semiparalysis of the buccinator muscles and of the velum palatinum, which manifests itself by violent snoring ;-sleeplessness, fear of death ; the organs of the senses are torpid and insensible, the eyes are principally af- fected ; the eyelids droop as if paralyzed; the pupils are almost constantly and considerably dilated; all objects seem smaller and farther removed from the focus of vision; they may be seen as through a gauze; diplopia; the pulse is always slow, fifty to sixty in the minute ; sometimes it feels even hard and tense like a wire ; all the muscles may be pai alyzed; in partial paralysis the left side is more frequently attacked, a phenomenon that may be connected with the marked heart-symptoms caused by lead;-the paralysis affects equally the motor and the sentient nerves, is often attended with violent pains in the paralyzed parts, likewise with consider- able contractions of the paralyzed parts, especially of the extensor muscles which feel hard as wood; in other cases the spasms are tonic which, if they reach their full development, run into com- pletely epileptic convulsions. The muscles of the affected parts become atrophied. If the paralysis is not complete, the patient's gait is unsteady, with particular tendency to fall forward. Even the respiratory muscles seem to be susceptible to the poisoning action of lead, on which account such individuals are often attacked with a high degree of dyspnoea. The sphincters are scarcely ever paralyzed; if they should be, death is imminent. This description of the essential features of lead-poisoning not only shows very fully Cerebral Apoplexy. 85 and clearly where lead conies into play after an attack of apoplexy, but it likewise shows the characteristic differences between a poison- ing by lead and one by copper. Lead might suggest itself at the very outset of an apoplectic attack, if we merely look at the symp- toms without considering the mode and manner of their origin; this poison never acts instantaneously, or in every case with a certain degree of rapidity ; on the contrary, a long time intervenes between the commencement of the intoxication and the fatal termination, from which we infer that the medicinal action must likewise be very slow. This may likewise serve as a hint that the drug should not be discontinued too soon. If we deviate in this instance from our purpose to omit all re- marks concerning doses, and allow a suggestion bearing upon this point to slip in, we have to justify this exceptional proceeding by the importance of the subject. The last-named medicines act much better in paralysis when given in high than when given in low potencies. If one of them has not effected any thing in the lower preparations and still seems indicated by the symptoms, it should by all means be tried in the higher potencies and in less frequent repetitions before it is dismissed as not suitable. We have seen too many cases where good results were not obtained until this change was made, to justify our urgent advice. The following remedies may likewise be added to the present list: Argenturn, Graphites, Rhus toxicodendron, Anacardium. Regarding dietetic and other rules, it seems hardly necessary to offer any suggestions. We would warn, however, against the diet being too severely restricted in every case of apoplexy. Though this should undoubtedly be done in the case of well-fed or perhaps too well-fed individuals, yet apoplexy may likewise befal persons with impoverished constitutions; in their case it would certainly be wrong if we were to deprive the body of the diet which it requires in order to restore the normal equilibrium of its functions. As we have previously contended against sanguineous depletions, we here contend against applications of cold water or ice. In simple congestion these applications refresh the patient a good deal, and certainly do not do the least harm; but in a case of apoplexy we deem such applications both useless and hurtful, so much the more the older and feebler the affected individual, and the greater the difficulty of restoring the lost warmth. 86 Diseases of the Bram. Inflammatory Affections of the Brain and its Membranes. The phenomena of most of the inflammatory affections of the brain resemble each other so much in all their general character- istics that it is sometimes impossible to point out, during the life- time of the patient, the precise locality of the brain that is the seat of the affection. We may dispense with the almost useless trouble to specify the particular processes, so much more as it is of no part- icular use in practice. Viewed from this point we shall discuss only three kinds of the inflammatory processes as being distinguished from each other by essential characteristics: meningitis, a partial inflammation of the cerebral substance, and granular meningitis. 1. Meningitis. This species of inflammatory affection of the brain is by far the most frequent; it is seated in the pia mater, but most generally the arachnoid and even the brain become involved in the pathological process. Regarding its origin, it is scarcely ever a genuine primary, more frequently a secondary affection. In the former case the caus- ative circumstances which we have mentioned already as causes of cerebral hypersemia, are likewise applicable to meningitis, more especially the poisoning by alcohol and excessive mental exertions, nor ought we to omit mentioning sexual excesses as an exciting cause. Very often no opportunity is given for ascertaining the par- ticular causes of the inflammation. It may set in in the form of a secondary affection as a continuation and complication of other pathological processes within the cranium, for instance of inflam- matory affections of the ears, or it may constitute a continuation of a neighboring inflammation to the brain, as in erysipelas, or it may exist as a complication of the inflammation of other important organs, as in pneumonia, more particularly if the serous membranes of these organs are the seat of the inflammation, (pleuritis, pericar- ditis, etc.,) or finally it may set in suddenly as a most serious com- plication during the period of convalescence or, at any rate, during the decrease of some important disease of the general organism. This is most frequently observed during the course of acute exan- thems from whose sudden disappearance we are too easily disposed to derive the opinion that the inflammation has a metastatic origin, to which subject we shall refer more fully when treating of the exanthemata. We may likewise mention that in France an epi- Inflammatory Affections of the Brain and its Membranes. 87 demic meningitis lias been observed, the more immediate cause of which is still enveloped in obscurity. In almost all cases the seat of meningitis is the convex portion of the brain, scarcely ever the base, which, however, may become involved in the inflammatory process in a more or less intense de- gree. The pia mater is found injected in various degrees of intens- ity and extent, the arachnoid is covered with a layer of exsudation, and the subarachnoideal space is filled with an exuded substance, most generally of the consistence of jelly. If the brain is involved in the inflammation, the cortical Substance is alone affected. In chronic meningitis the pia mater is found dim, thickened, adhering more or less firmly to the brain; the subarachnoideal space con- tains a small quantity of a badly colored exuded material. Stf ni ptoms mid Course.-The symptoms of incipient meningi- tis differ according as it sets in as a primary or secondary affection. In the former case the disease often commences like other inflam- mations of important organs, with a violent chill, which is very speedily succeeded by a great increase of temperature, or the attack may be preceded by a precursory stage where, beside a gen- eral feeling of sickness, disturbed appearance of the countenance and violent headache, no other local symptoms are yet present. As soon as the disease has reached its full development, the most striking symptom is an unusual increase of the temperature and an equally unusual frequency of the pulse, as high as 160 beats in the minute. The headache increases to an almost intolerable degree of intensity, the organs of the senses are extremely sensitive to exter- nal stimuli, the eyes more particularly are sensitive to the light, touching the skin even causes pain. The face shows a peculiar ex- pression of anxiety and tension, the look is restless and confused, the conjunctiva is strikingly injected. Sleep is restless, disturbed by frightful dreams from which the patients are frequently roused with a loud cry; or else the patients are completely deprived of all sleep, and during the few moments of slumber they may sink into, the observer is struck by a constant motion of their hands. There is consciousness, but it is confuse, and the patients are apt to give uncertain, tardy answers. If there is sleeplessness, delirium of a light character often sets in during the waking state of the patient. Respiration is very irregular, at times strikingly hurried, at other times unusually calm. At this stage the pupils are generally con- tracted. Vomiting is not unfrequent. In this condition, which has few characteristic symptoms peculiar to it and sometimes seems so 88 Diseases of the Brain. little threatening that no apprehension is felt regarding a change for the worse in the next stage of the disease, the patients continue sometimes one, and at times even eight days, when all at once the more dangerous symptoms break out, usually attended with short- lasting convulsions, a prominent feature of which is a contraction of the cervical muscles. The delirium now becomes more continu- ous, at times furibond, at others more muttering, consciousness disappears more and more, the patient's look becomes staring and fixed. Paroxysms of clonic as well as tonic spasms set in. In pro- portion as the other threatening'symptoms increase, the pulse does not increase in frequency, on the contrary it becomes slower, some- times irregular and intermittent, the cutaneous temperature be- comes unequal, hands and feet are often icy-cold while the rest of the body feels burning-hot. The patient sometimes falls very sud- denly into a deep sopor from which he wakes only for a few brief moments half-conscious or delirious; the features sink as if col- lapsed. The headache evidently still continues, the patients grasp at their heads, which now begin to feel cold whereas their bodies continue hot. At this stage the pulse almost always becomes slower, either resuming its normal frequency or sinking even below it; the irregularity of the respiration likewise becomes a very prominent symptom. Symptoms of paralysis sometimes make their appearance, occasionally with rigid contraction of single bundles of muscles; whereas the bowels are obstinately confined, the urine passes off involuntarily. While these threatening symptoms develop them- selves, an apparent improvement sometimes takes place which is, however, deceptive. Death ensues during the sopor, sometimes after a previous acceleration of the pulse and the respiration, scarcely ever beyond the third week. If the disease runs a favor- able course, the improvement commences with a deep sleep during which the pulse and the respiration have to improve if this sleep is to be regarded as a favorable prognostic. In such a case the patient wakes restored to consciousness which, however, is not entirely free; in general, recovery from this disease takes place very gradu- ally. The diagnosis of this disease is not, by any means, absolutely reliable. In the first stages it is easily confounded with simple hyperemia or acute anaemia. This, however, would only be of im- portance in regard to anaemia, whereas in hyperaemia the treatment is pretty nearly the same as in the first stages of meningitis. It is much more important, however, if meningitis is confounded with typhus. That such a mistake can be easily made and for a long Inflammatory Affections of the Brain and its Membranes. 89 time, has been shown us by the case of our own child, which the many physicians who saw it, diagnosed as meningitis, whereas the true character of the affection was only revealed during the period of convalescence, when everybody who had nursed the child had a more or less violent attack of abdominal typhus. The only symp- tom which induced us to adhere to our opinion that the child had typhus was a diarrhoea that lasted a fortnight. Whatever favor- able an opinion we may entertain of a purely symptomatic treat- ment, we certainly shall have to investigate the real origin of the symptoms, since it cannot be regarded with indifference whether we treat a case of typhus or meningitis even if the symptoms should be ever so similar. Of the other affections that may be confounded with meningitis, we mention uraemia and an acute attack of tuber- culosis. It is likewise difficult to establish a sure diagnosis in cases where meningitis sets in from the start as a complication of inflam- mations of important organs, such as the lungs, pleura or pericar- dium. In such a case the inflammation of the brain is very readily overlooked in consequence of the absorbing interest excited by the inflammation of the other organs. As a secondary affection the disease sets in very gradually ; the patient at most complains of headache, after which the symptoms of exudation break out quite suddenly, the patient becoming dull, indifferent, the features collapse, a light delirium sets in, the ex- tremities become less movable, the pulse decreases in frequency. Death ensues amid a continual increase of the sopor and the para- lytic phenomena. The prognosis in this affection is always very dubious, generally very unfavorable, the more so the more marked and extensive are the symptoms of paralysis. Nevertheless we know that, under homoeopathic treatment, a cure is still possible in every stage of the disease; whereas physicians of other Schools declare that, in the stage of exudation, recovery is so little possible that, where it is supposed to have been accomplished, it is almost certain that some other affection had been mistaken for meningitis. Statistical evi- dence in meningitis and diseases of the brain generally, is very little reliable, since an absolutely certain diagnosis can only be estab- lished in very few or fatal cases. In homoeopathic statistics a number of cases would undoubtedly be impugned as incorrect: is this not done by our opponents even in regard to cases whose diag- nosis has become a thing of absolute certainty to every educated physician ? On the other hand it cannot be denied that in our 90 Diseases of the Brain. literature many cases are described as meningitis which, in reality, are simple hypersemia of the brain; all we have to do, in order to be satisfied on this score, is to compare Ruckert's short extracts, (Klinische Erfahrungen, vol. I., page 105, etc.) If all these cases had been cases of incipient meningitis, it would imply that we pos- sess much more efficient remedies for meningitis than we do for other inflammations whose diagnosis we are able to watch and establish at every step with perfect certainty. Why do we scarcely ever hear of pneumonia cut short ? Is it more difficult to cut such an inflammation short ? It is undoubtedly proper to treat all such lucky and successful cures to a good dose of scepticism. Treatment. Belladonna is one of the medicines that is most frequently resorted to at the commencement of a supposed meningitis. In Ruckert's above-mentioned work, loco cit., we find the reports of a number of strikingly successful and rapid cures which excite in our minds most particular doubts. An attentive comparison will show that in those cases only the remedy acted in a marked manner where a sure diagnosis was not yet possible, whereas in inflammations that had progressed to a higher degree, the improvement was either slower or else was not at all due to the sole action of Belladonna. A number of reasons prompt us to believe that Belladonna is no remedy for meningitis, or, at any rate, that we possess better remedies for this disease. This opinion is confirmed by the results of post- mortem examinations incases of poisoning with Belladonna, where we indeed find a high degree of hypereemia, but never a trace of exudation; it is likewise a known fact that the lighter cases of poisoning with Belladonna, having no fatal termination, recover in a proportionally short period of time in spite of the severest cere- bral symptoms. Nevertheless, in spite of all opposing arguments, the symptoms of incipient meningitis will first and foremost point to Belladonna, and almost any one who is familiarly acquainted with the Materia Medica, will first exhibit this remedy without laying particular stress on a precise diagnosis. That the Belladonna enables us to establish such a diagnosis, may be asserted without fear of contradiction. This medicine exerts so positively a curative in- fluence upon hyperemia when simulating meningitis, that, where it does not cure, it at least causes an improvement within at most twenty-four hours with so much certainty, that to most cases we may apply the rule: where, in apparently inflammatory conditions of the brain, Belladonna is not succeeded by, at least, a striking Inflammatory Affections of the Brain and its Membranes. 91 improvement, within twenty-four hours, no hypersemia is present; in such a case it should be discontinued, and some other remedy should be given in its stead. Another symptom which counter- indicates Belladonna to some extent, is an extraordinary frequency of the pulse, which is very seldom present in hyperaemia of the brain. Aconitum. At the commencement of meningitis this remedy is almost as important a remedy as Belladonna at the commencement of hyperaemia. It is almost always suitable to the previously ex- pressed conditions, where Belladonna seemed indicated, but had no curative effect, namely in the initial stage of meningitis; if menin- gitis can be arrested in its course by any one remedy, it is by Aconite. Corresponding as it does to the whole process of the in- flammation, the improvement caused by Aconite cannot be as rapid and complete as the improvement caused by Belladonna in hyper- semia. This remedy is in its place as long as no symptoms of exu- dation have macle their appearance. As soon as the pulse becomes slower and the intensity of the general symptoms increases; as soon as the first symptoms of paralysis set in, Aconite is no longer in- dicated. Opium. In so far as this drug is recommended as a remedy for meningitis, we have to apply to it the remarks which we have offered in a previous paragraph concerning Belladonna. At a later stage of the disease, when sopor sets in, it frequently acts very favorably against this condition, and, when given as an intercurrent remedy, it paves the way for other medicines, as has been observed more fully when speaking of apoplexy. Rhus toxicodendron. In simple primary meningitis a case will never occur where this medicine is indicated ; on the other hand it may prove indispensable in erysipelas of the face which sometimes develops itself as a secondary disease in the course of meningitis, if this disease assumes a typhoid character and is attended with un- usually violent symptoms. In such cases Apis may have to be con- sidered. However, our clinical experience with this agent is as yet insufficient to enable us to furnish more particular indications for its use. Arnica. Meningitis is more frequently than is generally believed a consequence of slight injuries or mechanical concussion of the head. Arnica not only meets this general indication in most cases most fully, but the symptoms of the drug represent most perfectly the image of meningitis, both in the congestive and exudative 92 Diseases of the Brain. stage. The absence of all signs of reaction contra-indicates this agent most decidedly. [Concussion of the brain may result from a very slight me chanical injury, and the symptoms of meningitis caused by the in- jury may not develop themselves until two or three weeks after the accident had happened. A lady standing by the mantel-piece, dropped a match. She stooped to pick it up, and on raising her head rather suddenly, she knocked it against the sharp edge of the mantel-piece. Concussion ensued which developed meningitis four weeks after the accident occurred. The case terminated fatally in the hands of the late dis- tinguished Valentine Mott. A boy of twelve years while running after his sister, stumbled against the mantel-piece. Concussion of the brain took place which resulted in meningitis about a fortnight after the occurrence of the accident. It was a bad case, but the patient recovered in a fort- night in my hands. H.] Bryonia. The pathogenesis of Bryonia embodies a characteristic image of meningitis. Moreover we know from practical experience that Bryonia is a capital remedy in all serous inflammations, hence also in meningitis. As a general rule the selection of this drug is determined by the period when Aconite ceases to be indicated ; in other words, when symptoms of incipient exudation are beginning to set in. At a later stage of the disease, its favorable action be- comes doubtful, more particularly when all symptoms of reaction which constitute essential indications for the use of this drug have become effaced by paralysis of the affected organ. The most im- portant indications are: a livid, flushed face, a high temperature of the body together with readily breaking out, copious sweats, nausea, with desire to vomit, and obstinate constipation, with dis- tention of the abdomen; scanty and painful secretion of urine. Helleborus niger is one of the most important remedies if the meningeal exudation may be considered as having reached its climax. Although we do not altogether agree with Wahle's sanguine recommendation who promises good results from the use of this drug even in a few hours; on the other hand, if success is still possible, no other medicine is more likely to achieve it than Helleborus niger. The proper period for its application has arrived if reaction has almost entirely ceased and the symptoms of paral- ysis are more or less completely developed. Sulphur has been exhibited with success in many cases. Its em- Inflammatory Affections of the Brain and its Membranes. 93 ployment is governed by general considerations of analogy rather than by its physiological action upon the tissues. It will only be found appropriate as a means of assisting the delaying resorption of the exuded fluid, hence in the stage of paralysis after it has continued for a time without any perceptible change. As a matter of course no certain result ought to be expected in the presence of such an unfavorable prognosis; but the important and practically ascer- tained action of Sulphur upon the absorbent system in other organs (we mention more especially pneumonia and peritonitis) furnishes sufficiently adequate reasons for its employment in the exudative stage of meningitis. Of the other remedies that belong to this category, we mention as particularly noteworthy: Hyoscyamus, Stramonium, Digitalis, lodium, Mercurius, Tartarus stibiatus, Zincum. In the order in which these remedies have been mentioned they will very generally be found to constitute the successive series in which their use may be required in the management of a case. [In the place of lodium, Kafka recommends the Iodide of Potas- sium as better adapted to effect the resorption of the exuded fluid, and to ameliorate the constitutional diathesis. If Belladonna does not effect a speedy improvement, he generally recommends the Sulphate of Atropine 3 to be given in solution, a spoonful every hour or two hours. II.] As regards the management of such patients in other respects, we must not omit to notice several important points. With refer- ence to sanguineous depletions we refer the reader to what we have stated in this respect in our remarks concerning apoplexy; we have to condemn them likewise as hurtful and therefore useless in the management of meningitis. The effect of cold applications to the head is at all events very uncertain; with some patients they dis- agree very decidedly. If such applications are to be resorted to at all, it has to be done with a good deal of discretion. In the stage of exudation when the vital activity of the organism is depressed to a dangerously low degree, it is certainly a hazardous proceeding to continue the application of external cold. At the commencement of the disease when the fever is high, the patients refuse of them- selves every thing except fresh water. Abundant draughts of this beverage should be given the patient during the whole course of the disease. If the vital turgescence is lowered, we need not fear to administer milk and water, and beef-broth ; these things are even imperatively necessary. It is likewise proper and pleasant to the 94 Diseases of the Brain. patient that the action of the skin should be stimulated by fre- quently and cautiously used cold ablutions followed by friction of the moistened surface. During convalescence the utmost caution has to be used in eating and drinking as well as in regard to mental labor. In the case of children it is well to converse with them as little as possible, (a precaution which is unfortunately too often neglected;) to keep all objects and persons that might excite the patients, away from them. Adults had better be kept strictly isolated. 2. Encephalitis. Cerebritis. Inflammation of the substance of the brain never extends over the whole brain, but is always confined, to single localities. It occurs proportionally very rarely. It may occur in every age, but is most frequently met with in persons of middle age. It is not always possible to determine its causes with absolute certainty; the most frequent causes are: mechanical injuries, (which often seem trifling,) the irritation caused by extravasated fluid, tumors, dis- eases of the skull-bones, (especially of the mastoid process,) morbid conditions, with decomposition of the blood. The inflammation may be located anywhere in the brain, but it occurs chiefly along the boundary between the white and gray substance. Encephalitis commences with exudation between the fibres of the brain, some- times confined to a very small space and at other times extending over a space of the size of a hen's egg. Owing to the peculiar structure of the brain, an exudation of this kind results in softening and disorganization of its fibres; red softening of the brain sets in, which afterwards, through resorption, assumes a more yellow color. Or else, in consequence of influences which it is difficult to account for, the exuded fluid changes to pus and an abscess forms in the brain. Such an abscess may have various terminations: it may be- come circumscribed and a gradual resorption may take place, or it may penetrate into the ventricles or work up to the surface of the brain, thus causing meningitis and speedy death. The abscess generally results from an injury, but need not necessarily correspond to the locality of the injury. Lastly encephalitis may terminate in the formation of a cyst in consequence of the definitely circum- scribed localization of the inflammatory process. The destruction of the walls of the vessels permeating the inflamed portion of the brain may likewise readily lead to apoplectic extravasations. Symptoms, The phenomena of encephalitis are remarkably Inflammatory Affections of the Brain and its Membranes. 95 vague and uncertain. There are numerous cases where the first symptom of the disease indicates a meningitis breaking out suddenly and running a rapid course; or where death takes place quite suddenly in consequence of effusion into the ventricles, or apoplectic extravasation. In such cases the inflammation is not necessarily confined to a limited space, but may be quite extensive, showing in a most striking manner that large portions of the brain may become disorganized without its functions being correspond- ingly or even to any considerable extent impaired. But even in cases where encephalitis sets in with a whole series of symptoms, they are not sufficiently definite at the first outbreak of the disease to enable us to establish a positive diagnosis upon such an uncertain foundation. All we can do is to conjecture with more or less cer- tainty the character of the disease from the few circumstances that may be positively known to us. In such cases the phenomena of a gradually, never tumultuously increasing pressure on the brain be- come manifest, such as : headache generally violent and continued, and attended with vertigo; disposition to fainting fits ; deep dis- turbance of the emotive sphere; heaviness in the limbs and an un- steady gait without any decided symptoms of paralysis; sensitive- ness of the organs of sense; wandering pains in the extremities. These symptoms are very speedily followed by more general symp- toms of depression, the organs of sense become duller, the extremi- ties lose their sensibility, the paralysis of the motor system of nerves becomes more apparent. The mental functions are almost always impaired, and from the very commencement of the disease exhibit characteristic signs of depression: the j atients are apa- thetic, drowsy, think slowly, the memory is weaker, the speech is interfered with, and is either heavy or is no longer serviceable as a means of distinct utterance. In the further course of the disease it often happens that the patient is troubled with vomiting, syncope, epileptiform convulsions; the pupils become dilated, the pul e and the respiration become slower; according as one or the other portion of the brain is affected, paralytic conditions of very limited extent may supervene. If the disease runs a slow course, with occasional momentary periods of distinctly perceptible ameliorations, the morbid process may continue for months before the increasing paral- ysis or the supervention of other affections terminates the patient's sufferings. Complete recovery can only take p'ace in the first period of the disease; a partial recovery takes place when consequent upon the formation of a cyst or the localization of the abscess within a 96 Diseases of the Brain. definite capsule, the phenomena of paralysis depending upon the disorgmized portion of the brain, of course remaining unchanged. In a number of cases the symptoms of paralysis are so little per- ceptible that the cure may be considered complete and that the evidence of a previously existing inflammation can only be traced to the cicatrix which a subsequent post-mortem examination of the brain may reveal. As has already been stated, in many cases it is impossible, and in other cases difficult to diagnose encephalitis ; hence it may not be unp ofitable to enumerate some of ihe leading diagnostic signs of this disease. T.ie gradual development of the symptoms of pressure on the brain precludes the idea of apoplexy as well as of meningitis-, except perhaps chronic meningitis, from which, however, encephalitis is distinguished by the presence of striking symptoms of partial paralytic conditions. Tumors in the brain are the least easy to diagnose, which likewise are very fre- quently attended by symptoms of a gradually increasing compres- sion of that organ. The uncertainties attending a case of this kind are more or less cleared up by the fact that the paralytic symptoms of encephalitis are character.zed by more or less marked remissions which are entirely absent in the case of tumors. The prognosis is doubtful in every case, the chances being de- cidedly rather against the patient than in his favor. If the patient recovers, the recovery is generally only partial. The position of the physician in such cases become < still more complicated by the cir- cumstance that the malady runs such an extraordinarily protracted course. Treatment. We cannot unfortunately point to any cases of encephalitis in our literature calculated to shed light on the treat- ment of this disease. Hence we have to confine ourselves to a few cases in our own practice all of which terminated fatally; it is true they were intrusted to our care only after the disease had been pro- gressing for some time towards its final termination. As a rule the patients should be kept free from all violent excitement; such signs of congestion as may manifest themselves have to be counteracted at once by appropriate remedies. The diet has to be regulated with as much strictness as possible. The most suitable remedies for this affection almost all belong to the category of inorganic medicines. It is only at the beginning of the disease, more particularly if it can be traced to external injuries as their primary cause, that Arnica is the most appropriate remedy. Other remedies which, however, we mention, without any further particular indications for the reason Inflammatory Affections of the Brain and its Membranes. 97 that their useful effect in this disease is very questionable, are: Mercurius^ lodium, Cuprum., Sulphur, Zincum, and more especially Plumbum. lodium has obtained some reputation in chronic affec- tions of the brain even in the hands of our therapeutic opponents who, on the other hand, very frequently furnish us material for toxicological observations. I have been treating for years a young man who had been afflicted with constitutional syphilis. After having been treated both internally and externally with a quantity of mercurial preparations, his physicians decided to subject him to a rigid course of Iodine treatment. I was unable to ascertain how large a quantity of lodine-preparations he had used. Alter the treatment had lasted about a fortnight, he was attacked with vio- lent headache and some fever. Continuing the Iodine by direction of his physician, he lost in a few days almost suddenly all conscious- ness, and his left lower extremity became paralyzed. This case offers a striking picture of partial encephalitis. We may observe that in this case the paralysis still continues in the form of hemiplegia. We beg leave to refer to Plumbum among the remedies for apoplexy; to the indications we have furnished in that paragraph we here add the following post-mortem appearances: head and brain hypersemic; in the left hemisphere, at the base of the middle lobe, a prominence of the size of a hen's egg and of a yellowish color, is perceived, very soft to the feel and surrounded by dark-red places. An investiga- tion revealed within the swelling four smaller nuclei of a yellowish softening, separated from each other by normal cerebral substance that merged into the softening without any definite boundary. This abscess had formed in the space of several years in consequence of gradual poisoning. This is an appropriate place to mention a pathological process which is closely related to, or rather identical with, encephalitis: we allude to yellow softening of the brain properly speaking. Its origin is as yet enveloped m great obscurity. It generally occurs only in indi- viduals of an advanced age, and looks very much like the spon- taneous death of the cerebral substance; in rare cases it is met with in young subjects of a cachectic habit of body. It may exist in the brain as an isolated affection, or side by side with a distinct in- flammatory softening or apoplectic effusions, with which, however, it has no immediate connection. It is principally met with in the large brain. The phenomena which the yellow softening develops are almost identical with those of encephalitis. The curability of 98 Diseases of the Brain. this disease is very questionable; the remedies that may he em- ployed against it are the same that have been indicated in the pre- vious paragraph. [In encephalitis, when the symptoms of cerebral hyperaemia still predominate and the disorganizing metamorphosis is progressing, Kafka has been for some years in the habit of employing Glonoin 1 to 2, with the best success, giving children six to eight drops of the second attenuation in half a tumbler of water, of which solution they take a teaspoonful every two hours. To ad.ults he gives one or two drops of the first or second attenuation on sugar of milk two or three times a day. The effect is truly surprising; in twenty- four or forty-eight hours the turgescence, heat in the head and the engorgement of the vessels diminish much more promptly and safely than could be accomplished by means of sanguineous deple- tions, cold applications or the use of purgatives. This treatment secures moreover the incalculable advantage that the strength of the patient is spared in the fullest measure, and the disease is enabled to institute its retrograde metamorphosis without being arrested in its course. Kafka relates the following case, which we reproduce as worthy of note. A man, sixty-five years old, who had had an apoplectic attack two years previous, in consequence of which his left side remained paralyzed, was, at the time we undertook his treatment, in a condition of cerebral hyperaemia, so that his relatives appre- hended momentarily and very properly another apoplectic attack. Side by side with the symptoms of cerebral hyperaemia, (see this chapter,) those of cerebral softening, with progressive increase of the morbid phenomena, likewise co-existed. We prescribed Glonoin 1, two doses a day, with the most marked success; the congestive phenomena disappeared entirely. The patient being robust and corpulent, lodiurn 2 was exhibited in two daily doses. Until the end of March, 1865, the patient who had first come to us in Decem- ber, 1864, remained in a condition of tolerable ease and comfort; the hyperaemia of the brain did not return, and the speech, sensi- bility and motor-powers of the patient improved very strikingly. At that period a death took place in the family which made a deep impression upon the patient; the hyperaemia returned and was im- mediately followed by convulsions. They were of a clonic nature. While the face and the extremities were thus convulsed, the patient uttered a roaring cry. The consciousness remained unimpaired. Inflammatory Affections of the Brain and its Membranes. 99 When asked why he roared so horribly, he answered that the roar- ing was involuntary and that he could not help it. Our explanation of this phenomenon was that the roaring was a violent expulsion of air produced by a spasmodic contraction of the diaphragm or a sudden and spasmodic compression or contraction of the bronchia. For the convulsions with cerebral hyper tomia we prescribed Bella- donna 3, and, no improvement having taken place in forty-eight hours, Atropinum sulph. 3, likewise without any result. Looking into Dr. Clotar Mueller's Repertory, we found, page 18, art. " Clonic convulsions attended with cries," Arsenicum mentioned as a chief remedy verified by clinical experience. After giving a few doses of this drug, one every hour, the spasms as well as the cries ceased, nor have they so far occurred again, end of August, 1865. IL] 3. Tubercular (granular) inflammation of the meninges. Hydrocephalus acutus. This disease is one of the most important affections of the brain, partly on account of its relative frequency and partly on account of its extraordinary tendency to a fatal termination. It is only recently that a more correct discrimination between tubercular and simple meningitis has become possible, whereas formerly by tuber- cular meningitis was simply understood an inflammation of the brain attended with profuse exudation. The difference, however, is not merely founded in the granular character of the disease, but these two forms of meningitis differ even with regard to their local- ity, a difference that accounts very fully and satisfactorily for many distinctions in their symptomatic manifestations. Granular meningitis is more particularly located at the base of the brain; only in rare cases the convex portion of the brain be- comes involved. As in simple meningitis we find in the subarach- noideal space an exudation of a jellylike consistence; in the pia mater we see the millet-sized yellowish-white granulations which sometimes occur in simple miliary tuberculosis without exudation. The ventricles contain a more or less copious quantity of exuded serum, in consequence of which these cavities not only become very much distended, but the adjoining parts become softened to an extraordinary degree. It is this circumstance which has led to the designation of acute hydrocephalus. Granular meningitis is very rarely an entirely primary affection, but most generally constitutes a partial manifestation of a more general tubercular process, especially of pulmonary tuberculosis ; or 100 Diseases of the Brain. it is a sequel of previous affections, more particularly of measles, typhus and whooping-cough, after which diseases the tubercular inflammation at the base of the brain frequently develops itself as the first symptom of constitutional tuberculosis. It chiefly invades the infantile organism between the ages of two and ten years, very rarely older children or adults. It may be inferred from these remarks that perfectly healthy children are scarcely ever attacked by this disease as a primary malady, although the presence of tuber- cles may sometimes remain hidden until they are revealed by a post-mortem examination. Either the children exhibit at a previous period more or less prominent symptoms of a scrofulous taint; or they are delicate subjects, the offspring of tuberculous parents, stunted in their bodily development, but endowed with a good deal of mental quickness, and distinguished by a precocious intellect. This precocity is very apt to induce parents to stimulate the mental powers prematurely, and thus, by this continued stimulation of the brain, to hasten the outbreak of this malignant disease. As in sim- ple meningitis, so in this disease, external injuries, a fall, blow, etc., may, if the organism is otherwise endowed with the necessary con- stitutional predisposition, constitute the proximate causes of an actual manifestation of the malady; at any rate it will often be remarked that the change observed in the conduct of the patient prior to the outbreak of the disease dates from the time when some external force had exerted upon the skull only a slightly disturbing impression. Very frequently, however, all perceptible causes to which the disease might be attributed are wanting, and the out- break takes place with an unexpected suddenness. Symptoms. The disease scarcely ever begins without any mor- bid phenomena, in a manner that would justify one in conjecturing an affection of the brain at all with any thing like positive cer- tainty. For a longer or shorter period the outbreak of the disease is preceded by precursory symptoms which not unfrequently are so slight that they are often overlooked even by the nearest relatives who afterwards are reminded of them when the more violent symp- toms begin to develop themselves. However, inasmuch as it is necessary, for a timely correctness of the diagnosis, that the pre- liminary stage of the disease should be accurately known, the phy- sician should never content himself with a general denial of all morbid symptoms by the relatives, but should institute minute in- quiries into all the particular circumstances of the case. The chil- dren who have hitherto been of a bright and playful disposition, Inflammatory Affections of the Brain and its Membranes. 101 seem changed, avoid play, become taciturn and, contrary to their former habit, sit by themselves in some remote corner, their sleep is restless, and they are tormented by many anxious dreams. If their intelligence is sufficiently matured, they complain of headache at an early stage of the disease, although not all the time. There is no marked fever, the appetite vanishes, or, in rare cases, is occa- sionally very much increased, and an incipient loss of flesh cannot be overlooked. The complexion is not all at once altered, pallor of the countenance generally predominates. Even at this period an unsteadiness in the gait of children becomes noticeable; they incline to fall more readily than before, (which is regarded by the parents as accidental,) and are indisposed to walk any considerable distance. Very frequently the beginning of these phenomena dates from a fall or from some violent emotion. The patients sometimes remain in this condition for weeks without any more dangerous symptoms supervening. If we consider these symptoms as the preliminary stage, the real first stage of the disease most generally sets in with the first par- oxysms of vomiting. This does not occur as a consequence of indi- gestion, or in a quiet posture of the body, or soon after a meal, but particularly when rising from a recumbent position, walking about or while the children are carried round. During the attack the abdominal walls exhibit almost constantly a peculiar tension and depression. At this stage the headache greatly increases in inten- sity ; the higher organs of sense become abnormally sensitive, some- times to a high degree; slight convulsions set in, the patient starts frequently as if frightened, is very nervous and excited, the mind seems to dwell on one idea which the patient utters to himself repeatedly ; the sleep becomes restless, with frequent gritting of the teeth; the patient is tormented by frightful dreams from which he wakes with a piercing cry without being able to free himself at once from the disturbing phantasm. The pupils now are generally contracted, the pulse is accelerated or at times quicker, at other times slower ; other prominent febrile symptoms are wanting. The face is usually pallid, or else pallor and flushes suddenly alternate; the expression of the countenance is peculiarly altered, it is an expres- sion of suffering. The bowels are confined, the urine is scanty, satu- rated and generally turbid. The peculiar cry, however, the nature of which cannot possibly be misapprehended, is not by any means a characteristic symptom of tubercular meningitis, but is likewise peculiar to other affections of the brain. It may be heard, for in- 102 Diseases of the Brain. stance, in cases of simple hypenemia; and in the case of typhus, of which mention was made in our chapter on meningitis, this cry was as characteristic and occurred as frequently as it is possible to do in the most marked case of tubercular meningitis. It seems to be extorted from the patient by the paroxysmal exacerbations of the headache. Contractions o± the posterior cervical muscles which cause the peculiar boring with the head into the pillow, generally initiate the second stage and henceforth continue to the end. After the first stage has lasted for a few days, the second stage generally commences with convulsions of various degrees of inten- sity, at times partial, at other times general, and scarcely ever entirely wanting; these convulsions are followed immediately by symptoms of incipient paralysis. Consciousness vanishes more and more; the children no longer complain of pain, but grasp very fre- quently at the head, from which it is evident that they experience an intense pain in that region; they are generally restless, and the peculiar cry continues unabated. The vomiting ceases almost en- tirely in most cases. The eyes become completely insensible to in- tense light, and the little patients no longer hear even if spoken to in the loudest tone of voice. The pupils become dilated, generally unequally, and squinting sets in. On one side the extremities arc often rigidly contracted, while on the other side they are completely paralyzed. The pulse generally becomes slower than natural, and even falls below sixty beats; on the other hand, however, it often retains a frequency of one hundred and twenty beats, and even higher. It may likewise assume an intermittent character, but this is not a characteristic symptom. Respiration is always unequal, at times very feeble and inaudible, and then again a deep sighing moan is heard. The coma becomes more and more persistent, there is no longer a trace of lucid intervals ; the eyes either remain open or are only half closed, the upper lid being evidently paralyzed. Convul- sions continue to set in in paroxysms of more or less intensity, gen- erally on one side. The urine is discharged involuntarily, the bowels remain confined. This stage continues variously, sometimes only a few days, and at other times several weeks. We frequently observe during this stage striking remissions of single symptoms, which, however, have no favorable meaning; they may even take place with a certain typical regularity ; or a striking improvement in the condition of the patient may delude us for a time, for it will soon enough be superseded by a change for the worse. The last stage lasts seldom longer than forty-eight hours. It com- Inflammatory Affections of the Brain and its Membranes. 103 mences about the time when the pulse rises to an extraordinary number of beats, even one hundred and eighty and upwards ; at the same time the number of respirations increases considerably, where- as the temperature of the skin decreases and a profuse perspiration breaks out. The paralysis has now reached the highest degree; it is only now and then that the possibility of motion is made mani- fest by short paroxysms of convulsions. The remarkable changes in the pulse and respiration are evidently consequences of incipient paralysis of the vagus. The breathing becomes rattling, during which death relieves the patient. Recovery may take place in every stage of the disease; in the last stage, however, after the pulse has risen in frequency, the chances of recovery are undoubtedly very slim. It can scarcely be said that the patient ever recovers entirely, for the reason that the disease scarcely ever attacks perfectly sound individuals and is generally complicated with tubercular deposits in other organs. Health can therefore at most be restored only to what it was previous to the attack. Very frequently isolated symp- toms of paralysis remain, owing probably to the circumstance that the effused fluid in the ventricles is not completely re-absorbed. Even if the disease runs a course ever so favorable, it must be ex- pected to break out again sooner or later after it has once taken hold on the organism. The diagnosis of acute hydrocephalus is undoubtedly a ticklish point. Even from simple meningitis the tubercular form cannot always be readily distinguished, particularly in the first and even in the second stage. The affection is not by any means recognizable by absolutely characteristic symptoms, on which account great im- portance is to be attached to the preliminary stage, which scarcely ever has a longer duration in simple meningitis. As a matter of course a correctly discriminating diagnosis in these two forms of meningitis is of the utmost importance. The tubercular process in granular meningitis has to be managed very differently from simple inflammation of the meninges. As regards other affections of the brain, they will scarcely ever be confounded with tubercular men- ingitis. The possibility of this disease being confounded with typhus has already been alluded to in the chapter on simple meningitis. Under all circumstances the prognosis is involved in a great deal of uncertainty and doubt, so much more as it is very questionable whether, what was supposed to be a cure of tubercular meningitis in the first stage, was not rather a case of simple meningitis or even only of cerebral hypersemia. However, even though we should have 104 Diseases of the Brain. to eliminate a number of cases reported in our books as cases of tubercular meningitis, on account of their questionable character, a sufficient number of cases undoubtedly remain to substantiate the fact that this generally fatal disease can be cured with homoeopathic remedies. The sooner the suitable remedies arc employed against the disease, the better the prospect of effecting a cure; the more generally and completely the symptoms of paralysis have become manifest, the more questionable will be the final result. Where the pulse has risen to the above-mentioned frequency, recovery can scarcely be expected. Treatment. The management of this disease is without doubt one of the sorest trials to the feeling physician. If he succeeds in effecting a cure, he is haunted by the thought that he has been mistaken in his diagnosis ; if the patient dies, the fatal result simply tends to corroborate his bitter conviction that the disease is in its very nature an incurable malady. The distressing condition of the patient may continue for months without a ray of hope shining athwart the gloom of the sick-chamber; night and day the physi- cian's mind is filled with anxious thoughts concerning the little patient, all imaginable drugs have been tried, and yet the case runs onward towards a fatal termination. The painf ilness of the situation is increased by the circumstance that children who are attacked with tubercular meningitis have become an object of in- tense parental affection on account of their bright intellect and sensitive disposition. Assuredly this is a situation where the phy- sician has it in his power to show that he is such in the noblest acceptation of the term. Under these circumstances we cannot sufficiently guard against an untoward influence which is apt to creep in and complicate the case. The frequent visits both friendly and professional, which it may be necessary to make, but too frequently tempt the attending physician to change the medi- cine, a proceeding that entails more injury in this affection than perhaps in any other. Inasmuch as the nature of the morbid process renders it impossible for any remedy to effect a rapid and decided change in the symptoms, we should be loth to abandon a remedy if it does not effect a striking improvement in the first twelve or twenty-four hours. Such an improper change of medicine has not only the immediate but likewise the general disadvantage of depriv- ing us of the opportunity of acquiring certainty regarding the action of our drugs and that this lack of positive experience leaves us as ill-advised in all subsequent cases of this kind as in the former. Inflammatory Affections of the Brain and its Membranes. 105 We may likewise just as well observe at the outset that it will be found extremely difficult to select a remedial agent in all such cases in strict accordance with the symptoms, and that such a purely symptomatic selection would afford very little probability for a successful treatment. On the contrary, in selecting our remedy it is of paramount importance not only that the peculiar nature of the exudatioA and the pathologico-anatomical alterations should be kept in view, but that our selection should be made with special refer- ence to such pathological products ancLchanges. This is likewise conceded by Hartmann, who does not exactly favor this mode of selecting a remedy. Hence if, in the subsequent paragraphs, we leave medicines that had been recommended in other affections of the brain, unnoticed, it is simply because a more general mode of reasoning has satisfied us that they are out of place in this disease. Definite indications for the treatment of each special stage of this disease have likewise been deemed inappropriate by us, and we prefer considering each medicine separately in its relation to the general features of the disease. Bryonia alba. We have already made mention of this drug in speaking of simple meningitis, and we likewise enumerate it among the remedies for granular meningitis for the reason that we have witnessed the most striking effects from its use in other forms of the tubercular disease. It is in all respects adapted to the pre- liminary stage, more so perhaps than to the more fully developed disease. The precursory symptoms undoubtedly point .to the fact that the exudative process has already set in, and it is for this period that we have likewise recommended Bryonia in simple meningitis. In order to do justice to the symptoms we call to mind the resemblance of the preliminary stage to an incipient typhus where Bryonia is very frequently the only prominently in- dicated remedy. In our opinion the therapeutic efficacy of the drug is bounded by the first manifestation of the paralytic symptoms. Arnica montana. This drug shows likewise in every respect a striking correspondence with incipient granular meningitis, except that the characteristic disposition to vomit is not found in the pa- thogenesis of this agent. It is preferable to Bryonia in cases pri- marily originating in mechanical causes and where the febrile symptoms are more marked. Arnica, however, is not, as in simple meningitis, endowed with a specific influence over the tubercular exudation. 106 Diseases of the Brain. Veratrum album corresponds in every respect to the symptoms of the primary stage of this disease. Among the characteristic indica- tions we note more particularly: great inequality in the distribution of animal heat; vomiting and great increase of the cephalic distress when raising the head; proportionate ease in a recumbent posture; the least motion causes nausea and vomiting; considerable un- steadiness of the extremities; rigidity of the posterior cervical muscles ; disposition to convulsive movements ; peculiar alteration of the features and pallor of the countenance, or else flushes on one cheek only. This characteristic combination of symptoms will scarcely be met with as fully in the pathogenesis of any other drug. Our literature exhibits only a few cases confirmatory of the good effects of Veratrum album in this disease. Digitalis purpurea is likewise one of the most important remedies in acute hydrocephalus. This remedy is not so much indicated by its symptomatic similarity to the disease as by the circumstance that it develops the most characteristic symptoms of acute hydro- cephalus even in the same successive series as the disease itself. Hence this remedy will appear suitable in every stage of the dis- ease, from the precursory symptoms to the paralysis of the vagus. For a detailed statement of the gradually increasing action of Digi- talis in this disease, we refer to the Materia Medica, contenting our- selves in this place with furnishing a series of the most characteristic indications: mental depression, interrupted by short periods of ex- citement ; predominant sensation of coldness irrespective of the character of the pulse, with heat and pallor of the face; vomiting at every movement of the body; coma, with twitchings and con- vulsions ; the pupils arc either dilated or contracted; rapid emacia- tion, without any correspondingly profuse abnormal evacuations; increase of all the symptoms when abandoning the horizontal pos- ture ; semi-lateral twitchings, especially in the face; continued con- stipation and diminished secretion of urine. To these highly charac- teristic symptoms we have to add the character of the pulse. After small or even larger doses the pulse appears at first accelerated, small and feeble; after large doses, or after the drug has continued to act for some time, the pulse becomes abnormally slow, or, after the organism has been thoroughly impregnated with the action of the drug, the pulse becomes so rapid that it can scarcely be counted, and is moreover, if not intermittent, at least continually irregular. No other drug has this characteristic peculiarity of the pulse in granular meningitis as fully as Digitalis. As regards the tuber- Inflammatory Affections of the Brain and its Membranes. 107 cular diathesis generally, we know that Digitalis is extremely effi- cacious in scrofulous as well as in tubercular affections, and that it possesses a special affinity to the lymphatic system; and that its physiological effects likewise embody very fully the symptoms of pulmonary phthisis in the first and second stage of the disease. And lastly we must not omit to state that Digitalis is one of our best remedies for acute serous effusions to which this disease is indebted for its name of acute hydrocephalus ; whereas, on the contrary, its curative action in chronic dropsies still continues doubtful and ex- ceedingly uncertain. Zinc urn is recommended by Hartmann very urgently in the irri- tative stage, with the assertion that he has often seen a decided im- provement set in in twelve or twenty-four hours after its first employ- ment. We are perfectly certain that these cases where such a rapid improvement was noticed, were not cases of tubercular meningitis; on the other hand we do not doubt that Zincum may be adapted to the preliminary stages of the disease; of the symptoms which charac- terize any of its subsequent stages as prominent symptoms, only a few are found in the pathogenetic series of Zincum ; it is much more suitable in simple meningitis, although even in this disease we do not regard it as one of the leading remedies. lodium will scarcely ever be selected in this disease on account of its symptomatic similarity, although it has a few symptoms that might serve as starting-points in our selection of the drug. It is when judging by analogy, that the choice of this agent will appear much more justifiable. No one can doubt its extraordinary efficacy in scrofulous affections ; of its importance , as a remedy for phthisis we shall speak when treating of this disease. Coupling these gen- eral indications with the symptoms of the drug, we shall obtain sufficient reasons for its practical application. Cuprum is one of the most noteworthy remedies in granular meningitis. It will scarcely ever be indicated in the first stages of the disease, but will be found so much more applicable in the stage of decided exudation when convulsions have begun to set in. This is one of the few remedies that cause .great irregularity of the pulse which may likewise, like the pulse of Digitalis, fall considerably below the normal standard. This circumstance alone is calculated to direct our attention to this agent whose pathogenetic symptoms do not by any means contra-indicate its use. If one of the remedies we have named has effected an improve- ment, but if some of the functions of the brain continue to remain 108 Diseases of the Brain. disturbed, it is advisable to continue the drug that had effected the favorable change, in less frequent doses until the remaining symp- toms of the disease are removed or until the appearance of other new and striking symptoms renders a change of medicine impera- tive. Owing to the diversity of the symptoms that may manifest themselves, it is impossible to determine a priori what this new medicine may be. Among the remedies which, in addition to those above described, may still be required, we mention: Mercurius, Helleborus, Plumbum. Beside these, other medicines have been urged upon the Profession, probably without any adequate reason, since the cases where these medicines are recommended are not distinguished by very accurate diagnostic statements. At all events we would most likely fall back upon the following series of drugs: Pulsatilla, Belladonna, Aconi- tum, Straynonium, Hyoscyamus, Opium, Cina, Artemisia, Rhus toxico- dendron. As regards the last-named drug, it probably owes its recommendation by Hartmann and others to its successful employ- ment in typhus which, as we have stated before, is so easily con- founded with granular meningitis. So far as the dose is concerned, our best observers unite in affirming that frequently repeated doses of low attenuations are preferable in this disease. [In the place of lodium, Kafka often substitutes the Iodide of Potassium, especially if a constitutional tubercular diathesis lies at the foundation of the cerebral disease. Glonoin, Apis and Atropin are likewise recommended, for the particular indications of which we refer the reader to our chapter on simple meningitis. IL] It is scarcely necessary to allude to any dietetic rules during the management of. the disease, since the patients, in their almost un- interrupted state of unconsciousness, are scarcely able to swallow during the whole course of the disease. As long as deglutition is possible, it would of course be ill-advised to refuse the patients strengthening nourishment; on the contrary, it is of the utmost im- portance to sustain the struggling vitality by means of broth and milk diluted with water. Fresh water is the best beverage to quench the thirst which torments the patients, although they may not manifest it by any perceptible signs. External applications can- not be of any possible use in this affection, nor can they afford any relief. During convalescence the digestive process has to be nursed with the utmost care, and the physical and mental wants of the patient generally have to be attended to with unrelenting discre- tion, since we ought to be well aware that the fundamental cause Hydrocephalus. 109 of the trouble, the tubercular deposit, is still present, and, even if no relapse is caused by imprudences, will sooner or later break out again as an actual disease in some other organ. In the case of such individuals a dose of Calcarea carbonica or phosphorica given from time to time for a certain period of time, may accomplish a great deal of good. Above all things, mental exertions, excessive study, excitements of the fancy are strictly to be avoided; children who are often the most eager to learn, should be kept away from their books, if necessary by main force. Hydrocephalus, (stricte sic dictus.) In a general sense we understand by hydrocephalus every ab- normal accumulation of fluid in the cavity of the skull. It may either be acquired or congenital. Acquired hydrocephalus is always seated in the ventricles; it is seldom an idiopathic affection, but is generally symptomatic of some other constitutional affection. It becomes an important symptom when the disease sets in as chief complication of granular menin- gitis ; or when it develops itself so rapidly that it acts like apoplexy and speedily terminates fatally, (serous apoplexy.) The diagnosis of this disease is always very uncertain ; its symptoms are the same as those of granular meningitis. It scarcely ever necessitates a special treatment, nor is this feasible. If therapeutic means should have to be used, the remedies that have been mentioned for tuber- cular meningitis will have to be resorted to. Congenital hydrocephalus is likewise seated in the ventricles. It commences already before the child is born, but may increase after birth. The quantity of the accumulated serum may be very large, and hence the skull may acquire an extraordinary volume. Its effects upon the child are sometimes imperceptible, at other times very decided; the mental functions of the brain are mostly in- volved ; it is only in very fully developed cases that the motor system is affected, a more or less complete paralysis sei ting in. The life of the patient is not absolutely threatened; it may even be ad- mitted that hydrocephalic children who have got over the period of infancy, have pretty nearly escaped the most imminent danger of death. However, they always remain weakly, irritable and un- usually disposed to frequent and malignant diseases. Hydrocephalus is a curable disease, but such a cure is mostly spontaneous, taking place in proportion as the bodily development progresses. A cure may indeed be facilitated by artificial means, but not by medicines. 110 Diseases of the Spinal Marrow. A main point is to bring up such children with great care, to accustom them to light and nourishing food and to active exercise, and not to excite their mental faculties prematurely by a forced development. Among medicines we may select Calcarea carbonica and Arsenicum, but in small and rarely repeated doses. Bandaging the head with strips of adhesive plaster, which has been recom- mended by some pathologists, has seldom been of any use, but has very frequently been attended with the most dangerous conse- quences, either in consequence of the violent compression exerting a dangerous pressure upon the brain, or even in consequence of the activity of the vessels of the pericranium being materially inter- fered with. Judging by analogy, it is indeed not only possible but even probable that a cautious use of this method of treatment may be followed by favorable results. B. DISEASES OF THE SPINAL MARROW. The spinal marrow is essentially liable to all the morbid processes that occur in the brain, the structure of both these organs being essentially the same. All these processes may be found described, theoretically rather than practically, in pathological manuals, with- out it being possible to establish a proper diagnosis at the sick-bed and to initiate a treatment based upon it. For this reason we are not disposed to furnish a detailed description of the manifold patho- logical conditions of the spinal cord, and shall treat only of two of the best known and most important of them, inflammation of the spinal cord and spinal irritation. Most of the other conditions can be attached to the former as accessories. Inflammation of Ilie Spinal Cord and its Membranes. This disease is one of the rarer sort, but is very likely considered so because it is not always properly diagnosed and is often mistaken for another affection. The inflammation may be seated exclusively in the meninges, but if the spinal cord itself is inflamed, the accompanying meningitis is never wanting. The course of the dis- ease is either chronic or acute. The acute form extends mostly over a larger surface, depositing an exudation in the subarachnoideal space, and rarely invading the spinal marrow. The chronic form leads to thickening of the membranes and a more or less copious accumulation of serum in the vertebral canal. Inflammation of the Inflammation of the Spinal Cord and its Membranes. 111 substance of the cord leads very speedily, as in the case of the brain, to softening and disorganization of the fibres of the spinal marrow, likewise to the formation of an abscess ; it is generally not very extensive, but always results in an inflammatory affection of the meninges. If we may believe what is said regarding the causes of spinal meningitis, they are manifold. Among the most certain causes we enumerate: mechanical injuries, a shock, blow, fracture of the ver- tebrae ; affections of the vertebrae, especially spondylarthrocace; apoplectic extravasations; extension of inflammatory affections of the brain to the spinal cord. Less certain causes are: acute exan- thems ; suppression of haemorrhages; sexual excesses. In many eases, however, the inflammation seems to arise quite spontaneously. Symptoms. The symptoms of meningitis spinalis are almost the same as those of myelitis ; slight differences will be pointed out. In most cases the disease begins with a chill like all other inflam- mations of more important organs. The chill recurs quite frequently in paroxysms of shivering. At the same time the patient experi- ences a local pain at some spot in the vertebral column, which can be pointed out with definiteness; the pain is aggravated by press- ure, and is increased to a most violent and even intolerable degree of intensity by moving, and especially by rotating the spinal col- umn. These symptoms are attended with a not inconsiderable fever. As a general rule, the patient complains of pains at the very beginning of the attack; very often these pains constitute the first manifestation of the disease. Very soon the first symptoms of in- cipient paralysis supervene, consisting in the first place of painful contractions, or twitchings of the correspondingly involved bundles of muscles, or even of tetanic convulsions, after which the paralytic symptoms increase to paraplegia with more or less rapidity. A cer- tain degree of anaesthesia is scarcely ever wanting, commencing with a sensation of pithiness or numbness and gradually increasing in intensity. According as one or the other portion of the cord is inflamed, the symptoms exhibit considerable differences. If the superior portion of the cord is involved, as a matter of course the parts to which nerves are given off by the more deep-seated portion of the cord become paralyzed. Paralysis of the respiratory muscles is particularly inconvenient and dangerous, since an accident of this kind may speedily terminate fatally. If the lumbar portion is the seat of the disease, violent paroxysms of colic are experienced by the patient. The bladder and rectum are almost always more or 112 Diseases of the Spinal Marrow. less paralyzed. Very peculiar, although not of constant occurrence, are the convulsive shocks in the paralyzed parts, which bear a great resemblance to the reflex-movements consequent upon poisoning with Strychnine. In cases where the disease does not run a too rapid course, all these symptoms exhibit distinct remissions and exacerbations. If the cord is alone affected, the consciousness remains undisturbed; the patients are, however, unusually excited, and are cither deprived of all sleep or else their sleep is very restless. The disease may terminate fatally very speedily, especially when seated near the brain, but may likewise last weeks before the patient dies of exhaustion. Recovery from this disease is scarcely ever com- plete, especially if the substance of the marrow itself is involved, in which case various paralytic symptoms always remain behind. It may likewise pass into the chronic form. Before treating of this form, we will describe the symptoms by which meningitis is dis- tinguished from myelitis. In meningitis the pain spreads over a larger surface and is very much aggravated by motion, whereas in myelitis the locality of the pain is circumscribed within very nar- row limits, and the pain itself is essentially increased only by press- ure. In meningitis the fever is more violent. In myelitis paralysis sets in rapidly and totally, whereas in meningitis it develops itself gradually. As has been said, the chronic form may develop itself out of the acute. If it arises without any previous acute attack, the pains are less violent, and there are no febrile symptoms. These pains are scarcely ever as severe at the place where the inflammation is seated as in the corresponding parts of the periphery, especially in the lower extremities, and at the commencement of the disease resemble altogether rherfmatic pains. The paralysis sets in so slightly that it is scarcely perceived, and its increase is just as gradual. Here likewise as in the acute form, anesthesia is never altogether want- ing. As the disease progresses, the bladder becomes paralyzed. This accident, together with the gangrenous destruction of the dorsal integuments, most commonly results in a fatal termination. Chronic myelitis differs somewhat in its phenomena, especially if, as is generally the case, the meninges are not involved. The local pain as well as the pain at the periphery, is less violent, sometimes quite dull and undefined, only slightly aggravated by pressure and motion. The patient experiences a peculiar sensation as if his body were encased in a tight hoop round about. This pathological pro- cess is always accompanied by a higher or less degree of anesthesia. Inflammation of the Spinal CcrJ and its Membranes. 113 Convulsive twitchings need not necessarily be present. The paral- ysis of the motor sphere commences as a vague feeling of heaviness in the extremities, by which the process of walking is very much interfered with. The gait exhibits a peculiar unsteadiness. The patient raises his foot high from the ground, throws it far out, then sets it down as if it had the appearance of falling down, and sets it down a good deal farther back than he seemed disposed to do when first throwing the foot forward; sometimes the foot is set down outside the straight line. It is a peculiar feature of this disease that the patients are unable to walk with their eyes closed. Amid a gradually increasing waste of the tissues the patients die, as in chronic meningitis, of cystitis and gangrenous destruction of the dorsal integuments. Complete recovery is rare; all that can be accomplished in most cases is a partial improvement or even a mere arrest of the disease. In acute spinal meningitis the prognosis, so far as a fatal termina- tion is concerned, depends more particularly upon the seat of the affection; the nearer to the brain the paralytic phenomena make their appearance, the more rapidly the disease terminates fatally. Under any circumstances the physician has to be very guarded in his promises to effect a complete cure, since partial paralysis is apt to remain in most cases. A good deal is gained in many cases if we succeed in changing the acute to the chronic form of the disease. Simple meningitis justifies the hope of much more satisfactory results than myelitis. In the chronic form the prognosis is par- ticularly dubious after the disease has lasted for some time and the paralysis is complete. Treat nt ent. The proper selection of drugs in this disease is just as much involved in obscurity as the certain diagnosis of the patho- logical process itself. Our literature contains only a very small number of cases; in Ruckert's Collection we find only a single case of chronic myelitis. This paucity is certainly not owing to the small number of cases-or else the author of this work must have been very fortunate in not having had any more cases to treat- but rather to the circumstance that the therapeutic results have been very unfavorable, and that unsuccessful cases from which a good deal, however, might be learned, are but too seldom published to the world. This affords an additional inducement to lay before the reader a case that came under our observation in the course of last summer, and which, although the patient resided in a distant locality, took such a characteristic turn that there is no reasonable 8 114 Diseases of the Spinal Marrow ground left for misapprehension. A farmer, 60 years old, who had hitherto enjoyed the most robust health, was attacked with dysen- tery in the month of August. To make sure of the diagnosis, he had kept some shreds of mucous membrane which he had passed with the stool. He had taken some domestic remedy, after which the evacuations ceased and obstinate constipation took place. On the fourth day after the cessation of the discharges we first visited the patient, who, at first sight, did not seem to be suffering much. He complained of violent pains in the left lower extremity, which resembled ischias, extended from the tuber ischii to the knee, in- creased in paroxysms, and were made worse by the warmth of the bed. The patient was restless, had no sleep, the pulse was normal, there were no febrile symptoms. We gave him Coloeynthis. Two days after the exhibition of this drug the patient reported his pain and whole condition worse. This written report induced us to administer Belladonna. No improvement resulting, we visited the patient a second time five days after our first visit. The disease now presented a very different form. The patient was lying part- ially turned over on his left side. He felt the pains in both lower extremities, not very acutely except in paroxysms; there were twitchings of single muscles or of the whole extremity; violent, but sometimes remitting pains in the lumbar region, the lumbar vertebrae, however, not being very sensitive to pressure. During the night these pains increased to a fearful degree of intensity. Tingling formication in the skin from the pelvis to the feet; the lower extremities felt very cold to the patient. Paralysis of the bladder; the sphincter of the rectum was unable to prevent the emission of flatus. For the last thirty-six hours the lower extremi- ties had been paralyzed so that he was unable to stand without support; if he tried to put on his shoes, he put the foot forward beyond the place where the shoe stood; he was unable to walk ex- cept by hanging on to two persons, one on each side. Some fever. Stool normal. Appetite scanty. Almost complete insomnia, with the following characteristic peculiarity. If, late in the evening, the patient did not drink a small portion of not very strong coffee, he remained perfectly sleepless. On walking after having slept a few hours, he was unable to fall asleep again unless he partook of a little more coffee, which acted almost immediately like an opiate. He had tried for some nights to sleep without taking any coffee, but had remained sleepless until he took coffee. We prescribed Mercurius third trituration, requesting him at the same time to con- Inflammation of the Spinal Cord and its Membranes. 115 tinue the coffee, the soporific effect of which seemed to act so bene- ficially upon the patient; at the same time, however, suggesting the propriety of trying every now and then to sleep without the previous use of this beverage. The patient continued the remedy for nine days, after which we visited him again. He was now able to move his legs off the bed alone and rapidly, introduced his feet into his slippers at once and without missing, and walked across the floor six times by means of a cane upon which he, however, leaned only by way of precaution. The pains had abated quite consider- ably, the anaesthesia had almost entirely disappeared, the bladder and rectum were no longer paralyzed. The coffee had continued its good effect during the whole of this period, but had no longer been required for the last two days. We now prescribed Veratrum album. The improvement continued and the patient recovered per- fectly. His disease affords undoubtedly a perfect picture of mye- litis. About the same time a second no less marked case of chronic myelitis came under my treatment. The affected locality was be- tween the shoulder-blades. So far the treatment, having now lasted five months, has been unsuccessful, but the distress has not in- creased. Perhaps we may be able to furnish further details con- cerning this case before this work leaves the hands of the printer. Among the remedies which may have to be used in this disease, the first place should undoubtedly be assigned to Mercurius. So far as we know, this remedy has not as yet been used to any great ex- tent in this disease. We should think, however, that a single case like that of our farmer, ought to entitle this drug to the most care- ful consideration in this disease, so much more as other remedies, to our knowledge at least, have not as yet been used with any great success in this affection. The mere inspection of persons whose organisms have been impregnated with Mercury shows, even in the absence of all pathogenetic symptoms in our Materia Medica, that this agent must have some specific affinity to the spinal cord. But we do find all the characteristic symptoms of spinal meningitis enumerated in our Materia Medica; if the drug-picture of this dis- ease should be judged incomplete, we can easily complete the list of symptoms from the many reports of chronic mercurial poisoning which may be found scattered in great abundance through our trea- tises on toxicology. They show that among the toxicological effects of Mercury we may find recorded all the different phases of par- alysis of the lower extremities, of the bladder, rectum, with dispo- sition to the peculiar convulsive shocks; violent pains in the spinal 116 Diseases of the Spinal Marrow. cord aggravated by motion; the restlessness and sleeplessness which is equally characteristic of Mercurius as of myelitis; and finally the anaesthesia of the skin. In the case of our farmer the aggravation at night, while lying in bed, was eminently indicative of Mercurius. [We think Baehr is mistaken regarding the fact that this farmer was cured by Mercurius or Veratrum. The domestic remedy which this farmer had taken undoubtedly contained Opium, as all such domestic preparations for dysentery do, and the checking of his dysentery by Opium was tantamount to a case of poisoning with Opium. Or, if we please, the case presented a case of Opium- meningitis. This is the reason why coffee, as the antidote to this Opium-poisoning, acted so beneficially. It is coffee which, in this case, effected the cure. Neither Mercurius nor Veratrum had any thing to do with it. The true remedial agents in this case would have been remedies that antidote the action of Opium, namely, Aconite and Belladonna. If Aconite had been administered alone, or Aconite and Belladonna in alternation, a cure would have been effected in a much shorter space of time. H.] Secale cornutum. There is scarcely a medicine which has such characteristic symptoms of myelitis, more particularly of the utter extinction of the functional activity of the cord, as Secale. We have the convulsive twitchings and shocks, painful contractions, tetanic phenomena, complete paralysis side by side with continued and even increased reflex action, violent pains in the back, espe- cially in the sacral region, the most complete ansesthesia, paralysis of the bladder and rectum, and lastly the peculiar tendency to gan- grenous disorganization which in myelitis is represented by the gangrenous bedsores. Unfortunately we have no post-mortem appear- ances of individuals that have died of ergotism. This remedy is not only suitable in the acute, but likewise, and perhaps still more specifically, in the chronic form of this disease. lodium is recommended as a remedy for affections of the spinal marrow, probably for the reason that it antidotes Mercury, which so often produces them. Its effect seems to be concentrated upon the brain, on which account it arrests the paralytic symptoms in the extremities. lodium has not yet been known to produce an(es- thesia. Nux vomica. So many of the symptoms of myelitis are contained in the pathogenesis of Nux that it almost seems as though this medicine ought to be the main remedy for that affection. It has Inflammation of the Spinal Cord and its Membranes. 117 been urgently recommended by a number of practitioners. It is, however, very doubtful whether such a recommendation will be corroborated by clinical facts. There are few medicines of which we possess as many toxicologico-physiological experiments, as of Nux vomica, more particularly its alkaloid, Strychnine; but in not one of them do we see any form of myelitis, although a strongly marked, venous hypersemia of the meningeal membranes is men- tioned in most of them. This circumstance is undoubtedly striking. Nux vomica has not so much a paralytic condition at the periphery, as violent tetanic contractions; instead of anaesthesia it has rather excessive hypersesthesia with increased reflex action, which latter phenomenon is rather the exception than the rule in myelitis. Hence it is our opinion that Nux vomica is rather adapted to non- material affections of the spinal cord and that, among the inflam- matory affections of this organ, it is at most suitable in spinal meningitis before the disease has progressed to the stage of actual exudation. Rhus toxicodendron is at all events a noteworthy remedy in mye- litis. Although it is possible to derive the pathogenetic symptoms pointing to paralysis from the decomposition of the blood which is peculiar to Rhus, this point of view does not justify a one- sided application of Rhus as a therapeutic agent in this disease. In the first stages of myelitis the slight fever would rather counter- indicate Rhus, except perhaps in cases where the affection is occa- sioned by an acute exanthem. On the other hand the stage of complete paraplegia will be found much more adapted to Rhus, both in chronic as well as in acute cases. For myelitis caused by exanthems, Hartmann recommends Dulcamara as a specific remedy; only the symptoms which he enumerates, as symptoms of myelitis, do not seem to be the disease of which he supposes them to be characteristic indications. Veratrum album is one of the most suitable remedies in this dis- ease, and is especially adapted to the symptoms of the second stage. In the above-mentioned case of our farmer it helped very decidedly to bring about a favorable termination. Whether it will prove suitable in chronic cases, will have to be verified by practical ex- periments. Plumbum has evidently as marked an action upon the spinal marrow as we have shown it to have upon the brain in our article on encephalitis. It is to be regretted that the poisonous action of Plumbum upon the spinal cord has not been ascertained by post- 118 Diseases of the Spinal Marrow. mortem examinations, which would have revealed with positive cer- tainty the portion of the cord that is morbidly affected by this agent. The known effects of Lead upon the brain justify us to conclude by a process of reasoning from analogy, that it is the mar- row itself which is invaded and destroyed; otherwise the paralytic phenomena would not be so completely developed. Owing to the slowness of its action the drug is not adapted to acute cases; in chronic cases a characteristic feature of the paralysis for which Lead is indicated, would be the speedy emaciation of the paralyzed parts which are at the same time violently and painfully contracted. Colicky pains proceeding from the spinal cord would likewise point to Plumbum as a leading remedy. Cuprum. If it is generally difficult to discriminate between the effects of Copper and Lead, this discrimination is so much more difficult with special reference to the spinal cord. It is admitted that among the symptoms of Copper the paralytic symptoms are less clearly defined and that the spasmodic symptoms prevail, whereas in the case of Lead the opposite effects are observed. Both these medicines act decidedly in the same direction, with this differ- ence, that Cuprum is more suitable at the beginning, and Plumbum at the termination of the series. Hence Plumbum may have to succeed Cuprum with tolerable certainty, whereas the reverse will scarcely ever be the case. Cocculus is another exceedingly praiseworthy remedy, especially at the commencement of myelitis. If we were to select a remedy according to the locality of the disease, Cocculus would be more adapted to inflammation of the lumbar portion of the cord, less to such portions as are nearer the brain; however it still remains dif- ficult to determine whether Cocculus does not, like Nux vomica, rather modify the functional activity of the marrow without caus- ing any material alterations. We must not omit to make mention of a few other remedies which have either been urgently recommended by physicians or which, at any rate, seem suitable. As regards Belladonna and Aconite, it is our belief that their employment involves a loss of time without producing any curative results. In myelitis the reac- tion is never sufficiently violent to oblige us to control the febrile symptoms by means of either of these two drugs. Neither has a marked affinity to the spinal marrow. Ignatia occupies pretty much, the same position in this affection as Nux vomica. Phosphorus is said to be excellent where the inflammation has been superinduced Inflammation of the Spinal Cord and its Membranes. 119 by sexual excesses. Sulphur may be thought of in cases where the disease has been arrested and where we desire to act upon the remaining exudation in the spinal canal with a view of improving the paralytic symptoms. Sulphur is here a very important remedy, as is shown by the good effects of Sulphur baths in paralytic con- ditions remaining as consequences of myelitis. We are acquainted with a lady who is nearly sixty years old and has been suffering for the last ten years with chronic meningitis. The disease seems to exacerbate once or twice in the course of a year, is seated in the lower thoracic portion of the medulla, but does not seem to affect the substance of the medulla very deeply, since the paralytic symp- toms are not very distinct, except in the arms; moreover, as is often noticed in spinal hemiplegia, we observe in her case a general increase of her embonpoint., except on the paralyzed parts. Every summer this lady uses weak artificial Sulphur baths with decided benefit; even the paralysis of the arms improves every summer very visibly. We have likewise treated in the same place an em- ploye of a company, whose lower extremities had been completely paralyzed for two years, in consequence of myelitis of the lumbar portion of the cord, and who had been using for some time various remedies, among others Sulphur^ without any further benefit than that he was enabled to move about on two crutches with great dif- ficulty. He was sent by his employers to the Sulphur springs at Eilsen, where he remained for some three months, after which lapse of time he was able to walk with a cane. His recovery is not com- plete. Cases of this kind show that Sulphur has a decidedly cur- ative action in myelitis, where it may possibly be much more effi- cacious when used in the form of baths than when taken internally. Calcarea carbonica deserves attention, if the inflammation is caused by diseases of the vertebrae, not so much because this medicine has a direct action upon the cord as because it acts in opposition to the causative disturbance. Among the springs which undoubtedly exert an influence upon spinal paralysis, we have to mention Gastein, Pfeffers and Wildbad; of course they should not be used until the inflammatory symptoms have entirely disappeared. They doubtless afford the most help in cases depending upon sexual excesses as their primary causes. [We do not think that Baehr's condemnation of Aconite in this disease is justified by experience. In the acute form of meningitis we have succeeded with Aconite alone in effecting a perfect cure in a comparatively short space of time. But we neither give high nor 120 Diseases of the Spinal Marrow. middle potencies in this disease, but a few drops of the tincture or no higher than the first decimal attenuation of the root in ten or twelve tablespoonfuls of water, of which mixture the patient is given one or two teaspoonfuls every half hour or hour until an incipient improvement renders it desirable to lengthen the inter- vals. If the spine is very hot, tender to the touch, with throbbing, stinging or lancinating pains, we do not hesitate to apply to the spine linen or 'flannel compresses soaked with a solution of a tea- spoonful of the first decimal attenuation of Aconite root in half a pint of water. Gelseminum causes hyper semi a of the spinal cord and has been used with good success by our physicians in congestive and inflam- matory affections of the spinal cord. The consciousness is not much impaired. There is either general or partial paralysis. The patient shows a remarkable tendency to close his eyelids. The pulse is feeble and the temperature of the body very much depressed. Ve rat rum viride is administered with more or less special reference to the condition of the pulse. If the pulse is rather full and bound- ing, of more than ordinary frequency, or else feeble and rapid, and the patient complains of fulness and pain in the head, feels very much prostrated, and the extremities feel numb, twitch and are threatened with paralysis; or if the spinal congestion is attended with a general typhoid state of the system, drowsiness, indistinct consciousness, restlessness, Veratrum viride will induce a very speedy and favorable reaction, if given in quantities of two or three drops of the strongest tincture in ten tablespoonfuls of water, a good teaspoonful at a dose every half hour or hour until an im- provement sets in. It is often desirable to alternate Veratrum viride with Belladonna. Kafka, in his " Homoeopathische Therapie," has an interesting chapter on inflammation of the vertebrae (spondylitis) which we have deemed it advisable to transcribe literally for the benefit of the American reader. " Chronic myelitis as occurring in the course of spondylarthro- cace has been for years an object of our most careful observations and therapeutic investigations. The results which we have ob- tained, being exceedingly favorable, we feel induced to commu- nicate the important facts that we have been able to gather up in this domain of medical science. Inflammation of the vertebrae, (spondylitis,) in consequence of which the meninges of the spinal marrow and the marrow itself Inflammation of the Spinal Cord and its Membranes. 121 participate in the inflammation, is always attended with swelling and softening of one or two, or in exceedingly rare cases, of several vertebrae. Without experiencing any pain or any feeling of illness, children who seem perfectly healthy, or else scrofulous, rickety or tuberculous children, are attacked with a crick in the spinal col- umn arising from softening of one or more bodies of the vertebrae, the body of the softened vertebra being no longer capable of carry- ing the superimposed weight of the trunk, and, having to succumb to the law of gravitation, becoming displaced to such an extent that its spinous process is turned upwards and forms a prominence which causes the vertebral column to appear curved so as to form an obtuse angle at that point. The immediate consequence of this curvature and swelling of the vertebrae is a pressure upon the spinal marrow, which becomes much more marked if exudations take place between the transverse pro- cesses and between the tendinous structures of the vertebral column, by which exudations the spinal marrow is compressed on all sides. If one of the lumbar vertebrae is affected, the children experience at once a gradually increasing weakness in the lower extremities; they are unable to walk a long distance or for any length of time; they find it difficult to stand, get easily tired, prefer sitting or lying down, their gait becomes dragging, labored, they do not seem to make the least headway. Finally the lower extremities become partially paralyzed and lose their sensibility. If one of the thoracic vertebrae is the seat of the inflammation, the above-mentioned symptoms develop themselves more slowly, but, on the other hand, become associated with pressure in the epigastrium, dyspepsia, flatulence, constipation, difficulty of urin- ating, etc,, according as the different abdominal viscera are in an- atomical and physiological dependence upon the inflamed portion of the spinal marrow; lastly we have paraplegia together with paralysis of the sphincters of the rectum and bladder. If the cervical portion of the vertebral column is inflamed, the curvature is in most cases located between the first and second cer- vical, or between the last cervical and the first thoracic vertebrae; in the former case the head, deprived of its point of support, leans over obliquely to the right or left side, in the latter case the head sinks down between the shoulders, and it is only with great dif- ficulty and a visible effort that it can be maintained erect. In either case the curvature is accompanied by great difficulty of breathing, or by coldness, weakness and paralytic phenomena in the upper 122 Diseases of the Spinal Marrow. extremities. The dyspnoea often increases to a high degree, and is attended with cyanosis, extensive bronchial catarrh and nocturnal cough. If the articulation of the atlas is invaded by the inflam- mation, we observe dysphagia, dyspnoea, hoarseness and a constant rigidity of the nape of the neck, without any signs of morbid affec- tion of the larynx, trachea or lungs. We have introduced this pathological statement in order to understand the connection of the symptoms as they appear be- fore us. If we are fortunate enough to be intrusted with the manage- ment of spondylitis at the very outset of the attack, we have it in our power to arrest it very speedily and thus to prevent the further progress of myelitis and meningitis spinalis. Even if the inflam- mation of the vertebra? has continued for a time and a considerable amount of fluid has become exuded, but no abscess has yet formed, if the children are so feeble that they are unable to walk, but have to lie down for the most part of the time, or if they have become dyspeptic, bloated, peevish and sullen; or if the dyspnoea, cyanosis and a wide-spread bronchial catarrh have already set in, we still may effect a decided improvement by the exhibition of Phosphorus 3, two or three doses a day. In a few days already the children be- come more cheerful and active, the weakness of the lower extrem- ities begins to yield; very soon, sometimes already in five or six days, they begin to sit up or attempt to creep about on the floor; the appetite returns, the abdomen loses its bloat, the cough dimin- ishes very strikingly, the cyanosis disappears, the dyspnoea becomes less, and in at most a fortnight the children begin to walk, their posture becomes more and more erect, and every symptom of dis- ease and feeling of illness gradually disappears. Only the vertebral curvature remains; but upon examining the vertebrae more closely, we find that their sensitiveness to pressure gradually decreases, the swelling; of the vertebrae and their surrounding^ becomes less and the phenomena of compression of the spinal marrow disappear entirely. In the most fortunate cases, of which we might mention quite a number, we have never seen the angle of curvature become less obtuse owing to the circumstance that the vertebrae which had become compressed in consequence of the softening of their sub- stance, are no longer able to return to their normal size. If the improvement goes on very slowly and we have to continue the use of Phosphorus for a long time, it is advisable, after having used this drug for a fortnight, to discontinue its employment for Inflammation of the Spinal Cord and its Membranes. 123 a week, or to administer Natrum muriaticum 6, in two daily doses as an intercurrent remedy, after which period the Phosphorus may be resumed until all morbid symptoms have entirely disappeared. In a former chapter we have directed the attention of the reader to these two remedies in interstitial distention and swelling of the bones, especially the vertebrae, and, after an experience of many years, we are prepared to affirm their efficacy in these diseases. Even if the knee, tarsal and elbow-joints were the seat of these affections, we have derived good results from the use of Phosphorus and Natrum muriaticum. Both these remedies correspond to the scrofulous as well as to the rhachitic and tuberculous diathesis; only, if such conditions are present, the remedies have to be administered at long intervals, alternating them at most only every week. As soon as abscesses form, which generally break out at the above designated localities and are attended with shiverings or slio;ht creeping chills, or with an increase of the febrile symptoms, but may likewise develop themselves without any other perceptible morbid phenomena, the curative range of the above-mentioned two remedies is closed; for now we have to deal with soft exudations passing through a purulent or ichorous metamorphosis; these changes require a corresponding change of remedies. As long as the abscesses are small and not very tense, we give at once Silicea 6, two doses a day, ordering at the same time, especially if the patients are weak, pale and emaciated, a nourishing and strengthening meat-diet, and a refreshing beverage. If the season is favorable, we send the patients to the mountains or to a region of country with plenty of woods and meadows. Under this manage- ment the abscesses, in favorable cases, become smaller and softer, a gradual absorption may even take place, and a complete disappear- ance of the paralytic conditions, of the anaesthesia and the spas- modic symptoms, may be the result. In order to obtain it, however, this kind of management has often to be continued for weeks and even months, more particularly in cases where one of the above- mentioned diatheses is present. In such cases, after having con- tinued the exhibition of Silicea for a fortnight, we are in the habit of giving Sulphur 6, one or two doses daily, as an intercurrent remedy, or we discontinue all medication for a few days, after which we resume the use of Silicea. Both remedies correspond perfectly to the above-mentioned con- 124 Diseases of the Spinal Marrow. stitutional anomalies, and their employment is often crowned with the happiest results. In less fortunate cases resorption may likewise take place with- out it being necessary to open the abscess; the subsequent improve- ment, however, is not perfect; the extremities remain atfected with a paralytic weakness, the sensibility of the parts returns only partially, and there frequently remain spasmodic contractions of the muscles, from which phenomena it is evident that the pressure on the spinal marrow has not entirely ceased, or even that structural changes have already taken place in this organ. In such cases we resort to electricity by induction, which is sometimes capable of determining a further improvement of the morbid process that had become arrested at a certain point. If the abscesses are large and tense; if they do not show the least tendency to discharge on the outside; if the patients are at the same time amemic, feeble, emaciated, cachectic, etc., we open the ab- scesses with a bistouri, taking care that they do not discharge too rapidly and that no air penetrates into their cavity. The entrance of atmospheric air into the cavity of the abscess causes the formation of coagula on the inner walls of the abscess, in consequence of which it becomes lined with a membrane resem- bling mucous membrane, by which the healing of the abscess is impeded. If the discharge is yellow and inodorous, we give Silicea 6 very persistently in order to act upon the carious disorganization which the suppurative process may have initiated on the exterior portions of the vertebrae. This remedy, in conjunction with a strengthening diet, is in many cases sufficient to effect a complete cure of the caries. If the pus is ichorous and has a fetid odor, we first try to correct the quality of the secretion by means of Sulphur 6, giving two doses a day; as soon as this object is accomplished, we give Silicea. As a matter of course we never lose sight of the duty of nourishing up our patient by substantial and readily assimilated nutriment in order to make up for the loss of strength and vital fluids entailed by the profuse ichorous discharge. We have succeeded in curing cases of a far advanced caries of the vertebrae by the persistent use of these two remedies, which we are very fond of administering in alternation. It is not very long ago that surgeons were very much indisposed to plunge their lancets into a so-called cold abscess, for the reason Inflammation of the Spinal Cord and its Membranes. 125 that they were apprehensive of an unfavorable termination, most generally of the supervention of hectic fever. No later than the year 1850, we had the greatest difficulty in persuading our honored friend, Professor Pitha, to plunge his lancet into a large and cold abscess in the lumbar region, which was connected with spondylitis and accompanied by a high degree of amemia, emaciation and de- bility. The quantity of the discharged pus amounted to at least four or five pounds; it was of a very thin, fluid consistence and without any bad odor. By giving two doses of SUicea every day, during periods of eight days, allowing an interval of three days between each two successive periods, the assimilative powers of the patient, a girl of six years, were so much improved that she gained rapidly from day to day in weight, strength and external appear- ance, and she soon was able to boast of a perfect recovery. The curvature of course remained unaltered, her gait as well as her general posture, movements and feelings were almost normal. The patient is now a married lady and has enjoyed good health ever since her previous sickness. We are now treating a boy of six years who, two years ago, was attacked with inflammation of the second and third thoracic verte- brse, in consequence of which he became afflicted with dyspnoea and cyanosis to the highest degree. A catarrhal rale was heard in both lungs, the respiration was short and superficial, only with great effort the patient coughed up a serous-frothy sputum. Upon ex- amining the thorax it was found to be affected with a rickety mal formation, both the anterior costal spaces below the nipples were pressed in, the sternum bulged out a great deal, and the chest itself was very flat and narrow. In consequence of this deformity the posterior and upper portion of the lungs was evidently compressed, for at the apex of the scapulae there was bronchial respiration with- out any dulness of percussion or consonant rales in the correspond- ing localities. The boy was the child of perfectly healthy and opu- lent parents and is said to have enjoyed good health until the present sickness set in. His former physicians, supposing that the lungs had become incurably cedematous, had given up ail hopes of his recovery. We gave him Phosphorus 3 in solution, a dose every hour, ordered the little patient to be kept perfectly quiet and free from all excite- ment, and gave him four times a day a weak broth, without salt and stirred up with a little ground rice or flour. Already on the third day symptoms of improvement set in; the dyspnoea became 126 Diseases of the Spinal Marrow. less, the expectoration was thrown oft' much more easily, the mu- cous rale decreased, the cyanotic symptoms disappeared more and more. In proportion as the bronchia became disembarrassed, the bronchial respiration decreased, the digestion became more active, and in about three weeks the patient was aide to leave his bed and to maintain a more erect posture. Uis gait became more steady, but the bent in the vertebral column and the swelling of the verte- brae remained unchanged. The painfulness of the vertebrae to press- ure likewise decreased very sensibly, and the trunk was moved in every direction, without pain or trouble. After the symptoms of spondylitis had been almost entirely removed, and with a view of modifying the constitutional anomaly, we put the patient for some time on Silicea 6, after which the patient, to our own and the par- ents' joy, developed within a short space of time, both mentally and physically, to great advantage. This apparent improvement con- tinued for nine months. At this time the protruding vertebrae be- came again inflamed owing to frictions with oil, kneading and squeezing, which the parents had permitted to be done to prevent the boy from remaining a cripple. The consequence of this return of inflammation was paralysis of the lower extremities, with simul- taneous loss of sensibility, continual spasmodic stretching of the muscles and occasional muscular twitchings. Stool and urine were passed involuntarily. There was dyspnoea, evening and night-fever, sleeplessness and a high degree of morose temper. For this intense degree of spondylo-myelitis we again prescribed Phosphorus, and ordered absolute rest. The general condition of the patient soon began to mend; almost every morbid symptom had disappeared at the end of four weeks, only the paralysis and the phenomena inci- dental to this condition obstinately resisted Phosphorus as well as the subsequent employment of Mercurius solubilis 3, Iodide of Potas- sium 1, Plumbum 6, Arsenicum 3, Nux vomica 3, Strychnine 3. Even the douche had no effect. Electricity by induction diminished the anaesthesia and the spasms of the extensor muscles. During this time the exudation softened and an abscess formed. After Silicea 6 the abscess grew smaller and softer, and showed signs of incipient re-absorption. As the exudation became softer, the sensibility in the lower extremities increased more and more. Afterwards when the abscess became more tense and larger, and the Silicea had been continued together with a strengthening diet and an invigorating country-air, the first voluntary motion took place in the month of July of the same year. After opening the abscess, which discharged Inflammation of the Spinal Cord and its Membranes. 127 a fine healthy pus, the mobility of the lower extremities increased more and more. The supervention of a chronic intestinal catarrh which yielded to Phosphorus 3, caused a high degree of emaciation and debility; these symptoms were soon, however, controlled by a nourishing diet and the use of ale. At the present time the boy is able to walk without support, and is generally doing finely. We have stated this case in extenso in order to show that, under a suit- able management, even a high degree of myelitis can be reduced in intensity and improve very greatly. If we desire to effect a speedy and complete cure of spondylitis, it is necessary that the patient should be kept in a state of absolute rest. The most suitable position is on the stomach, with the extremities extended and the head raised. Where absolute rest is not enjoined, we have often seen relapses ensue, and the spondylitis spread further and further in consequence of this neglect. If the tuberculous disposition is hereditary, or the exudation as- sumes a tubercular character, the spondylitis frequently terminates fatally. The inflammation is very apt to set in again, evening or night-fever occurs every day, with profuse sweats, emaciation, pallor of the integuments and colliquative, diarrhoea. The abscesses dis- charge an ichorous, badly smelling fluid, decubitus sets in and the patients die of tubercular caries of the vertebrae. If the tubercular diathesis is noticed in season, Phosphorus, Cal- carea, Natrummuriaticum, Silicea, Podium fir Sulphur, together with a suitable diet and good country-air, arc capable of ameliorating the constitutional disposition so as to give a favorable turn to the disease. Hence it is of importance that in a case of spondylitis, no matter what its character, the physician should institute careful in- quiries into the hereditary or constitutional tubercular disposition. Cod-liver oil has been of use to us in the treatment of this disease. To improve the tubercular, rhachitic or scrofulous constitution, we have employed with good effect saline springs and sea-bathing; or, if a high degree of anaemia prevails, the use of chalybeate springs is highly to be recommended. Paralytic conditions and consequent ailments are treated in the same manner as the paralytic conditions consequent upon meningitis spinalis. If we have reason to suspect that the myelitis is occasioned by the presence of a syphilitic exostosis, an energetic anti-syphilitic treatment will have to be instituted." H.] 128 Diseases of the Spinal Marrow. In conclusion, we will offer a few general remarks concerning the treatment. We are not often called to treat a case of myelitis when the disease first breaks out; most generally the patients have already been tortured with sanguineous depletions and other losses of vital fluids before a homoeopathic treatment is determined upon. In such cases a main question will always be how far we may encourage the hope of a favorable result in the patient's mind, and we think that our promises in this respect can never be too guarded. Sometimes we succeed in effecting an improvement even in old cases; but very often all medicinal action remains ineffectual; if the paralysis has been of long continuance it will probably always be impossible to effect a complete cure. In the former series of cases an improve- ment is undoubtedly effected by the gradual resorption of the meningeal exudation which exists side by side with the disorganiza- tion of the spinal marrow. A result of this kind alone is sufficient to constitute an essential improvement for the patient. In chronic meningitis a more or less copious accumulation of serum takes place in the meningeal space, the resorption of which is succeeded by the disappearance of a variety of paralytic symptoms. Hence it is our duty in all cases to at least make the attempt of improving the patient's condition, only we should be cautious in promising a cure of the paralysis when superinduced by the destruction of the me- dulla. Regarding sanguineous depletions we offer the same con- demnatory remarks that have already been recorded in our article on apoplexy. Whether a patient afflicted with myelitis should remain in an exclusively horizontal posture, had better be decided by the patient himself, who is the best judge whether motion is hurtful or beneficial to him. It is certainly never productive of absolute mischief, whereas a forced recumbent position may entail great disadvantages. In chronic cases the hope of recovery is in a great measure based upon a methodical, cautious use of the para- lyzed parts, as has been, for a long time already, shown by the beneficial results obtained by the movement-cure. In conclusion we will mention a method of treatment the pernicious influence of which in this disease we have had occasion not long ago to witness in the case of a lady: we mean the cold-water treatment. Under certain circumstances it may be useful even in myelitis, but cer- tainly not very often. The cause undoubtedly is, that in a case of myelitis the skin is in a measure deprived of its properties of sensi- bility and irritability, and hence unable to develop the degree of reaction necessary to experience the blissful effects of cold water. Inflammation of the Spinal Cord and its Membranes. 129 On this account an excess of warmth is withdrawn from the or^an- ism, without this loss being repaired by a corresponding supply of vital warmth. In the case of the above-mentioned lady the cuta- neous anesthesia has undoubtedly become aggravated since the application of cold water. This is a suitable place for mentioning an atfection whose symp- toms bear a great resemblance to the chronic inflammatory processes in the spinal marrow: we allude to tabes dorsualis. So far the path- ologico-anatomical results of this affection have not by any means been distinctly defined. In many cases, it is true, atrophy of single portions of the cord is met with, but it is not clearly defined, whereas in other cases the atrophy is either entirely absent, or, at any rate, does not come within the ken of our observation. The most correct definition of tabes dorsualis is undoubtedly to regard it as a grad- ually increasing paralysis of the spinal marrow. The causes of such a paralysis are not by any means clearly defined, and it is undoubt- edly wrong to regard sexual excesses as the most common of them. It is undoubtedly true that they constitute a very frequent cause of the disease; but excessive exertions of the back generally may likewise superinduce a wasting and paralysis of the spinal marrow. It is not probable that paralysis of the spinal marrow is the conse- quence of inflammatory conditions of that organ; the paralysis runs almost always a painless course, and the cadaver exhibits no traces of an inflammatory exudation. The disease attacks principally men of middle age. The symptoms resemble a good deal those of chronic myelitis. The disease does not commence with pain, but with signs of weakness in the muscles of the lower extremities, such as: rest- lessness, feeling of weariness from the least exertion, tendency to drop to sleep; these symptoms are accompanied by a peculiar, but seldom painful feeling of emptiness in the spine. At an early period of the disease the condition of the genital organs becomes altered. They are not primarily debilitated, on the contrary, they are easily excited; erections and seminal emissions are very frequent, but they have not the normal vigor, more particularly during sexual intercourse, when this want of vigor is particularly apparent. In the further course of the disease the paralysis increases, spreads to the bladder and rectum, until, after the lapse of years, the paralysis of both the motor and sentient spheres of the lower extremities be- comes complete. At this stage, portions of the marrow nearer the brain become involved, even the brain becomes affected, vision be- 130 Diseases of the Spinal Marrow. comes disturbed, the memory is weakened, apathy and even com- plete stupor set in. According to most physicians the treatment of this disease is almost always unsuccessful; most authors assert that it is unsuc- cessful in every case. If taken at the outset it might perhaps be possible to effect a cure; but at the beginning the affection is not considered so very dangerous, or the patient has no proper concep- tion of the nature of his disease, and neglects, or does not persevere in, the proper treatment. If medicines are to be used, we have to select them among the number of those that have been recom- mended for myelitis, to which may be added Silicea, Causticum, Aluminium metallicum. The condition of the sexual organs points to Phosphorus, but it is questionable whether the exhibition of this agent will be attended with good results. At a later stage of the disease the main point is to maintain the strength of the patient and to see to it that it is not crushed down by excessive exertion. The duration of the disease for years, and the unsuccessful admin- istration of remedies, drive such patients from one physician to another; they generally apply to any one who promises them a cure and drains their pockets as well as their constitutions. This cir- cumstance alone renders a cure impossible, even if it might other- wise be attempted with a chance of success. [Meningitis Cerebro-spinalis, Cerebro-spinal Meningitis, Spotted Fever. Professor Felix Niemeyer has recently published an interesting memoir on this epidemic under the title: "Cerebro-spinal Menin- gitis according to observations instituted in the Grand-duchy of Baden," Berlin, 1865, in which the following concise and character- istic picture of the disease is offered: "Without any other precur- sory symptoms the patient is at once attacked with a chill attended with violent headache and vomiting. The headache speedily in- creases in intensity, the patient becomes exceedingly restless, tosses about, the pupils remain contracted, the sensual consciousness re- mains unembarrassed. The pulse rises to eighty or one hundred beats, the temperature of the body remains moderate, the respira- tions increase to thirty or forty per minute. Already at the end of the first or on the second day, much less frequently at a later period, we notice that the head is somewhat drawn backwards; the patient continues to complain of violent headache and the pain spreads from the head to the posterior cervical region an^ to the back. The rest- Meningitis Cerebro-spinalis, Cerebro-spinal Meningitis. 131 lessness becomes excessive, the thoughts of the patient become con- fused, the pupils remain contracted, the abdomen caves in, the bowels are constipated. The frequency of the pulsations and respir- ations now increases to about one hundred and twenty of the former and upwards of seventy of the latter per minute; the bodily tem- perature continues moderately low, increasing perhaps to 39° R., and upwards. In the course of the third and fourth day the tetanic spasms of the posterior cervical and dorsal muscles become more and more prominent, and are sometimes attended with lock-jaw. Opisthotonus supervenes with an extraordinary degree of intensity; the consciousness is gone, but the patient still continues to toss about in the bed, the pupils still remain contracted, the bowels constipated, the abdomen sunken, the urine is discharged involuntarily or else the bladder remains distended and the urine has to be drawn off with the catheter. The patient now lapses into a profound sopor, the moaning respiration is accompanied by a rale, and death takes place with the phenomena of an acute oedema of the lungs. This picture of the disease is sometimes modified by the occur- rence of a short preliminary stage which is marked by slight pains in the head and back; or by the breaking out of herpetic vesicles or of scattered, dark-colored roseola-spots on the first, second or third day of the disease; or else the above-described symptoms develop themselves in a much shorter period, which circumstance constitutes one of the most important modifications of the disease, so that the consciousness vanishes even on the first day of the attack and a violent tetanic spasm of the posterior cervical and dorsal muscles begins; or finally the disease may set in with such terrible violence that a fatal termination is reached even on the first or second day." Further on, Niemeyer writes: "This cursory picture of cerebro- spinal meningitis and of the general course of the disease applies indeed to most, but not by any means to all cases of the epidemic. This picture does not comprehend phenomena that occur in a variety of cases, such as: deafness on one or both ears, diplopia, ptosis of the upper eyelid, softening and destruction of the cornea, and finally paralysis of the facial nerve, and of the extremities either on both or only on one side of the body." These last-mentioned phenomena are attributed by Niemeyer to the exudation resulting from the intense inflammation at the base of the brain where the exuded fluid exerts a pressure upon the ad- joining portions of the brain and nervous trunks; whereas in spor- 132 Diseases of the Spinal Marrow. adic meningitis the exudation takes place for the most part on the convex portions of the hemispheres. This epidemic has visited several parts of our own country and, under alloeopathic treatment, has proved a murderous scourge. The States of New Jersey, New York, Pennsylvania, Vermont, Massa- chusetts, Ohio, Maine, Michigan, Virginia, and the District of Columbia, have been visited by this fell destroyer. In the November number of the North American Journal of Homoeopathy an inter- esting article on this disease is published by Doctor Bushrod W. James, of Philadelphia. He professes to have treated a considerable number of cases with very uniform success, losing only one case in about sixty, which seems to us claiming a great deal, whereas under alloeopathic treatment the mortality was about fifty cases out of every hundred. In the Philadelphia epidemic prostration seems to have been a very prominent symptom. It sometimes set in with such a stidden violence that persons who were afflicted with heart- disease dropped down dead in the street in consequence of the sud- den shock. This happened in a number of cases. Many persons died twenty-four or forty-eight hours after being seized with cho chill. Operatives over-tasked in the factories of Manayunk near Philadelphia would very often die in fourteen or sixteen hours from the chill. The general features of the disease seem to have been: vertigo with headache; diarrhoea, sometimes of a prostrating and colliquative character; in other cases diarrhoea alternating with constipation; moderate fever, flashes of heat mingled with creeping chills; piercing pains through the head; soreness and stiffness of the upper portion of the spine, with aching pains in the spine, formica- tion; soreness and sensitiveness of the skin; severe muscular pains; numbness of the limbs, with partial paralysis; spasmodic twitchings of the muscular system, sometimes amounting to tetanic convulsions with lock-jaw; the consciousness was not much affected, except when the disease was at its height, when a more or less active delirium and finally coma set in; in the cases that we have treated the conjunctiva was more or less congested and the hearing was impaired. The pulse had a moderate frequency, averaging about one hundred per minute; the tongue remained moist and, in the course of the disease, became covered with a dark brownish fur; the respir- ation was somewhat accelerated and interrupted by moaning in- spirations; during the tetanic spasms the expirations had a hissing sound, the air seeming to be forced out with an effort; the skin had a peculiar bluish pallor in this disease owing to the general tur- Meningitis Cerebro-spinalis, Cerebro-spinal Meningitis. 133 gescence of the venous system; the spots which have given to this disease its name broke out on different parts of the body, generally on the chest, abdomen, and thighs. Sometimes the skin had a mot- tled appearance, or the spots looked like measle-spots, or had a rose-colored tint. Doctor James regards cerebro-spinal meningitis as'a very change- able and deceptive disease; "one hour the patient will seem quite well, and the next the most alarming symptoms may be present." In the few' cases which w'e have treated in Michigan, this feature of the disease has never come under our observation. An admirable monograph on this disease has been published by Professor Alfred Stille, of Philadelphia, which has been very favor- ably noticed by Professor A. Flint in the January number, 1868, of the American Journal of the Medical Sciences. Doctor Stille has observed about one hundred and twenty cases of the disease in the Philadelphia Hospital. He rejects the name " Spotted fever." According to Stille the disease is both a blood-disease and an in- flammation of the cerebro-spinal membranes combined. "The inflammatory element and the septic element are both necessary to constitute the disease; either may be in excess and overshadow the other. According to the relative predominance of one or the other, the disease assumes more of a typhoid, or more of an inflam- matory type, and it is this diversity in its physiognomy which has led to such opposite doctrines in regard to its nature and its noso- logical affinities." The cases treated exhibit a striking uniformity of symptoms: headache, nausea, vomiting, diarrhoea or constipa- tion, thirst, hypersesthesia of the abdomen or of the cutaneous sur- faces generally, more or less active delirium, comatose stupor, con- gestion of the conjunctiva, tenderness of the spine, opisthotonos, subsultus tendinum, severe muscular pains, insatiable thirst, tongue covered with a whitish or brown fur, or sometimes glazed, erythem- atous and petechial eruptions. Deafness and partial paralysis some- times remained for some time as sequelse of the disease. As regards treatment, Dr. James professes to have derived the most beneficial results from the use of deodorized alcohol of the strength of ninety-five per cent. He seems to have resorted to this stimulant at the onset in every case as soon as the nature of the disease was ascertained. His mode of administering the alcohol was to add two teaspoonfuls of it to two, four, six or eight teaspoonfuls of water, according to the nature of the case, and to give a teaspoon- ful of this solution everv half hour until there was a decided abate- 134 Diseases of the Spinal Marrow. ment in tlie symptoms. In cases threatening immediate dissolution, the dose was increased for a brief period. On the other hand, Dr. Stilld objects to this indiscriminate use of the alcoholic stim- ulant. " On the whole," writes this author, " we regard alcohol as a medicine which ought not to be included in the ordinary and systematic treatment of epidemic meningitis, but as a cordial to be held in reserve against those signs of failure in the power of the nervous system, which call for its administration in diseases of whatever name." The remedies employed in this disease were: Aconite, Gelseminum, Belladonna, and Veratrum viride, during the congestive stage, when the congestive and inflammatory symptoms predominated. The Aconite has proved less useful in our hands than Gelseminum and Veratrum viride, both of which medicines we did not hesitate to alternate with Belladonna or Ilyoscyamus, if the inflammatory and typhoid symptoms seemed to co-exist. Belladonna and Hyoscyamus were relied on if a more or less active delirium had set in, the patient was inclined to sleep, the conjunc- tiva was found congested, the pupils were alternately contracted or dilated, or one pupil contracted and the other dilated; subsultus tendinum, opisthotonic spasms. Bryonia and Rhus toxicodandron were used with more or less bene- fit when the inflammatory condition seemed to give way to typhoid phenomena: subsultus, lock-jaw, incipient loss of consciousness, sopor with expression of deep suffering in the countenance; symp- toms of paralysis, difficulty of protruding the tongue, the corners of the mouth are drawn down; the muscular pains are very severe. It is very difficult to determine well-defined lines of demarcation between the respective spheres of action of these different drugs. Owing to the uncertain character of the symptoms, we have found ourselves compelled to give many of these remedies in alternation, for instance: Aconite and Bryonia, or Bryonia and Belladonna, or Veratrum viride and Belladonna, or Aconite and Gelseminum, or Rhus tox. and Hyoscyamus, or Ilyoscyamus and Arsenicum. Arsenicum, 2d or 3d decimal trituration, was given when the septic symptoms, foul discharges from the bowels, signs of decom- position of the blood, malignant looking petechise, etc., indicated its use. Calomel was given if the diarrhoea and the hypersesthesia of the abdomen seemed to require the use of this agent. Cuprum aceticum seemed to relieve the paralytic symptoms and Spinal Irritation. Neuralgia Spinalis. 135 the mental hebetude which sometimes remained as sequelae of severe attacks of the disease. Opium was resorted to as a last resort, if the coma and the par- alytic symptoms did not yield to Belladonna or Hyoscyamus, or showed a tendency to become more inveterate. Relapses in this disease were difficult to manage and, as a general rule, proved fatal. At any rate, this has been our experience in this part of our country. II.] Spinal Irritation. Neuralgia Spinalis. For a long time this affection has given rise to a, good deal of dis- cussion, and a number of writings have been published on the sub- ject pro and con, until more recently physicians have adopted the general conclusion not to regard this disease as an independent pathological process, but as a symptomatic manifestation of a more general affection. By spinal irritation we understand a condition where a more or less extensive portion of the vertebral column is abnormally sensitive to pressure, and where all sorts of disturbances are manifested in the sentient and motor sphere of the nerves pro- ceeding from the affected portion of the cord, 'in this affection no material changes of the spinal marrow or its envelopes have as yet been discovered; and it is probably for this reason that the affection has been designated as a neuralgia, by which means the vagueness of the genuine pathological conception has indeed become more pointed and conspicuous. In many cases partial hyperaemia may be the cause of the phenomena; in other cases the cause undoubtedly resides outside of the vertebral canal, the marrow becoming second- arily irritated and sensitive. On this account we see spinal irrita- tion accompany a number of febrile as well as non-febrile affections. Very seldom we may be able to trace the phenomena of spinal irri- tation to a sensitiveness of the vertebrae as their primary cause. The disease is mostly limited to the female sex between the age of pubescence and the climacteric period; in the male organism the disease is not only seen much less frequently, but is generally much less extensive and prominent. All kinds of influences have been assigned as causes of this trouble; we shall not attempt to enumer- ate the whole list of them here, and content ourselves with men- tioning the following as the main causes of the disease: all kinds of excessive exertions affecting more specially the spinal marrow, more particularly all sexual excesses; continued losses of vital fluids, excessive nursing, leucorrhoea, exhausting diseases. 136 Diseases of the Spinal Marrow. According to the locality of the disease, the symptoms of spinal irritation differ so greatly that it is impossible to describe the whole series so as to meet every case. As a general rule the symptoms are located within the domain of the nerves proceeding from the affected portion of the marrow If the upper portion of the medulla is af- fected, the pains are principally located about the head, and may even lead us to suspect a cerebral disease, for we do not unfrequently observe illusions of the senses, amaurosis, deafness, even delirium. An affection of the lower thoracic portion of the spine, where the stomach becomes predominantly involved, is likewise of great im- portance. In a case of this kind, as in all other cases of spinal irri- tation, it is interesting to inquire whether the affection of the stom- ach or of other organs is not rather the primary, and the irritation of the spinalmarrow the secondary trouble. This distinction is all the more important since the irritation of the spine not unfrequently develops symptoms that completely simulate one or the other severe affections of the diseased organ. The irritation almost always runs a slow chronic course, the duration of which is numbered by years. Usually, however, the symptoms remit, the remissions being charac- terized by a regular type to such a degree that a subsequent exacer- bation may be regarded as an entirely new disease. Indeed it is impossible to determine with perfect certainty the degree of con- nection between a simple irritation of the spine and other affections, more particularly paralytic conditions, emanating from the spinal marrow. The frequent occurrence of spinal irritation in the case of hypochondriac individuals very often leads to an increase of the mental disturbance until actual dementia results from the spinal disease. Regarding the treatment we cannot do better than to transcribe Hartmann's own words, vol. II., pages 378 and 379: "The reader comprehends without my reminding him of it that no specific treat- ment can be indicated for the multitude of symptoms which I have described as diagnostic signs of spinal irritation, and which repre- sent more or less independent groups of diseases to which I have applied generic names. Homoeopathy cannot and should not be guided in the selection of hei* remedies by the essence of the disease of which we have a very imperfect knowledge in the present case; otherwise she might tumble into a vague and unsatisfactory mode of generalizing which is decidedly antagonistic to the spirit of her teachings. I do not see how such a method can be considered con- sistent with homoeopathic principles; what would it avail if I were Spinal Irritation. Neuralgia Spinalis. 137 to indicate here a number of medicines every one of which has been found useful for this or that symptom of spinal irritation ? It would not be any the less necessary to take a careful record of the totality of the symptoms and to contrast them with the medicine to be chosen. For what purpose, then, have I here introduced such a general description of the symptoms of spinal irritation? For no other purpose than to enable the reader to obtain a correct com- prehension of the morbid symptoms presented to his view, and to decide with more certainty whether a remedy had been selected in perfect accord with these externally or phenomenally reflected mani- festations of the internal disease. There is no contradiction in these statements, as might be supposed by older homoeopaths who have remained ignorant of the modern tendency of medicine and have given an erroneous interpretation to Hahnemann's teachings in this respect, and who would fain excommunicate me on this account from the pale of orthodoxy. I think I have correctly apprehended Hahnemann's meaning, when he says: it is only the externally re- flected image of the disease which shows the physician what is to be cured; profound thinker as he was, he knew very well what he ought to think of each single symptom; the subjective symptoms were as valuable to him as the objective; in his mind a generic image of the disease was involuntarily called up side by side with the spe- cial symptoms of the case; this is shown by his Chronic Diseases and by his later provings, in the preface .to which he takes pains to direct attention to the general character of each special drug. Un- consciously perhaps he meant to convey the doctrine that it was necessary not only to acquire a correct knowledge of the specific symptoms but likewise of the general therapeutic sphere of a drug. May not this consciousness of the absolute necessity of possessing a general knowledge of the curative range of a drug have been awakened in his mind by the conviction that, in order to obtain a complete image of the generic disease, a full record had in the first place to be instituted of all its special symptoms? I cannot conceive of any other meaning; otherwise there would be no special use in looking at the physiological effects of a drug in any other aspect than that which is most strikingly perceived by the senses, unless it was found necessary, with a view of benefiting therapeutics, to bring Physiology into harmony with Pathology and thus to restore the faded glory of a purely symptomatic treatment. A great deal more might be said on this subject, if the size and object of this work admitted of more enlarged developments." 138 Diseases of the Spinal Marrow. Spinal irritation is not a morbid process encompassed within defi- nite boundaries, hence there can be no treatment assigned to it. But it is important to correctly apprehend its true character as a partial manifestation of other affections, and to consider its symp- tomatic appearances with the utmost care, with a view of selecting the right remedy. In the few cases where spinal irritation seems to be the primary affection, it will always be found difficult to select the appropriate remedy; this difficulty will likewise exist where the irritation simulates a more deep-seated affection. But it is strictly impossible to indicate a priori remedies for affections of such a gen- eral character. Nor is it feasible to seek remedies for spinal irrita- tion that are generally applicable, since, after all, it is questionable whether the same treatment would apply no matter whether the cervical or the lumbar portion of the spine constitutes the seat of the irritation. Hartmann has taken pains to furnish, after the fashion of a Repertory, a series of remedies corresponding more particularly to the symptoms of the back; he takes care, however, to preface this series with the remark that he does not attach any great practical value to it; indeed, the most superficial inspection of this list shows that the symptoms mentioned in this series bear very little resemblance to the symptoms of spinal irritation. For such investigations a Repertory is the best thing to use, and will be the more available the more incoherently the single symptoms pre- sent themselves. Only one form of spinal irritation may be men- tioned in this place, because it generally appears with the same symptoms: we allude to spinal irritation caused by onanism. The patients generally complain of a pain in the lumbar portion of the spine; it is a peculiar burning pain, is principally excited by unex- pected motion, violent exertions and long continuance of the back in the same posture. The mind is generally very much involved. The sensitiveness of the vertebrae is sometimes very great. The remedies indicated in this affection are, in the first place, Nux vomica and Sulphur. Both these remedies are so specifically antagonistic to this vice that, if they do not help, it may with certainty be affirmed that the medulla is already affected with a more deep-seated disorder. [The remedies which we have more generally employed for spinal irritation are the tincture of Aconite root, Gelseminum, Arsenicum, Phosphorus, Sulphur. For the stinging and boring, gnawing and wrenching pains, and for the great heat and tenderness in the spinal region, we have found compresses moistened with a solution of Aco- nite, one teaspoonful to half a tumbler of water, and applied to the back by means of bandages, very beneficial. H.] C. DISEASES OF THE NERVOUS SYSTEM. 1. Epilepsy. By epilepsy we understand spasmodic attacks which occur in paroxysms, are separated from each other by free intervals, and are accompanied by a complete suspension of the consciousness, sensi- bility and the power of voluntary motion. The pathological changes accompanying this disease remain enveloped in perfect obscurity in spite of all investigations and the frequent occurrence of the par- oxysms. We may consider it as proven that the medulla oblongata is the starting-point of these very peculiar nervous paroxysms; but we have no certain knowledge of the changes taking place in the medulla or of the manner in which other derangements affect this organ. Epilepsy is a disease of frequent occurrence and has a very chronic course. Its causes are manifold, some of which are indeed as yet questionable, others, on the contrary, are definitely known, although the nature of the connection between these causes and the disease is still involved in obscurity and doubt. One of the leading causes of the disease is its hereditary character. Our statistics have shown that a large number of our epileptic patients are either born of epi- leptic parents, or of parents afflicted with other spasmodic affections, and that, in transmitting the disease, the mother exerts a more powerful influence than the father. Nor does it often happen that the disease skips a generation altogether. Females seem to be more disposed to epilepsy than males; it is more particularly the transi- tion forms between epileptic and other convulsive affections that occur among females in a larger number than among males. The disease is seldom traceable as congenital, breaks out most frequently between the tenth and twentieth year, almost as frequently between the fifth and tenth year, rarely at an earlier age, and uniformly de- creasing in intensity as patients advance in age. ■ As regards consti- tution it is difficult to lay down definite rules, but it must appear self-evident that individuals who are endowed with a very sensi- tive nervous system are particularly predisposed to the disease. Whether a scrofulous and rhachitic diathesis entails a similar pre- disposition is questionable; whether the lower classes are likewise more predisposed to epilepsy than the higher, or whether abstemi- ousness from all sexual enjoyments favors the disease, is likewise a matter of doubt. 139 140 Diseases of the Nervous System. Although cases of epilepsy occur that can he traced to an affec- tion of some particular organ, yet in most cases the convulsive paroxysms can be traced with more or less certainty to abnormal conditions of one or the other organ as their starting-point. It is, however, a mistake to base upon these organic differences a classi- fication of the epileptic convulsions into thoracic, uterine, etc., for the simple reason that the form of the convulsions is not modified by their local origin. However, no proof is required to satisfy the homoeopath of the importance of ascertaining with positive certainty what organ is primarily affected; and what is the nature of the affection; is not the individualization of every case of disease one of the first requirements of Homoeopathy? Hence it cannot be deemed superfluous, if we state here the main facts that have become known to us in this direction, to which we would add the advice that in every case of epilepsy the possible existence of other morbid conditions be carefully inquired into, and that a simple diagnosis of the epileptic paroxysm be not deemed sufficient. Every one of the various affections of the brain may develop epilepsy, but this disease cannot be traced to any of them as its regular or pre- vailing cause. The structural changes revealed after the death of epileptic individuals may have been antecedent to, as well as con- sequent upon epilepsy. This remark is especially applicable to hypertrophy of the brain, which has often been noticed in post- mortem examinations. It is well known that long-lasting epilepsy affects the brain, from which we may infer that it must gradually produce structural changes in this organ, which a post-mortem in- vestigation does not fail to reveal to us and which we are too apt to regard as the primary cause of the disease. It is to adventitious growths in the brain that the origin of epileptic convulsions can be traced with most certainty. Among psychical influences, fright holds the first rank, not only as the primary cause of the first attack, but likewise as the cause of subsequent paroxysms. It is said to cause one-third of all epileptic attacks; we have numerous oppor- tunities of witnessing its extraordinary influence upon epileptic patients. All violent emotions, more particularly the sight of epi- leptic individuals during an attack, act, if not with the same inten- sity, at least with an unmistakable force. Epilepsy is likewise often traceable with positive directness to mechanical impressions on the brain caused by a blow, fall, or other violent injuries, or even the causes which may lead to cerebral hyperfemia, excessive heat or cold, insolation, may likewise cause epilepsy. Tracing the disease Epilepsy. 141 to affections of the thoracic organs is more uncertain. The fre- quently mentioned hypertrophy of the heart may both be cause and consequence of the disease. Very frequently and positively, epilepsy may depend upon affections of the abdominal organs. We dis- tinguish helminthiasis, uterine affections, amenorrhoea, nocturnal emissions, sexual excitement, onanism. The last-mentioned cause is certainly much more frequent than is generally supposed; it is indisputable that the most obstinate cases of epilepsy are occasioned by this vice. Other evident causes of epilepsy are injuries of single nerves, pressure upon nerves by cicatrices, tumors or neuromata; epilepsy has been cured by cutting the affected nerve. Lastly we mention chronic intoxications with alcohol or lead as causes of epi- lepsy. Symptoms. Epileptic attacks show a great variety of symp- toms. It is this very circumstance that compels us to define the pathognomonic signs of the disease in such general terms. Eor the most part, however, we can distinguish three distinct stages, the first or last of which, and still less frequently both together, are scarcely ever entirely wanting. The precursory stage is the least clearly defined. The^prodromata may consist of general phenomena emanating from one or the other portion of the nervous system or else involving the whole of it. These prodromata are a general restlessness, palpitation of the heart, a peculiar anxiety, pallor of the face, great depression of spirits or else excitement of the mind which may increase to complete derangement of the faculties. Such phenomena may precede for days the real attack, and very often the patients understand per- fectly well the meaning of such phenomena. Much more frequently, however, such precursory symptoms are of short duration. They have been designated as the aura epileptica, because the patients describe the sensation of the approaching attack as a warm or cold breath moving from the periphery, especially from the lower ex- tremities, upwards. The aura is likewise described as a sensation of formication, a simple feeling of coldness or heat, as an ascending ball, or else it consists in simple vomiting. As soon as the peculiar sensation reaches a certain definite point, the paroxysm breaks out. In one, this point is the pit of the stomach, in others the neck, heart, or the head itself. As a general rule, the aura does not last longer than a few minutes, and is frequently so short that it passes off with the rapidity of lightning. It may be stated with a certain degree of emphasis that the origin of the aura, as felt by the patient, 142 Diseases of the Nervous System. does not by any means, not even with any degree of probability, indicate the organ which produces the disease. This remark like- wise applies to the cases where psychical emotions take the place of the aura. The second stage is that of the spasm. In almost all cases of fully developed epilepsy, the spasm sets in with a cry. At the same time as this cry is uttered, the patients fall down without consciousness, so that they are entirely unable to guard against injuries which generally happen to them sooner or later in consequence of the fall. This point becomes important when we are called upon to unmask feigned cases of this disease. It is only when the aura lasts for some time that the patient may find it possible to reach a place of safety before the attack overtakes him. In most cases the cry is at first followed by a tetanic rigidity of the whole body, during which the trunk as well as the extremities are stretched out, the head is drawn backwards or sideways, the mouth is tightly closed. The eyes are fixed, the look staring, the respiration arrested in con- sequence of the spasm of the respiratory muscles. The face now begins to bloat, turns blue and the veins become turgid with blood. After the rigidity has lasted a few moments, (it is never entirely absent,) the convulsions change to clonic spasms which are some- times ushered in by violent shocks. The whole muscular system is now powerfully shaken. The face becomes distorted, the eyes are alternately closed and opened, the lower jaw is moved to and fro; at one time the mouth is opened, at other times it is closed again, sometimes with an extraordinary force, during which teeth are sometimes broken and the tongue is injured. A frothy sputum which is sometimes mixed with blood oozing from the bitten tongue is seen forcing its way between the closed lips. The head and even the whole trunk are tossed to and fro. The extremities are stretched out, twisted and bent with terrible violence; at the same time the thumb is mostly clenched and even the toes are flexed. The for- mer symptom is regarded by many, although improperly, as a characteristic sign of epilepsy; for this symptom likewise occurs in many other convulsive'attacks, whereas it may be entirely wanting in well-defined cases of epilepsy. The convulsions are not always equally violent during the whole of the attack; there are short remissions which, however, do not point to a cessation of the attack. In consequence of the respiratory muscles being very much involved in the attack, the respiration is greatly interfered with, even in the absence of all spasmodic closing of the glottis; the inspirations are Epilepsy. 143 unequal and forced, and in making an effort to overcome the con- traction of the glottis, the patient sometimes utters an anxious cry. The pulse is generally smaller and more rapid. Very frequently stool and urine are discharged involuntarily. Erections and even ejaculation of the semen sometimes take place. The consciousness and sensibility are entirely suspended, to such a degree that the patient remains unconscious even of the most frightful pains. It has happened that by falling against hot stoves or the like, the patients were frightfully burnt. This stage seldom lasts beyond a quarter of an hour, and is sometimes limited only to a few minutes. Very seldom the attack ceases with a sudden cessation of the con- vulsions ; they abate very gradually, and the paroxysm terminates in most cases by a deep expiration. This stage passes into the third stage, that of sopor, through a scarcely perceptible transition. After the convulsions cease, the expression of the countenance becomes calm, the complexion pales, the inspirations become full and deep. In most cases this abatement passes into a sopor from which the patients wake after an interval of longer or shorter duration without being aware that they have passed through a paroxysm of convulsions. In very few cases the consciousness returns immediately after the attack; still less fre- quently the cessation of the convulsions is succeeded by a return of a perfect feeling of health. Generally the patients feel exhausted, with a dull and confused feeling in the head, unsteadiness of gait, headache, sometimes vomiting, and usually an extraordinary desire to sleep. A quiet sleep, even ever so short-lasting, generally puts a stop to all unpleasant after-feelings, and, until the supervention of the next attack, the patient is generally quite well. Not every attack, however, ends so free from all unpleasant consequences; nervous derangements often remain which are worse than the attack itself. Distinct symptoms of dementia, such as an excess of good humor, or else a dulness of perception, errors of language, fixed ideas, even a raging mania, or else an impaired memory, amaurosis, partial paralysis, sometimes remain after the attack, often for a long period; in inveterate cases they never disappear altogether. In the previous paragraph we have offered a picture of a fully developed paroxysm of epilepsy. This picture, however, does not cover all epileptic attacks. Affections of this class show transitions from other spasms to epileptic paroxysms, and from incomplete to complete paroxysms, in which cases the diagnosis is determined by the loss of consciousness. Such incomplete attacks frequently con- 144 Diseases of the Nervous System. sist only in a momentary loss of consciousness, during which the eye stares and the face turns pale without the patient falling down or a single spasm becoming visible. The attack is more complete if it begins with vertigo which obliges the patient to sit down or causes him to stagger and fall, in which case slight twitchings of the facial muscles and trembling of the hands take the place of the convul- sions. In a few minutes the consciousness returns, and the patient almost immediately feels well again. We have known a patient whose attacks always came on while he was sitting at his writing- desk, the consciousness vanished without vertigo, and an extremely fantastical and pleasant dreaminess set in, which lasted at most half a minute or a whole minute, after which he was able to resume his writing at the very word or letter where he had left oft. He never was able to describe his reveries; all he knew was that he felt ex- tremely happy and elated. If such incomplete attacks are neglected and remain uncured, they often pass gradually, or even quite sud- denly, into severer forms, on which account they have to be watched with the greatest care. Inasmuch as no single paroxysm of epileptic convulsions, were it otherwise ever so complete, justifies the diag- nosis of epilepsy, but may be set down as a paroxysm of eclampsia, of which we shall treat in a subsequent paragraph, we deem it in- cumbent to devote a few remarks to the intervals between the par- oxysms. These intervals are of indefinite duration. It is rarely the case that epileptic convulsions set in at definite periods, (more par- ticularly about the time when the catamenia are expected;) most generally the return of the paroxysms takes place irregularly, and every new exciting cause may upset the established order. The free intervals may last for years. Sometimes, instead of a single parox- ysm, a number of paroxysms may take place in rapid succession, after which the free interval begins. Such groups of paroxysms generally imply a deep-seated character of the affection. In most cases the intervals are quite free from morbid symptoms, unless the attack leaves derangements which disappear either slowly or not at all. Epilepsy always runs a chronic course, provided always the con- vulsions are not the expression of some organic affection super- inducing a rapid dissolution. The patients may live to an advanced age, nevertheless in the course of the disease derangements result, which do not disappear again with the outbreak of the paroxysms, on the contrary, increase in proportion as the paroxysms become more frequent and violent. The mental condition must necessarily Epilepsy. 145 be affected by the disease, were it for no other reason than because there is something horrible in such attacks to every beholder. The mere thought of the horrible nature of this disease may excite in some individuals aversion to company, irritability of temper, mel- ancholy, etc., without these symptoms depending in the least upon structural alterations in the brain. Such alterations are never ab- sent in the severer forms of the disease. Gradually the patients lose their memory, the intellect and judgment become impaired, the countenance assumes a peculiar expression of dejection of spirits and subsequently of mental hebetude. We have already stated that partial paralysis sometimes remains after an attack either moment- arily or even permanently. The frequent and excessive excitement of the sexual system is a very striking concomitant of the disease. It not ^infrequently happens that an increase of the morbid phe- nomena during the intervals is attended with a decrease of the frequency of the paroxysms. There are properly speaking but two terminations of the disease, either recovery or other forms of disease. Death very seldom results as the direct consequence of a single paroxysm, but only in conse- quence of the organic changes that may have been developed by the disease. Complete recovery is unfortunately a less frequent termi- nation than one is apt to suppose. Recovery can only be regarded as certain in cases where the frequently returning paroxysms either cease suddenly or become gradually less frequent and intense. Nu- merous deplorable instances show that even in such cases a peculiar disposition to relapses remains; it is more particularly violent emo- tions that give rise to new attacks. Even a partial recovery may be considered a great success, if the paroxysms, for instance, occur less frequently or with less violence, or without any abnormal phe- nomena during the intervals. There is no doubt that epilepsy may get well spontaneously; a spontaneous recovery may take place gradually, or may be superinduced all at once by the supervention of some acute disease, or may be consequent upon the shock caused by some startling event, or upon the disappearance of the derange- ments that had caused the paroxysms, such as retention of the menses, helminthiasis. Epilepsy may run into a variety of other diseases, but these changes are mostly confined to paralytic condi- tions of the central organs of the nervous system, among which we likewise number mental derangements, idiocy, imbecility. The prognosis is from the very start very dubious; in no case can a cure be promised with perfect certainty. A good deal depends 146 Diseases of the Nervous System. upon the age when the paroxysms first break out. Persons of middle age are the most difficult to cure; next to these the greatest diffi- culty is experienced at the age of pubescence. The exciting causes likewise exert an influence; if these can be removed, a cure becomes much more probable. The worst cases are those that have been caused by a long-continued practice of self-abuse; epilepsy excites the sexual system with a disturbing violence, and onanism of itself is apt to superinduce changes in the functions of the brain and spinal marrow. The more recent the disease; the less important the derangements in the intervals between the paroxysms, the more promising the prospect of a cure. Tj eatment. Uartmann has the following in his introductory remarks: "Although the homoeopathic treatment of this disease has obtained proportionally fortunate results, yet a great deal remains to be done to make our treatment a perfect success, as I can affirm from personal experience. Even if I were to accuse myself of my want of success,-which I do not feel disposed to do, since the treatment of epilepsy affords us an abundance of time to consult our books and select the appropriate remedy in accordance with all the individual symptoms of the case,-we may safely assert that two-thirds of the cases of inveterate epilepsy are beyond the reach of the specific method of treatment; unfounded assertions to the contrary cannot shake my convictions on this point. Epilepsies depending upon internal causes may generally be considered incur- able, and even such as are consequent upon violent emotions pre- sent great difficulties to the practitioner, for the reason that a cer- tain predisposition undoubtedly exists in individuals thus attacked. I do not care to decide whether the many reports of cured cases of epilepsy were really the disease; many of these cases were nothing more than violent spasmodic paroxysms, and could not be regarded as epilepsy for the simple reason that the truly pathognomonic signs were wanting, namely loss of consciousness and loss of sensibility at the very outbreak of the convulsions. It is well to know that an anti-epileptic treatment offers many difficulties even to us homoeo- paths, and that a successful cure of an inveterate case of epilepsy is just as rare under homoeopathic as under any other form of treat- ment, and that it should be more or less attributed in every case to the fortunate occurrence of accessory circumstances." We have deemed it indispensable to transcribe this judgment of an experi- enced practitioner in order to meet at the onset the belief that we possess in our Materia Medica a number of approved remedies Epilepsy. 147 against epilepsy, and that we have it in our power to treat this dis- ease with comparative certainty of success. In treating epileptic patients we always have to keep in view three points: the causal indication, the treatment of the special par- oxysm, and of the disease generally. The causal indication is a subject of great importance, even under homoeopathic treatment. In most cases the diagnosis of the excit- ing cause is unfortunately either impossible or very unsafe. In cases where the attacks can be traced to disturbances of particular organs, we have in the first place to aim at remedying them. If the attacks are caused by the pressure of cicatrices upon adjoining nerves, the cause can only be removed by the knife. Cures may likewise be effected by dividing the main nervous trunk of the affected organ, provided the operation is feasible. This result has been satisfactorily demonstrated in cases of epilepsy depending upon degeneration of the testes. Menstrual derangements, helminthiasis, excessive nocturnal emissions, have to be cured before a cure of epi- lepsy can be thought of. However, even if such derangements have been removed, the stoppage of the convulsions does not necessarily follow; hidden influences may render the convulsions a permanent disease. This result may be expected with the more certainty the longer, the more frequently and more violently the paroxysms have already taken place. Moreover we should not forget that we often fancy we can trace the cause of the disease to functional derange- ments which really are mere complications of the convulsions with- out having any causal connection with them. The treatment of the paroxysm itself is not within the range of mere medicines. Where the aura is distinctly marked and the cir- cumstances otherwise permit the thing to be done, we may try to ward off the attack by applying a ligature to the extremity in- volved. It is said that in many cases this proceeding has been attended with success. In other respects, we should constantly bear in mind that the patient has to be protected in every possible man- ner against injuries; he should, for instance, not be allowed to go out alone, and, during the paroxysm, he should be placed so that he cannot injure himself. This precaution is so much more necessary as it has happened that patients have inflicted fatal injuries upon themselves during the attack. That this may readily take place is evident from the violence with which epileptic patients are thrown down, and from the terrible agitation of the muscular system, in 148 Diseases of the Nervous System. consequence of which fractures may occur in spite of the greatest care with which the patient is placed. So far as the medicinal treatment of epilepsy is concerned, it offers, as has already been said, great difficulties, for the reason that we have not yet succeeded in assigning definitely specific remedies to corresponding forms of the disease. The cause of this is that, al- though it is certainly true that a large number of epileptic patients have been treated homceopathically with perfect success, cures of epilepsy are scarcely ever what might be termed typical cures, and hence cannot be given to the public. Another cause is, that it is equally difficult to build up the categories of epileptic convulsions with well-defined discriminating distinctions, and that, with a few exceptions, our remedies do not enable us to construct correspond- ingly accurate diagnostic series. It is certainly wrong to place the symptoms of the actual paroxysm in the foreground. Of course they are essential; but it is equally true that phenomena occurring be- tween the paroxysms deserve a much more attentive consideration. The case is with epilepsy as with intermittent fever which is treated much more successfully with remedies chosen in accordance with the symptoms that characterize the apyrexia. This rule mainly co- incides with what we have said previously regarding the causal indication. Where functional derangements of some particular organ prevail, they should constitute the main object of our treat- ment, no matter whether convulsions are present or not. Only after the local derangements have been removed, a special treatment can be instituted against the epileptic paroxysms unless they should have previously disappeared together with the local trouble. The greatest difficulty in selecting a remedy is undoubtedly experienced in cases that seem to be of an idiopathic nature, and where the inter- vals do not show the least symptom of bodily ailment. In the fol- lowing paragraphs we will mention every remedy that has been rec- ommended for epilepsy with more or less reason; however, it will be impossible to mention every remedy that may have to be em- ployed for the different local derangements which constitute so many exciting causes of epilepsy; for a knowledge of these remedies we refer the reader to the chapters where these pathological pro- cesses are more specially described. Cuprum is one of the few remedies of which we know positively that poisonous doses cause epileptic paroxysms. This circumstance has led to the frequent use of Copper in epilepsy. A great many cures have been effected with this agent. In cases of idiopathic Epilepsy. 149 epilepsy this remedy is one of the first that will have to be used; on which account, however, it may not be any the less suitable in complicated cases. In this latter class of cases the accessory symp- toms will be found to constitute valuable and characteristic indica- tions for the use of Copper. It is more particularly when the epi- leptic paroxysms break out in the night, that Copper is supposed to possess specific curative powers, although, as we have said before, such statements are unfortunately not confirmed by a sufficient number of clinical observations. Whether Cuprum metallicum is preferable to Cuprum aceticum is still an open question. The latter preparation is undoubtedly more effective in the lower attenuations, whereas the former had better be used in the higher potencies, and less frequently. In the treatment of epilepsy it seems generally better to employ the higher attenuations in less frequently repeated doses. We make this remark here once and forever in order to avoid unnecessary repetitions. Plumbum is very nearly related to Copper, both in its general therapeutic character as with regard to the convulsive symptoms. Hartmann says that Plumbum seems to suit epilepsies emanating from the splanchnic system of nerves, whence they radiate over the sentient and motor nerves of the spinal system and finally reach the brain and the senses. According to this statement, Plumbum is particularly adapted to epileptic attacks with a well-defined aura, or to attacks where paralytic conditions, entire or partial loss of consciousness, remain for some time after the attack. These general statements do not, however, show what special cases of epilepsy do more particularly come within the curative range of Plumbum; we shall have to content ourselves with the general knowledge that this remedy is adapted to epilepsy. More special indications will not be expected, for the reason that the peculiar nature of the dis- ease does not admit of any; hence the remedies for epilepsy will always have to be employed with more or less uncertainty as regards their strict homoeopathicity. Plumbum acts very slowly as we have already stated when speaking of encephalitis; on the other hand its action lasts much longer and is much more penetrating. On this account alone, even if for no other reason, Plumbum is more particularly suitable to cases of long duration, even if struc- tural changes have already been superinduced in the brain. Calcarea carbonica is highly prized by Hartmann as a remedy for epilepsy. However, he is evidently embarrassed in endeavoring to justify the selection of this drug. He bases it more particularly 150 Diseases of the Nervous System. upon the general therapeutic character of the drug and its action in persons with a scrofulous diathesis and sensitive nervous system, for the two symptoms which he mentions as characteristic scarcely account for its use upon homoeopathic principles. The influence of scrofulosis upon epilepsy has not yet been definitely ascertained; at any rate this influence is not very marked, any more than that of a sensitive constitution. Hartmann has informed us what is to be thought of the usus in morbis as applied to the treatment of epi- lepsy. There is no difficulty in admitting that Calcarea will do good service in the case of children, especially of scrofulous chil- dren; or that, by the removal of complications, it may exert a bene- ficial effect on the course of epilepsy; but it will be found to have very little direct influence over the epileptic paroxysm generally, and in uncom licated cases we shall have to use it with a good deal of diffidence. Hartmann applies almost the same remarks to Causticum. We coincide with him in opinion in this respect; would however call attention to the fact that some cases of epilepsy have undoubtedly been cured with this agent, on which account, owing to the paucity of our anti-epileptic agents, it deserves some notice at our hands. Belladonna has among its pathogenetic symptoms the whole series of the phenomena which characterize an epileptic paroxysm, on which account it deserves to be ranked with Cuprum and Plum- bum. A careful examination of its pathogenesis reveals, however, some very essential differences. The epileptic Belladonna-convul- sions are the consequences of an intense intoxication of the organ- ism ; while running their course they may recur several times, but never in the form of a chronic affection, as is the case with Cuprum and Plumbum. Hence the Belladonna-convulsions, as we indeed know from experience, correspond rather to eclampsia, which has been very properly designated as acute epilepsy. We do not mean to imply that Belladonna should never be used in the treatment of epilepsy. There are plenty of cases where it is difficult to dis- tinguish between epilepsy and eclampsia, and where the further course of the disease has to shed light upon the nature of the exist- ing attack, although even in such a case we are often left in the dark. In all such doubtful cases Belladonna will undoubtedly often be selected and will be found efficient. A special indication for Bella- donna are the cerebral congestions occurring during and between the paroxysms. Cicuta virosa undoubtedly reflects by its pathogenetic effects a Epilepsy. 151 faithful picture of epilepsy, but very little is said of its curative virtues in this disease. Hartmann recommends it for the following symptoms: Strange movements of the head and trunk, lock-jaw, a bloated and bluish countenance or cadaverous pallor of the face, protrusion of the eyes, vomiting, a weak and scarcely perceptible pulse, scarcely perceptible and intermittent respiration. The attack is preceded by: Strange feeling in the head, extreme sensitiveness of the eyes to the light, delirium while walking about, slow pulse. There is no aura, properly speaking; the attack is succeeded by in- sensibility, more or less complete lethargy, the patient lies in a state of stupor. In other respects, special indications for Cicuta are the prevalence of venous congestion, especially of the abdominal viscera: convulsions occurring in confinement or during the act of parturition, although they belong more properly to the category of eclampsia. Opium has among its effects the characteristic symptoms of epi- leptic convulsions, for which it is indeed recommended by many practitioners, more particularly for convulsions which occur at night while the patient is asleep. However, according to all the information which we possess concerning this remedy, it does not seem adapted to deep-seated, chronic forms of epilepsy. It has been recommended from theory rather than from practical observa- tions. Otherwise we know that Opium-eating, when continued for years, very frequently causes epilepsy which is most generally pre- ceded by an intense derangement of the mental functions, and that for this reason Opium deserves particular notice in cases where, as is so often the case, the convulsions take place in the case of insane persons as complications of the mental disease. Secale cornutum has, in our opinion, been rather slighted as a remedy for epilepsy The toxicological effects of this remedy are so striking that scarcely any other can compete with it as an anti- epileptic agent. The Secale-convulsions with or without conscious- ness hold a high rank among its pathogenetic indications. It is difficult to understand why such a remedy is not much more fre- quently employed than others which are not near as homoeopathic to the disease. Unfortunately we are without any more specific indications in the use of this drug; all we can do is to recommend it for sudden and rapidly recurring paroxysms, with rapid sinking of strength and paralysis of the spinal nerves. Of other medicines among whose pathogenetic symptoms we have convulsions with loss of consciousness and which have been used 152 Diseases of the Nervous System. with partial success against epilepsy, we mention: Agaricus, floc- culus, Hyoscyamus, Stramonium, Lycopodium, Acidum nitricum, Ra- nunculus bulbosus. The number of remedies that are used for the accompanying ailments of epilepsy, rather than for the disease itself, is so large that an accidental omission of one or the other of them will have to be excused. They will be mentioned when treating of the func- tional derangements of the different organs. Some among the fol- lowing list owe their employment entirely to the crassest empiri- cism ; although we are not disposed to deny their efficacy on this account, yet they certainly do not deserve to be placed in the front rank as homoeopathic anti-epileptic agents. These remedies are: Ar- senicum, Artemisia, Argentum nitricum, Cina, Digitalis purpurea, Ignatia amara, Indigo, Ipecacuanha, Lachesis, Nux vomica, Pulsa- tilla, Stannum, Sulphur, Veratrum album, Zincum, Rana bufo. Some of these remedies enjoy such high repute, as anti-epileptic agents, that it is necessary to mention them more in detail. Ignatia and Nux vomica are among the most prominent. However, the convulsions caused by these medicines are not attended with loss of consciousness, nor are these convulsions in other respects strikingly similar to epileptic spasms; both these medicines occasion only violent reflex-phenomena, whereas in epilepsy the reflex-action is almost completely extinct. Hence these medicines can only be recommended empirically. Hartmann tries to give more definite indications for Nux,but his indications are entirely erroneous; they may indeed apply to convulsions with increased reflex action, but not to epileptic convulsions. Epilepsy may indeed arise from an excess of reflex-action; in such cases these two remedies may be used, if not in the expectation of effecting a cure, at least with a view of palliating the intensity of the paroxysms. Regarding Lachesis Hartmann says that it is regarded as one of the most efficient remedies for epilepsy, provided the recommenda- tions bestowed upon it by its advocates could be implicitly trusted: "The symptoms of the drug, however, are so mixed up, physiology and pathology are thrown together in such a confused mass, that a scientific physician finds it impossible to employ this poison in epi- lepsy without incurring the reproach of frivolity. We, therefore, content ourselves with hinting at Lachesis in this disease, and refer the practitioner who wishes to make use of it to the original trea- tise on this agent." These words do not argue much in favor of Lachesis, and are indeed based upon truth. Lachesis has no con- Epilepsy. 153 vulsions with loss of consciousness; what is recorded concerning it, in those forms of epilepsy for which it is deemed suitable, is not obtained by means of a carefully instituted proving on individuals in perfect health, but has been observed on the sick, hence is en- tirely unreliable. Digitalis deserves a prominent place in the list of anti-epileptic remedies in all cases caused by onanism or excessive nocturnal emissions. There is scarcely a drug that diminishes and even arrests nocturnal emissions with as much promptitude as this one. We have employed it in many cases, and always with marked success. We are in the habit of giving the alkaloid Digitalin., third tritura- tion, one grain every two days. It produces at once a favorable effect in cases of weakness of the sexual organs caused by onanism. The remedies that have likewise to be thought of in such cases are: Phosphorus, Acidum phosphoricum, China, Nux vomica. Artemisia, whose physiological action is still uncertain, owes its reputation to the use that has been made of it in domestic practice; its beneficial results cannot be denied. Rana bufo has more recently been employed empirically rather than otherwise; but it cannot be denied that this agent has evinced decidedly beneficial effects in epilepsy. A young man whom we had been treating for three weeks, and who, in consequence of practising onanism, had become afflicted with daily paroxysms of epilepsy, received a remedy for this disease from a friend to whom it had been sent by a foreign non-professional correspondent with the assurance that a great many had been cured with it. After the first doses, the paroxysms stopped for three weeks, but then returned again because the patient, as was afterwards found out, continued his miserable practice in spite of all admonitions. We learned after- wards that the powders contained Rana bufo in some attenuated form. Observations of this kind bespeak the most careful considera- tion for this agent. [Doctor G. Cook of Buffalo, N. Y., reports the following interest- ing cure of epilepsy in the Am. Hom. Observer: The patient was a girl of thirteen years of age. She was attacked at intervals of seven, ten and fifteen days, usually at four o'clock in the morning, with spasms. The first admonition her mother had of an impending attack was that the girl straightened out in bed and made the noise peculiar to this disease. The face almost immediately became livid and, unless the temples and face were rubbed during the fit, dark purple spots remained for two or three days. After a few minutes 154 Diseases of the Nervous System. the muscles relaxed, and she went into a comatose sleep in which she remained several hours. Felt languid on awaking; head ached, and had a severe pain always at the pit of the stomach, and some- times nausea. She ate nothing for twenty-four hours and then felt nearly as well as usual. At fourteen, the catamenia appeared with- out, however, mitigating or changing the time of the spasms. She was treated allopathically for a whole year without the least bene- fit. Animal magnetism and the Acetate of Copper relieved at first, but the spasms soon returned with the former violence. The doctor now prescribed Bromide of Potassium., two drachms to half a pint of water, a teaspoonful three times daily. Being greatly bene- fited by this prescription, she was given three-grain doses, three times daily at first, and increased until she took ten grains at one dose, all the time improving. These ten and twelve-grain doses were continued until the patient was entirely cured, in about six months. No ill effects have resulted. The patient has remained well eight months, and is now eighteen years old, and appears to be healthy; her intellect is perfectly sound. Dr. Benedict, of the Imperial-Royal Society of Physicians at Vienna, cures epilepsy by means of subcutaneous injections of Curare, on the neck; he uses solutions of the officinal preparation in the proportion of one to sixty, and injects one-eighth of a grain at a time. The injections are thrown in three times a week, and continued from six to eight weeks or more, as the case may be. Dr. Goullon reports a case of epilepsy of long standing, cured with Causticum, 3d atten., giving the medicine every alternate week. (See All. Hom. Zeit., vol. 69.) Hydrocyanic acid is undoubtedly homoeopathic to epilepsy. II.] 2. Eclampsia. By this term we understand convulsions with complete or partial loss of consciousness, which can only be distinguished from epilepsy by the general course of the paroxysm. According to the age and condition of the individual we have eclampsia infantum and eclampsia parturientium. a. Eclampsia Infantum. Although we here class eclampsia among the diseases of the nerv- ous system, yet there is every reason to regard it as a pathological condition arising from some anomaly of the blood, since it affects more particularly the two epochs in human life where the vegeta- tive sphere is very peculiarly circumstanced, namely childhood, and Eclampsia Infantum. 155 pregnancy or rather the period of confinement; and otherwise breaks out only where the mass of blood is altered by the intensity of the morbid process, intoxications, etc. Eclampsia occurs most frequently at an age when epilepsy is least frequent, namely during the first months of infancy until the fourth year. As a general rule, feeble, impoverished children incline most to this disease; nevertheless it is likewise quite frequently met with in well-fed children with apparently robust constitutions. A heredi- tary disposition cannot be denied, in so far, for instance, as children of the same parents may all of them be subject to convulsions, with- out either father or mother being afflicted with them; and likewise in so far as parents afflicted with the disease may transmit it to their offspring. Eclampsia is likewise said to be favored by hereditary syphilis. What is more probable, however, is that the disposition to eclampsia is acquired. This view is sustained by the more fre- quent occurrence of the disease among the poorer classes in the country, who manage their new-born babes in the most outrageous manner, and'feed the children, after they are once weaned, indis- criminately with all kinds of proper and improper articles of diet. More special, etiological causes are: mental excitement of the mother or nurse; the partaking of noxious substances by either, such as spirits, narcotics which are also given to the child in order to keep it quiet. Exciting causes on the part of the child are: morbid condition of the stomach and of the digestive organs gener- ally; dentition; febrile diseases where, however, the convulsions are of no greater significance than is, in the case of adults, the chill at the commencement of serious diseases; cerebral diseases, more par- ticularly cerebral anaemia; helminthiasis. Sy mpUrms mid Course of the disease: Eclampsia sets in with- out any premonitory symptoms only in cases where it constitutes the first symptom of the invasion of some acute disease. As an idiopathic disease it is almost always preceded by preliminary symp- toms. These are: ill-humor, a whining mood, obstinacy, indisposi- tion to play, sudden starting when touched ever so lightly without expecting it; sleeplessness or restless sleep, during which the lids are not entirely closed, with a peculiar twist of the mouth, (risus sardonicus,) gritting of the teeth; change of color from the least cause; crying out without any apparent cause; sudden relinquish- ing of the nipple; uneasy, unequal breathing; sometimes a peculiar livid color around the mouth and eyes, and pointed appearance of the nose and chin. 156 Diseases of the Nervous System. After these premonitory symptoms have lasted for a time which cannot be accurately defined, the actual paroxysm breaks out with the same suddenness as an epileptic attack, only with this difference that the patient utters no cry. Otherwise the attack has all the characteristic features of an epileptic paroxysm. At the beginning the convulsions are generally for some time tonic, after which they become clonic, and, in less frequent cases, affect only one side. The features become distorted, the eyes stare, generally squinting strongly upwards; the body is tossed to and fro, nevertheless the extremities are not as rigid as they are during an epileptic attack. The respiration is very much impeded, spasm of the glottis is not unfrequently present, the abdomen becomes distended. The face either looks blue-red and bloated, with considerable turgescence of the vessels, or else it is pale and sunken; the bodily temperature is rather decreased than raised. During the height of the convulsion the consciousness and sensibility are completely extinct. Usually the paroxysm ends with a deep, moaning inspiration, after having lasted a few minutes or even a number of hours, and the patients sink into a deep sleep from which they wake in apparent health. The paroxysm does not always reach such a fearful degree of in- tensity ; eclampsia as well as epilepsy has a series of gradations, the attack being sometimes marked only by partial convulsive move- ments of the muscles, a staring look with some squinting, risus sar- donicus, etc. The consciousness remains either entirely undisturbed, or is only partially interfered with. Sometimes the attacks consist in a comatose sopor which lasts for hours, with the almost charac- teristic half-closing of the eyelids, and a few convulsive twitchings taking the place of the convulsions; even the face may retain its normal expression and color. A single paroxysm is scarcely ever the end of the trouble. In the first place there generally remains a disposition to relapses, and in the second place several paroxysms usually follow one after the other, the intervals between the paroxysms being of indefinite dur- ation, and the intensity of the attack varying in degree, sometimes increasing, at others decreasing in violence. The intervals are not always free from morbid symptoms, but the phenomena which we have designated as the preliminary stage sometimes continue more or less until the next attack sets in. Altogether the whole duration of the attack is very indefinite. Eclampsia may terminate in recovery, partial recovery or death. The former may take place after any paroxysm, sometimes quite Eclampsia Infantum. 157 unexpectedly, so that a child may be found playing about in the morning which, the day previous, was still the victim of terrible convulsions. In partial recovery some of the symptoms of the attack remain either permanently or disappear only gradually. In such cases it is a question whether such permanently remaining consequences of the attack do not rather originate in some cerebral disease which was likewise the primary cause of the attack. Among such consequences we number paralysis of the muscles of the eyes, less frequently of the muscles of the back, idiocy or only a certain degree of backwardness in the development of the mental faculties, accompanied with an unusual degree of nervous irritability. Death results either during the attack, or else the subsequent coma termi- nates in death. The only disease into which eclampsia may be transformed is epilepsy, in which case it is, however, always diffi- cult to determine whether the original affection was only eclampsia. It is likewise difficult to draw the line of demarcation between eclampsia and epileptic spasms. Nevertheless it is of essential im- portance to distinguish with accuracy between eclampsia and epi- lepsy, both on account of the prognosis as well as the treatment. As a general rule we may take it for granted that, whenever the attack cannot be traced to any definitely exciting cause, the charac- ter of the convulsions is that of epilepsy. This rule, however, is not of uniform validity. The prognosis depends upon many accessory circumstances, and is always rather doubtful. Age is an important consideration; the younger the patients, the more readily they succumb to the attack, more particularly infants at the breast. In hereditary cases the prognosis is decidedly unfavorable. The more rapidly the parox- ysms succeed each other, the greater the danger of a fatal termina- tion, more particularly if they continue to increase in intensity, and the subsequent derangements continue for a long time. The more readily the primary disturbance is quieted, the less apprehension need be entertained regarding the final result. Convulsions setting in at the commencement of the invasion of some acute disease, are scarcely ever dangerous. On the contrary, if the convulsions set in during the course of the disease, they almost always justify the most serious apprehensions; they generally mean death. The danger is greatest in the case of robust and corpulent children. Treatment. As a general rule the treatment of eclampsia is just as uncertain as that of epilepsy, for the reason that we can never be sure whether the paroxysm that had just passed is the 158 Diseases of the Nervous System. end of the disease. A number of paroxysms may succeed each other in rapid succession, in which case, if they stop suddenly, we may feel pretty certain that the disease is cured. On the other hand, the intervals may be of long duration, in which case the certainty of a cure is of course less absolute. On this account it is not enough that the paroxysm should be ended; the subsequent developments of the ease will have to be watched for a time, and the same medicine had Letter be continued for some time longer. In a case of eclampsia the causal indication deserves a much more attentive consideration than in epilepsy, for the reason that in the former disease it is much easier to trace the latter to its exciting cause. Although not in every case, yet in most cases this cause can be determined with tolerable certainty. The sole exceptions are con- vulsions depending upon cerebral affections. Here it may be diffi- cult to arrive at a certain knowledge of the cause. Among children, however, such cerebral disturbances seldom manifest themselves for the first time with the first breaking out of the paroxysm; we gen- erally have had opportunities, previous to the occurrence of the con- vulsions, of obtaining certainty concerning the character and exist- ence of the cerebral disease. Tn all cases it is of importance to direct our treatment against the exciting- cause, so much more as we need not apprehend that the convulsions have become firmly rooted as is the case in epilepsy. In the subsequent paragraphs the reader must not expect to find a record of every remedy that may be indicated by the various exciting causes of eclampsia; their list will be found limited to the most important. To some extent the prophylactic treatment of eclampsia coincides with our previous remarks. That a prophylactic treatment is pos- sible cannot be denied, for it is a notorious fact that children who are attacked with the disease, are brought up in contravention of all natural rules. It is not only a matter of importance that the child should receive the proper nourishment at the proper time, but that the disposition of the child should be managed with becoming attention from the moment of birth. It often happens that in the first years of the child's existence the mother or nurse is subject to its tyrannical caprice, whereas it is afterwards expected to yield implicit obedience to their behests. How difficult it is to induce a mother to insist upon her will being law from the very first moment of the child's existence. If the child cries, it has to be nursed at once, or has to be rocked or carried about. It is such practices as these that make the child restless and headstrong and have a decid- Eclampsia Infantum. 159 edly injurious effect, upon the nervous system. Every child, if other- wise healthy, can easily be accustomed to do without lood at night; a little firmness will readily teach it. Our own experience should admonish us that a night's quiet sleep, uninterrupted by the crying for food, must exert a beneficent influence upon the child. During the day, likewise, little children should be allowed to remain in a recumbent posture, for as long as the muscle - of the back are not strong enough to support the head, children can only be injured by being carried all the time. As a matter of course it is ; roper to try to harden the child within reasonable bounds; above all things it should be remembered that the head must not be kept too warm by an excess of covering. The influence of the first management of children cannot well be demonstrated by numbers, but any one who will take the trouble to inquire, whether eclampsia and various other affections do not occtir much less frequently in families where children are brought up with a reasonable systematic regularity, will find that our condemnation of the faulty management of early infancy is well founded. As a prophylactic measure it is likewise important that the child's mind should not at once be unnaturally excited as soon as the first dawn of a mental awakening is perceived; on the contrary, the child should be left to its own spontaneous tendencies. It is well known that milk drawn from the-breast of a mother or nurse shortly after an immoderate excitement, more particularly anger, has a deleterious influence upon the child; mothers and nurses should never lose sight of this circumstance. Special attention should be devoted to children during the teething period, especially if they have shown a disposition to convulsions at a prior period. The period of dentition acquires additional impor- tance from the circumstance that it generally coincides with the period of weaning, not to mention the prejudices with which the physician has to contend. Lancing the gums is scarcely ever of any use, but may retard the liberation of the tooth in consequence of the formation of cicatrices. We need scarcely add that there are many cases of eclampsia which it is impossible to prevent by treatment. Before mentioning the remedies for this disease, it may be well to inquire whether it is at all proper to administer remedies during the attack. In general we feel disposed to deny the propriety of this sort of medication, more especially in cases where the convul- sions break out suddenly, without any premonitory symptoms. We are not by any means sure of hitting the right remedy, and it is 160 Diseases of the Nervous System. much better not to give any medicine until the attack is over, pro- vided the intensity of the symptoms is not attended with any im- mediate danger, or we wore unacquainted with the primary cause of the convulsions. Hartmann advises to strip the little patients of all clothing, in order to make sure that the convulsion - are not ex- cited by tight dresses or the prick of a pin. Not all the remedies which we shall mention, have among their physiological symptoms convulsions with loss of consciousness. The presence of this symptom which is characteristic of epilepsy, is much loss so of eclampsia. Moreover in a case of eclampsia the medicines can be selected much more appropriately in accordance with the accessory symptoms, without paying particular attention to the character of the convulsions which seldom break out as an idio- pathic affection. Belladonna is without doubt the main remedy for eclampsia; most cases will be found to come within the curative range of this drug. It is particularly indicated in the case of robust and corpulent children with unmistakable symptoms of cerebral congestion. In order to show the correspondence existing between this drug and eclampsia, we here mention the symptoms of four children who were poisoned with Belladonna, which will show how constantly the berries of Belladonna produced eclampsia in these cases: Already an hour and a half after eating the berries the children were attacked with the following symptoms: complete stupor and insensibility; exceedingly restless tossing about in the bed, with occasional shrill cries as if the patients were tormented by great anxiety; frequent chorea-like movements of the arms; bright redness of the face; the pupils are dilated; the reflex motions of the lids are entirely suspended; the eyes stare and look glassy, in one case they were in constant, vibrat- ing motion ; respiration moaning, sobbing; the lower jaw was firm'y pressed against the upper; occasional electrical shocks through the whole body; the head is violently drawn backwards; the urine is voided involuntarily. These symptoms not only are remarkably characteristic of eclampsia, but they occur in almost every case of poisoning with Belladonna, and demonstrate with remarkable ac- curacy the truth of the principle of similarity as a therapeutic maxim; for it will seldom happen that a second attack of convul- sions will occur after the administration of Belladonna. Hyoscyamus acts very similarly to Belladonna. According to Hartmann the indications for Hyoscyamus are: dark redness and bloat of the face, the abdominal walls are firmly drawn in, the Eclampsia Infantum. 161 clonic spasms attack now these and then other parts of muscles, and the attack is caused by fright. Stramoyuum is likewise very similar in its action; the turgescence is considerable, clonic and tonic spasms occur in frequent alternation; the increase of temperature affects the whole body rather than the head. Chamomilla is employed in eclampsia more frequently than seems founded upon scientific accuracy. Hartmann agrees with us in doubting the homceopathicity of this drug to the attack itself; he recommends it for the premonitory symptoms. The question in such cases is, whether the medicine has been of any use. Cicuta virosa deserves our attention in eclampsia as much as in epilepsy; the cases where it is indicated are not so much characterized by spasms, as by the circumstance that the children assume all at once a rigid and immovable appearance, which, after a short period, is superseded by a profound prostration lasting some time and attended with a comatose condition. Opium, as is well known, affects the infantile organism differently from that of full-grown persons. This phenomenon, however, is likewise peculiar to other drugs, such as Belladonna, and has not as yet been accounted for. We are in possession of a considerable number of cases of poisoning among little children, where the fol- lowing effects of Opium are almost uniformly present; the face, lips and eyelids are swollen, the color of the skin is almost violet, the temperature is depressed, especially at the nose and on the extrem- ities; deep coma with convulsions at rather long intervals which are frequently preceded by vomiting; the respiration is slow and ster- torous, the expirations especially are very slow and protracted; the pulse is imperceptible. Attacks of eclampsia with a similar group of symptoms, are not very frequent; the symptoms, taken sepa- rately, point to acute anaemia rather than to hyperaemia of the brain, which latter, in the case of adults, is an almost constant effect of Opium, and which has caused us in previous paragraphs to mention this agent among the list of remedies for cerebral dis- eases. Practical observations have not yet enabled us to determine the cases of eclampsia to which Opium is homoeopathic, and we do not consider Hartmann's advice in this respect as of much use. He considers Opium indicated in convulsions arising from fright when attended with fear. They are supposed to commence with trembling of the extremities, which is interrupted by starting of the body and the extremities, attended with a shrill cry; after a while a sort of sopor overwhelms the child, from which it can- 162 Diseases of the Nervous System. not be roused; such paroxysms are said to break out only at night. Ignatia amara is a much more important remedy for eclampsia than for epilepsy; it is more particularly adapted to cases where the spinal marrow is deeply involved and where the convulsions are chiefly tonic. Such convulsions are frequently met with at the onset of febrile affections; if they are very violent, it is ad- visable to commence the treatment with lomatia, and afterwards to give the remedy more particularly adapted to the disease. Nux vomica holds the same relation to eclampsia as Ignatia. The remedies that have been mentioned so far, except perhaps Opium, correspond to convulsions attended with cerebral hyper- femia. These convulsions are undoubtedly the most frequent; but those which are either dependent upon, or complicated with, an- aemia, such as frequently occur among children in consequence of losses of animal fluids, are undoubtedly of more importance be- cause more dangerous. In such cases Ipecacuanha deserves the first rank. It is to be exhibited before any other remedy, when the convulsions set in after protracted diarrhoea caused by improper or excessive feed- ing, or perhaps by the use of too fat nourishment; the face is pallid or livid, the skin is very cool, or is covered with a cold sweat. Cuprum has already been prominently mentioned as a remedy for convulsions arising from cerebral anaemia. It is one of the most important remedies for this disease even in its most violent and dangerous forms, more particularly if the lethargy continues in the intervals between the paroxysms which follow each other in rapid succession, and if the constitution of the child lias be- come impoverished in consequence of improper or deficient nour- ishment. Conditions of this kind occur most frequently as malig- nant complications towards the end of acute or subacute diseases, such as typhus. Veratrum album is very nearly related to Cuprum; it will prove particularly useful in convulsions caused by rapid losses of vital fluids during an attack of cholera or cholerine, and where the affection sets in in a very acute form. In such cases Camphor may prove serviceable. Platina is likewise recommended by Hartmann as a specific remedy for convulsions arising from anaemia; the consciousness is not suspended ; the spasms are rather tonic, trismus may be Eclampsia Parturientium. 163 present. In this place Arsenicum, Stannum and Zincum deserve particular mention. The last-mentioned remedy has been more recently employed with particular success in cases of eclampsia, more especially if it seems to be symptomatic of some cerebral affection. We would have to add a long list of remedies if we were to enumerate all that have reference to the exciting pathological causes; in order to avoid unnecessary repetitions, it will be more convenient to defer their enumeration until we come to treat of the special functional derangements of the affected organs. If eclampsia ushers in some acute disease, it is scarcely ever necessary to heed the merely transitory convulsions. It is only in case the convulsions should threaten to become dangerous that a specific treatment has to be pursued. In such a case Belladonna and Ignatia would be the most indispensable remedies. The case is different when convulsions occur in the course of acute diseases. Under these circumstances they become so threatening that the treatment has to be mainly directed against the convulsions instead of against the general affection. b. Eclampsia Pariurientium. By this term we understand convulsions that are perfectly similar to epilepsy, and which only occur during pregnancy and parturition or shortly after confinement. This accident is not very frequent, only one case to about four hundred confinements being the general average. At certain periods the disease occurs with more than usual violence without atmos- pheric or other causes being at the bottom of it. As a general rule, the disease occurs during the ninth month, and even at a later period, scarcely ever before this time, never in the first two or four months. The constitution does not seem to exert a peculiar influence in this disease; robust, plethoric individuals are said to be more readily attacked than others of opposite constitutional tendencies. By far the largest number of patients are to be found among the primiparse. The disease most frequently occurs about the time when the os tincse first begins to dilate; next shortly after the ex- pulsion of the foetus. A variety of circumstances are mentioned as etiological causes of the disease, whereas more recently Frerichs has pointed out Bright's disease of the kidneys as the only cause of the convulsions. This question, however, is not yet decided. It is true that eclampsia most frequently attacks women afflicted with 164 Diseases of the Nervous System. albuminuria; but whether this is a symptom of Bright's disease is questionable, for the reason that, if the patients recover, the symp- toms of albuminuria very speedily disappear, which would not be the case if the kidneys were organically diseased. At all events, it is certain that albuminous urine, with oedematous swellings, always augurs badly for parturient females, and very frequently results in the occurrence of convulsions. On the other hand, it is an admitted fact, that these convulsions may occur without the albuminuria and oedema. Proximate causes are: disproportionate dimensions of the sexual organs and the foetus, rigidity of the uterine fibres, excessive labor-pains, hemorrhage, retention of remnants of the placenta, ex- cessive mental excitement. When occurring during confinement, convulsions generally imply the commencement of an inflammatory uterine affection. Sumptoms. In many cases, but not as a rule, the true par- oxysm is preceded by precursory symptoms. The head is heavy and dull, a violent headache is frequently present; the patients show signs of mental hebetude, the'memory is impaired ; photopsia, even transitory blindness, buzzing in the ears, sensation of some approaching danger, unsteady gait, heaviness of speech, dulness of mien, attended with strikingly glistening eyes, heat about the head, painfulness of the uterine region: these are the leading phenomena from the presence of which the outbreak of convulsions may be prognosticated with a tolerable degree of certainty, more par- ticularly if eclampsia had existed during former confinements, or if the urine contains albumen, cylindrical casts, etc. The precursory stage may last indefinitely from a few minutes to some days. The paroxysm itself is very much like epilepsy, generally, however, the peculiar cry and the falling down, as if the patient were struck by lightning, at the outbreak of the convulsions are wanting, suddenly the patients become quiet and close their eyes. Very soon peculiar muscular movements are seen in the face, the eyelids are rapidly opened and closed, the eyeballs are turned in every direction, the pupils are dilated and become immovable, the muscles of the mouth begin to twitch, the lips are drawn to one side, the tongue is pro- truded between the teeth. The clonic spasms now extend to the neck which is often stretched with an extraordinary rapidity or bent to one side; then to the arms which first tremble and then are jerked out; the lower extremities are not so much affected and remain rigidly extended, they are only slightly moved to and fro. At every increasing paroxysm the respiration becomes more im- Eclampsia Parturientium. 165 peded, it consists of mere sobs, becomes irregular, is even suspended for a short period, the movements of the heart likewise become irregular. In consequence of this interference with the action of the heart and lung's the vessels of the head and neck become turgid. In the midst of these changes the whole body sometimes starts as if struck by some electric shock. After these violent clonic spasms have lasted for some minutes, there is an apparent interval of rest, during which a complete tetanic rigidity prevails with the most diversified contractions of the limbs. For a short time the respira- tion ceases entirely, the heart works very irregularly, its beats fre- quently intermit, the skin becomes covered with a cold perspira- tion, and the discharges from the rectum and bladder are frequently involuntary. This rigidity continues for about half a minute, after which all the phenomena gradually decrease in intensity. The con- vulsive movements become less frequent, the breathing and the action of the heart become more normal, and lastly a general relax- ation takes place with which the patients lapse into a soporous con- dition. According as the paroxysms are more or less frequent and violent, this stage has a longer or shorter duration, and may even continue for three days. The consciousness gradually returns, and derangements of the senses or mental faculties sometimes remain for some time after the attack. Headache generally lasts longest. Eclampsia either terminates in complete recovery, or in other dis- eases, or death. Death seldom takes place during the convulsions, or, if it does, it is caused by cerebral apoplexy; more frequently it occurs during the stage of.sopor, likewise in consequence of cerebral apoplexy; or it is caused by acute oedema of the lungs consequent upon the violent interference with the action of the heart and lungs. The affections consequent upon eclampsia generally relate to the functions of the brain: they are mania, idiocy, loss of memory, amaurosis, deafness, or muscular contractions and paralysis. Very frequently puerperal inflammations have resulted after an attack of eclampsia. Complete recovery never takes place suddenly, but more or less gradually. The effect of the convulsions upon parturition differs according to the period when the accident takes place. If it takes place dur- ing pregnancy, uterine contractions are excited by the convulsions and miscarriage takes place. If they take place at the commence- ment of parturition, the act is considerably delayed in consequence, whereas if they take place towards the end of the act of parturition, the expulsion of the foetus is considerably hastened in consequence. 166 Diseases of the Nervous System. If taking place after parturition, the uterine contractions are gen- erally arre ted, which may lead to metrorrhagia, retention of frag- ments of the placenta and consequent inflammatory affections. Par- turition influences the convulsions, in so far as they never cease en- tirely until the uterus has been entirely freed from its contents, and may even continue with less intensity for hours after the birth of the child. The influence upon the foetus is not necessarily fatal; according to Scanzoni about one-half of the chidren who are born in the midst of convulsions die; the shorter the period between the occurrence of the convulsions and the termination of the act of par- turition, the less the danger to the child. The prognosis is very uncertain. The disease is one of the most dangerpus, and becomes so much more dangerous as it may develop equally dangerous diseases. If the convulsions occur at a very early period, the danger to the patient is so much greater. The later they occur, and the greater the chances of a speedy delivery, the better the prospect of a successful issue. Of course the degree of intensity of the convulsions is likewise to be carefully considered in establishing a prognosis. Treatment. Hartmann introduces his remarks concerning the treatment of this disease with an inquiry whether it is rather a dis- ease of the blood or the nervous system. This point is not yet set- tled, and, in the present state of our Materia Medica, is of very little importance. We have slightly alluded to it in a previous paragraph. Of far more importance is his advice not to leave a patient who had been attacked with convulsions, until the action of the heart and lungs has resumed its normal character, and, by this means, to pre- vent any improper interference on the side of the family, and to obtain a satisfactory certainty that the process of parturition is developing normal phenomena. Ko remedy responds to this disorder as completely as Belladonna. The fact, says Hartmann, that it is repeatedly mentioned in the most diversified forms of disease, should suffice to satisfy beginning practitioners of Homoeopathy of the importance of this medicine; and to invite them to study its physiological effects with an in- creasing care and accuracy, until their leading characteristics have become well defined to the general comprehension, and may be relied on as safe guides in the selection of this drug. That the action of Belladonna is similar to a paroxysm of eclampsia and has, moreover, a special affinity to the condition of a parturient female, is not only shown by our Materia Medica, in spite of the incoherent arrange- Eclampsia Parturientium. 167 ment of its symptoms, but may likewise be learned from any recog- nized toxicological treatise. Moreover it is an admitted fact that Belladonna acts more penetratingly upon the .organisms of children and women, and is more particularly adapted to the latter class, if the circulation of the blood is prominently active. The curative effects of Belladonna in this disease have been practically illustrated in a number of cases, and we may rely upon this agent with perfect confidence in cases where our Old-School brethren have to resort to the most heroic and most pernicious treatment. Although both Ilyoscyamus and Stramonium are intimately re- lated to Belladonna in this disease, yet we believe that both these remedies are effectually superseded by the last-named agent. The difference which Hartmann has indicated between these two medi- cines, does not seem to us founded in fact, and of difficult applica- tion in practice. Aconite exhibits likewise among its toxicological effects a complete series of the symptoms of eclampsia, more par- ticularly an alternate change from clonic spasms to tetanic rigidity, and may have to be resorted to, more especially if the convulsions set in subsequent to parturition, and will have to be regarded as symptomatic of an inflammatory puerperal disease. [An admirable medicine in puerperal convulsions is the Bromide of Potassium in larve doses, which is now beo-innino- to be uni- versally used by American as well as European homoeopathic prac- titioners. It will often prove efficacious where Aconite, Belladonna or any other medicine, seem to be powerless. Some interesting cases of cure of this frighttul malady by Gelseminum sempervirens have been published by Dr. Douglas, of Milwaukee, in Lodge's Observer. See also Hale's New Remedies, second edition, pages 444 to 448. H.] Concerning Opium Hartmann offers the following remarks which deserve to be transcribed literally: "Opium seems to me, some- times, like a veiled Goddess; I perceive general outlines, but sharply marked features, pointing to some definite characteristic sphere of action, are entirely wanting. Hahnemann's observation that Opium can only be used with success in recent and shortly- lasting disorders, has only contributed to darken, instead of clear- ing up, the clouds hanging over the curative sphere of Opium. We can hardly suppose that physicians have been wrapt for thou- sands of years in a maze of illusions concerning Opium, without ever dreaming that this agent has a very equivocal therapeutic action! And what brilliant cures have not been accomplished by means of Opium! No, indeed! Hahnemann's assertions regarding 168 Diseases of the Nervous System. Opium are of the same paradoxical character as so many other views, opinions and notions of his, that had not yet become settled in his mind, and which he either favored or rejected according as they agreed or disagreed with his purposes; if he was unable to loosen the Gordian knot, he cut it with an authoritative assertion. Opium fared similarly in his hands; his provings of this agent did not develop any symptoms of pain, and hence he decreed: Opium does no* cure pain! He took many Opium-symptoms from old authors who had observed them in Opium-eaters, and had found that the continued use of this drug develops, even in young people, symptoms that bear a close resemblance to the ailments incident to old age; hence his decree: Opium cures the ailments incident to old age! The long-continued use of Opium causes nervous irritability to such a degree that Opium-eaters start at the least urprise; hence he decreed: Opium removes the bad effects of fright I It is easily seen that morbid conditions of this kind are not obtained by means of regular p:ovings on persons in health, but in consequence of the long-continued and energetic use of the drug, as is the case with a number of others; but then it is wrong to infer that the medicine can only be properly used for a very limited number of symptoms, for the reason that it is only capable of occasioning a small number of ailments which are, moreover, of a very general character. In such cases the medi- cine, if it is experimented with for a sufficient length of time, will undoubtedly develop a number of fine symptoms that may prove highly valuable in the treatment of diseases. Of course we must not obstinately and foolishly reason in this wise: Because many drugs will cure diseases when administered in high attenu- ation, therefore all drugs will be capable of accomplishing the same result. By no means; one medicine will cure in small doses whereas other medicines may have to be given in larger quantities. Opium belongs to this latter category. It will scarcely ever prove efficient in the tenth, twentieth or much less in a higher potency, but will almost always have to be given in larger doses, without forfeiting, on this account, its position as a homoeopathic agent. Not till I cut myself loose from Hahnemann's decree con- cerning the normal dose, did I learn to make a correct use of many medicines, and even Opium has enabled me to do a great deal of good with it, which will ever remain inaccessible to those who swear by the words of the Master. In eclampsia, Opium is an admirable remedy in the case of robust parturient females when Eclampsia Parturientium. 169 the attack was, perhaps, excited by a sudden fright or even an unexpected joyful event during the process of parturition. Even if the effects of Opium were only palliative, the medicine would still be of inestimable value, for the reason that the disease only has a few paroxysms which the physician is called upon to hush in order to save two lives; a protracted treatment is anyhow un- necessary inasmuch as the exciting cause of the disease is only of short duration, and the circumstances which favor and feed the pathological process, very soon disappear. I am not able to furnish a list of the special symptoms the presence of which is necessary to justify the use of Opium in this disease; the reader will have to contrast the symptoms of the case with those of the Materia Medica, and will perhaps feel grateful to me for giving him now and then an opportunity of depending upon his own judgment, instead of being held in leading-strings by another whose advice, after all, may be fallible like that of other mortals." To these words of Hartmann we will add the following remarks: Under allopathic treatment Morphium aceticum is considered the only reliable remedy for eclampsia, but it is given in such enor- mous doses-Scanzoni gives one-sixth to one-fourth of a grain every half hour, together with injections of twenty to thirty drops of the tincture of Opium-that it seems almost criminal to pursue such a course of treatment. The disease is, of itself, very apt to superinduce mental derangements, and the medicine may cause a chronic loss of memory. Unfortunately we have no statistical data to show that mental derangements are more readily, more frequently and more permanently caused by the allopathic use of Morphium than by the use of this agent in homoeopathic hands. Large doses of this drug should never be given by a homoeopath at the commencement of his treatment, they should only be re- sorted to as a last resort. Of Laurocerasus we have no clinical records as far as we know; if it should be used, it will be necessary to administer it in com- paratively large quantities. Of other medicines belonging to the present list, the most important have already been mentioned in the chapter on eclampsia. Digitalis may be found useful more particularly if hemorrhages are present; if not indicated at the commencement of the paroxysms, it may be an appropriate remedy for the subsequent derangements. Of great importance to the successful treatment of eclampsia is the correct management of the process of labor. Scanzoni gives 170 Diseases of the Nervous System. the following advice bearing upon this point: If the convulsions occur during pregnancy without causing labor-pains, artificial delivery is only justified in case the spasms steadily continue to increase in duration and intensity, and the life of both mother and child is threatened. If the parturient woman is already dy- ing, it is better to perform the Cesarean section immediately after her death than to resort to a forced delivery, because the latter jeopardizes the life of the child much more than the former. If, at the onset of the disease, the os tincae is sufficiently dilated and there are otherwise no counter-indications, the forceps may at once be resorted to; this should, however, be avoided if labor has so far advanced that a few more pains will accomplish the ex- pulsion of the foetus. If the paroxysms continue after parturition, the placenta should be removed as soon as possible. As regards the sanguineous depletions which are so universally recommended in this disease, we will express our opinion in a few words. Not unfrequently eclampsia is the result of hemorrhages or causes them; how then are we to account for the fact that sanguineous depletions can be of any benefit in this disease ? Or what pos- sible explanation of the use of depletions can at all be given in this disease? How can the usefulness of such depletions be main- tained when so many other heroic remedies are employed at the same time? The usefulness of a remedial agent cannot be prop- erly contended for until it has produced satisfactory clinical re- sults, without its action being obscured by a combination with other drugs. As regards the dietetic treatment of eclampsia, it seems to be unnecessary to go into details. Such patients require the same nursing as any other women whose confinement is perfectly free from untoward complications. All excesses of any kind should be carefully avoided. 3. Chorea. By chorea we understand spasmodic movements of the voluntary muscles taking place contrary to the will of the affected individual. It has different names: Chorea St. Viti, Choreomania, Epilepsia saltatoria, St. Vitus's dance. Chorea is a disease of the latter years of childhood. It is very seldom seen previous to the sixth year of age, rarely after the fif- teenth, it occurs most frequently between the tenth and four- teenth year. Females and individuals with very irritable nervous Chorea. 171 eystems are more particularly inclined to this disease, whereas the bodily constitution otherwise seems to be without any influence over the disease. The etiological causes are involved in obscurity ; one fact is well ascertained: the disease occurs most frequently dur- ing the second period of dentition and at the age of pubescence. Other exciting causes are: a desire to imitate (in some cases the habit of unusual motions has led to the disease) emotions, espe- cially fright, helminthiasis, onanism. It is frequently, met with among individuals with tuberculous constitutions, or with strik- ingly developed chlorosis. The classification in chorea minor and major is altogether founded upon the degree of intensity of the morbid phenomena, and is so much more unimportant as the two degrees frequently pass from one into the other. For this reason we have taken no special notice of this classification in the present instance. Symptom* and Course. A preliminary stage, properly speak- ing, seldom occurs in chorea; what has been considered as such, generally has already the peculiar character, the involuntary mo- tions of chorea. At first the patients show a certain unsteadiness in their movements, and an unusual hurriedness; these symptoms are accompanied by a certain depression of spirits and irritability of temper, which may, however, result rather from the rebukes which the child receives on account of its apparent carelessness in handling things. It is only after some time that the child's parents become aware of the existence of some nervous disorder. After the symptoms have become more fully developed with a more or less gradually increasing intensity, a real paroxysm suddenly breaks out. It is generally excited more immediately by some violent emotion, fright for instance. The involuntary motions now begin, being either confined to single bundles of muscles or affecting the whole muscular system, in such a manner that the upper extremi- ties are more violently affected than the lower. The face shows every possible contortion, even the eyeballs are rolled about in every direction; the arms and hands are at times flexed, at other times extended ; objects can no longer be held firmly, the patient is no longer able to eat alone, or else has to bring the food to his mouth by a very circuitous route; the gait becomes unsteady be- cause the legs can no longer be put down with sufficient steadiness, and even the strength is wanting to keep them straight. Not all the limbs are always affected together; sometimes only those on one side are affected, sometimes only the arms or the face, very 172 Diseases of the Nervous System. rarely the lower extremities alone. A striking feature of the dis- ease is that the movements become so much more violent the more steadily the patient fixes his attention upon them. Eating seems likewise to exert an aggravating influence upon chorea. If the disease increases in intensity, the spasms which, in a milder degree, are continuous, often occur in paroxysms, and with various but distinct symptoms of impairment of the mental func- tions, sometimes even with total loss of consciousness. The move- ments now assume the form of strange leaps, dancing, turning or rolling the body while the patients utter the most varied sounds, sing, laugh and even roar like wild beasts. The intervals between the paroxysms are scarcely ever free from all spasmodic symptoms: on the contrary, the phenomena which we have designated as the milder degree of chorea, continue. If the disease lasts for a length of time, the assimilative functions suffer, and even febrile symptoms make their appearance. Sleep is impaired ; on account of the mus- cular spasms the patient is prevented from falling asleep; during sleep all abnormal movements become suspended. It is peculiar to the disease that even excessive muscular motions do not fatigue the patients. On the other hand they do not unfrequently complain of pains in the joints which generally increase in bed, and, in a measure, are most likely excited by the spasms, but may likewise be felt in parts not affected by the convulsions. A sensation of numbness and formication in the limbs is not caused by the attack itself. To- gether with the assimilative functions the mental faculties become depressed ; the teasing character of the disorder renders the patients exceedingly irritable, dejected and peevish, or even disposed to fits of rage. This is so much more to be deplored as these ebullitions of temper are apt to provoke an attack. After a gradual increase of the symptoms, the disease reaches its acme, where it remains stationary for a period, lasting a few weeks or even several months, and sometimes terminating in recovery either quite suddenly or only gradually. The cases where the con- vulsive motions become habitual, are very rare, yet single derange- ments are very apt to remain, such as partial paralysis, decrease of the mental faculties, general weakness of the limbs. Death is a rare termination of the disease. A great tendency to relapses gen- erally remains, on which account the patients have to be carefully guarded. That injuries, even fractures, may occur during a violent convulsive paroxysm, is self-evident. According to what we have said, the prognosis is almost always Chorea. 173 favorable; even if the convulsive movements outlast the genuine chorea-paroxysms, they likewise disappear after a while. Where the convulsions denote the existence of a cerebral disease, the prog- nosis depends, of course, upon its own nature and importance. Treatment. Inasmuch as most cases of chorea generally get well of themselves, although the process of recovery may proceed very gradually, it is always advisable not to interfere too busily with violent means. Reports of cures with medicinal agents should be received with a great deal of caution; a great deal of experience is required to determine whether a case of chorea has yielded to the medicines employed, or whether the disease has terminated spontaneously. Hence we shall only furnish very brief indications regarding the drugs that are adapted to this disease. Cuprum metaliicum is one of the leading remedies in this disease. Unless the existing symptoms contraindicate its use very decidedly, this drug will generally deserve our first*consideration. This agent has sufficed in our hands to cure most cases of chorea; under its use the disorder continued very rarely longer than three or four weeks. It is, however, more suitable to chorea minor than chorea major; in this latter form of the disease the violent symptoms which characterize the paroxysms, may require some other remedy before Cuprum is employed, until the spasms are mitigated and have assumed the milder form of chorea minor. Stramonium is more particularly indicated if the whole body is involved in the spasms and the patient is compelled to perform the most grotesque leaps, dancing motions, etc., and at the same time utters the above-described peculiar sounds. According to Hart- mann, Stramonium is indicated by the following symptoms: The attack is for some time preceded by formication and a feeling of weight in the extremities, attended with melancholy mood. The disorder inclines to break out about the equinoctial periods, and the convulsions have the characteristic feature of affecting the parts of the body crosswise, for instance the left upper and the right lower extremity, whereas the two other extremities remain unaf- fected; on the other hand, the muscles of the head and neck are very much agitated. Altogether Stramonium has a number of symptoms that point to chorea. According to Hartmann it has likewise a good effect in the mental derangements remaining after chorea. Here too we cannot forbear to range Belladonna and Hyos- cyamus side by side with Stramonium, only that the last-mentioned drug seems to be more adapted to chorea and the two former to 174 Diseases of the Nervous System. eclampsia. Belladonna is moreover said to deserve more especial consideration if the flexor muscles are particularly affected. Ignatia amara deserves mention in this affection, probably with more propriety than in any of the previously mentioned diseases. It is more particularly indicated by the following general consider- ations: The disorder is caused by fright or by some violent mental agitation; the attacks are worse after eating, and abate when the patient lies on the back; the patient is very irritable and peevish. Hartmann is of opinion that many cases of chorea major have been cured with Ignatia with a remarkable rapidity, that were mistaken for epilepsy by the attending physician. The diagnosis, however, is scarcely ever so intricate that the misapprehension could have lasted for a long time; it is more likely that such pretended cures of epilepsy were rather so many cases of eclampsia instead of chorea. At all events the therapeutic value of Ignatia is not impaired by the fact that it is equally curative in affections which resemble each other so closely. Zincum. We do not understand why Hartmann has not men- tioned this drug in his list of chorea-remedies. Zincum enjoys a well-earned reputation against chorea; the cures of this disease which have been effected by the use of Zincum, can all be traced to the homceopathicity of this agent to the chorea-spasms. Homoe- opathic physicians likewise have employed this agent with success. It is particularly indicated where the convulsions are attended with a deep feeling of illness and the mind is very much depressed. A merely superficial glance at the symptoms of Zincum will at once show that it deserves our attention in chorea, more especially in the minor form, and is pre-eminently suitable in the subsequent morbid changes of the mind. Beside the above-mentioned remedies the following have likewise been employed or recommended: Asafoetida, Secale cornutum, Cina, Crocus, Graphites, Rhus tox., lodium, Pulsatilla, Sulphur, China, Cocculus. We cannot afford the space to furnish all the particular indications for the use of each of these agents, nor does this seem necessary, since a case will scarcely ever present itself where these remedies may have to be used. If after the termination of the more violent spasms, convulsive motions of single parts of muscles remain for some time, or if such remnants of the disease are for the first time entrusted to our pro- fessional care, the result of our treatment will always be more or less doubtful and uncertain. The remedies which have to be used in Chorea. 175 such cases, and always at rather protracted intervals, are: Cuprum, Causticum, Graphites, perhaps also Cocculus, tox. A proper hygienic and dietetic regimen should not be lost sight of. In chorea the selection of the remedial agent is less dependent upon accompanying complications and determining circumstances than in eclampsia and epilepsy, for the simple reason that chorea is a much less important disease. On the other hand it is of great importance to consider existing complications in case of relapses or where relapses are tolerably certain to occur. Three conditions have to be more particularly dwelt upon. First, the age of pubescence and its but too frequent accompaniment: onanism. It is often dif- ficult to exert a controlling influence in this particular, for the reason that we do not always succeed in obtaining a frank confes- sion from the patients. Nevertheless, an absolute cessation of this horrid practice is indispensable to a cure; onanism causes that general irritability of the nerves, and the deficiency of mental energy by which the original disease as well as relapses are excited. Anaemia is another important complication; it occurs but too fre- quently, even before the age of pubescence, and is undoubtedly pre- maturely excited by self-abuse, Lut may likewise owe its existence to other circumstances that will be mentioned in subsequent para- graphs. The third and worst, although not the most frequent com- plication, is tuberculosis. In a case of chorea we should investigate the existence of tubercles for this additional reason that convulsions very often constitute the first striking symptom of tubercles which it may be possible to cure at such an early age. When giving special indications, we shall mention the remedies that are suitable to such conditions. To the aforesaid three determining causes we may add a fourth, namely a morbid irritability of the nervous system gener- ally. We admit that this may be hereditary; but in most cases it is the result of a faulty education. Premature mental efforts, ex- citement of the imagination while condemned to a sedentary mode of life, are the great defects of our modern systems of education and the direct causes of the excessive nervousness which has be- come fashionable among the young ladies of the higher classes and is one of the principal causes of the many weaknesses with which our young women are more than ever afflicted, ansemia, tubercu- losis, convulsions, etc. A long chapter might be written on this theme. To what extent a morbid nervousness-not to mention the desire of imitation inherent in all children-predisposes to convul- sions, is shown by daily experience without having to quote Beer- 176 Diseases of the Nervous System. haave as authority for this statement. In one of our young ladies' seminaries for the higher classes, spasmodic attacks, especially dur- ing the hours devoted to prayer-meetings, constitute a rule; scarcely ever a case occurs singly, generally several at once. From what we have said, the measures that will have to be taken in order not only to cure or prevent chorea, but many other ail- ments attendant upon this disorder, may easily be inferred. Relapses may likewise be prevented by such measures. Premature mental development, or too great a variety of mental labor, or too persistent a strain on the mental faculties, should be prevented not only in the case of older children but likewise of those who have entered upon the period of their second teething. An excessive activity of the fancy should be prevented by every possible means. A proper development of the muscular powers and exercise in the open air should be well attended to. Gymnastic exercises are the best means for this purpose: they not only strengthen the body, but likewise invigorate the mind. Such exercises are not only a preventive means, and excellently adapted to the cure of subsequent ailments, but they likewise render efficient service against the convulsive movements themselves. In France especially they have been vari- ously employed with a great deal of success in the treatment of chorea, sometimes in connection with music, either on account of the influence of the rhythmical measure, or because music has a strikingly beneficial influence over a number of such patients. Gymnastic exercises are particularly advisable in cases where auto- matic movements of sinofle muscles threaten to remain and to o become chronic. [In recent cases of chorea, Aconite and Gelseminum are the best remedies that can often be used. A case of chorea of the left arm that had remained after pneumonia of the left lung, the patient, a girl of ten years, having been treated allopathically, yielded at once to a few doses of Aconite. A case of chorea of the upper ex- tremities in a very scrofulous child, and having come on spontane- ously, was speedily cured by means of a few doses of the tincture of Aconite in water. A case of the lower extremities brought on by fright, yielded with equal promptitude to the tincture of Aconite. A terrible case of chorea was cured with Phosphoric acid. The patient was a girl of ten years. For some time she had allowed things to fall out of her hands, cups, plates, etc., which the parents attributed to carelessness, and for which she was duly scolded. Catalepsy. 177 Gradually the spasms began to set in with increasing violence. Every part of the body, from the head to the feet, became •affected. The convulsions were frightful to behold. The patient had to be strapped to her bed. She was scarcely able to swallow a drop of liquid. The spasms lasted uninterruptedly day and night. She was utterly unable to articulate a single word. The patient was brought to town from the country, when I had a fair chance to examine her. I had been trying various remedies without success. As soon as the patient had arrived in town, I examined her urine and found it loaded with albumen. She now was placed upon the officinal Phosphoric acid, beginning with five-drop doses three times a day, and gradually increasing the dose; after taking the acid for six weeks she was completely restored to health. An improvement in her condition became perceptible already on the second day of this treatment. H.] 4. Catalepsy. We mention this disease which has remained enveloped in a mysterious obscurity up to this moment, in order not to be accused guilty of a sin of omission. By catalepsy we understand a condi- tion during which the consciousness and the voluntary mobility of the muscles become suspended, though they retain the faculty of passive motion. There are but few well established cases of this affection on record; a most striking case is the one in Skoda's Clinic in the winter of 1851 to 1852, which we had an opportunity of witnessing*. It continued for months and was the most interest- ing phenomenon in the large hospital. A detailed description of this case may be found in the " Zeitschrift der Gesellschaft cler Aerzte in Wien,'' vol. VIII., 1852. A second undeniable case oc- curred in our own practice; the patient was a lady who had been magnetized. Skoda's case likewise is said to have originated in magnetism. As an accompaniment of other affections, when it is generally of short duration, we meet the cataleptic condition in epilepsy, eclampsia, hysteria and other diseases of the general nervous system. It will scarcely ever be necessary to institute a medicinal treat- ment against this disease; such a treatment must always be uncer- tain, because it is impossible to determine how soon the cataleptic condition might have terminated spontaneously. Skoda's report of his case embodies everything that was done for the patient, but 178 Diseases of the Nervous System. fruitlessly. Cataleptic patients may be safely left without treat- ment, for the reason that no case of catalepsy, to our knowledge at least, has as yet terminated fatally. The greatest difficulty in chronic cases is the impossibility to induce patients to swallow; in- jections and the stomach-pump have to be resorted to. 5. Tetanus and Trisinns. By the term tetanus we designate tonic spasms of the voluntary muscles of more or less extent, without the consciousness being suspended; by the latter term we designate a tonic spasm of the muscles of deglutition. Tetanus is more particularly a disease of hot climates, but is like- wise frequently met with in our own climate, more particularly as trismus and tetanus neonatorum. Its main causes are wounds, especially such as are complicated with contusions, and are located on the extremities or in the face. It is not quite certain whether it is indispensable to the supervention of tetanus, that a nerve should be ligated, torn or involved in a cicatrix. Tetanus may undeniably be caused by sudden and violent exposure to a keen wind and other catarrhal influences. This form of tetanus has been termed rheu- matic, in contradistinction to the traumatic form. Tetanic convul- sions do not often, like eclampsia, occur at the onset of violent diseases, such as typhus and contagious exanthemata. Robust individuals, and men generally, are more readily attacked by the disease. Symptoms and Course of the disease. The convulsions are generally preceded by some slight premonitory symptoms, generally of a rheumatic character, on which account they are confounded with rheumatism so much more easily as the patients generally complain of having taken a violent cold. Side by side with slight febrile symptoms the patients complain of stiffness of the nape of the neck, difficulty of deglutition, drawing and tearing pains in the extremities. If there is a wound, it generally assumes a bad look. Either gradually and with paroxysms of rigidity of single muscles, or else suddenly the tetanic convulsion sets in with a violent shock, at times invading the whole body, at other times single localities, particularly the dorsal muscles, the muscles of the jaws, and the extensor muscles of the extremities. In the more violent and more extensive cases not all the muscles are seized at once, generally the spasm progresses from above down- wards. The picture of a case of this kind is furnished us with Tetanus and Trismus. 179 every epileptic paroxysm; in tetanus, however, the face, in conse- quence of the extraordinary stretching of the muscles, assumes a still more frightful aspect. Owing to the contraction of the dorsal muscles the back is at times bent backwards, (opisthotonos,) or laterally, (pleurothotonos,) or forwards, (emprosthotonos,) or is stretched erect, (orthotonos,) according as one or the other mus- cular locality, or all the muscles together, are invaded by the tetanic spasm; as a general rule, opisthotonos is the most frequent form. Most usually the posterior cervical muscles first become rigid, after which the trunk and lastly the extremities are seized. In propor- tion as the phenomena increase in intensity, the respiratory and ab- dominal muscles, and the muscles of deglutition likewise become involved in the attack ; convulsions of the last-named organs render the attack particularly dangerous. In cases which run a rapid course, death takes place by asphyxia, and in cases running a less rapid course, death takes place in consequence of starvation and deficient oxygenation. For the more violent the paroxysms be- come, the more easily the least motion excites them, so that it be- comes utterly impossible for the patient to swallow; even all arti- ficial introduction of food has to be abandoned. From the very beginning of the paroxysm the muscles are perfectly rigid and remain so; nevertheless exacerbations and more or less distinct remissions take place, the latter becoming shorter and more and more incomplete in proportion as the convulsions increase in inten- sity. The contracted muscles are exceedingly painful, and every new attack often increases this painfulness to an extraordinary de- gree. Otherwise, so far as the body generally is concerned, no mor- bid phenomena of any consequence can be perceived. The skin is cool, the pulse is not more rapid, but harder, the patients experience hunger and thirst, alvine evacuations take place, the conscious- ness remains unimpaired; only sleep is disturbed, the exhausted patients only slumbering now and then for a few moments ,at a time» As the convulsions increase the pulse becomes more rapid, smaller, intermittent., the symptoms of sopor become more and more prominent, probably in consequence of the stupefying action of the carbonic acid gas which, owing to the impeded respiration, is no longer neutralized by the atmospheric oxygen; the tongue becomes dry. Tetanus most generally terminates in death. It either takes place at the very beginning in consequence of sudden suffocation (spasm of the glottis,) or in consequence of acute oedema of the lungs, or sometimes in consequence of cerebral apoplexy. Or if the 180 Diseases of the Nervous System. disease lasts any time, the patient dies of asphyxia by carbonic acid gas, starvation and thirst. Recovery is always gradual, sometimes taking place with copious sweats; the paroxysms iirst become shorter, less violent and frequent, and the muscles gradually lose their rigidity. Weeks, however, may pass away before this mus- cular rigidity disappears entirely, and an equally long period of time sometimes elapses before the patient recovers his strength. If the disease terminates fatally, it may last from one day to three weeks, but in most cases death takes place on the third day. In traumatic tetanus the prognosis is generally unfavorable. Tetanus neonatorum is essentially the same disease as traumatic tetanus, from which the former is distinguished only by the pecu- liar features of infantile age. The cutting and tying of the umbil- ical cord here takes the place of the wound. That this is really so, cannot be doubted; the accident generally takes place in the first week of the child's existence, and the umbilicus is almost always found in a state of suppuration and discoloration. In the form of trismus the disease is likewise, though seldom, met with among older children. In the case of children the symptoms vary somewhat from those of adults. In the case of infants likewise the disease seldom begins all at once; in the first place the infants lose their ability to nurse, although the hurried manner in which they seize the nipple, be- trays hunger; they have a sick and sunken appearance. Derange- ments of the digestive functions are not always, but generally pres- ent. In a day or so the paroxysm sets in with rigidity of the mus- cles of deglutition, in consequence of which the lower jaw becomes immovable although not firmly pressed against the upper, from which it remains separated by a narrow interval. The tetanic rigidity now gradually spreads from above downwards, the same as in traumatic tetanus; however, it is frequently mingled with paroxysms of convulsive starts resembling violent electric shocks. At first the attacks are short, with intervals which frequently last for days; but the former keep constantly increasing in duration whereas the latter are as constantly growing shorter. Death takes place more or less rapidly by starvation and impeded respiration. The prognosis is much more unfavorable than in the tetanus of adults. Treatment. To judge from the paucity of the cases of tetanus which are recorded in our literature, homoeopathic practitioners have had but few cases of this disease to treat. We have reports Tetanus and Trismus. 181 of cases where tetanic symptoms were present, but of genuine tetanus we have only one case recorded by Bethmann in the tenth volume of the "Allg. Hom. Zeitung." If a case should occur in our practice, we should rely upon the curative effects of Nux vomica and of such other medicines as contain Strychnine. The similarity of the poisonous effects of Strychnine to tetanus not only extends to muscular rigidity and to the extraordinary increase of reflex action, but even to the most trifling circumstances. The spasms of Nux vomica have distinct intermissions which grow shorter and more indistinct in proportion as the paroxysms occur more frequently and with more violence. The respiration is very much interfered with; the sensibility and the mental functions remain intact. The effects of Nux generally correspond equally fully to single organs and systems. According to these statements Nux vomica must be an ex- cellent remedy in tetanus, if there is any truth in the homoeopathic law. We do not deny that there are other remedies homoeopathic to tetanus, but many of those which are mentioned in manuals and repertories, are undoubtedly very doubtful. The characteristic phe- nomena of the disease have to be found in the pathogenesis of the drug, otherwise its choice would not be justifiable; in tetanus these characteristic phenomena are the rigidity of the muscles, the in- crease of reflex action and the preservation of the consciousness. Now with what right can Opium be recommended as a remedy for tetanus, since the Opium-convulsions, although they may resemble tetanus to some extent, are always attended with loss of conscious- ness ? The same question might be asked in regard to other reme- dies which have been recommended for tetanus probably for the mere reason that a few tonic spasms are found among their physio- logical effects. Although weave willing to admit that, at the pres- ent time, we are not yet able to get along without drawing con- clusions from analogy, yet they should not be too bold. Arnica has been mentioned among the remedies for traumatic tetanus, probably for no better reason than because it is traumatic; for, with the ex- ception of the increased sensibility, Arnica has no symptoms corres- ponding to tetanus. Besides, the wound itself is not the real cause of tetanus, but it is an unknown something which sometimes does not supervene until the wound has lasted for weeks. Rhus is said to deserve attention in tetanus caused by a violent cold; isolated phenomena speak indeed in favor of this drug, but they are not characteristic. Among other remedies we have to select those that have a decided influence over the spinal marrow, such as: Cicuta Diseases of the Nervous System. 182 virosa, Veratrum, Lachesis, Secale cornutum, [Aconite, tincture of the root, and Bryonia should not be forgotten. II.] Tetanus neonatorum is, as we have already mentioned, quite similar, symptomatically, to the tetanus of adults; it is probably a form of traumatic tetanus and therefore requires the same treat- ment. Moschus is particularly recommended for tetanus neona- torum, more especially if the dyspnoea is very great. Aconite is a drug which hitherto had not been known to cause tetanic phenomena. In the December number, 1860, of the British Journal of Homoeopathy we find a case of poisoning by Aconite. After eating a few Aconite-roots, a girl was attacked with tetanus and trismus which gradually decreased in intensity, after which she recovered. Trismus alone occurs much more frequently than tetanus ; it is most frequently met with among small children, seldom among adults. Together with the remedies that have already been men- tioned, we direct the reader's attention to Camphora and Bella- donna. With the last-mentioned drug we have effected a rapid cure in the case of a girl, fourteen days old. We need hardly suggest that, in order to effect a genuine cure, it is necessary to avoid all the circumstances that might possibly excite an attack. Deglutition may have become so much impeded that it may be impossible to introduce medicines by the mouth; in such cases we have to resort to the hypodermic method. From the British Journal of Homoeopathy we transcribe the following extract from the New Sydenham Society's Year-book of Medicine: " Haughton cured three out of five cases of tetanus wifh Nicotine, one-half to two drops, three to six times a day. It lowers the pulse, and causes an immediate relaxation of the spasms of the muscles of expression, deglutition, respiration, back and ab- domen, cessation of delirium, and relief from agonizing pain, profuse perspiration with smell of snuff, tendency to sleep. Ghesini cured a case of traumatic tetanus by subcutaneous in- jection of Curare. As much as forty-seven grains of Curare were injected in sixty single and thirty-two double and treble injections. The treatment was commenced on the fifth day, and the patient was convalescent on the seventeenth. Cannabis indica in large quantities has cured tetanus in the hands of Dr. O'Shaughnessy of Calcutta; he gave it in doses large enough to produce narcotism. [This treatment seems purely palliative or antipathic. H.] Paralysis. 183 6. Paralysis. Under this name we comprehend so many different conditions that it is necessary to justify this classification. Paralysis is almost always a consequence of a variety of other affections; nevertheless it is not always possible to recognize the primary affection, so that a paralysis is frequently supposed to be an idiopathic affection when it is in reality something else. We should have been obliged to resort to endless repetitions if we had chosen to treat of paralysis when speaking of the functional derangements which may occasion the attack, and again to describe the disease with reference to its locality. For this reason we have deemed it preferable to devote a special chapter to this class of accidents. By paralysis generally we understand a suspension of nervous action. It may differ in character according to the number of nervous trunks involved, or accordino; to their characteristic func- tions and anatomical arrangement. Hence different names have been applied to different kinds of paralysis. By paralysis we under- stand the complete cessation of both motor and sentient nervous action; if either the sentient or motor nerves are paralyzed, we term this condition incomplete paralysis, or paresis; if only one side of the body is paralyzed, we designate this condition as hemi- plegia ; whereas by paraplegia we understand a transverse paralysis, of both upper and lower extremities. Besides this, the paralysis may be universal or partial, the last of which is again differently named according as one or the other part is affected, such as blepharoplegia, glossoplegia, &c. The etiological causes of paralysis are various. The most im- portant are: Suspension of the cerebral activity in consequence of apoplexy, inflammation, softening and other morbid processes of the brain impairing its functions; suspension of the action of the spinal cord by the same causes. There are, however, many other influences to which paralysis may be traced as their direct result. The main causes of this class are: excessive exertions of the parts to which the paralyzed nerve is distributed, in which category we have to number paralysis occasioned by convulsions; continued and excessive pains; interruption of the nervous current from the brain to the periphery by swellings, neuromata, ligatures; a stroke of lightning; rheumatism, hysteria, gout, pregnancy; violent acute diseases, among which contagious and miasmatic diseases occupy the first rank; such as scarlatina, measles, variola, typhus, dys- 184 Diseases of the Nervous System. entery; and finally poisoning by vegetable, animal and more partic- ularly inorganic substances. The symptoms of paralysis may readily be inferred from the functional nature of the organ to which the paralyzed nerves are distributed; we can only meet with difficulties in cases where the paralyzed organ is not directly accessible to our vision. The prognosis depends upon the nature of the exciting causes and upon the possibility of removing them. Where apoplectic effusions or other pathological processes of the brain or spinal cord constitute the primary disease, recovery is much more uncertain than where paralysis depends upon some cause at the periphery or is a remnant of some acute disorder. That the prognosis is rendered much more doubtful by an advanced age, an enfeebled constitution, and an extension of the paralytic phenomena over a large surface, is a matter of course. Treatment. Paralytic attacks being almost without an excep- tion secondary affections, it is evident that, in treating them, it is of the utmost importance to investigate the primary affection with the utmost care. There are indeed many cases where every diag- nostic inquiry into the causes of an attack leaves us in the dark; these cases are, however, rare, and, whenever they occur, the paral- ysis generally depends upon a single nervous trunk. Such cases are the most difficult to treat, for the reason that it is exceedingly difficult to select the proper remedy in accordance with symptom- atic indications. Inasmuch as diseases of the brain and spinal marrow are the main causes of paralysis, we refer here more espe- cially to the chapter treating of these diseases where the most important remedies have already been mentioned, and we avoid by this means all unnecessary repetitions. In other respects our best course undoubtedly is to mention the remedies appertaining to this category, in a concise series, for which purpose we shall, although not literally, transcribe Hartmann's own arrangement. Cuprum is one of the most efficient medicines in paralysis. When speaking of apoplexy and the other diseases of the brain, we have treated extensively of Cuprum, and shall here add only a fewT short remarks. It is not only to the convulsive paroxysms themselves, but likewise to the remaining paralysis that Cuprum is essentially adapted; it likewise deserves attention in paralysis remaining after cholera, typhus, dysentery, etc. Plumbum has to be ranged next to Cuprum as being most nearly related to it. The last-named remedy is more prominently adapted Paralysis. 185 to paralysis of the motor nerves, sensation is not extinguished, the assimilative process is frequently disturbed, though never in a very high degree, and the paralyzed parts frequently show signs of convulsive twitchings. In the case of Plumbum, on the contrary, both motion and sensation are suspended, the paralyzed parts emaciate very rapidly, and their temperature decreases con- siderably. With Cuprum the consciousness and the cerebral func- tions are less disturbed; with Plumbum, on the contrary, always and even violently. Both agents are specially related to the functions of the tongue and, in paralysis of this organ, they undoubtedly occupy the first rank. Rhus toxicodendron. Concerning this medicine, Hartmann offers the following remarks: In former times, when the homoeopathic Materia Medica was not as well stocked with medicines as it is at the present period, I have made several cures of paralysis of the lower extremities with Rhus tox., even when the paralysis remained after typhus. If I place this remedy in the front rank, it is not because I have a particular preference for it, but because I am anxious to recall this powerful anti-paralytic to the attention of physicians, lest it should be overlooked in the presence of more recently introduced remedial agents whose importance I do not, however, mean to undervalue. Among the primary effects of Rhus, we note a disposition to extinguish organic activity even to the degree of paralysis; a sensation of numbness and a decrease of sen- sibility in the affected parts constitute chief symptoms of Rhus. Although crampy and contracting sensations, as from shortening of tendons, do not particularly come within the category of paral- ytic symptoms, yet it cannot be denied that they are to some extent dependent upon a diminished activity of single nervous trunks. This is likewise the case with the bruising and dislocation pains caused by Rhus, and which have often been removed by this agent. It is not always paralytic ailments that we have to combat at the very onset, but it is distressing and gradually increasing drawing pains in the extremities while in a state of rest and the removal of which requires the affected limb to be moved the more vigorously, the longer it had persevered in a state of rest. These pains have the peculiarity of leaving after their disappearance a sort of lameness in the affected part, which, in proportion as the pain lasts longer, becomes more and more intense and permanent, and distinctly points to incipient paralysis. Is not the feeling of weariness and numbness 186 Diseases of the Nervous System. which Rhus causes, a lower degree of momentary paralysis? A leading symptom of Rhus is: lameness in the extremities with stiff- ness of the joints, worse when rising from a seat; or complete paralysis, hemiplegia as well as paraplegia, with dragging, slow, difficult gait. According to these statements, Rhus is not adapted to paralysis of the central organs, hut rather to paralysis at the periphery, and to such as remains after typhus. It is, moreover, par- ticularly useful in rheumatic paralysis, to which the whole series of the pathogenetic symptoms of Rhus corresponds with great accuracy. Arnica has been extensively mentioned as a remedy for cerebral diseases. It is not only suitable in paralysis depending upon cere- bral exudations, but likewise in any other form of paralysis depend- ing upon exudations of any kind. Causticum is an important remedy which penetrates the organism very deeply, and has been found particularly efficacious in chronic maladies. The reputation of this drug has been somewhat im- paired by the circumstance that its primary effects manifest them- selves more slowly than those of other long-acting remedies. In paralytic conditions Causticum is at all events one of the most im- portant remedies; its usefulness has been tested on too many occa- sions to be disputed at this late day. Hartmann has seen the best effects from it in partial paralysis caused by a keen draught of air, and in hemiplegia after suppressed eruptions, attended with striking coldness, especially of the head and feet. After apoplexy he recom- mends it, when the proper paralytic symptoms are accompanied by frequent congestions of the head, with anxiety, vertigo and a cloudy feeling in the brain. In paralysis of one side of the face, paral- ysis of the facial nerve, it has been found curative by Hartmann as well as by other physicians. In paralysis of the tongue it is un- doubtedly a prominent remedy, although we do not by any means mean to say that every case of this kind can be cured with it. It is well known that this form of paralysis is particularly inaccessible to remedial influences. As a general rule Causticum is more effi- cient in the paralysis of single nervous trunks than in general paralysis, more efficient in paresis than in complete paralysis, for where Causticum is indicated, the sensibility is generally unim- paired. According to Hartmann Cocculus is most efficient in paralysis of the lower extremities. It starts from the small of the back, and is supposed by the patient to be owing to a cold. As a general rule Paralysis. 187 it is recent cases that are particularly suitable to Cocculus, especially when the paralysis is accompanied by violent pain in.the paralyzed parts, or when symptoms of spasm show themselves in these parts. Paralysis of the tongue, face and pharynx is likewise adapted to the curative action of Cocculus. Sulphur. If we do not reproduce Hartmann's statements regarding the action of Sulphur in this disease, it is because his views and our own do not agree. This is not the proper place to discuss the question of latent psora; enough has been said on this point, and very uselessly. We are not one of the believers in the psora-theory, which we simply regard as a convenient means of getting over diffi- culties that we do not know how to solve, and over which we glide with vague generalities. It might be very difficult to show what practical benefit has been derived from this theory. Whether a par- tisan or an opponent of this theory, Sulphur will prove eminently useful in the hands of either, and not simply because it facilitates the action of remedial agents employed after Sulphur. This agent corresponds more particularly to paralysis based upon material changes. In this respect it acts similarly to Arnica, with this dif- ference, that Arnica is more particularly indicated in recent, and Sulphur in more chronic cases. In paralysis remaining after acute diseases, Sulphur will likewise prove curative, probably for the reason that it exerts a favorable influence over exudations, as in typhus, that had not yet been absorbed. Baryta carbonica is undoubtedly one of the most distinguished remedies for paralysis after apoplexy, and for paralysis of old people, where a want of steadiness, a feeling of debility in the whole body, giving way of the knees and pain in the lumbar portion of the spine had been complained of for some time previous. This agent is well known as a remedy for the ailments incident to old age, and this reputation of our drug has likewise been verified in the paralytic conditions of old people ; on this account, however, it is not excluded as a remedy for paralysis of young people ; we refer more particu- larly to paralysis of the tongue, which is seldom cured without the use of this agent. (Hartmann.) Secale cornutum is a remedy of some importance in paralysis; its sphere of action is, moreover, more distinctly defined than that of many other drugs. All sorts of spasms come within the category of morbid conditions to which this agent may be adapted. It is well known that long-continued or frequently-returning spasms of the same parts often lead to paralytic conditions and even actual 188 Diseases of the Nervous System. paralysis of single limbs, where art has to interfere even though the spasms should have entirely ceased. It is to these forms of paraly- sis that Secale corresponds ; if the lower extremities are the seat of the disorder, involuntary discharges of the faeces and urine are fre- quently present, and the paralyzed parts emaciate very rapidly. (Hartmann.) Aluminium metallicum is still of too recent use to admit of definite indications of its use in the treatment of diseases. Boenninghausen's recommendation, which he backs up with clinical results, may suf- fice to claim our attention to this new agent. A drug which is useful in tabes dorsualis, in genuine progressive spinal paralysis, must certainly possess a prominent effect upon the nervous system; our stock of remedies for paralysis being anyhow limited, Alumi- nium is so much the more to be thought of as a remedial agent in this class of disorders. Dulcamara seems to have been a favorite remedy with Hartmann. He says in reference to Dulcamara: It is certain that this remedy is used much too little by modern homoeopaths, and that it is even ignored by many of them as an useless medicine. Nevertheless it has the same medicinal virtues now that it manifested in such a striking degree at a former period, and its curative virtues become so much more manifest, the more familiar we become with the use of this agent. How many paralytic attacks are caused by exposure to intense cold or to wet, or even to the suppression of scrofulous eruptions, where a latent psora is evidently the fruitful soil in which the susceptibility to paralytic attacks is rooted. It is this class of paralytic attacks where Dulcamara constitutes a real specific, and where it will almost always be found curative in alternation with Sulphur. For this reason it is adapted to almost every form of par- alysis, as its symptoms show. Moreover we find Dulcamara useful for paralysis of the arm, with icy coldness, as if the patient had been struck with apoplexy; paralysis of the upper and lower extremities; paralysis of the tongue and bladder, where Dulcamara is of prominent importance. Arsenicum, Mercurius and even lodium, after a long-continued use, cause paralytic symptoms, as we know to our perfect satisfaction from a number of cases of poisoning; however, we are not able to specify the particular indications by which we might be guided in the use of these remedies, and we have to content ourselves with the general knowledge that these three medicines exert a powerful infiu- Paralysis. 189 ence over the nervous system, and hence may prove powerful auxili- aries in the treatment of paralysis. Other medicines that may be classed in the category of anti-para- lytic agents are: Oleander, Stannum, Colchicum (for rheumatic par- alysis), Lachesis, Cantharides (for paralysis of the bladder), Anacar- dium, Zincum, Veratrum album, Staphysagria, Silicea, Phosphorus, Natrum muriaticum, Stramonium, etc. For the sake of having a cursory view of the different remedies adapted to the different forms of paralysis, we here subjoin their list: Paralysis of the tongue: Baryta, Cuprum, Plumbum, Stramo- nium, Dulcamara, Acidum muriaticum, Cocculus, Belladonna, Caus- ticum. For paralysis of the facial nerve: Causticum, Cocculus. For paralysis of the pharynx: Cantharides, Stramonium, Belladonna. For paralysis of the bladder: Belladonna, Dulcamara, Cantharides, Lycopodium, Natrum muriaticum For paralysis of the rectum: Lycopodium, Ruta graveolens. Paralytic attacks caused by poisoning require the employment of suitable antidotes, and subsequently remaining ailments have to be treated with smaller doses. The most frequent kinds of paralysis from this source are: Paralysis caused by Mercury: Stramonium (Hartmann), Acidum, nitricum, Staphysagria, Sulphur. Paralysis caused by Arsenic: China, Ferrum, Graphites. Paralysis by lead : Opium, Cuprum. [It is beyond our comprehension why homoeopathic practitioners who are acquainted with the pathogenesis of Aconite, and with pathology, do not assign to this agent a prominent rank among the remedies for paralysis. We have cured with it time and again the most violent attacks of paralysis of internal organs as well as of the extremities. The causes are various: Violent emotions, a sudden fright, exposure to keen winds, humidity, draughts of air, etc. The symptoms which indicate Aconite, are: a full and slow pulse, or sometimes an accelerated and small, thready pulse; numbness, a pricking sensation; sense of coldness in the part, or the opposite sensation of increase of temperature, wuth heaviness and aching pains in the part; sensation as if the part were swollen. The symp- toms of course vary according as one or the other organ is affected. We have: paralytic ischuria caused by exposure to a current of air, w7et or by suppression of the perspiration; paralysis of the rec- tum and anus; paralysis of the tongue, with a pricking sensation and a sensation as if the tongue were swollen, increase of tempera- ture in the tongue; paralysis of the optic nerve with intense pain 190 Diseases of the Nervous System. as if caused by pressure; paralysis of the face, of the oesophagus, etc. Very many attacks of this kind, if caused suddenly by ex- posure to rheumatic influences, yield to the use of Aconite in a very short period of time. In some cases we use the tincture, a few drops in half a tumbler of water, in other cases we have got along with attenuations. We recommend these observations to the care- ful consideration of practitioners. II.] As regards dietetic and other measures in the management of paralytic patients, we find it impossible, in view of the great differ- ences prevailing among the different forms of paralysis and their various degrees of intensity, to furnish specific directions; we will content ourselves with indicating one auxiliary agent which has an important bearing upon the treatment of paralysis, namely the movement-cure. Cautious, moderate, as far as possible active, or even passive movements of the paralyzed parts have effected an im- provement even in inveterate and desperate cases. It seems as though the paralyzed nerve remained in a state of inaction simply because it is deprived of an unusual stimulus to action, which the movement-cure is to supply Hence this cure is much more useful in chronic paralytic conditions than in those of recent origin. In spite of the sanguine expectations of its friends, electricity has accomplished much less in the treatment of paralysis than the movement-cure. This lack of success may in a measure result from an imperfect use of this agent, but an imperfect use cannot be the only cause of a want of success. The disappointment in the use of the electric current is in a great measure owing to the impatience of the practitioner as well as of the patient. Great effects are ex- pected already after a few days' treatment, whereas it often requires weeks before a favorable change can be expected. An interesting case of this kind may be read in " Hirschel's Zeitschrift," 1861, Nov. 15th, where magnetism was likewise used with effect. The electric current should never be used with too much force which is always more hurtful than useful. The current should only be felt as a slightly unpleasant sensation, but should never be received as a shock. 7. Hysteria. It is not only difficult but almost impossible to furnish a satis- factory and sufficiently comprehensive definition of hysteria. The most diversified phenomena are ranged under this name, and a rigor- ous definition of the term hysteria is subject to so many different Hysteria. 191 individual views and opinions that it seems impossible to generalize them, except in the most comprehensive series. Considering the term hysteria from this general point of view we understand by it a modification of the nervous functions which is almost exclusively peculiar to the female sex, the motor as well as the sentient nerves, the psychicalas well as the vegetative activity of the female organ- ism are involved in this modification, sometimes with, at other times without any material changes. Hysteria is a disease of the full-grown woman. Hence it mani- fests itself between the periods of pubescence and a change of life; it may outlast the latter period, but is scarcely ever distinctly mani- fested previous to the former. Alen, too, are said to be liable to attacks of hysteria. This, however, is questionable for the reason that the term hysteria is not defined with absolute precision. Hys- teric symptoms in the case of a man do not justify the term hys- teria, the true definition of which has been more obscured by the fact that men also have been supposed amenable to the Protean forms of this disease. The etiology of hysteria is not as yet clear. Many material changes which are regarded as causes of hysteria, may just as well be consequences as causes of hysteria; it would be strange if so many different etiological influences should be capable of producing the same disorder. What is an undeniable fact, is that the trouble is rooted in the sexual sphere of woman, for this circumstance is proven by the fact that it breaks out exclusively among full-grown females; but what changes are necessary to the production of hys- teria, can only be pointed out with partial positiveness. The most frequent causes seem to be ulcerations of the os tincse, and displace- ments of the uterus, likewise pathological changes of the ovaries. There is much less confusion in determining the mental than the material causes of hysteria, or in tracing this disorder to a ming- ling of both. Onanism, abstemiousness, or an excessive irritation by sexual intercourse, may cause hysteria. Among the mental causes we number all those that impress a wrong direction upon the psychical life of woman, and more particularly feed her fancy to excess, as is unfortunately the case by our modern systems of edu- cation, which favor all sorts of fantastical and morbid tastes and extravagances. We should be carried too far if we would investi- gate this point to the bottom; moreover every physician has abundant opportunities to satisfy himself of the correctness of our remarks. We find hysteria very generally complicated with 192 Diseases of the Nervous System. another affection, which is likewise almost exclusively to be attrib- uted to the wrong education and faulty mode of life of the female sex-we mean chlorosis; we would not, however, assume the re- sponsibility of asserting that chlorosis is the cause of hysteria. That hysteria may likewise be favored by unusual mental occupa- tions, even of a serious or scientific kind, is shown in the case of female teachers. Besides these more or less gradually penetrating psychical influences, hysteria may likewise be caused by the action of some sudden and violent mental excitement, especially when of a depressing character. Symptonis and course, A satisfactory definition of hysteria is perhaps less difficult than to furnish a general view of its various phenomenal manifestations, for the reason that in a case of hysteria every organ may be apparently, not actually, implicated in the ab- normal process, and hence the picture of the disease must vary a good deal. Moreover hysteria complicates and modifies every acute and chronic affection, whose form it often changes to such a degree that the affection is no longer recognizable. Hence it is of the utmost importance to determine whether a woman is afflicted with hysteria; for this knowledge gives us the clue to most of her troubles. The more general diagnostic signs of hysteria are best studied with reference to the nervous sphere where these signs are located. The mental activity is always and generally very strikingly altered. In the lower degrees of hysteria we meet with a capricious and very fitful demeanor, attended with an unusual sensitiveness to some- times trifling mental impressions, even mere notions. This sensi- tiveness. however, is usually more felt towards unpleasant things, and gradually develops a disposition to habitual melancholy and dejection of spirits. Being constantly preoccupied with herself and exposed to the jests and gibes of those near her, the patient simu- lates an artificial cheerfulness with a consistency and firmness that often seem incredible, and in spite of the most agonizing distress. In the higher grades of hysteria we meet with all sorts of mental conditions that may very properly be ranged in the category of mental derangements, and are sometimes characterized by a peculiar irritability of temper, at other times by extreme depression. The power of volition is sometimes so completely gone that the most serious mental alienation may be apprehended. We have known an hysteric lady who could not make up her mind to anything, not even to go to bed; she frequently remained standing in her chemise for Hysteria. 193 three or four hours in a room without fire, although the cold was intense. This absence of will-power is very marked in hysteric spasms, which can often be arrested by no other means than by ex- citing this power. We are acquainted with a lady who was fre- quently attacked with spasms, likewise during her first pregnancy and shortly before her confinement. The child died of eclampsia shortly after birth. We urged upon the mother the conviction that she would never give birth to a healthy child unless she made every effort to suppress the spasms. This advice proved so effectual that the spasms have ceased ever since, and that, whenever a recurrence of the spasms was threatened, they were instantly subdued by the husband reminding her of our advice. It would be wrong, how- ever, if on this account, we were to consider hysteric spasms as pure dissimulation. This is not so; there is simply a lack of internal energy to suppress the convulsive motions. That this psychical sensitiveness likewise extends to the views about men and things, is a matter of course ; this manifests itself in excessive inclinations or disinclinations, and frequently gives rise to the most extraordinary idiosyncrasies. Next to the moral disposition, the sensibility is generally altered most strangely. This change assumes more promi- nently the character of an excessive sensitiveness, which, in com- mon parlance, we are apt to designate as nervousness or nervous debility, and which may affect the whole nervous system. The organs of sense are sometimes extremely sensitive to the most tri- lling impressions, which would remain unnoticed by persons in health; at other times the perception of external impressions is the opposite of what it would be in a normal condition and vice versa, so that the most offensive odors, for instance, seem pleasant, and agreeable odors are repulsive. This nervous irritability sometimes manifests itself in the form of neuralgia, such as megrim, clavus hystericus, pains'in the joints, cardialgia, spinal irritation ; or it is perceived as a peculiar sensation of pain, wThile such organs as the lungs, heart, bowels, etc., whose action remains unperceived by per- sons in a state of health, fulfil their functions in a normal manner. The patients often carry their complaints to such a degree that it is only through the most minute investigation, and the complete ab- sence of all objective pathological changes, that we can satisfy our- selves of the utter absence of some intense organic affection. De- rangements in the motor sphere generally assume the form of spasms. They cither consist in local convulsions, or they resemble epilepsy, catalepsy or tetanus so closely that even the most practised eye may 194 Diseases of the Nervous System. be deceived for a time. A chief sign for a correct diagnosis is the continuance of the consciousness. Beside the extremities, other parts may be attacked by clonic spasms, such as the pharynx, the diaphragm; the frequently occurring laughing or weeping spasms belong in this category. Paralytic conditions are less frequent; they may assume a variety of forms. That they have not a very deep significance, is shown by the fact that they shift about or dis- appear quite suddenly, or that the paralyzed nerves show a normal susceptibility to the electric current. However, even after we have by such means ascertained that the paralysis is neither caused nor supported by a more deep-seated affection, it is not on that account removed with any more ease, and often resists every possible thera- peutic means with the most obstinate perseverance. These nervous derangements are attended with a peculiarly characteristic condition of the bladder. Most hysteric females void the urine very often; it is generally colorless ; a diminished secretion of urine is much less frequent. All the above-mentioned functional disturbances, except perhaps those of a lighter grade, do not continue permanently , they are very apt to break out in the form of paroxysms, which are excited by influences that it is difficult to trace, most generally, however, of a psychical nature, and the intensity and duration of which are unde- finable. Not unfrequently these paroxysms appear periodically, they may even be preceded by certain precursory symptoms, other- wise they are without any fixed rule, and set in quite unexpectedly. Hartmann gives a cursory mew of hysterical local affections which is not unessential to a comprehension of the general character of the disease, and which'we therefore transcribe in this place. We would, however, premise that such abstract statements do not con- stitute the rule, and that the local hysteric disorder is most gen- erally attended with partial manifestations of one or the other derangements. Hysteria cephalica consists in hemicrania, clavus, sensation of coldness at the occiput, sopor and coma, symptoms of inflammatory cerebral affections, delirium, obstinate sleeplessness. Hysteria of the mind: Frequent repetition of certain syllables, words, phrases, melodies; nymphomania. Hysteria of the spinal marrow: Drawing pain through the whole spine, attended with pain in the extremities, formication, muscular contractions, cramps in the calves, paralytic conditions, neuralgic Hysteria. 195 affections of the pectoral and intercostal nerves and articulations. The pains are scarcely ever seated, but always wandering. Hysteria uterina: The patients complain of pain, tension in the hypogastric and pubic region, frequently with drawing pains in the loins and small of the back, along the course of the round and broad ligaments; they feel as if the uterus were forcibly lifted from the bottom of the small into the larger pelvis. Sometimes these pains are of a colicky nature, at other times they are accompanied with a sensation as if a ball were rising. The sexual instinct is either violently excited or else very much depressed. Menstrual derangements are very frequently present; the catamenia are at times scanty, at other times profuse, generally irregular, the blood flowing by fits and starts, and often attended with leucorrhcea. The hysteric paroxysms are most violent at the time of the menses, and at the commencement occur at very regular intervals. In proportion as the catamenial irregularities increase, the paroxysms cease to be connected with the appearance of the menstrual flow. Hysteria of the bladder, hysteria vesicalis: The patients are attacked with violent contracting, sometimes burning pains in the lumbar region, following the course of the ureters through the whole pelvis, in the region of the bladder, without sensitiveness to hard, external pressure, by which circumstance the disease is distin^ guished from nephritis and cystitis. These pains are accompanied by violent urging to urinate, the emission of urine being either suppressed or intensely painful. The voided urine is clear and liquid as water. Hysteric affections of the bowels, {colica hysterica}: It consists in spasms generally proceeding from the coecum or from the sigmoid flexure, the patients experiencing a sensation as if a ball in that region were continually augmenting in size. The pain is like a most violent colicky pain, burning, tearing and stabbing as if the bowel were torn to pieces. The patient utters a piercing cry when any one attempts to touch her, whereas she bears a strong pressure if, during the examination, her attention is directed to some other object. There is borborygmus, tympanitis, sometimes an enormous distension of the transverse colon, with oppressive anxiety, shortness of breathing, vomiting, &c. There is no trace of fever. Hysteric affection of the stomach: The patients complain of a pain in the stomach which is at times constrictive, burning, or spasmodic, and is attended with oppression, nausea, vomiting, dread of contact, and yet the patient bears violent pressure. In this list 196 Diseases of the Nervous System. belongs the sensitiveness of patients to large doses of the drug, so that even Canstatt observes that a cure can only be effected by truly infinitesimal quantities. Asthma hystericum: Sometimes hysteric patients are afflicted with violent oppression of breathing, anxiety as if they would suf- focate, stitching pains in the chest; nevertheless they are able to draw a long breath, as evidence that there is no trouble with the lungs. Sometimes there is cough, and then again it is missing; it is generally dry, sometimes barking like whooping-cough. In many cases the respiratory process is carried on by means of the abdom- inal muscles; in other cases the breathing is panting, anxious, the patients have to sit up erect in their beds. Physical signs and fever are wanting. Hysteric affection of the larynx: The patientshave a loud, dry, almost barking cough coming on in paroxysms and being more especially excited by emotions and nervous agitation, also attended with spasm of the rima glottidis and a croupy respiration. Another form is hoarseness and aphonia. This form breaks out suddenly and disappears as suddenly, sometimes after having lasted for years. Sometimes, after a violent mental excitement, the patient speaks again in her natural tone of voice, whereas shortly before she was only able to speak in a whisper. In this category we have to range the sounds of beasts, like the barking of dogs, &c., which are some- times emitted by hysteric patients in involuntary paroxysms. Hysteric affection of the heart: Hysteric women are in the habit of complaining of palpitation of the heart, and oppressive anxiety in the region of the heart. The palpitation can be seen externally, and not unfrequently it becomes so violent that it would seem as though the ribs would break. It generally comes on periodically, but without any regular intervals. The hysteric ball, globus hystericus, one of the best known hys- teric symptoms, consists in a constrictive sensation in the throat as if a ball were lodged there; eructations sometimes afford relief. This enumeration of the local forms of hysteria does not by any means exhaust the multitudinous forms of this disease; however it contains its most important and most usual forms very completely. The course of the disease is always very chronic; it is only in rare cases that hysteric symptoms show themselves only about the time of the menses or during pregnancy, which disappear again with the menses or the termination of pregnancy. The most noteworthy terminations are: Transformation of the Hysteria. 197 hysteric convulsions in real epilepsy, and of the mental irregulari- ties in permanent dementia. Paralytic conditions remain much less frequently. The prognosis is generally doubtful, and even unfavorable, be- cause we are not able to completely eradicate the defects of educa- tion in the mental range, and the necessarily long duration of the treatment fatigues both physicians and patients. The more nearly the disease resembles a mental disorder, the less the prospect of relieving the patient. A long continuance of the disease likewise diminishes the chances of recovery. The prognosis is likewise com- plicated by the advanced age of the patient, for the reason that the prospect of putting off the pernicious habits and prejudices of youth becomes dimmer with every additional year. Where pregnancy is accompanied by hysteric, convulsive symptoms, the danger of a miscarriage is not slight; and the appearance of such symptoms during confinement frequently leads to lasting and generally incur- able mental derangements. The nearer the paroxysms resemble those of epilepsy, the more readily they assume the form of the lat- ter more formidable disease. Where the disease can be traced to definite causes, the chances of a cure depend in a great measure upon the nature of these causes. Treatment. Following Hartmann's example we introduce this paragraph with Schoenlein's words: "The treatment of hysteria is one of the most difficult tasks, not merely on account of the diffi- culties inherent in the diagnosis and on account of the protracted course of the disease, but likewise on account of mental complica- tions. The patience of the physician is sometimes tried to the utmost; for, whereas he may be satisfied that the disease is of not much importance, he has to lend a willing ear to the everlasting lamentations of his patient, and has to listen to hundredfold repeti- tions without showing the least signs of impatience ; for the patients are so sensitive, that if the physician* should betray the least indif- ference to their sufferings, and only listen to their statements with a half-closed ear, his credit is instantly lost. If a physician wishes to treat hysteric females, he has to show them the greatest compas- sion, has to listen patiently to their complaints, and should never appear indifferent or out of humor if he does not wish to be dis- charged." The treatment of hysteric patients has to be looked at from a variety of points of view, so much more as it is almost impossible to confine ourselves in our treatment to separate local affections, 198 Diseases of the Nervous System. and to pursue a special treatment for each of them. Again, we ask the question which we have already presented on a former occasion, whether it is possible to treat hysteric patients exclusively in ac- cordance with symptomatic similarities; what becomes with such a supposition of the various derangements of organs which are simulated by hysteria? According to what we have said in the chapter on the etiology of hysteria, the determination of the specific cause is a subject of great importance. Where the disease is founded upon sexual derangements, a cure is impossible until these derangements are cured; if they are incurable, hysteria itself will likewise remain an incurable malady. Where we have to suspect abuse of the sexual organs, we shall find ourselves in a very ticklish situation, more particularly if our patient is unmarried, in which case a frank and full confession is very much impeded by the sensitiveness of the patient, which outweighs all other considerations of recovery. In such cases a cure, unless the exciting cause can be removed, is like- wise not to be thought of. Sometimes, however, we are able to attain, by a circuitous route, the end that would forever be beyond our reach, if we sought to attain it by a direct road. If hysteria depends upon chlorosis, a successful treatment may be more readily expected than otherwise; only we must not forget that chlorosis likewise may be occasioned by some of the above-mentioned hidden causes, in which case it can likewise be removed, but with more difficulty. Medicinally the disease can be treated with a large number of medicines, of which it would be impossible to furnish a complete list, so much more as their action has not been confirmed by expe- rience. This chapter is so fully treated by Hartmann, that with the exception of trivial changes, we here transcribe his remarks contained in the second volume of his Treatise on Therapeutics, page 500, etc. Nux moschata responds to hysteric spasms with great debility. It is particularly suitable for females who show a fitfulness of mood, characterized by a rapid transition from extreme sadness to excessive cheerfulness. It is indicated where, previous to the paroxysm, the least labor is followed by lassitude and a sensation as if syncope would set in. It may likewise be found suitable where the disease succeeds fever and ague or typhus accompanied by spinal irritation ; likewise in cases depending upon derangements of the sexual sphere, where the menses appear too late or are too scanty, where they are Hysteria. 199 preceded by pain in the small of the back as if a stick lying trans- versely across the back would be pressed out, together with head- ache, lassitude, cardialgia with waterbrash, pain in the liver; where the menstrual blood is thicker and darker than usual, whereas, at the time when the catamenia ought to have appeared, leucorrhoea took their place. Valeriana deserves our serious attention in hysteric paroxysms where the nerves are morbidly excited, with sensation of lassitude and extreme susceptibility of all the senses. This drug has not like the former medicine, a fitful mood, but the disposition is rather of a fearful and desponding cast. Though the symptom of an ascend- ing ball is not found in the pathogenesis of this drug, yet another symptom of equal importance, namely the sensation of warmth sud- denly ascending from the epigastrium, with oppression of breathing, takes the place of the hysteric ball. The symptom is attended with nausea as if the patient would vomit, which arises in the umbilical region and ascends to the pharynx, attended with a sensation as if a thread were hanging from the pharynx down the oesophagus, with a good deal of ptyalism and vomiting. Concerning Viola odorata, which some have vaunted as a remedy for hysterical paroxysms, not much can be said. The recommenda- tion of this agent seems to be based upon the peculiar idiosyncrasy of hysteric patients according to which offensive odors are pleasant to their nostrils, and who find the delicious odor of violets less agreeable than the pungent smell of burnt feathers. The disposi- tion to weep without knowing why, the excessive susceptibility to emotional excitement, the continued affection of the chest, the pain- ful dyspnoea, the difficult and painful inspirations and expirations attended with an apprehensive anxiety and mingled with violent palpitation of the heart, may perhaps be suitable indications for the use of Viola. Secale cornutum, which has already been mentioned in other spas- modic affections, is so much more specifically suitable to hysteria as this disorder is very generally dependent upon disturbances in the female sexual system. At any rate it occupies the first rank against such paroxysms of hysteria as occur during the act of par- turition or during confinement. The phenomena of the emotive sphere and of the general sensorium deserve special attention in selecting this drug. Au rum is one of the few remedies which, beside acting with a penetrating energy, exerts an extraordinary influence over the mind 200 Diseases of the Nervous System. and spirit, almost always in the same direction. Religions melan- choly, grief at one's fate which one had caused by one's own indis- cretions, great anxiety and apprehension proceeding from the heart, shyness and dread of men, are so significant as therapeutic indica- tions that they alone justify the selection of gold in hysteria as a remedial agent. At all events Aurum is rather a remedy for hysteria generally as for certain separate local symptoms or par- oxysms. Pulsatilla should be so well known to everybody that it ought only to be necessary here to mention it merely by name. Its pro- minent relation to the sexual organs, more particularly to the men- strual functions and to mental operations, stamp it indisputably as a remedy for hysteria ; the local symptoms are, moreover, of such a nature that their paroxysmal character points to the selection of this drug, especially where the stomach, heart or uterus are promi- nently affected. Moschus has from time immemorial been employed in nervous and more especially in hysteric conditions, very frequently with remarkable success. The following symptoms are characteristic indications for its choice: hysteric patients frequently complain of painfulness in the whole body without defining more particularly the locality of the pain; when asked where they suffer pain, they feel it more keenly; with tears in their eyes they complain of weari- ness all over, with a feeling of malaise as if they would faint; spas- modic paroxysms which resemble hysteric paroxysms, are relieved by Moschus, such as: sudden rush of blood to the head, with star- ing eyes and spasm in the mouth, followed by a hurried and con- fused talking, and by death-like paleness with excessive sweat over the whole head; or else sudden staring eyes with pallor of the face, heaviness of the head, pressure in the nape of the neck, cold- ness of the body, nausea, afterwards obscuration of sight, contrac- tion of the pupils, loss of equilibrium, with rigidity and extension of the hand; sudden vanishing of the senses with slight pressure on the vertex, anxiety, palpitation of the heart, stupefying head- ache, or as if a nail had been stuck into the head ; oppression at the stomach and pit of the stomach, with anxiety proceeding from this region ; violent sexual excitement, with intolerable titillation ; chok- ing constriction of the larynx. These and many other symptoms assign to this drug a high rank among anti-hysteric agents. Conium maculatum is often suitable in the hysteric paroxysms of unmarried females whose trouble emanates directly from the sexual Hysteria. 201 sphere. They complain of violent itching of the genitals and in the interior of the sexual organs, with pain as if the uterus were being pressed down, stitches in the vagina; the menses are either sup- pressed or, if they make their appearance, they are too scanty; the patients are troubled with a smarting, excoriating leucorrhoea, attended with a frequently recurring contracting pain in the abdo- men like labor-pains. A characteristic indication for this drug is a feeling of pressure in the pharynx ascending from the pit of the stomach, as if a round ball were ascending- from this reg-ion. The patient is of a gloomy and melancholy turn of mind ; she is dissatis- fied with herself and with everything around her. The paroxysms consist of a disposition to weep when alone, scintillations, indistinct vision, lassitude in all the limbs, with a dull headache, or the patients complain of weariness and chilliness, obliging them to lie down, with headache and violent palpitation of the heart, and a pain at every pulsation as if a knife were thrust through the occi- put, the beats of the heart being at times strong, at others rapid, and then again unsteady and wavering. Coccu'us has often rendered good service when the patients com- plained, among other distresses, of frequently recurring singultus, a choking contraction in the pharynx with oppression of breathing and an irritation inducing cough ; the menses are delayed and finally set in with cramps, anxiety, oppression on the chest, cramps in the chest, attacks of nausea even unto fainting, and twitching of the extremities. Natrum muriaticum. " I have often been tempted to believe that many hysteric patients possess the power to obtain a sort of internal perception of their distress, and, by means of this state of clairvoy- ance and divination, prescribe for themselves such medicines as may lead to their recovery. It is true they do not possess a clear con- sciousness of their actions, but they are impelled by a sort of intui- tion to add a little more salt to the food which they usually relish without it: to use quantities of vinegar, to devour greedily chalk or lime. The same thing is true with the so-called idiosyncrasies of hysteric females which gives them such a strong desire for Asa- foetida, Musk and other drugs having a strong and, to normal organs of smell, disagreeable odor. Whether these views are merely hypo- thetical, it is a curious fact that it is precisely these abnormal desires which furnish us the most indubitable indications of the most cer- tain remedy in the case before us. At any rate, I have seemed to make this observation more especially with regard to Natrum muri- 202 Diseases of the Nervous System. aticum, and I have found the choice of this remedy confirmed by contrasting its pathogenetic symptoms with those of hysteria. However, I do not wish to be misunderstood as though I meant to recommend the use of salt only in cases where the abuse of this agent by the patients led me to suggest it. Not at all; this empi- rical use of salt would constitute a slim basis upon which its recom- mendation as a remedy for hysteria could stand, and which might plunge us into a maze of deceptions. Salt is recommended by its own internal wealth of symptoms, the complex of which responds most fully to the diversified shades of hysteria." So far we trans- cribe Hartmann's views, which are undoubtedly hypothetical; but, on the other hand, may stimulate us to devote more serious atten- tion to the management of hysterical idiosyncrasies. Natrum muri- atieum does not, like Gold, directly affect the mind and spirit, but involves these spheres in so much more intense sympathetic suffer- ing with other organs whose functions are deranged. Its main effect upon the brain and nervous system is depressing, without, however, any further signs of irritation ; at any rate, if any are present, they are insignificant and evanescent. The whole series of its symptoms would seem to indicate salt in hypochondria rather than in hysteria; but both affections resemble each other so closely that the same remedies are applicable to both. Special indications are: Frequent recurrence of the nervous paroxysms during the day and vanishing of the same as soon as sweat breaks out; deathlike paleness or a yellowish-gray color of the face, and general debility; a drawing sensation from the left shoulder towards the head, with pressing in the temples as though the head would burst, with pain in the brain as if sore and bruised ; continued nausea as if vomiting would take place; desire to lie down, and chilliness with heat in the face; fre- quent paroxysms of syncope; feeling in various parts of the body as if they had gone to sleep; vivid, fantastical dreams during a light sleep ; desponding and melancholy mood ; whining melancholy, want of firmness, wavering disposition; absence of mind; clavus in the left side of the brain, delaying and more and more decreasing catamenia. Asafoetida is particularly adapted to hysteric paroxysms where the hysteric ball is very sharply defined, with the following symptoms : She complains of pressure in the oesophagus, with constriction of the throat as if a foreign body were rising in the throat which obliges her to swallow quite frequently ; this pressure mostly ema- nates from the stomach up the oesophagus, with sensation as if a Hysteria. 203 foreign body were ascending; nausea and feeling of fulness in the pit of the stomach; compressive sensation in the abdomen. Sepia is one of the most important remedies not only for females generally, but in hysteria in particular. It is particularly suitable for weakly subjects with a fine, sensitive, delicate skin; there is no appearance of weakness externally, since the rotundity of the patient's form is rather beyond the normal size; and the color of the face, aside from a frequent and rapid change, is rather bright-red than pale, with a yellowish-dark circle around the eyes; there is great disposition to excited feelings. More specially characteris- tic are the phenomena which Sepia causes in the sphere of the emotions: there is constant sadness and depression of spirits; the mood never changes, there is great disposition to start; trifling causes induce vehement ebullitions of temper; dread of company. These ailments are ameliorated when pleasant impressions act upon the patient. In addition to this, Sepia has striking relations to the female organs of generation, for further details concerning which we refer to the Materia Medica. Specially adapted is Sepia to hys- teric paralytic conditions of short duration and frequently shifting from one place to another. Beside these more general indications, Sepia has likewise phenomena in most organs, which recommend it for local hysteric affections ; it will be found so much more suitable the more the disorder is centred in the digestive organs. Magnesia muriatica is, according to Hartmann, very nearly related to the female organs and to the abdominal viscera. More particular indications are: Disposition to take cold, frequently recurring pain, as if bruised, through the whole body; general feeling of illness, fainting fits at dinner, with anxious feeling, nausea, pallor of the countenance, green and red light before the eyes, trembling of the whole body, with subsequent eructations which afford relief; spasms proceeding from the uterus; pains in the small of the back, and leucorrhoea, both of which symptoms grow worse in proportion as the catamenia delay more and diminish in quantity, moreover they break out periodically and the cramp-pains spread over the whole abdomen and down the lower extremities. Beside the above-mentioned remedies, Hartmann mentions Cal- carea carbonica and Nitri acidum, with which he professes to have obtained brilliant results, with the former especially if the convul- sions bear such a great resemblance to epilepsy that it was difficult to diagnose between them. In addition to these leading remedies for hysteria in general, 204 Diseases of the Nervous System. there are many other medicines which had better be mentioned as referring to local symptoms without any further special indications. For hysteric affections of the head: Valeriana for a stitching or pressive pain in the forehead and orbits, alternating with a condi- tion of sopor; Belladonna for a periodical nervous headache; Mer- curius for a nightly, stitching, boring or tearing headache; Hepar and China for a nocturnal headache; for hemicrania more particu- larly Nux vomica, Sepia, Colocynthis, Verbascum; for clavus hysteri- cus: Coffea, Ignatia, Platina, Bryonia, Veratrum alburn, (when the head is cold,) Aconite and Belladonna when the pain increases to a maddening degree of intensity; for the sleeplessness which is fre- quently an attendant on headache, China, Silicea, Hepar, Coffea; for the opposite sopor: Opium, Tartarus emeticus, Hyoscyamus. Of the hysteric derangements of the psychical sphere, we mention the most important: nymphomania. The main remedies for this disease are: Platina, Phosphorus, Belladonna (when occuring during confinement), Veratrum and Cantharides. Hysteric spinal irritation does not, properly speaking, exist sep- arately, and it might therefore be very difficult to indicate remedies for this condition, for the reason that their selection would mostly depend upon the accessory phenomena co-existing with the spinal irritation. Hysteric uterine affections almost always accompany or even cause the whole malady; for this reason all the remedies that have been mentioned for hysteria, are likewise applicable in this class of diseases. Also we recommend Causticum for delaying menses, with violent colicky pains as if the bowels were torn, with a tearing and bruising sensation in the small of the back and in the back, especially during motion, oppression and fulness in the abdomen with disposi- tion to belch up wind, &c.; she has to loosen her clothes. Phosphorus when the menses are either retarded or entirely suppressed, with severe cutting colicky pains in the right side and toward the small of the back, pain in the back as if bruised, vomiting, palpitation of the heart, anxiety. Stannum for uterine spasms like a frequent pressing deep in the hypogastrium, aggravated by external pressure and accompanied by a constant yellowish and very debilitating leucorrhoea. In very rare cases only these spasms are isolated, on the contrary the adjoining organs are likewise suffering, even the stomach and diaphragm are involved in the distress which the patient always describes as emanating from the womb. The prevail- ing sensation is a crampy-tensive pain below and above the Hysteria. 205 umbilicus, rather towards the small of the back, which is alleviated and dispersed by expanding the trunk, stretching the arms, and pressing the abdomen against a broad and firm object. Stramonium is suitable when the menstrual flow is excessive, attended with spasms, and more particularly when the flow is attended with hysteric derangements of the moral or mental sphere. Where the phenomena are principally located in the uropoietic range, Sepia is particularly suitable. Beside Sepia we have: Bella- donna, Zincum, Cantharides, Lycopodium. Asthma hystericum occurs rarely, scarcely ever separately, but generally as a symptom of the general paroxysm; the remedies for this form of asthma are: Ignatia, Pulsatilla, Cuprum, Veratrum and Ipecacuanha. For the palpitation of the heart with anxiety, to which hysteric females are so frequently subject, without the accompaniment of material changes, Aconite is the best remedy, and in the case of debilitated and perhaps anaemic individuals: China. [Aconite is more frequently required in the different forms of hysteria, than many physicians are willing to admit. It may per- haps afford a palliative relief only, but even this is of inestimable value to the patient. The hemicrania, clavus, the various constric- tive spasms, the sensation as if a current of air or a ball were ascending in the throat or irom the uterus, the various illusions of sight, hearing and smell with which hysteric women are afflicted, the oppression of breathing, and the extraordinary depression of spirits, the fitfulness of mood, the forebodings of evil and a variety of pains which characterize hysteria, are very frequently relieved with a few doses of Aconite more promptly and permanently than by means of any other drug. Cimicifuga racemosa or the black cohosh will prove an excellent remedy in hysteria depending upon menstrual suppression; it may be necessary to prescribe the medicine in tolerably large doses. IL] The selection of the right remedy being so very difficult in hysteria, it behooves us to direct our attention at a very early period of the disease to other accessory remedial means. A chief rank among these extra-medicinal means is occupied by the moral treatment of the patient, which should never be neglected, since hysteria can be numbered among the diseases of the mind with the same propriety as among the material or bodily diseases. Although it is necessary, on the one hand, not to contradict hysteric women, yet, on the other hand, it is sometimes indispensable to show them 206 Diseases of the Nervous System. firmness and determination. The physician has to try with a good deal of caution which course of conduct is best adapted to the case. If it is a difficult task for a physician to regulate his conduct toward a patient, it is still more difficult for him to obtain the proper in- fluence over the mind and temper of the patients and to win their confidence as well as their conscientious willingness to follow the instructions of their physician with scrupulous punctuality. The want of confidence is the cliff on which all attempts to cure the distress, strand but too offen. Hysteric women scarcely ever possess the faculty of determined volition; if they once have been brought to will a thing firmly, the cure is half accomplished. • For this purpose we have to resort to various accessory means of treatment, cold water, for instance, in order to counteract the disposition of such patients to indulge in effeminate habits and modes of living. It is not always possible to order a rigid cold-water treatment, although it might be the very best thing for this class of patients; we may have to content ourselves with systematic cold ablutions of the trunk or the whole body. Even these effect a rapid and decided change. In other cases a sojourn in a mountainous region, with a good deal of active exercise, affords striking advantages, or sea-bathing may be resorted to with equal success. Patients who have been in the habit of indulging in all kinds of luxuries, should be sent to springs where simplicity and frugality have not yet been superseded by the pernicious habits of a luxurious civilization. The occupation of the patient should likewise be regulated with a great deal of care. Hysteric women generally prefer a kind of work that leaves to their fancy full swing, a purely mechanical or rather automatic occupation, such as sewing, knitting, crocheting, &c. In such cases we must insist upon such labor being performed by them as will tax their bodily strength in an unusual although not fatiguing manner. It is likewise well to select suitable reading matter for them, and to discard novels and the like from their presence. Our remarks concerning the etiological causes of hysteria lead us to infer that there must be a prophylactic treatment of this disease, which is of particular importance, and indeed more easy of execu- tion in cases where the physician, in his capacity of medical adviser of a family, has an opportunity of watching the development of the young girls entrusted to his professional care. For more detailed remarks bearing upon this point we refer to what w6 have said in our chapter on chorea. Where the proper equilibrium between Hypochondria. 207 mind and body is kept up, hysteria need not be apprehended; un- fortunately only a small number of our young ladies enjoy this salutary advantage. The antagonism between the demands of a teacher and those of a rational system of development, is often very great. Is this the fault of the teacher, or rather that of the phy- sician ? 8. Hypochondria. Hypochondriasis, Spleen. If hysteria is to be considered a mental rather than a bodily dis- ease, this is much more the case in regard to hypochondria, where all signs of material changes are decidedly wanting; but inasmuch as it frequently exists as a complication of other affections, this has seemed the most suitable place to treat of this disease. By hypochondria we understand a morbid alteration of the men- tal condition, in consequence of which the patient only cares for, and is only busy with himself, overruled by a peculiar feeling of illness of a high and remarkably striking degree of intensity, with- out any, or at least without any corresponding objectively percep- tible abnormal alterations of functions. Hence hypochondria may be designated as a morbidly developed egotism. Hypochondria is almost exclusively an affection of male adults, which is scarcely ever noticed before the age of eighteen or twenty years. It is either an idiopathic disease, in which case it is desig- nated as hypochondria sine materia, or else it exists as a complica- tion of other abnormal conditions of the organism: hypochondria cum materia. Its etiology is rather obscure, because we are unable to account for the fact that the same etiological influence which, in one, causes hypochondria, has not the effect in others even under otherwise similar circumstances. In some cases there may prevail an hereditary disposition, in other cases there is no sign of it. The following causes have been established with tolerable certainty: Depressing moral and mental impressions; continued, one-sided and exciting mental occupations; homesickness; grief and care; haz- ardous speculations; in general, all kinds of influences which keep up a continual irritation of the nervous system and, as a conse- quence, depress its energy. Of somatic influences the most impor- tant are: Sedentary mode of life, sexual excesses, self-abuse, gastric derangements, abnormal conditions of the sexual organs, especially syphilis and disorganizations of the testes. Diseases of this kind lead to the diligent study of medicinal works; though in many cases this mania may already constitute a symptom of a fully de- 208 Diseases of the Nervous System. vclopecl hypochondria, in other cases, on the contrary, it is the main cause of this abnormal condition of the mind. Besides these causes hypochondria, like hysteria, is frequently the result of intense and exhausting general diseases of the organism. There are, however, hypochondriacs who lead a very active life in the open air, a 1 whose disorder cannot be traced to any of the above- mentioned causes. Comparing all the circumstances that bear upon this disease, it seems proper to regard the sexual system as its most probable starting-point. If the disease cannot always be traced to this cause, it may be owing to the imperfect reports of the patients, or to their intentional omissions and deceptions. Symptoms. Inasmuch as it would be very difficult to draw a complete picture of hypochondria, the Protean forms of which would require a multitude of different delineations, we prefer adopting Hartmann's method, who divides the symptoms of hypochondria in three groups, those of the mind, those of the digestive apparatus, and those that involve the nervous system generally. The psychical symptoms are the following: Ill-humor, especially during the period of digestion ; depression of spirits, sadness, dis- couragement, intense and almost exclusive preoccupation, with morbid sensations, which are interpreted by the patients as some dangerous disease which day after day assumes a new form ; ex- travagant and self-satisfying description of their own sufferings, delight in reading medicinal writings, and inexhaustible acuteness in hunting up reports of cases that are very much like their own; an exceedingly egotistical contemplation of everything concerning themselves; tyrannical demand that those who are with the patient should sympathize with his distress , unusual irritability of temper, melancholy, distrust, taciturn mood, dread of death, darkness of his prospects; although he suffers, yet he is not averse to living ; lastly, inability to do any work, even to live, from sheer distrust in his own strength, and from dread of personal injury These consti- tute the most essential phenomena in the moral sphere of the hypo- chondriac. Sometimes the mental dejection is relieved by lucid intervals of cheerfulness, even of an unusual flow of good spirits, but only for a short time. The phases of the moon seem to exert a decided influence upon the hypochondriac; his condition is decid- edly worse during an increasing moon. Sometimes these moral symptoms constitute the whole of the disease, or the disease remains stationary at this degree sometimes for years. In spite of this men- tal trouble, the desire to work at first does not suffer; it is only Hypochondria. 209 after the disease has reached a higher degree of intensity that the patients become more and more indolent, unwilling to work, and apathetic towards their nearest friends. It is a peculiar character- istic of hypochondria, that such patients scarcely ever lose the hope of getting well again, and that this hope impels them to try the most absurd means of treatment. The symptoms of the digestive range do not necessarily accom- pany a case of hypochondria, but they are scarcely ever wanting. In spite of a good and generally regular appetite and healthy ap- pearance, these patients indulge in constant lamentations about bad digestion. After, and sometimes even while eating, they feel a tightness and pressure in the abdomen which is sometimes really distended. They are disposed to regard this continual development of gas as the sole foundation of their trouble and its inherent incon- veniences. Sometimes there is a perceptible bloat under the short ribs and in the epigastric region, sensation of incarcerated flatulence which causes oppression and anxiety, palpitation of the heart, a mounting of heat to the head, loathing, heart-burn, sour eructa- tions, even vomiting of tenacious and sour phlegm are present, but much less frequently. The distress caused by the flatulence may increase so as to cause serious nervous paroxysms, vertigo, syncope, coldness of the extremities, etc. In spite of all these ailments, the appetite of the patients remains good for a time at least, showing that their digestive functions are not as bad as they would have us believe, although they examine every evacuation with the greatest care, and know of no greater delight than a copious stool. Gradu- ally, however, these at first subjective symptoms change to really objective perceptible derangements of the digestive functions. There would be too much hypothetical boldness in trying to account for this circumstance by the fact, that the patient's thoughts are con- tinually directed to these functions; the supposition that the pe- culiar anxiety and care about himself which torment the hypo- chondriac, finally have the same effect upon him as any other long- lasting mental disharmony has upon every organism, is undoubtedly more correct. A distressed and cachectic appearance becomes more and more prominent, and the assimilative functions are evidently impaired. These phenomena are in a measure owing to the patient's improper mode of living, more particularly as regards eating and drinking, and likewise to the enormous quantity and variety of the drugs which these patients, who cannot bear to do without medi cine, swallow. The mass of cathartics which they take either to 210 Diseases of the Nervous System. remove or ward off constipation, that is dreaded more by them than anything else, probably constitutes the chief cause of the disturb- ances in the digestive organs and of the irregular evacuations with which such patients are afflicted; every homoeopathic physi- cian knows that cathartics promote rather than prevent constipa- tion, and that it is extremely difficult to induce such patients to relinquish their use. The symptoms o/ nervous derangement are varied ; part of them have already been mentioned in the preceding paragraph; other- wise every part of the body, every function, may be affected sympa- thetically, on which account the symptoms assume such .multitudi- nous forms that only the main features of abnormal innervation can be recorded in this place. A sensation of coldness or heat or par- oxysmal alternations of both, as in fever; itching here and there, formication, asthma, cough, palpitation of the heart, beating in various parts of the body, especially in the abdomen; hemicrania, vertigo, buzzing in the ears, muscae volitantes, amblyopia, neu- ralgia, spasm of the bladder, frequent urging to urinate, conges- tions, increased secretion of saliva or of the tears, copious sweats, tremor of the limbs, convulsive motions, paralytic symptoms, etc.; these are a few of the symptoms that may present themselves com- bined and complicated in all sorts of ways. Sensibility is altered in a very peculiar manner, and so morbidly intensified that the least change in external influences, such as alterations of the tempera- ture, atmospheric pressure, electrical tension, trifling deviations from their habitual diet, affects such patients very unpleasantly. They complain of headache; are without sleep, or their sleep is restless and disturbed by heavy dreams ; they easily start up from their sleep; do not feel refreshed in the morning, on the contrary, they feel brighter in the evening than in the morning on rising. Like the hysteric patient, the hypochondriac discharges quantities of a watery, clear urine; sometimes, however, it is thick, cloudy, turbid, and causes a good deal of anxiety and care to the patient, who watches all these symptoms with a great deal of solicitude. As has already been stated, these local symptoms appear in a variety of combinations; but they have the peculiarity of being susceptible of rapid changes and not developing any objective phe- nomena, although, if the patient were to be believed, such phenom- ena ought certainly to exist. Hypochondria always runs a chronic course, no matter how it may have originated. If circumstances favor its development, it Hypochondria. 211 may last the whole year; but, as a general rule, it does not occur beyond the age of sixty years. During the course of the disease periods of remission of the symptoms occur; they may even cease entirely. This, however, would not justify the expectation that the disease is cured, for relapses are not by any means unfrequent. The prognosis is relatively favorable; only in rare cases, and when the disease reaches a high degree c-f intensity, it becomes dangerous to life. It is unfavorable when the diseaseis of long duration, and, by its capricious behavior and by the frequent change of its symptoms, causes the physician, as well as the patient, a great deal of trouble and anxiety. It is always difficult to enforce the promise of a favorable turn, for the reason that the patient who to-day had the greatest confidence in his physician, may lose it entirely over night. On this account the prognosis, in the case of fickle patients, is always more doubtful. But where the patient obeys the instruc- tions of his physician with confidence, where there is a possibility of changing the patient's mode of life and removing bad habits, the prospect of a successful termination may be very flattering. The more the assimilative functions have become impaired, the less favorable are the prospects of a cure ; this is likewise the case where sexual excesses or onanism are persisted in. Treatment. Hypochondria belongs to that class of diseases whose character it is very difficult to delineate with perfect accuracy. For this reason the physician should not neglect a single means of obtaining as complete a picture of the disease as possible, and like- wise of investigating the exciting causes. The patient would soon know whether the physician proceeds carelessly in making his ex- amination, and would become distrustful if the physician would undertake to console the patient by representing to him the dark and complicated group of his symptoms as nervous and hypochon- driac ailments. I consider it as a master-piece of art if a young practitioner knows how to examine a hypochondriac who generally moves in the higher walks of life, in such a manner as to win his confidence and to extort from him a smile of satisfaction by the adroit manner in which satisfactory answers are elicited to the physician's questions. The hypochondriac is distrustful, the read- ing of medicinal works has given him an overweening confidence in his knowledge, if not of medicine generally but of his own con- dition ; and his questions are often so cunningly devised that it requires a good deal of skill on the part of the physician to answer them with a propos and thus to dissipate his patient's suspicions- 212 Diseases of the Nervous System. If he has succeeded in this, not merely for the time being, but for the patient's permanent good, by a triithful and correct comprehen- sion of the disease, the treatment, were it ever so difficult, will cer- tainly be correspondingly successful, for the patient will adhere to it even if his improvement is but slow. (Hartmann.) It is evident, from the constant changes which take place in the phenomena of this disease, that it is impossible to fix even approxi- matively upon a positive treatment of hypochondria in accordance with the principles of Homoeopathy. This is much less possible with hypochondria than with hysteria, where local derangements are very often present, which is not the case in the former disease. Hence we can only furnish a very general survey of the remedies for hypochondria, and refer to the Materia Medica for all special cases. Nux vomica holds the first rank among the anti-hypochondriac remedies. It corresponds most completely to all the symptoms of the digestive apparatus, to their appearance after a meal, to the disposi- tion to gaseous flatulence and to constipation. Other circumstances which are of great moment in hypochondria, lead to the choice of this remedy. The circumstances are: the origin of hypochondria from sedentary habit, deficient exercise with rich living and excessive mental exertions; use of stimulants in order to keep awake at night; moreover the excitability of the temper which induces an ebullition of anger from the least provocation; continual cloudiness of the head, with more or less prominent signs of cerebral conges- tion, more particularly in the case of patients who are fond of wine and good eating. As a general rule Nux is more adapted to mate- rial hypochondria proceeding from derangements of the abdominal organs, much less to digestive derangements which are consequences of hypochondria. Sulphur is almost equally valuable as the former remedy, with this difference that the kind of hypochondria to which Sulphur is adapted, differs somewhat from that of Nux. It is the immaterial forms of hypochondria, exerting a considerable influence upon the process of assimilation, to which Sulphur corresponds, and the symptoms of which are found with remarkable completeness in the pathogenesis of Sulphur. It is likewise suitable in cases where Nux vomica is suitable, more particularly if luxurious living has given rise to haemorrhoids, the bowels are very torpid and the functions of the liver are manifestly deranged. Finally it is the main remedy where the improper treatment of syphilis has given rise to hypo- chondria. Hypochondria. 213 Staphysagria has a variety of applications. It is a leading remedy where hypochondria has been caused by onanism, or by syphilis and the abuse of Mercury. It is likewise very efficacious where the disease is caused by long-continued, depressing emotions, more especially long-gnawing grief and chagrin. The symptomatic indi- cations, especially in the digestive range, correspond very fully to hypochondria, above all we have great inconvenience from flatu- lence. Staphysagria may be distinguished from Nux by differences of complexion, that of Staphysagria being pale, of a yellowish- gray and dingy color, whereas a bright complexion is more charac- teristic of Nux. Natrum muriaticum is not even mentioned by Hartmann, yet it is indispensable in the treatment of hypochondria. If Hartmann has found salt so useful in hysteria and was reminded of it by the cir- cumstance that hysteric women are often so extravagantly fond of salt food, we have a right to be amazed that he should not have made mention of this agent from similar reasons in hypochondria. Certain hypochondriacs are exceedingly fond of salt, and, in spite of every effort to the contrary on the part of their physician, they persist in the excessive indulgence of this condiment. They are more particularly such patients as lead a sedentary life and perform a good deal of mental labor, and w'hose digestion is very weak. Persistent and careful inquiries will satisfy any one that the mania of eating salt is much more universal and deep-rooted than one imagines and that, in such cases, it is kept up by an instinctive desire as well as by the power of habit. A comparison of the symptoms of salt with the symptoms of a more fully developed hypochondria will satisfy us, that the two series are very similar to each other, more particularly when the digestion is very much dis- turbed, the patient has a distressed and yellowish-gray appearance, and symptoms of debility begin to manifest themselves. Hypo- chondria remaining after slow and exhausting diseases, especially after fever and ague and typhus, likewise corresponds to the patho- genetic series of salt; in such cases the symptoms seem to indicate China with which Natrum muriaticum is in very close affinity. Conium maculatum is likewise a powerful remedy for hypochon- dria, more particularly when it seems to proceed from sexual de- rangements without any excesses having been committed. TLe patients complain of great weakness of the sexual organs, with an unusual irritability of these parts, they are subject to frequent and exhausting emissions and most generally complain of the discharge of prostatic fluid at stool. Such patients are generally those who 214 Diseases of the Nervous System. in spite of excessive sexual excitement, maintain the strictest ab- stemiousness on account of their virtuous and unyielding principles. Such individuals sink more readily than other hypochondriacs into a state of melancholy, aversion to labor, loathing of life and idiotic weakness ot mind. In most cases we have a derangement of the urinary secretions, and a fixed pain in the lumbar portion of the spinal cord, especially after long-continued'exercise. Phosphorus is likewise a noteworthy remedy in hypochondria, if the disease originates in the sexual sphere, with this difference, that whereas the Conium-hypochondria is caused by extreme abstemi- ousness, Phosphorus corresponds to the hypochondria originating in sexual abuse, more particularly onanism. The symptoms in both forms of hypochondria are pretty much the same, except that in the case ot Phosphorus the painfulness of the spinal marrow is much more intense. Beside Conium and Phosphorus, which corresponds more specifi- cally to hypochondria, whose exciting cause resides in the sexual range, a great many other remedies having a particular affinity to the sexual organs, may likewise be found useful in hypochondria, more especially the following, which are distinguished by their affinity to the emotive sphere: Agnus castus, Anacardium, Aurum^ and likewise Clematis. Tae last two remedies deserve particular consideration where disorganization or simple swelling of the testes is present, disorders which often give rise to the most obstinate and intense forms of mental derangement, even a disposition to suicide, which symptom is particularly peculiar to Gold, (Aurum.) Stannum is recommended by Hartmann with so much urgency, that we cannot forbear transcribing his remarks literally. Stannum frequently has a marvellous effect in various spasmodic hypochon- driac ailments, which mostly originate in the ganglionic system. By walking about the patient is greatly relieved, whereas his distress returns again in a state of rest, which he would like very much to indulge in, owing to his feeling continually weak and weary, both mentally and physically; this makes him sad and melancholy, and he often feels so discouraged that he could almost weep. If with these symptoms are associated a stupefying, pressing distress in the brain, as if the skull were in a vice, or other abnormal sensations in the brain, illusions of hearing, distress in the stomach, with regular appetite, feeling of emptiness in the abdomen, constipation, exhaust- ing night-sweats, etc., the patient feels in the highest degree miser- able, and by exaggerating his ailments, renders life disagreeable to Hypochondria. 215 those around him. It is to this kind of hypochondria that Stan- num will be found to correspond, and where it will always be found effective. Besides these remedies which are always to be considered first, we direct the attention of the reader to the following: Zincum. Veratrum album. Calcarea carbonica, China, Pulsatilla, Gratiola, Acid am phosphoricum and nitricum. More important and effective than all medicines, is the dietetic and psychical treatment of hypochondria. This may be inferred even from the intermediate position which this affection holds between mental and material diseases, sometimes partaking rather of the character of the former, at other times of that of the latter. But even in cases where hypochondria depends upon perceptible material derangements, we cannot help recognizing the existence of some important mental disturbance; otherwise the same material de- rangement would have to cause hypochondria under any other similar circumstances, which is not the case. Besides these a priori arguments, experience shows that an appropriate psychical treat- ment of hypochondria is absolutely necessary to the restoration of health. We have already alluded to the influence which the man- ners and personal appearance of the physician exert over the hypo- chondriac patient; in this respect the physician cannot be too cautious if he means to preserve his patient's confidence. It is, moreover, important to turn the attention of the patient away from himself, which is sometimes very difficult. It is almost next to impossible to prevail upon the patient to discontinue the reading of medicinal works, and his everlasting conversations with everybody about liis ailments. Both these points are of importance. Besides these precautions we should see to it, that our patients indulge as little as possible in a state of rest, and spend their leisure hours in studies that are rather outside of the usual range of their regular avocations, and engage their attention in a more serious manner. All one-sided and monotonous mental labor is decidedly unfavora- ble to the hypochondriac; a variety of occupations is indispensable to his recovery. On this account we have likewise to regulate the pleasures and recreations of our patient, and vary even these, lest habit should transform into a labor what was designed to be a recreation. In this respect nothing has a better effect than inter- course with individuals of cheerful and lively minds ; only they must understand that it is not only not advantageous, but decidedly hurtful to the patients, if we deride their apparent, as well as their 216 Diseases of the Nervous System. real imaginings, by unkind jeers and jests. This deprives the phy- sician, as well as the patient's friend, of all moral influence. The degree of cultivation of the patient is, of course, to be considered in our treatment of his complaint. It is much easier to get along with individuals of less education, than with those who enjoy a high degree of mental refinement. With regard to their morbid sensa- tions, the judgment of the latter is indeed clouded, but in every other respect they remain possessed of their usual acumen; they perceive inconsistencies in the treatment with quick readiness, and every discovery of this kind diminishes their confidence. From these general reasonings we can readily draw inferences regarding the management of particular cases; at all events it would be impossi- ble to meet the requirements of every special case by detailed indi- cations ; there are too many ways which lead to the attainment of the main object, namely: to lead the patient's attention away from himself by exciting an interest in external objects. The dietetic treatment of hypochondria is undoubtedly much less important and efficient than the enforcement of moral rules; for many an hypochondriac who follows with the most minute regular- ity the dietetic regimen prescribed by the physician, yet remains an hypochondriac. It seems therefore to be proper, that not too high a value should be attached to the mode of living; dietetic rules, if enforced with too much strictness, have a tendency to perpetually remind the patient of his ailments, the very point that is to be avoided; habits prejudicial to health, or irregularities in the mode of living which are evidently hurtful, have, of course, to be discon- tinued. If the patient had been leading a sedentary life, and had indulged in continued mental efforts, he will have to be reasonably restrained in this regard, and more exercise in the open air will have to be recommended; where the disease seems to have been caused by too good living, a simple and regular diet has to be prescribed, etc. As a general rule, however, hypochondriacs apply for medical treatment when the disease has reached a degree of development, where the most rigorous diet has already been established as a rule, and we have to admit, that it is not by excessive eating or drinking that the hypochondria has been caused. The condition of the skin and the proper attendance to muscular development are, on the con- trary, very essential, for these two points are very often neglected. With respect to the condition of the skin, cold water is a panacea, for two reasons: it has a beneficial effect upon the functions of the skin, and the use of cold water stimulates the will-power, which is Hypochondria. 217 of no slight importance. The development and expansion of the muscular power imply exercise, but it is not by any means indiffer- ent what kind of exercise is indulged in. An hypochondriac pa- tient, for instance, takes, day after day, his routine-walk of miles in length, and yet his hypochondria does not leave him. Walking is certainly not the best kind of exercise, and will be found useful to a certain extent only, in cases where a sedentary mode of life had been pursued. Much better results are obtained by gymnastic exer- cises that give active play to the abdominal and dorsal muscles. For this purpose we recommend sawing and splitting wood, and occupations in the garden, the good effects of which nobody can deny. If this kind of exercise is not convenient, owing to the cir- cumstances of the patient, gymnastic exercises, fencing, etc., will have to be resorted to. Fencing, particularly, has a beneficial influ- ence over the whole frame, and can be indulged in without making any special arrangements as are required for gymnastic purposes. Journeys on foot in pleasant company are likewise very useful. Riding; on horseback affords more active exercise and often suits the wishes of the patient a good deal better than any other bodily move- ment ; driving in a carriage, on the contrary, is decidedly objection- able, since nothing favors preoccupation with one's self more than riding in a comfortable carriage. One other point has to be mentioned, which sometimes embarrasses the treatment, especially if conducted in accordance with the prin- ciples of Homoeopathy : this is the complaint of all hypochondriacs about constipation. The habit of taking something for constipa- tion day after day; the opinion that a daily evacuation is of the utmost importance to the general well-being of the patient, give rise to so many queer and even absurd notions in the patient's mind, that an interdiction of the use of all cathartics seems to him like a sentence of death. Nevertheless, such an interdiction is indispensa- ble, and the regulation of the alvine evacuations is sometimes a matter of the greatest difficulty. On this account, were it only to quiet the patient, it is necessary at the commencement of our treat- ment to order cold-water injections. In the long run, however, we succeed much better if we direct the patient to attempt an evacua- tion of the bowels every morning after breakfast, no matter whether he experiences a desire for it or not, and not to yield to it, if such a desire should be felt during the day. By this simple means I have removed many an habitual constipation radically, without any medicine, sometimes in a few weeks. SECOND SECTION. Diseases of the Head. A. DISEASES OF THE SCALP. Inasmuch as it seems more convenient to range most of the affec- tions of this class among the cutaneous diseases, we will content ourselves with here mentioning only one disorder, namely, Ceplialrematoma, Bloody Tumor of Ilse Scalp. By this term we designate an effusion of blood under the scalp, sometimes under the aponeurosis, and at other times under the peri- cranium. This disease is peculiar to new-born infants. The causes of this tumor are undoubtedly referable to the cir- cumstances under which the act of parturition took place; they are purely mechanical. It may be caused by the application of instru- ments, or by the pressure exerted upon the skull of the infant by a protracted labor, or by the narrowness of the parts, or a rigidity of the os, and occasioning a rupture of the vessels of the scalp. Such a rupture may result even during a comparatively easy labor, since even a moderate pressure may sometimes cause the laceration of one of the delicate vessels of the scalp. The tumor arises im- mediately after birth, but may commence so imperceptibly and may increase so slowly that it is seen only a few days after birth, and then gives rise to the opinion that it is not an immediate consequence of the act of parturition. It is generally located on one of the two parietal bones; its size varies, from one inch to three or four inches in diameter; its form is likewise uncertain. The color remains un- changed, fluctuation is distinctly perceptible. Pressure upon the tumor does not give rise to any particular symptoms ; pressure with the finger does not leave a trace behind. The sutures of the skull bones form a boundary beyond-which the tumor cannot expand, and hence its shape is very often determined by these sutures. The 218 Cephalaematoma, Bloody Tumor of the Scalp. 219 tumor may be raised above the skin to the height of an inch. The health of the child is not affected by the tumor, unless there should be special complications. In the course of the tumor three changes may arise. The extra- vasated blood may be simply reabsorbed; this change takes place only if the children are very small, and is completed in a few weeks. Or, perhaps, in consequence of the supervention of a peculiar process of exudation, the tumor may become ossified. The formation of bone commences where the detached pericranium unites with the skull, hence in the circumference of the tumor; it feels like crack- ling paper, may extend through the whole extent of the tumor, and after resorption of the remaining fluid has taken place, the bone at the diseased spot is found slightly thickened. Or, finally, the extravasation may become surrounded by inflammation, and an abscess may form. It is only this last-mentioned change that can endanger the child's life. Treatment. To Hartmann's remarks on this subject we add something of our own. Hartmann writes: " If we are sure of the presence of extravasated blood, we make an incision with a lancet at the point where the extravasation seems to be most copious, squeeze the contents out with great caution, insert a small plug of lint into the wound to prevent its healing too rapidly, cover the place with a compress of four thicknesses of linen moistened with a solution of two drops of Arnica in two ounces of water, and give internally a few pellets of Arnica 6. By pursuing this course the swelling generally disappears entirely in a few days." A well-founded objection can be raised against this proceeding. Every bloody extravasation, no matter where it may be located, by the contact with atmospheric air has impressed upon it a tendency to form pus; hence it is not advisable to favor this tendency un- less the non-opening of the tumor should be attended with par- ticular danger. A bloody tumor of itself is almost without any danger; it suppurates only after it is opened or in consequence of violent compression ; otherwise if left quietly alone, it is reabsorbed. Why should we, for the sake of obtaining a somewhat more rapid cure, allow ourselves to be led to perform an operation that is not without danger? It is much better to be patient for a few mo- ments. And if, after all, we decide to open the tumor, the plug of lint can do no good, for the reason that it promotes the communi- cation with the open air. In our opinion, as long as no suppuration has taken place, the opening of the tumor should be postponed. 220 Diseases of the Scalp. A weak solution of Arnica tincture may be applied; this can do no harm. Any kind of compression is improper, both as regards the tumor and likewise the head of the child. If pus forms, we should not open the tumor prematurely, lest the suppuration should be un- duly hastened, which is generally the case if the incision is made too soon. Under these circumstances Mercurius is the best remedy, and, after the suppuration has lasted for some time, Silicea. Other medicines which may have been recommended for this trouble, need not be recorded in this place. The above-mentioned treatment is sufficient, and such a trifling extravasation is so easily absorbed that we may readily be deceived in mistaking it for me- dicinal action. To open the tumor by making a much larger incision, seems to us an unjustifiable proceeding, and a trifling with the life of the child. Suppuration will always follow, and it is impossible to tell what the consequences may be. B. DISEASES OF THE CEPHALIC NERVES. 1. Cephalalgia, Headache. Headache is one of the most common accessory symptoms of febrile as well as non-febrile affections. Hence we might adduce a great many forms of headache arising from a variety of causes, without, however, helping the treatment in the least by such a mul- tiplicity of causal distinctions. The headache will disappear as soon as the affection upon which it depends is cured. It is true that it is not always so very easy to find out the causes of headache; it is sometimes very violent when the general affection seems very slight, and seems, on that account, to be more or less an idiopathic condi- tion of distress; but all attempts to point out a therapeutic pro- ceeding for all such cases would be in vain; in such cases the selec- tion of a drug is altogether difficult, and disappoints us very often. For even if we compare the statements of the patient concerning the quality, locality and peculiar character of the pain with ever so much care, the proper remedy is not found, for the reason that we have to shape our treatment in accordance with the subjective .• tate- ments of the patient. Everybody knows how deceptive the lan- guage employed by different patients is, and that one calls pressure what another designates as tension or a feeling of weight. If the Hemicrania or Megrim. 221 headache is simply an accompaniment of other complaints, it is of not so much importance what kind of a headache it is. On this account we have only to discuss one form of cephalalgia, namely, Hemicrama or Megrim. By this term we designate a kind of headache which occurs par- oxysmally at more or less regular intervals, the paroxysms being of equal duration and intensity, and having the characteristic peculi- arity that they only affect one side of the head. There are various reasons to regard hemicrania as a purely neu- ralgic affection of the cerebral nerves. It is, indeed, true that it sometimes accompanies other ailments, but it occurs just as often as a separate disease, and cannot be accounted for by any anatomical lesion. It seems, moreover, that only the more delicate nerves of the meningeal membranes, not the nerves of the external integu- ments of the head, are the seat of this affection, even some twigs of the trigeminus being sometimes involved in the attack. The causes of megrim vary a great deal. Where it occurs as a complication of other diseases, it may depend upon liver-complaint, gastric derangement, cardiac anomalies, but more particularly on a morbid condition of the sexual organs. As an idiopathic affection, it is only met with in constitutions to which, on account of a preva- lence of nervous sensitiveness, we apply the term nervous. Hence it is more prominently met with among persons of the female sex. That it is not always and exclusively dependent upon abnormal sexual functions, is evident from the circumstance that it is some- times met with even in children. As remote causes, we may regard the various influences which engender an excessive irritability of the nervous system, such as precocious mental development, excess of fancy, excessive mental labor, in short all those defects in the pres- ent mode of living of our young women, of which mention has already been made in our remarks on. hysteria, of which megrim is very often a mere symptom. Losses of animal fluids and protracted diseases likewise often cause that species of nervousness of which hemicrania is a phenomenal manifestation. In general the symptoms of hemicrania are very constant and uniform, and mostly vary only in their less essential points. In most cases without any precursory symptoms, much less frequently after a previous feeling of malaise, the patients wake in the morning with a violent and constantly increasing headache. The pain is sometimes described as throbbing, at times as tearing or boring, or 222 Diseases of the Scalp. as an ache, and is generally confined to a sharply circumscribed locality on one side of the head, usually the left. External pressure affords relief rather than it aggravates the distress. Every mental and physical effort is painful, whereas an agreeable excitement of the mind by conversation or some attractive occupation, affords relief as soon as the patient makes up her mind to give herself up to it. This, however, is a difficult task, on account of the general feeling of lassitude complained of by the patient. As the pain increases, the eyes become affected: they are very sensitive to the light, and there is a copious flow of tears. When the pain is at its height, the patient vomits up a watery phlegm after having experienced nausea for some time previous. It is characteristic of megrim that the pain is very often accompanied by a sensation of hunger, and the attack is sometimes shortened if the patient can make up her mind to eat a great deal. After the vomiting, the patients feel better and want to sleep, and after a sound sleep, they generally wake quite well, only somewhat weary. Such paroxysms sometimes recur in a few days already, sometimes not till months have elapsed ; in the case of females they are apt to come on about the catamenial period. The general condition of the system is not always affected by the attacks ; in the intervals between the attacks the patients may have the appearance of enjoying good health. Very rarely the pain lasts beyond twelve hours; if it lasts longer, it may continue for thirty- six hours. The prognosis is not particularly favorable even if we succeed in removing the cause of the difficulty. The younger the patients the more we have a right to expect a complete cure. It always takes a good deal of time to achieve success; very frequently we have to content ourselves with diminishing the frequency and intensity of the paroxysms. Treatment. It has to be shaped so as to meet various phases of the complaint; it has to be directed against the special attack, against the attack as a part of the general affection, and has like- wise to act as a prophylactic against the influences which we are satisfied are the determining causes of the paroxysms. The treatment of the actual paroxysm presents difficulties, in so far as the selection of the appropriate remedy is rendered doubtful on account of the homogeneous character of the symptoms; and it is, moreover, difficult, in view of the variable intensity of the attack, which it is impossible to determine a priori, to what degree the duration or intensity of the paroxysm had been modified by the Hemicrania or Megrim. 223 medicine that had been taken. In addition to this, the physician is seldom called at the commencement of the attack, but in most cases only after it had reached its climax. Of the many remedies which have been recommended for this disease, we mention only a few more in detail, for the reason that we deem this part of the treatment as the least important. Coffea. Hartmann begins a paragraph about the treatment of hemicrania, with a remonstrance against the use of coffee. We shall find that, as a general rule, all persons who are tormented with this affection, are passionate lovers of coffee, and in many cases the disease can be traced to this abuse as its cause. Since hemicrania affects more particularly individuals of irritable nerves, it is easily seen why they should be so devoted to coffee; it is a pleas- ant stimulant for relaxed nerves. This is the reason why we find it so difficult to restrain such patients from the use of coffee, although this deprivation is indispensable to a cure, which is sometimes achieved by it alone. This observation leads us to recommend Coffea as an important remedy for hemicrania in the case of persons who do not use coffee as an habitual beverage. They are some- times marvellously relieved by a few teaspoonfuls of good coffee, so that coffee has become a'domestic remedy for megrim. Medicinally it is used as a wTatery or spirituous extract of the fresh, pulverized bean. The headache which coffee causes, has peculiar features with which we are abundantly acquainted from personal experience. The head feels hot and heavy, in very rare cases the forehead is covered with a cool perspiration ; there is weariness and great lassi- tude ; the individual is unable to sleep, is tormented by an anxious restlessness and oppression, and experiences a feeling of uneasy and nervous exhaustion, which is exceedingly distressing. The head- ache is generally a throbbing pain, and accompanied by the sensa- tion of a dull pressure in one temple. Kause'a is generally present, sometimes attended with a feeling of emptiness in the stomach, but does not result in vomiting. Regarding the curative effects of Coffea cruda in hemicrania, when given in small doses for a period of time in succession, we have no observations to offer; so much more frequently we have observed a favorable and almost opium- like effect from a few doses of ordinary coffee in the cases of a num- ber of persons. Nux vomica. Irrespective of the different headache symptoms which this medicine develops, and which we request the reader to look up in the Materia Medica, a few other circumstances invest 224 Diseases of the Scalp. this agent with the character of a leading remedy in hemicrania. Among these circumstances we point out, in the first place, the an- tidotal relation of Nux vomica to coffee and other spirituous bever- ages ; next the peculiarity that exercise and the open air are almost unbearable; and lastly, an extreme irritability of the senses. The selection of Nux is moreover determined by a choleric, sanguine temperament, continued mental exertion, together with want of exercise; disposition to congestions and constipation. It is a vio- lent aching pain that is more particularly influenced by Nux as its curative remedy. Not unfrequently it will be found that the exhi- bition of Nux is followed by vomiting of a bilious fluid, which is to be regarded as a particularly favorable curative result. In our hands small and seldom repeated doses have never had any marked result. Nux vomica can likewise be administered for this affection when invested with the character of a constitutional morbid dispo- sition, in which case the accessory symptoms have principally to determine its choice. Ignatia amara is in close affinity with the former medicine in a great many respects. It is more particularly suitable for females with irritable nerves and disposition to convulsions, more particu- larly in the case of hysterical persons. For Ignatia likewise, a pressing aching pain is a prominent symptom, and, according to Hartmann, the remedy is especially indicated when the patients complain as if a nail were pressed into their brain from without inwards. Whereas a red and turgid face is more particularly adapted to Nux, Ignatia, on the contrary, has pallor of the counte- nance. A marked disposition to vomit is not characteristic of Ignatia. Belladonna, in comparison with the previously-named remedies, will be but rarely found suitable in hemicrania; even the peculiar time of day when the headache first breaks out, is opposed to Bella- donna. Violent congestions, even to the presence of delirium, have to be present in order to justify the use of Belladonna; moreover excessive irritability of the senses, more particularly of the eyes. The pain is throbbing and stitching, and seems to be excited by every single pulsation. Belladonna will be found more especially suitable in attacks of hemicrania lasting beyond the period of twelve hours. According to our own frequently repeated observations, Arseni- cum quiets nervous pains better than any other medicine. Its effect is rapid, and sometimes rivals a powerful dose of Opium. It is Hemicrania or Megrim. 225 characteristic of Arsenic to exert this soothing influence only in the case of pains that become worse towards the approach of night, reach their climax about midnight, and are accompanied by an ex- traordinary degree of anxious restlessness. Hartmann furnishes the following more particular indications: The pain is throbbing and stupefying, either in the forehead, and more especially above the root of the nose, or above the left eye, and leaves almost always a weakness of the head, and a qualmishness in the pit of the stomach. The pain is, moreover, characterized by other accessory symptoms; for instance: it regularly breaks out after a meal, abates by applying cold water to the part, and is aggravated a great deal by removing the cold water; is most violent in the evening and at night, when it is diminished by walking about, by external warmth, and by pressing the head between the hands; not unfrequently, even if the pain is not very violent, it is attended with a general feeling of lassitude and prostration, obliging the patient to lie down. Glonoin has been frequently recommended for hemicrania, but in spite of very frequent trials, we have never been able to derive any good from it in this disease. We now come to the series of drugs which correspond to this affection in its essential or inherent integrality. The most important among them is Sepia. We advise the reader to look up the headache symptoms of this drug in the Materia Medica; they are very characteristic of Sepia, and, in view of the practical results to which these symp- tomatic indications have led, they deserve the most careful atten- tion. We are not disposed to indicate particular pains as decisive of the choice of Sepia. The accessory phenomena, which play an important part in the selection of the drug, are much more essen- tial. Sepia is most suitable for the female organism, more par- ticularly for females afflicted with liver-complaint and abdominal congestions. A pale, anaemic and cachectic complexion is no rec- ommendation for our drug; on the contrary it is rather indicated by vivid redness, with variable complexion and a yellowish tint, especially under the eyes. Such individuals are exceedingly sensi- tive to mental impressions, whether pleasant or of a depressing character, and such impressions very readily provoke a pa - oxysm of headache. It is more particularly the condition of the sexual qrgans that has to be considered in the case of Sepia. T e menses are irregular, not sufficiently copious, always preceded by local pains and a general feeling of malaise, and generally succeeded by leu- 15 226 Diseases of the Scalp. corrhoea; the headache generally occurs about the time of the menses. Sepia is so much more indicated if the sexual instinct is abnormally excited, even during the headache. The remedy has to be frequently repeated at long intervals, since we cannot be sure whether another paroxysm may not occur. If the attacks do not occur too rarely, perhaps every fortnight, or about the menstrual period, it is well to give a few doses after every attack, and then patiently to await the result. This single remedy is often suffi- cient to cure even cases of long standing. We must not omit Hart- mann's remarks concerning the exhibition of Sepia in hemicrania; he does not seem to think much of this remedy in hemicrania, but recommends it rather for arthritic headaches, a designation that seems to us rather baseless. He ranges Sepia side by side with Belladonna, recommending the former for the constitutional dia- thesis and the latter more particularly for the special paroxysm. The pain is stinging, is located in one of the frontal or occipital protuberances; the stitches flash through the brain, where they seem to leave a deep impression evert after they have darted through it; the more frequently the stitches are felt, the more the patients complain of heat in the head, which finally gives way to a feeling of dulness, which is attended with great sensitiveness of the scalp. These symptoms likewise occur during an attack of hemicrania, on which account we have recited them in this place. Platina is related to Sepia by its action upon the sexual sphere, only the symptoms of these two drugs in the genital range differ very essentially. Platina is indicated when the menses are very profuse, are accompanied by colicky pains, either at the commence- ment or during their whole course, and generally cause marked derangement of the nervous functions. Platina is more particularly adapted to plethoric, animated and very sensitive individuals. The headache which Platina occasions, is characterized by pressure, sometimes as from a dull point, at other times as from a tight band- age, and is seated in the sinciput; it is accompanied or succeeded by a peculiar sensation of numbness. If cardiac anguish and dyspnoea are present, or if the disorder seems to be caused by structural changes of the heart, Platina is so much more in its place. Spigelia. The headache to which this remedy corresponds, varies greatly in its forms. According to our experience it seems to be most suitable in tearing, rheumatic headache, more particularly it the pains are darting; it is additionally indicated if the facial nerves are involved in the distress and the paroxysms occur periodically Neuralgia Trigemini. 227 or nearly so. The sensation as if the brain were detached, is like wise found among the symptoms of other drugs, but among the remedies for hemicrania this symptom is more prominent in the pathogenesis of Spigelia than that of any other remedy; the pain is considerably aggravated by every somewhat unusual motion of the head, especially by stooping. We must not omit alluding to the relation of this drug to the heart; this may be accounted for by the circumstance that the headache affects more prominently the left side. The complexion is usually pallid; a flushed face may be regarded as a counter-indication to Spigelia. Silicea corresponds to paroxysms of hemicrania, and of chronic headache, generally, which break out very frequently and maintain a marked periodicity; they are attended with rush of blood to the head and occasion great sensitiveness of the scalp. That the head- ache affects the integuments of the head, is likewise evidenced by the falling off of the hair and by excessive perspiration on the hairy scalp. To these most important and most efficient remedies a number of other drugs might be added, the effect of which is in a measure doubtful, or which are adapted only to very particular cases, and the use of which depends more especially upon the general affection of which the headache is a mere symptom. Among this latter category we number all those drugs which are more particularly suitable to the hemicrania of anaemic individuals, such as Pulsa- tilla, Ferrum, China, Natrum muriaticum, Calcarea carbonica. We shall give more particular indications concerning the use of these drugs when speaking of anaemia, to which article we refer the reader. Beside these the following series deserves attention: Colo- cynthis, Capsicum, Veratrum album, Acidum nitricum, Aurum, Ver- bascum, Sanguinaria, Phosphorus, Bryonia. [Aconite, in tolerably high doses, should not be forgotten in this disease. IL] As regards a prophylactic treatment, it is just as important in .this affection as in other previously described affections of the ner- vous system to which females are especially liable (chorea, hysteria, &c.), and in order to avoid repetitions we refer the reader to what we have already said concerning them. 3. IVeuralgia Trigemini. Fothergill's Prosopalgia; Tic douloureux; Prosopalgia, Face-ache. Of all nerves, if we except perhaps the ischiadic nerve, the tri- geminus becomes most easily the seat of neuralgic pains. This sus- 228 Diseases of the Scalp. ceptibility can easily be accounted for by the fact that it spreads through parts which are exposed to a variety of external hurtful influences, and further by the course it takes, almost all its rami- fications passing through very narrow orifices of the skull bones. The etiology of prosopalgia is very uncertain; it often happens that no causes whatever can be ascertained in a special case. We may arrive at some approximate certainty regarding the seat of the exciting cause; far-spread neuralgias necessarily owe their existence to some morbid impression upon the main nerve, whereas, if the neuralgia is confined to one branch or to part of a branch, the cause of the neuralgia must be located rather at the periphery. The char- acter of the morbid impression has not yet been revealed even by the most careful pathologico-anatomical investigations; it is only in proportionally rare cases that structural alterations of the bones or tumors pressing upon the nerve have been discovered. As mediate etiological influences we may regard all those conditions that have already been pointed out as causes of hemicrania. We have, more- over, wounds, mechanical impressions generally, abuse of poisonous cosmetics, toothache, abdominal ailments, suppression of habitual bloody discharges, syphilis, arthritis, rheumatic complaints. This form of neuralgia may originate in miasmatic influences and is more or less paroxysmal. Sex has undoubtedly more or less influence, for females are more generally attacked with this form of neuralgia than males. It is likewise a well ascertained fact that it occurs most frequently between the ages of thirty and fifty years. Children do not seem to be liable to this disorder. The symptoms of this disorder, although the same in essence, yet differ a great deal as respects their location and extent, according as one or the other branch of the main nerve is affected. Proso- palgia almost always comes on in paroxysms separated from each other by irregular, but most generally perfectly free intervals ; the painful sensations which continue without intermission, cannot prop- erly be termed neuralgic. The paroxysms either occur in rapid suc- cession, or in groups which are succeeded by a complete remission for a certain period; or else the paroxysms occur only at long intervals. They are very rarely preceded by preliminary symptoms; if such are present, they are altered sensations in the tract of the nerve. The pains set in suddenly, generally with a moderate degree of in- tensity, which gradually increases. They follow the cour.-e of one or more of the larger trunks of the trigeminus, but may likewise be confined to the portion of a larger trunk. The right side is Neuralgia Trigemini. 229 often more prominently affected; among the single branches the superior maxillary, and next to it the ophthalmic branch is more particularly the seat of the pain. When at its acme the pain seems intolerable, jerking, tearing, burning, darting or flashing, so that the patients cry out aloud. It is rarely continuous, in most cases it breaks out in paroxysms. The face is at times pale as in death, at other times it has a bluish appearance and, if the paroxysms last any time, it looks bloated, which bloat sometimes remains perma- nent if the paroxysms recur frequently. In most cases the motor- nerves participate in the attack, giving rise to twitchings of the muscles, distortion of the features; even more distant parts of the muscular system are convulsively affected, the cause of which, in most cases, is undoubtedly the extreme pain. We need not partic- ularize the manner in which the pains radiate to different parts, since this can easily be inferred from the anatomical distribution of the different branches of the nerve. It is only in special cases that we may find it difficult to arrive at a correct diagnosis of the dis- order, namely when the more deeply-coursing twigs of the trigem- inus, those, for instance, which provide the eye with functional power, are the seat of the pain. The neuralgia likewise affects the vascularity of the affected organ, the eye, for instance, appears in- jected, the salivary glands secrete more saliva. During the par- oxysms the irritability of the affected nerves becomes extraordinary so that the least irritation (a current of cold air, talking, etc.) pro- vokes a fresh exacerbation. On this account the patients desire to remain absolutely quiet, and to avoid every impression from the outer air. The duration of a paroxysm, when several attacks follow each other in succession, varies a good deal; so does the duration of the separate attacks. The general paroxysms may not come on again till years have elapsed; the single attacks may only be separated by intervals of a few minutes. Neuralgia depending upon mias- matic influences, returns again after regular Intervals, but their total duration is likewise uncertain although, on account of the greater facility with which they are cured, it is shorter than that of other forms of neuralgia. The prognosis is in so far favorable as life is not directly threat- ened by an attack of prosopalgia. It happens, however, that exces- sive and frequently returning neuralgic pains become the cause of suicide; apoplectic attacks are likewise said to have been caused by such violent attacks of neuralgia. In its higher grades the disorder 230 Diseases of the Scalp. always has a pernicious effect upon the general constitutional con- dition, the mind is easily affected, and melancholy is the result; but even without such disastrous consequences the nervous system becomes very irritable and the sensitiveness excessive. The possi- bility of a cure depends upon several circumstances. Where the affection is occasioned by organic changes of structure, such as osseous disorganizations, tumors, etc., there is scarcely any hope of a cure, whereas intermittent neuralgia and a neuralgia that had been caused by a recent cold, is easily cured. The shorter the dur- ation of the paroxysms, the less frequently they occur, the less intense and wide-spread they are, the sooner we may hope to effect a cure. Treatment. Prosopalgia is one of those affections which is best calculated to substantiate the superiority of the homoeopathic method of cure over other modes of treatment. We often cure cases that had been treated fruitlessly for years, by other means, and even, where we do not effect a cure, we at least succeed in moder- ating the violence and frequency of the attacks. This of itself is often rendering the patient a great service. The peculiar nature of the affection; the mystery in which its causes and the anatomical changes which act as determining causes of the attack, are still in- volved ; frequently oblige us to select a remedy simply in accord- ance with symptomatic similarities, a course of treatment that- often leads to the best results. Of course it is difficult to select the best remedy for an affection that has only subjective symptoms, and we may meet with frequent disappointments. A remedy is much more easily chosen where we can trace with more or less cer- tainty the causal relation of prosopalgia to some other morbid con- dition or some definite deleterious influence; in such cases a number of remedies necessarily suggest themselves among which a choice is offered. Here too, as in the case of other ailments, of which we have already treated in former chapters, we have to select remedies for the special attack and likewise such as will prevent a recurrence of the paroxysms. For even if, after the exhibition of a suitable remedy, no other attack follows, this result cannot be regarded as the rule, and we have every reason not to anticipate too hastilv a radical recovery. In the following paragraphs we only mention a few remedies more in detail, giving only the names of the balance, the number of which is very large and whose pathogenesis may be looked up in the Materia Medica. Neuralgia Trigemini. 231 Spigelia deserves, in our opinion, the first place in the list of remedies for prosopalgia. If we were to apply a general designa- tion to the pains for which it is most suited, we should term them rheumatic. The pain is more particularly a violent jerking or tear- ing pain, is aggravated or excited by dampness, contact or even by motion, is sometimes a periodical pain, and is always attended with a feeling of anxiety at the heart and great restlessness. The face is pale, disfigured, frequently bloated. The pain is more especially felt in the nerves of the forehead, orbit and upper jaw, or it may emanate from the teeth, where Spigelia likewise excites peculiar jerking pains. If Spigelia affords prompt and permanent relief in prosopalgia, it is probably owing to the fact that the kind of neu- ralgia to which Spigelia responds, is more easily cured than any other form of the disease. In chronic cases its use is questionable but even in such cases, if the symptoms are similar, we may at least obtain relief, if we cannot effect a cure. Belladonna. The pain is more particularly a violent cutting pain, and involves a great many branches of the trigeminus. It is at- tended with symptoms of vascular excitement, such as flushed face, injected eyes, lachrymation, great nervousness and restlessness, pal- pitation of the heart, buzzing in the ears, scintillations before the eyes. The pains break out towards evening, and are most violent towards midnight. Convulsive movements of the facial muscles are likewise present. Every motion or contact of the affected part is exceedingly painful. According to Hartmann, it is particularly the neuralgia of the infraorbitalis for which Belladonna is indi- cated. As for an exciting cause, we would call attention to proso- palgia, caused by abuse of Mercury, and likewise to a form of pro- sopalgia which accompanies an inflammatory affection of the face as a coexisting complication; in the Belladonna-prosopalgia, the affected side of the face is sometimes swollen and looks inflamed. Verbascum, though not one of our very carefully proved drugs, has been successfully used in a number of cases of prosopalgia. The pain to which it corresponds is a stupefying, pressing pain, or a ten- sive pain, breaks out in short paroxysms, is more particularly seated in the zygomatic bone, is aggravated by pressure, by mastication, and likewise by exposure to cold air, and is accompanied by vertigo and a feeling of fulness in the head, together with great coldness of the rest of the body. Sepia. As we stated in our remarks about hemicrania, the Sepia pains vary a great deal, and may be studied more fully in the Ma- 232 Diseases of the Scalp. teria Medica. Sepia is one of the most important remedies for the prosopalgia and the nervous toothache, with which females are so frequently afflicted. Platina. The pain is characterized by a sensation as if the head were constricted, attended with a peculiar feeling of numbness. It is apt to break out at regular periods; is worse at night, and aggra- vated by rest. It is frequently accompanied by cardiac anguish and palpitation of the heart. Mercurius. This remedy has chiefly tearing, less frequently sting- ing pains; they either set in at night, or else-which is a still more characteristic symptom-they exacerbate at night, and reach their highest degree of intensity about midnight; they are increased by the warmth of the bed and likewise by external cold. The pains are accompanied by great restlessness and by sleeplessness, and very frequently the affected part is swollen and very sensitive. Mercury is particularly in its place when the pains emanate from carious teeth, and thence spread over the whole half of the face as far as the interior of the ears. This condition is more readily developed by catarrhal exposure, but may likewise originate in an inflamma- tory affection of the nerves. Mercurius is moreover indicated by a disposition to perspire, especially on the affected part. Mezereum. The pains are less characteristic; it is a stupefying pressure, especially in the region of the upper jaw from without inwards. This medicine is so much better indicated by the acces- sory symptoms. From the most painfully affected locality the pains spread like violent tearing pains over the face, neck and nape of the neck, break out in sharply defined paroxysms; are aggravated by warmth, especially by the warmth of a room after a walk in the open air; are accompanied by chilliness or by muscular twitches of the affected part, which is very sensitive to the least contact. The evening exacerbations are usually the most violent. In cases of prosopalgia where syphilis had existed previously, or where a good deal of Mercury had been used, Mezereum is worthy of particular consideration. Arsenicum is one of the most important remedies in this disease, and will be found the more effective the more purely nervous the pains are. The pain is chiefly burning or stinging as from a num- ber of red-hot needles. The paroxysms break out or exacerbate about midnight. The countenance looks distressed and sunken ; during the attack the patient is exceedingly restless. For proso- Neuralgia Trigemini. 233 palgia, caused by miasmatic influences, Arsenicum occupies the first rank as a curative agent. Colocynthis. According to present experience, this remedy is ex- cellent in neuralgia, generally and more particularly in recent cases where catarrhal exposure can be traced as the cause of the trouble. According to Hartmann, it is likewise indicated in cases arising from, or aggravated by, mortified feelings. The Colocynth-proso- palgia is mostly a tearing, tensive, less frequently a burning distress, greatly aggravated by every motion of the facial muscles, amelior- ated by perfect rest and external warmth, and generally attended with inflammatory heat and swelling of the affected part. The remedies which we have mentioned are the most important of those that may have to be administered for prosopalgia. Beside these remedies, the following likewise deserve our consideration: Aconitum, Stannum, Conium, Thuya, Capsicum, Staphysagria, Vera- trum album, Nux vomica, Ignatia, Pulsatilla, Lycopodium, Ferrum, Calcarea. Prosopalgia being a local affection, it is not so very dif- ficult to consult the Materia Medica in particular cases. If the prosopalgia is occasioned by chlorosis, syphilis, or some other pathological process, the medicines required by the primary affec- tion are likewise required for the prosopalgia. We refer the reader to the chapters where these primary affections are treated of. If prosopalgia is treated with the lower attenuations, we shall often produce homoeopathic aggravations whose occurrence it is impossible to deny. For this reason it is, as a general rule, better to employ the higher attenuations, and not to repeat the dose too often. Arsenicum especially requires to be used with a good deal of care; we have seen aggravations occasioned by the sixth attenua- tion and still more certainly by the sixth trituration. Among indi- viduals who are afflicted with prosopalgia, these aggravations can easily be accounted for by the extreme irritability of their nerves. This, however, is not always the cause of the aggravation, which is known to be occasioned by large doses even in the case of robust individuals. The patient's confidence in his physician is so easily shaken by such an occurrence that it is desirable to avoid it if pos- sible. [In prosopalgia caused by malarious influences, or occurring with the regularity or in the place of a fever and ague paroxysm, we have scarcely ever been able to get along without Quinine. Say what you please against Quinine, it is one of the most indispensable antidotes to the intermittent type of paroxysms resulting from the 234 Diseases of the Scalp. influence of malaria. We have so often and so satisfactorily cured intermittent prosopalgia with five or ten grains of Quinine, admin- istered in grain doses every two hours during the apyrexia, that we can recommend its use to homoeopathic physicians with all the ear- nestness of one whose knowledge is based upon the most unim- peachable experience, and we' advise our friends not to mind the absurd twaddle of a few antiquated ignoramuses, who would fain confine Homoeopathy to the narrow horizon of their own childish folly. Aconite is another great remedy in Fothergill's prosopalgia; it should be given in high doses, and may be applied externally, first or second attenuation, with great benefit. II.] 3. Spasmus Nervi Facialis. Tic Convulsif. Spasm of the Facial Nerve. Spasm of the facial nerve is not a very rare occurence, and is in so far of importance, as it may easily become habitual, in which case it is an incurable infirmity. As a symptomatic manifestation of other affections it is met with in prosopalgia, hemicrania, hys- teria, chorea, epilepsy, and several other morbid conditions, likewise in helminthiasis. As a mere symptom of other affections it has no particular significance and disappears, together with the main trouble, without leaving a trace behind. On the other hand it occurs rather frequently as an idiopathic affection, and, if lasting for some time, becomes very obstinate. As an idiopathic disease it arises mostly by exposure of the face to keen winds, a current of air, etc., or is caused by some violent emotion. Another cause which cannot be denied, is the habit of making faces; a cause of this kind prevails among young girls rather than boys. Spasms of the facial nerve, arising from such a cause, are just as obstinate as those that may have arisen from any other cause. As regards the extent of the spasm there is considerable differ- ence, although it is generally confined to one side. At times the spasm is limited to isolated convulsive motions of the eyelids, mouth, alee nasi; at other times we have tonic contraction of one whole side of the face. The patients are scarcely ever capable of preventing or arresting the spasm by the mere force of the will. The disorder is scarcely ever attended with pain, perhaps only at the commencement of the attack. The course and duration of the attack are uncertain ; if it sets in suddenly, the trouble may last for life. If the spasm continues a long time, the face may remain Diseases of the Eye. 235 permanently distorted. Such instances occur quite frequently, but escape our more particular notice; many persons retain forever the anxious expression of the countenance, which a deep mental agita- tion may have caused, even after every trace of the exciting cause had completely vanished. The treatment of this spasm bids fair to have a favorable ter- mination only in recent cases, and is unsuccessful in proportion as the disease has had a lono;er duration. The best remedies for spasm caused by a cold are: Rhustox., Belladonna and Ignatia ; the last-named remedy deserves particular consideration, if the spasm is caused by some mental agitation. Beside these remedies we have Cannabis and Veratrum album. In chronic cases Zincum and Cu- prum may be tried. A better result than from any medical treat- ment may be obtained from persevering trials to recover the normal control of the facial muscles by regular exercise; this result can always be accomplished to some extent, if not wholly. The favor- able action of electricity is still questionable; however, there are sufficient reasons why cautious and persevering experiments with the electric current should be tried. If children are attacked with the spasm in consequence of mimicking other children, the best means of cure is to constantly reprimand them; and if this should prove ineffectual, to inflict corporal punishment immediately after every indulgence of the naughty practice. [Two admirable remedies for this spasm are Gel seminum and Aconitum napellus, tincture of the root.] C. DISEASES OF THE EYE. Diseases of the eyes, as a general rule, are treated by pathologists as a special department so strictly, that no mention is made of them in therapeutic treatises. This arrangement is undoubtedly correct, in so far as the diseases of the eyes are too important to be dis- patched in a few short chapters, and a number of special treatises are at our disposal where these diseases are treated of in a compre- hensive manner. In our school, unfortunately, we have no special work devoted to affections of the eyes; and although the absence of such works can easily be accounted for, yet, on the other hand, it is to be regretted, since there is scarcely an organ whose diseases have been investigated as fully and intimately as those of the eyes. 236 Diseases of the Eye. On this account the effects of drugs in diseases of the eyes could be determined with more accuracy than in any other disease. In spite of this, ophthalmic practice has been very much neglected by homoeopathic physicians. We are anxious to investigate more fully the reason of this apparent neglect, since by so doing we depart much less from the object of a therapeutic treatise than it might seem at the first glance. Two circumstances it is which we have to notice more prominently. In the first place, the position of the homoeopathic physician is of such a nature, that it does not allow him to devote himself exclusively to a special department of medi- cine. Everybody, who has been engaged in homoeopathic practice, knows that this statement is correct. We are still too much upon the defensive towards our professional opponents, to enjoy the privi- lege of exclusively cultivating a department that requires extraor- dinary manual dexterity. But even supposing, that this privilege should exist, the homoeopathic practitioner will still find it very difficult to conquer for himself the position of an oculist, for the reason that it matters not, in general practice, how many prejudices a physician may have to contend against; but the case is different when a special department only is attended to. A physician of this class has to be pecuniarily independent, in order to be able to maintain his position in a dignified manner. We are still deprived of the only means by which our object could be attained in a differ- ent way,-we mean a sufficient number of large hospitals. But even if*all these material obstacles had been removed, an oculist would still have a great many difficulties to contend with, which are inherent in our Materia Medica. We confess without hesitation, that there is no section in our Materia Medica less useful and less adapted to homoeopathic treatment, than the symptoms referring to diseases of the eyes. This chapter is much less prac- tical than the symptoms referring to the cutaneous diseases or the morbid changes of the urine; for, in treating the eye, we have to consider a number of important organs, all of which are of essential importance, such as the conjunctiva, sclerotica, cornea, lens crys- tallina, etc. Our provings do not even contain vague allusions to these various parts, whose organizations and functions differ so greatly from each other. This is the reason, why we cannot boast of great success in our treatment of affections of the eyes; what we consider as an indispensable condition of successful treatment, an accurate determination of pathogenetic and pathological simi- larity, is wanting in the management of diseases of the eyes. It Conjunctivitis Catarrhalis. 237 is strange, that so little has as yet been done to remedy this defect. Yet this is so much more desirable, as diseases of the eyes are regarded with so much interest by the public, and nothing would contribute more to the spread of our doctrines, than numerous bril- liant cures of ophthalmic diseases. Hence, in diseases of the eyes, we have to depend in a great measure upon arguments suggested by analogy, and upon the em- pirical use of drugs. Nevertheless, in spite of these drawbacks, we effect more numerous and more satisfactory cures with our imper- fectly proved drugs than our allopathic opponents are capable of accomplishing with the whole apparatus of their surgical and me- dicinal appliances. * We may as well here call attention to a point, which has been discussed on many other occasions, but without any satisfactory completeness. The question namely is, whether in affections of the conjunctiva, for instance, it be not advisable to apply the proper remedies externally. That many medicines act more favorably when locally applied, is evident from the local use of the Sulphate of Zinc, Corrosive Sublimate, red Precipitate, etc. Unfortunately we are not in a position to reason upon the basis of comparative experi- ments, howsoever easy it would be to institute them, for, even the lower attenuations of any medicine may be applied to the eyes, pro- vided they are made with distilled water instead of alcohol, and the triturations may be locally applied without any modification. In the following chapters we shall treat only of the main dis- eases of the eyes, omitting all those which require operations, and likewise those which cannot be correctly diagnosed without the use of the more recently introduced appliances for the recognition of ophthalmic diseases. 1. Conjunctivitis Catarrhalis. As a simple inflammatory catarrh of the conjunctiva we define a condition of hyperaemia of this membrane attended with the more profuse secretion of a fluid similar to the normal one. Symptoms. While the patient suddenly experiences a sensa- * We see no reason why the author should feel discouraged regarding the success, which has attended the homoeopathic treatment of diseases of the eye. In some of the public ophthalmic Infirmaries of New York homoeopathic treat- ment has been substituted by the authorities in the place of the ordinary allo- pathic treatment, for the very reason, that the former has been found to be emi- nently more successful than the latter. H. 238 Diseases of the Eye. tion as if sand were under the eyelid, generally the upper one, the conjunctiva assumes a reddish appearance, single vessels of the con- junctiva, first of the tarsal and afterwards of the transition-portion, becoming injected. In slight cases the catarrhal irritation may not go any further; but if it should increase, the redness may spread to the conjunctiva of the bulbus; the vessels running from the transition-portion of the conjunctiva to the cornea, become en- gorged and, while the inflammation goes on increasing in intensity, approach more and more closely the margin of the cornea where a small pustule forms, generally near the outer margin. At the same time serum is effused under the conjunctiva which sometimes swells up quite extensively and even gives rise to small ecchymoses. The sensation of a foreign body generally continues for some time, and is accompanied by a violent itching or smarting pain with a pecu- liar feeling of dryness and heaviness of the lids. The eye becomes sensitive to the light, even complete photophobia sets in, much less frequently dimness of sight and photopsia. At first the secretion of the conjunctiva is rather diminished than increased, after which it becomes more copious, clear as water, and is mixed with mucous flocks, and. on account of the secretion going on continually, ex- coriates the skin of the face by keeping it moist all the time. It is not quite certain, but probable, that the secretion is conta- gious. All the symptoms exacerbate at night, less frequently in the morning. Cold, more particularly damp and cold weather intensifies the whole process, and more particularly promotes the serous infiltration of the mucous membrane. Humid warmth, on the contrary, is very pleasant to the eyes, at least in most cases. In violent cases the conjunctiva may swell up to such an extent that pad-shaped protrusions between the lids may prevent their closing. The cornea is scarcely ever involved. The causes of this catarrhal inflammation are not very certain. Undoubtedly it occurs more frequently at a period when catarrhs prevail generally during the transition-seasons of the year; it may, however, occur without any atmospheric influences prevailing. It is very much disposed to accompany a catarrh of the nasal mucous membrane. An inflammation of the Meibomian glands, so-called styes, may be the cause, a consequence or a complication of catarrhal conjunctivitis; styes may cause the disease, more especially if they are located on the inside of the lids. The disease may last indefinitely, from a few days to several weeks, if relapses take place; the acute form is very apt to pass Conjunctivitis Catarrhalis. 239 into the chronic. Unless culpably mismanaged, the inflammation scarcely ever leaves unpleasant consequences. Chronic conjunctivitis may develop itself without any previous acute inflammation, in which case it may result from swellings of the lid or from diseased conditions of the Meibomian glands; but as a general rule it arises from the acute form. In chronic conjunc- tivitis the conjunctiva of the bulbus remains quite free from inflam- mation, the tarsal and transition-portion of the conjunctiva look dark, even bluish-red, velvety, thickened and bulging out like a pad; the swelling is more prominent along the margin of the lid. The secretion is always more profuse than usual, the secreted fluid is turbid, of a gray-yellowish appearance, tends to agglutinate the lids, gives rise to excoriations both at the borders of the lids and on the cheeks. The subjective symptoms are not very considerable, and are only distinguished in degree from those of the acute form. This form of the disease may run a protracted course. Disastrous results, such as incipient ectropium, only occur as the consequences of very bad management. Almost every form of conjunctivitis can be ranged in the cate- gory, of which we have given a description in the previous chap- ters ; it may, however, be desirable to add a few remarks concerning the forms of conjunctivitis, which used to be described as rheumatic and arthritic, designations of which even Hartmann still makes use. We do not approve of such a classification, because it is of no use practically, and impairs the value of pathology in consequence of the Babylonian confusion which such classifications introduce into the nomenclatures of pathological treatises. If we compare the pathological pictures which Hartmann gives us, we discover scarcely a single essential difference between them, and if the rheumatic form is supposed to be characterized by a peculiar pain, we know very well that such subjective symptoms are too deceptive to be used as a basis for a pathological classification. We know more- over, that such classifications owe their origin to the mixing up of a variety of morbid conditions. Nor are such classifications really important to the homoeopathic treatment of the disease, for, it is self-evident, that in selecting a remedy we have to consider every symptom, the exciting causes, former diseases, etc. The best proof against the usefulness of such subdivisions is the impossibility of making them available in practice. Treatment, Before beginning a strictly medical treatment, we have to examine the eye with the most perfect care in order to 240 Diseases of the Eye. ascertain beyond all doubt, whether the foreign body, which the pa- tient imagines is in the eye, be really present. A strict search fre- quently reveals the presence either of a little hair which has become lodged in the eye, or of an eyelash that has grown inwards and causes the inflammation. Irritating causes of this kind have to be removed before we can expect to effect a cure by the use of medicines. At the commencement of the inflammation, Aconite is the best remedy in almost every case; unless very peculiar complications exist, it alone very often removes the inflammation in a few days. Belladonna will be found less frequently curative where the inflam- mation is still confined to the eyelid, and hence has not yet reached its highest degree of development. It deserves all the more consid- eration, the more the eyeball itself has become involved in the inflam- mation, and the more prominently the vessels have become injected in which case there is always a good deal of photophobia. Euphra- sia may be ranked side by side with Belladonna; additional indica- tions for Euphrasia are pustules near the border of the cornea and the co-existence of a violent nasal catarrh, attended with profuse secretion of mucus. For all that, in spite of the presence of these symptoms, Euphrasia will often disappoint us, as we know from abundant experience. When locally applied, Euphrasia often has a very excellent effect even after its internal administration had proved absolutely useless. If the eye-affection is accompanied by general catarrhal symptoms, we may expect much better and' much more certain effects from the use of Mercurius. In such cases it has just as good an effect upon the mucous membrane of the eye as in other cases upon that of the nose, and deserves the name of our most efficient remedy for catarrh. It will be found most useful in the case of children. Ilepar sulphuris is one of our more important remedies for conjunctivitis. At the outset it is less suitable than in the further course of the disease; it acts well after Belladonna, in the more acute cases, where a profuse quantity of thick mucus is secreted. In chronic conjunctivitis Ilepar sulphuris may likewise have to be resorted to, although we have better remedies for this form than Hepar. Euphorbium is an efficient remedy in the more violent forms of this disease, where the secretion is more purulent; it is particularly indicated by a feeling of great dryness in the eye, in spite of the increased secretion, and by the excoriations which so readily take place in the corners of the eyes. Rhus tox. is suitable in simple catarrhal inflammation of the eyes, wdiere a somewhat considerable serous puffing up of the conjunctiva is attended with Conjunctivitis Catarrhalis. 241 a comparatively scanty secretion and the pain is very great. It is likewise appropriate to the chronic form. Sulphur is not indicated in the acute form of the disease, but it will act with advantage when the passage from the acute to the chronic form has fairly set in and the hypersemia of the conjunctiva has begun to abate. At this stage Arsenicum will be found an excellent remedy, especially when the redness has assumed a dark tint and the margins of the lids show considerable disposition to become excoriated. It acts very beneficially if small quantities of the third or fourth trituration arc scattered on the lids. Beside these two, and other remedies that have already been recommended for the chronic form, we have lodium, Mercurius iodatus, Hydrargyrum prcecip. rubrum and Sta- physagria. With this last-named remedy we have cured several cases of a very obstinate chronic catarrh, with considerable swelling of the lids, after other remedies had entirely failed. [A favorite remedy for conjunctivitis is Apis mellifica; it is used with varying benefit; it will be found, however, that in cases where it is said to have produced striking results, it was generally given in alternation with Aconite. II.] Inflammation of one or more Meibomian glands, designated by the term hordeolum or stye, is sometimes a mere symptom of catarrhal inflammation, but may likewise exist as an idiopathic disease, especially during the prevalence of keen, damp and cold winds. It is very much disposed to relapses. This disorder is very seldom epidemic, and it is well to check it as soon as possible. For this purpose Mercurius is the best remedy, for, under its influence suppuration takes place very rapidly. As regards Pulsatilla, we have never seen the good effects from it, which Hartmann professes to have obtained; if, as he thinks, Pulsatilla prevents suppuration, the use of this drug can only have the effect of prolonging the course of the trouble. On the contrary, our best plan is to hasten the suppurative process as much as possible; if the patient is able to keep his room, it is even well to apply warm poultices, and to open the little abscess, taking care, however, to squeeze all the pus out. By this method a return of the difficulty is more effectually prevented than by any other means. If a larger number of glanda are involved, the margin of the lid becomes hypertrophied inconse- quence of the indurated glands which feel like hard lumps; there is, moreover, a constant disposition to inflammatory exacerbations. For tins condition Staphysagria is an excellent remedy, only we 242 Diseases of the Eye. should not expect any immediate results. Calcarea carbonica and Silicea may likewise be given with advantage. [For chronic conjunctivitis we likewise recommend Pulsatilla and Phosphorus, more particularly in the case of individuals with lymphatic temperaments; the former is more adapted to cases with profuse secretion of purulent mucus, the latter to cases where the eye remains dry, except perhaps a slight agglutination of the lids in the morning. An interesting case of inflammation of the lachrymal sac of the right eye, with swelling of the sac, pain on pressure, burning pain, and flow of tears over the cheek, is reported by Dr. Dudgeon in the 13th volume of the British Journal of Homoeopathy; the case was treated with Aconite, Silicea and other medicines, but yielded prin- cipally to Silicea. We have cured similar inflammations with Aconite, Pulsatilla and Silicea. II.] 2. Conjunctivitis ISIennorrlioica. Recent works on ophthalmic surgery are filled with so many different opinions and such a confusion of names regarding this disease, that it is next to impossible to exhibit a satisfactory and complete picture of this difficulty; we therefore prefer to adopt Arlt's exam; le of treating of this form of blennorrhcea. We distin- guish an acute and a chronic form. a. Acute Blennorrhcea. It is distinguished from catarrh principally by a plastic exudation into the tissue of the conjunctiva, the slimy-purulent secretion and its decided contagiousness. Amid the symptoms of a violent catarrh the whole conjunctiva of the lids looks puffed, swollen, and uniformly red, and from the transition-portion of the membrane numerous vessels run towards the cornea, the secretion is not clear, but rather turbid and mixed with firm yellowish flocks, and the lids begin very speedily to swell and feel hotter than usual. The more rapidly these symptoms develop themselves, the greater is the certainty, that we have to deal with a blennorrhcea. This first stage sometimes passes into the second stage even after the short period of twelve hours; the interstitial puffing of the conjunctiva increases so that the internal margin of the lid is no longer sharply circumscribed, the lid is no longer in contact with the bulbus, and the absorption of the tears is no longer possible. It Acute and Chronic Blennorrhoea. 243 is particularly the transition-portion of the conjunctiva, that looks swollen and deep-red, likewise the semilunar fold. The conjunctiva bulbi is likewise infiltrated, very much injected and red. The lids are swollen, generally to such a degree that they can no longer be opened. The secretion becomes thick, turbid, creamy, very copious. Photophobia is almost always present, generally there is fever, dul- ness of the head, and violent tearing or stinging pains in the eye. In the third stage all the phenomena, of which mention has been made, become worse; the lids are swollen to such an extent, that it is no longer possible to raise them, and the cheek becomes involved in the swelling. The secretion is very copious^ purulent or even ichorous. The pains are intense, sometimes unbearable. The in- filtration of the conjunctiva bulbi reaches a very high degree, so that the cornea looks as if surrounded with a deep-red wall, it even is partially covered by the swelling. The cornea, which at first retained its lustre, is now invaded by the disease; either it becomes inflamed and is rapidly disorganized, or it loses its epithelium, shows superficial ulcerations or pannus forms, that is to say: an exudation takes place beneath the epithelium, and the vessels look very much injected. b. Chronic Blennorrhoca. We subjoin here a description of the chronic form of the disease, because, so far as symptoms are concerned, both the chronic and the acute form run a similar course. In the chronic form, unless other very striking noxious compli- cations are present, the morbid process is confined to the palpebral conjunctiva. This form commences likewise with the symptoms of a catarrhal conjunctivitis, except that at the very outset the redness of the tar- sal portion looks darker and more velvety, and the swelling is more considerable. The patients complain of a feeling of dryness and roughness in the eye, and of an aching or burning pain, together with an increased secretion of tears. After this condition has lasted for a rather indefinite period of time, the second stage sets in, where infiltration of the conjunctiva of both lids is the most essential symptom. The papillary portion looks as if covered with closely crowded little warts, which are soft at first, and sometimes bleed readily, and afterwards assume a cartilaginous hardness, imparting to the conjunctiva an appearance as if cracked. Their color is dark- red. The conjunctiva of the bulbus is not involved in this morbid 244 Diseases of the Eye. process, except, perhaps, a little injected at the commencement. The swelling of the lids is not very considerable. The secretion is more copious, sometimes clear, with a few flocks floating in it; sometimes turbid, afterwards thick, creamy, and adhering with some firmness. If at this period specially irritating causes should affect the eye, a general blennorrhcea of the conjunctiva may develop itself, similar to that which we have described when treating of the third stage of the acute form. Course and Terminations. A retrograde metamorphosis of blennorrhcea may take place in the first as well as in the second stage, and the disease may either terminate or else it may pass into a chronic form; its course may likewise become so rapid that the cornea may be destroyed in thirty-six hours. If the disease remains stationary in the first stage, it is generally looked upon as simple catarrh, until its true character has become manifest by the infectious nature of its secretion, or the disease has acquired a higher degree of intensity by an additional cold or very impure air. In the second stage the disease may persevere for years without any decided change; but the passage into the third stage may take place at any moment. The exudation is either re-absorbed, a scar remaining, without, however, the cartilage becoming involved, or else the exudation terminates in a fungoid growth, in consequence of which the lids become everted. The cornea either remains unaf- fected, or else it is temporarily affected only, and as it were by acci- dent. In the third stage the disease always runs an acute course, and, if the cornea is invaded, the danger is always very great. The third stage seldom sets in until the other phenomena have reached their climax, and sometimes not till these phenomena have commenced to abate. The cornea softens very suddenly, becomes infiltrated with pus, and under these circumstances generally breaks. Iritis is apt to supervene during the affection of the cornea. Retrograde metamorphosis from the third stage generally takes place without leaving any fungoid growths ; sometimes, however, there remains a disorganization of the conjunctiva in the shape of puffed fungoid growths around the cornea, of a loose and flesh-colored appearance, so that it is either partially or totally covered. Causes. The disease may break out sporadically, but likewise among a large number of individuals at once, who live crowded to- gether. It is principally met with among new-born infants and Chronic Blennorrhoea. 245 among adults at the age of pubescence, and after they have attained the age of manhood. The blennorrhoea of new-born infants may originate in exposure to glaring light, in a cold, in epidemic influences, in contagion by the blennorrhoeic secretion from the mother during the act of par- turition, although the secretion need not necessarily have had a syphilitic character; simple leucorrhoea may cause blennorrhoea in the case of new-born infants. In rare cases only blennorrhoea breaks out among adults without any contact with some blennorrhoeic secretion; here a purely spon- taneous appearance of the disease has to be presupposed, which supposition is favored by the observation, that even a simple catarrh may assume the form of a severe blennorrhoea. As a general rule the blennorrhoea originates in some infection by blennorrhoeic secre- tion, no matter whether it emanates from the eyes or from the genital organs. We may observe that the limpid secretion of the first stage, and the clear secretion of the chronic form, are not con- tagious. On the other hand, the turbid secretion of the beginning second stage produces blennorrhoea of the first stage, and the puru- lent, more consistent secretion of the second and third stages, always causes a blennorrhoea, which passes rapidly through the three stages of the disease. The more intense the disease is, from which the contagious matter had emanated, the more suddenly the disease breaks out after the infection, even six or twelve hours after the infectious matter had been communicated at the third stage. It is self-evident, that the contagion is favored by every circum- stance which tends to facilitate it, above all things by the crowding together of a number of individuals in the same room, whence the disorder is so frequently met with among soldiers and in foundling- houses. The prognosis depends, in the first place, upon the more or less rapid course of the disease; the more rapidly one stage passes into another, the more we have reason to apprehend a disastrous termi- nation. If the quality of the contagious matter can be ascertained, the prognosis can be established with more certainty from such a basis. It is only when the cornea is invaded, that the visual power is threatened with danger. The duration is indefinite, from eight days for the lighter grades of the disease to several years for the chronic form. Before we enter upon the treatment of this disease, it behooves us to agree upon the nomenclature which other pathologists have 246 Diseases of the Eye. adopted. The acute form responds to the ophthalmia gonorrhoica, and in certain respects to panophthalmitis. The chronic form rep- resents granular ophthalmia, ophthalmia militaris, segyptiaca, con- tagiosa. Many other names may be recorded in the vast domain of ophthalmic surgery: at all events those which we have named are the best known and those in most general use. Treatment, After what we have said about the contagiousness of the disease, it must seem a matter of course, that special atten- tion should be paid to prevent the further spread of the disease, if it breaks out in localities where a number of individuals live closely together. Since it has been shown beyond a doubt-more particu- larly by ingenious apparatuses invented for such a purpose-that atmospheric air may act as a vehicle of the contagion, it is of the utmost importance that the patients should be kept isolated as much as possible. Moreover, the greatest cleanliness should be observed; the eyes cannot be too often bathed, and the secretion removed. The air of the room should be renewed as often as possible, and both the patient and those who are near him must have their attention directed to the facility, with which the disease can be propagated by contagion. Among the most important remedies after the disease has broken out, Arlt ranks applications of ice. Four to six thicknesses of linen are laid on ice wrung out and afterwards applied to the eye as closely as possible. They have to be continued day and night, and should be changed quite often. Where they cannot be made according to rule, they had better be entirely omitted. There is no doubt that an energetic application of cold can neutralize an existing contagion. Although in describing the disease we have avoided all details, we cannot well get along without them as soon as we undertake to point out the treatment, for the reason that as yet no remedy has been discovered, that embodies in its pathogenesis the full charac- teristics of the disease. Hence we have to dwell more particularly on the single stages of the disease, and upon the quality and course of the general affection. Owing to its rapid course, a blennorrhoea, caused by a very poi- sonous secretion, opposes great difficulties to the selection of an appro- priate remedy, for the reason that no time is allowed to await the full action of the drug. The similarity of the pathological process going on on the conjunctiva to syphilitic gonorrhoea, and the origin of blennorrhoea by syphilitic infection, lead us to the conclusion, that Mercurius is the most suitable remedy for the disease. As Chronic Blennorrhoea. 247 regards the kind of mercurial preparation that had better be used, we prefer most unhesitatingly the most powerful among them, the red or white Precipitate, and still more, the Sublimate. The last-men- tioned offers the great advantage that it readily admits of local application, which, in view of the great danger to which the visual power is exposed by the destructive agency of the contagion, should never be omitted. In order to elicit the best effects of Corrosive Sublimate, it will not be necessary to use a very powerful solution; on the contrary, we have found, that by using a solution of a few grains of the second trituration in water the same favorable change can be effected, without the disadvantages arising from the cauter- izing effects of a more powerful solution. This has more especially to be considered in the case of children, for whom it is any how very difficult to hold still, and where a second application is scarcely ever necessary, provided the first application was sufficiently thorough. Of other remedies, liepar sulphuris calc, seems to us the only one worthy of a trial, not so much on account of the phenomena which this drug has elicited on persons in health, as on account of its cor- respondence to the gonorrhceic infection. By giving other remedies, which might possibly be indicated by the accompanying pains, we shall simply lose a precious time, which we can hardly afford in this disease. Ophthalmia neonatorum, which is very frequently regarded as gonorrhceic ophthalmia, does not run such a terribly rapid course as the latter in its worst form. For ophthalmia neonatorum the most important remedy is likewise Mercurius, more particularly if a syphilitic taint can be traced in the mother. However, since other causes may have occasioned the disease, other remedies should like- wise be pointed out, among which Belladonna occupies the first rank. Beside Belladonna, we have Bryonia and Bhus tox. Hart- mann seems to understand by ophthalmia neonatorum every catarrh of new-born children, otherwise we could not account for the reme- dies which he recommends for the disease. Even Aconite, which is such an excellent remedy in other affections of the eyes, cannot pos- sibly be suitable in ophthalmia neonatorum, neither according to its symptoms, nor according to what we know of its effects upon other organs or upon the general organism. We suppose that it is recom- mended for the exceedingly violent inflammatory process ; this, how- ever, would be a very one-sided indication, and the result might not answer our expectations. Moreover, ophthalmia neonatorum should not be treated carelessly as time runs on. If the disease, as is often 248 Diseases of the Eye. the case, is the local expression of a general affection of the mucous membranes, only such remedies as are indicated for the general dis- ease can be properly used for the local affection, and the selection of which is determined with much more definiteness by the general condition of the organism than by the symptoms of the eye alone. For the less acute form of the disease, Belladonna will be found most suitable at the commencement to check the inflammatory pro- cess. The more, however, the conjunctiva becomes infiltrated, the more slimy and thicker the secretion, the less the remedy is indi- cated. At this stage of the disease, we have, beside Mercurius, Bryonia and Rhus tox. Bryonia, especially, has a few symptoms that are essential in this disease, namely: considerable swelling of the lids, purulent discharge and dark-red conjunctiva, which is like- wise very much puffed up. Hepar sulphuris likewise is appropriate for these symptoms. In the chronic form the diagnosis of the disease will at first have great inconveniences, unless we meet with a number of cases at once and the very fact of its spreading among so many individuals reveals the true nature of the disease. Under such circumstances Mercurius is again the most prominently indicated remedy. It is much more important to determine the medicines that are suitable in the second stage. On looking at the exciting cause, at the pecu- liar form of the granulations, we cannot help contrasting these granulations with similar symptoms on the mucous membrane of the sexual organs, and regarding the granulations as so many con- dylomatous growths. It might be somewhat hazardous to exclu- sively recommend Thuya for this form of ophthalmia. Since the symptoms of the drug represent a very strongly marked catarrhal affection of the eyes, it seems less illogical to recommend Thuya, and to try to cure the disease with this remedy. We have given a prominent place to Thuya for the reason that this remedy has several accessory symptoms which do not occur in such a full combi- nation in the pathogenesis of any other drug. Thuya likewise can be applied externally without the least difficulty; such an external application is so much more advisable as the usefulness of Thuja in condylomata is very well known. This is the place to introduce Sulphur. It has been so often recommended for the acute stage of blennorrhoea that it seems as though we ought to believe in its good effects in this disease although we have never witnessed them. It is certainly more adapted to the chronic form of blennorrhoea, since Sulphur is generally much more appropriate about the period when, Conjunctivitis Scrofulosa. 249 in acute affections, the exudation shows signs of being reabsorbed, but neither before nor during the development of the exudative process. Acidum nitricum is reported to have effected a cure of gonorrhoeal ophthalmia (see Allg. Hom. Zeit., vol. 19), which invites our attention to this drug, even if it had not otherwise a multitude of corresponding symptoms. Beside these remedies we direct atten- tion to Graphites, Silicea and Staphysagria; at the same time we are bound to admit that we cannot offer any practical illustrations of the curative virtues of these remedies in the above-mentioned diseases, and that the diagnosis in the few cases that have been reported, is very questionable. This shows that we are without much experience in the treatment of blennorrhoea of the eyes, and this want should excite everybody who has such a case to manage, to publish the details of his treatment as well as its results, no matter whether favorable or otherwise. Even unsuccessful cases may teach others a good deal of wisdom, were it only that they may learn to avoid the mistakes of their predecessors. Our own experience being rather limited, we dare not express ourselves too positively regarding the methods that other practitioners have pur- sued, although the results obtained by the latter, have likewise not been very brilliant. We must not omit to give publicity to the observation that, in the acute form, the Nitrate of Silver, and, in the chronic form, the Sulphate of Copper have been found to he the best cauterizing agents. [In the acute stage of this form of blennorrhcea we use the Nitrate of Silver in the proportion of one grain of the Nitrate to an ounce of water. With this solution we pencil the eye or eyes every four hours thoroughly, taking care to have the camel's-hair pencil washed out in fresh water before it is used for the other eye. This opera- tion is continued for a few days until the suppurative process has ceased. Appropriate internal treatment is attended to at the same time. II.] 3. Conjunctivitis Scrofulosa. This form of conjunctivitis is more particularly characterized by the circumstance that it only affects the conjunctiva of the bulbus, and that the cornea is generally involved in the inflammatory pro- cess. The fact that it is one of the most frequently occurring and most obstinate affections of the eyes, imparts to it a peculiar signi- ficance in the eyes of practical physicians, even if they do not make ophthalmic surgery an exclusive branch of practice. 250 Diseases of the Eye. Symptoms. Not unfrequently the beginning of the inflamma- tion is attended with febrile symptoms preceding for a short time the actual disease and, as a general rule, being regarded as the symptoms of a general catarrhal affection, to which they bear indeed a very strong resemblance. All at once, as if a foreign body had suddenly become lodged in the eye, the conjunctiva appears injected, and photophobia and a copious secretion of tears set in, the former symptom becoming so intense that it is almost impossible to obtain a view of the interior of the eye, for the reason that the spasmodic closing of the lids cannot be overcome, even if the children are ever so willing. The appearance of photo- phobia, however, does not imply that the conjunctiva of the bul- bus is already invaded by the inflammation, for this invasion may take place at a later period. The little patients may be seen for weeks, day after day, on the arms of the mother or seated in the corner of a sofa, with their eyelids firmly pressed together in order to prevent the light from penetrating between the eye- lids. A forcible opening of the lids is not advisable, for the rea- son that such a proceeding only tends to favor the disorganizing process, and that any considerable involvement of the cornea need only be suspected, if the margin of the upper lid looks swollen and red, and mucus is secreted. As a general rule the intense pains and the photophobia abate at dusk, when the patients open their eyes spontaneously. This is the best time to obtain a view of the condition of the inner eye, without any forcible means having to be resorted to. This is an important circumstance, for children are very apt to be intimidated by the application of force in examining their eyes. The alterations of the bulbus which may succeed the invasion of photophobia after an indefinite period of time, refer more particularly to the margin of the conjunctiva around the cornea, or to the conjunctiva of the cornea itself. In this locality a small, either vesicular, or pustulous, or papulous exudation arises, surrounded by an areola of a deeper redness, and frequently accompanied by a rose-colored narrow areola around the whole cornea or a portion of its periphery Two parts are scarcely ever invaded at the same time. Not till a vesicle has formed do the vessels of the conjunctiva running towards this vesicle begin to swell. The swollen vessels form a triangle the point of which is at the vesicle, and the basis lies in the transi- tion-portion of the conjunctiva. If the exudation is situated on the cornea, the vessels run towards it in the shape of a narrow Conjunctivitis Scrofulosa. 251 band. The conjunctiva may remain unaffected all this time, or else it may exhibit more or less distinctly marked catarrhal symp- toms. If the bulbus is affected, the photophobia does not furnish a sure criterium for the intensity of that affection; the photo- phobia may be intense and yet the affection of the bulbus may scarcely be perceptible, whereas the most dangerous ulcerations of the cornea may be unattended by scarcely any sign of photophobia. The secretion of tears is generally very profuse and, by keeping the cheek constantly moist, inflame and excoriate it, or cover it with clusters of pustules. The vesicles, which are never completely filled with a clear, watery fluid, either gradually disappear, or else break, leaving superficial ulcers with a suppurating base. The papulae form a grayish, vascular covering of the cornea, giving rise to pannus. Pannus may likewise accompany the breaking out of vesicles or pustules. It is upon these exudative processes and the structural changes resulting from them that the danger to vision in scrofulous oph- thalmia depends. If the exudation is located on the margin of the sclerotica or close to the margin of the cornea, vision is not en- dangered. On the contrary, if the exudative process is located more towards the middle of the cornea, the visual power is always more or less in danger. The best thing that can happen is, when the vesicles or pustules do not burst, in which case, after their re- absorption, they leave a sort of grayish dimness which gradually disappears of itself. The vesicles, after bursting, leave a colorless, superficial ulcer which heals, leaving a somewhat dim, milky spot behind. Nor does pannus, as a general rule, endanger the sight; only it lasts a long time. Ulceration, succeeding the bursting of the pustules, may become very dangerous, if it shows a tendency to attack the cornea very extensively; it may lead to the destruction of this organ and may involve the iris in the disorganizing process. The ulcerative process may lead to cicatrices in the cornea, its laminae may become infiltrated with pus; a staphyloma may result and finally the cornea may burst, and all the disastrous consequences of this accident may be entailed upon the patient. The duration of this affection does not follow a definite rule; not unfrequently, after a severe attack had been overcome, another attack takes place, sometimes on the same, and at times on the other eye. Only in rare cases both eyes are attacked at the same time and in the same manner. 252 Diseases of the Eye. In many respects the etiological causes of the disease are not dif- ficult to determine; in some cases, on the contrary, they are in- volved in a good deal of uncertainty. The most frequent cause of the disease is undoubtedly a scrofulous diathesis; but there are cases where the antecedents of the patient preclude the idea of scrofulosis, and again other cases where the disease commences with a simple inflammation of the eye. As a general rule, scrofula ac- quires its most marked development between the second and seventh year, although it may break out at any age. Unwholesome, dark, damp dwellings, improper nourishment, excessive quantities of far- inaceous food, want of cleanliness, insufficient exercise in the open air, are not only the causes of scrofulosis generally, but likewise the causes of scrofulous ophthalmia specially. Where a disposition to this disease prevails, an outbreak is provoked by mechanical injuries, catarrhal irritations, excessive use of the eyes, etc. The influence of the season is undeniable. This results from the circumstance that the inflammation is apt to return in the same individual at the same period of the year; it is particularly in spring and fall, during the prevalence of cold and damp weather and keen winds, that the disease is apt to break out. Not unfrequently ophthalmia changes about with eruptions in the face or otorrhoea. Howsoever often this phenomenon has been observed, yet it is impossible to account for it. What is certain, however, is that it is wrong to presuppose the existence of a metastatic process, so much more as both these morbid conditions sometimes replace each other for years. Treatment. It has to be directed against the attack itself, and likewise against the disposition to relapses, in other words against the scrofulous diathesis itself. In selecting a remedy for this disease, we have to consider the constitutional disposition of the patient, whether it is erethic or of the torpid and scrofulous cast, for the attacks vary accordingly. In the erethic form, as long as there is violent photophobia with- out any affection of the cornea, Belladonna is to be preferred, more especially if the pains are very acute and febrile symptoms are noticed. If there is photophobia without any corresponding pains or other inflammatory phenomena; if the photophobia is accom- panied by a violent spasm of the eyelids, or if, as is often the case, this spasm is the cause of the photophobia, Conium maculatum is preferable to Belladonna, but it is indispensable to administer the drug in rather large doses, a few drops of the concentrated tincture, as we can aver from abundant experience. Belladonna, likewise, Conjunctivitis Scrofulosa. 253 had better be administered in the lower preparations, the higher ones leaving us frequently in the lurch. If the disorder has reached the stage of exudation near and upon the cornea, Mercurius is un- doubtedly the best remedy, and more especially the Sublimate, which, if possible, should likewise be used externally. Since in scrofulous ophthalmia we cannot expect a sudden effect from any remedy, the exhibition of Mercurius should not be discontinued too soon, for the additional reason that it is likewise an excellent remedy against the ulcerative process. It is still more indicated by a co-existing exanthem, more particularly eczema in the face, with violent itch- ing. The local use has to be managed very cautiously after the ulceration has penetrated the cornea to a certain depth. Rhus toxico- dendron should not be overlooked. It is true we are not yet in pos- session of very positive, practically verified clinical indications of this drug; on the other hand, this remedy is certainly recommended by eczematous affections co-existing with ophthalmia, particularly eczema of the ears; marked swelling; of the lids and cheeks, and violent pains in the eye with rather scanty secretion. Graphites, likewise, should not be forgotten if exanthemata are present, more particularly if the trouble has already lasted for some time. In the decidedly torpid form of ophthalmia the photophobia is not near as violent as in the erethic form, nor is it as lasting;. It will not, therefore, be necessary to resort to Belladonna or Conium. In this form the disposition to the formation of pustules and ulcer- ation of the cornea is more prominent, and may render the exhibi- tion of Mercurius desirable; in general, however, Hepar sulphuris will act to better advantage. Hepar sulphuris is undoubtedly one of the most certain remedies in this affection, and is often alone sufficient to remove the disease speedily and completely. With Hartmann we likewise recommend the use of larger doses, second or third trituration. If the inflammation inclines to terminate in suppuration, and the deeper layers of the cornea have become at- tacked by the disorganizing process, Sulphur is undoubtedly appro- priate, as it is likewise appropriate in the case of ulcers, the bottom of which remains persistently unclean. This remedy deserves par- ticular attention if the cornea is covered with a firm exudation, or if pannus has formed and the affection evinces a decided disposition to run a protracted course. In this latter case, Acidum nitricum is likewise indicated. Beside the medicines that have already been mentioned, we still have to point out two other remedies that are frequently used in 254 Diseases of the Eye. scrofulous ophthalmia. One of them is Arsenicum. This remedy has undoubtedly a prominent effect upon the conjunctiva. It is particularly suitable in the chronic forms, where photophobia, exco- riation and redness of the lids are constantly present, and where we have frequent exacerbations by a recurrence of the paroxysms. Such exacerbations are met with in thoroughly scrofulous constitu- tions, for which Arsenic, independently of the ophthalmic affection, has proved an excellent remedy. During the paroxysms the use of this medicine may be somewhat questionable; sometimes the pho- tophobia seems to disappear more rapidly after the use of Arsenic; but then it is difficult to judge of the medicinal effect of a medi- cine, since a photophobia, which is very distressing one day, fre- quently disappears without any medicine on the day following. Arsenic is almost more than any other medicine indicated in affec- tions of the cornea running a rapid course, where suppuration and infiltration reach such a high degree in one day that they threaten the destruction of the organ. The second remedy is Apis mellifca. We must confess, however, that in spite of the brilliant encomiums of the advocates of the .honey-bee, and of the numerous trials we have made with it, we have not yet, in a single case, succeeded in producing with the honey-bee a single favorable effect in scrofulous ophthalmia. Hence our advice is not to experiment with the honey- bee until other well-tried remedies have been used in vain. Of other remedies belonging to this class, or having been recom- mended for scrofulous ophthalmia, we note the following: Pulsa- tilla, Staphysagria, Silicea, Cannabis, Ferrum, Calcarea carbonica. The treatment of the disease as an integral pathological condi- tion requires the same general considerations, that will be mentioned more in detail when we come to treat of scrofulosis generally. Otherwise it is not always necessary to eradicate totally the scrofu- lous taint in order to prevent the recurrence of new attacks ; all we are able to accomplish in many cases is to check the disposition to ophthalmia, whereas in other respects scrofulous phenomena may continue to remain. For a more detailed indication of the necessary remedies and dietetic rules we refer to the section on Scrofulosis; all we need do in this place is to confine ourselves to the special rules referring to the ophthalmic affection. The intense photophobia, and the painful spasm of the lids caused by it, render the patients so apprehensive of the least ray of light penetrating into the interior of the eye, that they retreat to the darkest corner in the room, or bandage their eyes in order to pro- Conjunctivitis Scrofulosa. 255 tect them from the light. Neither one nor the other of these pro- ceedings is proper. The former prevents the enjoyment of fresh air, the latter heats the eye. On the contrary, the eye should never be deprived of light altogether, and instead of bandaging the eye, it had better be protected by means of a dark pasteboard screen. Not merely lay-persons, but even practitioners, sometimes try to assuage the pain by applying cold water compresses to the eye at the very height of the inflammatory process. It is, however, a pe- culiarity of scrofulous ophthalmia not to bear the appl'ca ion of cold water; at any rate, the inflammation is not moderated by it. It is sufficient to bathe the eyes frequently with warm water; this is likewise the best means of moderating the painful excoriation caused by the constant flow of tears. As regards nourishment, we might easily be led by the idea that when an inflammation has to be subdued to confine the patient to a spare diet. This would be very wrong; on the contrary, the patient should have nourishing, although easily digested food. An excel- lent diet is good dried fruit, which does more to meliorate the diges- tion of scrofulous children than any other highly praised luxuries. It is strange that there is so much opposition to the use of fruit both among physicians and laymen. There is no reason for it. Only good fruit should be given. It will never produce bad effects, even if the digestive organs are ever so weak. The three kinds of conjunctivitis of which we have treated con- stitute those ophthalmic affections that are of the utmost importance to the practical physician, because they occur the most frequently, and because he is generally expected to treat them. We have hesi- tated for a long time whether it was desirable to treat of the affec- tions of the cornea and of the more deep-seated tissues of the eye, and at the same time to state what has been already accomplished in this direction by Homoeopathy; but various reasons decided us to omit this part of ophthalmic surgery. The diagnosis of these affections requires all the different instruments peculiar to modern science, and their treatment requires the necessary operative skill, two suppositions which a practical physician can scarcely comply with for want of time. Moreover, we are not as yet in possession of the necessary provings which might enable us to contrast the pathological series with a corresponding pathogenesis. This section would therefore necessarily have remained very imperfect. However, inasmuch as a physician who is somewhat isolated from other practitioners, may be placed under the necessity of treat- 256 Diseases of the Eye. ing affections of the internal eye, we cannot forbear indicating in subsequent paragraphs what has been accomplished by homoeopathic treatment. Inflammation of the cornea is generally a partial manifestation of conjunctivitis. The treatment of the former inflammation co- incides -with the treatment of conjunctivitis, as we have had occa- sion to show in former chapters where some particulars in this direction have already been furnished. "Where the cornea is pri- marily affected, the choice of the remedy depends upon the peculiar manner in which the exudative process establishes itself. For pan- nus the most efficient remedies are: Hepar sidphuris, Euphrasia, Baryta carbonica and Calcarea carbonica. For abscesses of the cor- nea Mercurius is the main remedy, so much the more, the more the suppuration is circumscribed within definite limits. For purulent infiltration and threatening rapid disorganization of the cornea Arsenicum is the most trustworthy remedy. lodium, Sulphur, Silicea, deserve our attention in chronic exudative processes. We must never lose sight of the fact that affections of the cornea, cor- responding to the peculiar structure of this organ, run a very pro- tracted course and that, on this account, we cannot expect a rapid effect from the medicines we may have to prescribe. The sclerotica is seldom affected isolatedly. Sclerotitis is gener- ally symptomatic of the so-called rheumatic ophthalmia, and is of importance in so far as it calls our attention to certain remedies which might perhaps not be thought of in simple conjunctivitis. A fine, uniform, rose-colored redness round the margin of the cor- nea is the characteristic symptom of this affection which is but too easily confounded with conjunctivitis. This phenomenon may like- wise constitute one of the symptoms of iritis. Iritis, like corneitis, is seldom an idiopathic disease, but is gener- ally a symptom of general ophthalmia. As a primary affection it most frequently depends upon syphilis. At the commencement of the disease, when there is no syphilitic taint at the bottom of it, Bella- donna, and perhaps also Aconite, may have to be prescribed, but always only at the commencement of the attack; for owing to the rapid course of the disease, we very soon have to resort to Mercurius as the main remedy, which should be exhibited in the form of Cor- rosive Sublimate. In the further course of the disease, when the exudation has come to its end, Sulphur and Iodine are indicated. Hypopyon does not require special mention, since, as a general rule, it is rapidly reabsorbed. Diseases of the Ear. 257 Cataracts are generally considered incurable by internal remedies. This proposition has been refuted in Ilomceopathy by a number of successful cures, and we can boldly assert that we have succeeded in controlling this disorder by the use of internal agents. Unfor- tunately, however, when the proper remedy is to be selected, we are compelled to admit that we have not yet succeeded in determining what remedies are adapted to the different forms of cataract. The main remedies are: Phosphorus, Pulsatilla, Sulphur, Calcarea carbo- nica, Lycopodium; the less certain and less tried remedies are: Silicea, Cannabis, Euphrasia. Of course we do not mean to say tha we can remove every cataract by homoeopathic remedies. As a general rule we can only say that the prognosis is so much more favorable the younger the patient, the shorter and the less developed the disorder. In the case of old people, where cataract may be regarded as a gradual dying out of the lens, it would be absurd to suppose that internal treatment is of any use. The prognosis of capsular cataract is more favorable than that of any other form. By means of the ophthalmoscope the diseases of the retina have latterly been much better appreciated and diagnosed than at any former period. We are as yet unable to indicate therapeutic pro- ceedings adapted to this advance in diagnostic means; in given cases we prefer referring the reader to a good Repertory by means of which the remedy corresponding to the generally subjective symptoms of the patient, can most easily be found. D. DISEASES OF THE EAR. As reg-ards diseases of the ears, we are still worse off than in diseases of the eyes. In general the diagnosis is a very difficult one, sometimes impossible; how then shall we be able to select the right remedy ? We have to confine ourselves to furnishing a cur- sory and condensed list of the pathological conditions and remedies, with which a somewhat empirical and not very reliable use at the sick-bed has made us acquainted; for the selection of a remedy in accordance with a symptomatic similarity, is still more deceptive in the case of ear-affections than in other morbid conditions; never- theless, it happens but too often that we have nothing else to fall back upon than symptomatic similarities. The inflammatory pro- cesses in the interior of the ears are among the less frequent dis- 258 Diseases of the Ear. eases, but are of particular importance for the reason that the brain becomes so readily involved in the inflammatory process, especially when it is localized in the inner ear. An inflammation of the outer ear likewise tends powerfully to pass to the inner ear; it is for this reason that we treat these two forms of inflammation of the ears somewhat more in detail. I. Otitis Interna. Internal Inflammation of the Ear. Inflammation of the inner ear is chiefly recognized by the extra- ordinary pain it causes. The pain is chiefly a tearing, throbbing or burning pain, is very much increased by motion, likewise by chew- ing, loud noise, contact of the outer parts. Inflammatory earache is one of the most distressing tortures that man can suffer. The excruciating character of this pain accounts for the cerebral irrita- tion which is almost always present in this disease. The fever is very violent, and the pulse hurried and small. The head glows, whereas the extremities are cold as ice; delirium and fainting fits set in, before the brain can be said to sympathize with the distress. The outer ear usually shows signs of inflammation; the meatus auditorius is swollen, sometimes entirely closed, red and very sensi- tive, and the swelling spreads to the ear and the surrounding soft parts. Otitis is very apt to result in suppuration, and is still more inclined to spread to the brain, more particularly if the cells of the mastoid process are inflamed. It is not certain whether the inva- sion of the brain takes place more easily when the inflammatory process has reached its height, or after the pus has begun to form. Suppuration supervenes but too frequently during the course of a chronic affection of the bones; hence suppuration of the mastoid process may involve the brain and lead to a fatal termination even after all danger consequent upon inflammation seems to be entirely removed. Otitis may be complicated with a meningitis which runs a very rapid course, and is one of the most dangerous diseases. Its treatment has already been indicated in a former chapter. Otitis may terminate in favorable cases in complete recovery; this result, however, is rare ; generally a disturbance of the functions of the ear remains behind, sometimes assuming the form of perfect deaf- ness. If pus forms, it is fortunate if it is discharged externally, even if the tympanum should be greatly injured and chronic otor- rhoea should be the result. The causes of otitis cannot be mentioned with positive certainty. Otitis Interna. 259 A cold is said to be one of the chief causes. Whether, as Hart- mann imagines, otitis may arise from suppressed itch, is very ques- tionable ; it is undoubtedly a convenient thing, after the previous existence of the itch has been ascertained with great trouble, to refer to it all chronic as well as acute ailments, even after years had elapsed between the itch and the subsequent disease. On the com trary it does happen that violent acute and sub-acute cutaneous diseases involve the ear in the pathological process, in which case the outer ear is, of course, first attacked by the inflammation, which thence spreads to the inner. Among the dyscrasia's it is particu-t larly syphilis and scrofulosis by which the ear is attacked. Treatment. We will first transcribe the following passage from Hartmann, page 551: "My experience in the treatment of otitis with del.rium and agonizing pains, with swelling and closing of the outer meatus, swelling of the ear and the adjoining parts, induce me to regard Pulsatilla as the specific remedy in this form of otitis. I rejoice at being able to communicate this experience to my colleagues, for, as far as I know, no one before me suspected that Pulsatilla had this specific curative power in otitis. Otitis from internal causes is a comparatively rare occurrence, and this may be the reason why but few homoeopathic practitioners may have met with it in their practice, and, for this reason, may not have had an opportunity of employing Pulsatilla in this disease. Lest a physician who may have a case of otitis to treat should be dissuaded from using Pulsatilla on account of the presence of some symptoms in the pathological group which do not occur in the pathogenesis of the drug, I will add that every homoeopath un- doubtedly knows from Hahnemann's Materia Medica, that Pulsa- tilla must not be given where excessive thirst and constipation are prominent symptoms; nevertheless, in spite of these symptoms, which are always present in this form of otitis, I have never hesi- tated to prescribe Pulsatilla, and the success which I have uniformly met with, has satisfied me that the presence of thirst and costive- ness in this disease are no counter-indication to Pulsatilla. " Now although abundant experience has satisfied me that Pul- satilla is the specific remedy in otitis where the external and inter- nal inflammations run a parallel course, both break out simultane- ously, and are equally acute and violent, yet there are cases where Pulsatilla is not sufficient, and where Belladonna has to be given in its place; this is the case when the internal inflammation is, from the start, more acute than the external, or when the consensual 260 Diseases of the Ear. affections of the brain, which are closely bordering on meningitis, such as a feeling of intense pain in the head, delirium and rage, convulsions, fainting-fits, aphonia and the like, are very prominent. In this latter case Phus tox. may prove a valuable drug." If Hartmann asserts^ that with appropriate homoeopathic treat- ment, he has always been able to prevent the inflammation from terminating in suppuration, all we can say is that this result speaks equally well for the superiority of the treatment as for the success of the physician, for not every one can boast of such favorable results in his practice. Suppuration will sometimes set in, in which case we shall find Mercurius the chief remedy. It will be found particularly suitable in cases where syphilitic individuals are at- tacked with the inflammation, provided they have not already taken Mercury in massive doses; otherwise it is perfectly appro- priate. Side by side with Mercurius we have Hepar sulphuris, in cases marked by a highly developed scrofulous taint or mercurial- syphilitic poisoning. In cases running an unfavorable course, the discharge of pus from the outer ear becomes profuse, the pus has a cadaverous odor, is ichorous, and the symptoms of a sudden collapse are very apt to supervene. In such desperate cases Arsenicum may sometimes be able to afford relief, and where symptoms of pyaemia have become prevalent, more particularly pyaemia of the lungs, Phosphorus is the only remedy from which help may still be expected, provided it is not too late. In a case to which we were called one day previous to the patient's death, after the disease had already lasted four weeks, the pysemic affection had reached the highest degree of de- velopment. The patient unfortunately was already moribund, and medical action was out of the question. If the suppuration has resulted in carious destruction of the ossicula, without any of the terrible symptoms that have just been described, Lycopodium some- times affords help, together with Sulphur and Silicca. [An interesting case of otitis interna, with discharge of foul-smell- ing pus, constant buzzing in the ears, agonizing pains in the ear from the moment the patient, a young lady of thirteen years, retired to rest until the morning, partial deafness, and very painful and considerable swelling of the mastoid process, yielded as if by magic to a single drop of Mercurius virus, 30. The case had been going on for nearly two years, and the symptoms were steadily increasing in violence. The noises in the head were exceedingly distressing, and the sensitiveness of the ear and the adjoining parts intense. Otitis Externa. 261 The patient took a single drop of Merc. viv. 30, at bedtime; in about an hour the distress vanished utterly, the young lady slept all night, woke perfectly free from any of the above-mentioned symp- toms, and has never been troubled with earache since. The deaf- ness continues to some extent, probably owing to the partial destruc- tion of the tympanum and the ossicula, but otherwise no trace of the otitis or earache is visible. The cure was effected some years ago. EL] As we remarked above, an inflammation of the external meatus usually accompanies an inflammation of the internal ear, and, by its presence, always reveals the existence of a higher grade of otitis interna. As an idiopathic affection, disposed, however, to extend to the inner parts of the ear, it is either an inflammation of the cel- lular tissue in the external meatus, spreading uniformly all around, very painful, but not very dangerous and of short duration, or else it consists in suppuration of one or more glands of the outer meatus auditorius. In such a case a small abscess is seen on one or the other side, more or less deeply in the inner ear. In this form of the inflammation the pain is likewise comparatively very acute, but usually ceases all at once, when at its height, by the bursting of the abscess. This inflammation very frequently accompanies, as a com- plicating disorder, an inflammation of the parotid gland or of other adjoining parts. Erysipelas likewise does not unfrequently attack the outer ear, and, if it begins at the ear itself, may lead to errors in diagnosis. For idiopathic otitis, the chief remedies, when the cellular tissue is the seat of the disease, are Bryonia and Pulsatilla ; Mercurius is principally indicated by the formation of an abscess; likewise Chamomilla, which generally, however, has already been abused as a domestic remedy when the physician is called. In the secondary forms the remedies which are adapted to the primary disease, upon which the otitis depends, are alone appropriate. [We wonder, that Aconite is not mentioned by the author as a remedy for otitis, whether internal or external. In rheumatic otitis, with dark redness of the inflamed part, stinging, lancing and throb- bing pain in the ear, swelling and great sensitiveness of the outer ear, discharge of blood and purulent serum from the ear, Aconite- Radix; a drop of the tincture, or a few drops of the first decimal attenuation, in a small goblet of water, in dessert-spoonful doses 3. Otitis externa. 262 Diseases of the Ear. every half hour or hour, will be found an indispensable remedy. It sometimes is advantageously given in alternation with Bella- donna. II.] As a consequence of otitis, but sometimes from other causes, we frequently meet with a discharge from the ears, which is at times slimy, at others purulent or ichorous, at others again watery or bloody. The slimy discharge is of a catarrhal nature, makes its ap pearance in the cases of many children, whenever they are attacked with a severe cold, and has no special significance. As a general rule, it very soon yields to a few doses of Pulsatilla. The other forms of otorrheea are symptomatic manifestations of otitis, and require the same treatment as this disease. Injections of lukewarm water have always a good effect, and should never be omitted. Hardness of hearing may depend upon a variety of causes, by the peculiar nature of which its curability is determined. If it proceeds directly from the auditory nerve, and is the commencement of com- plete deafness, it is not likely that much can be done for it by inter- nal treatment. If we choose to try it, we may use Causticum, Pe- troleum, Piatina, Plumbum. If the deafness is caused by a stoppage of the meatus externus, various obstacles may prevent the free en- trance of sound. The most common obstacle is the accumulation of indurated cerumen in front of the tympanum. This is most effectually removed by continued injections of lukewarm water, until the plug is loosened, after which it can readily be grasped with a pair of pincers and drawn out. If ap unopened abscess is the cause, which is not often the case, its reabsorption is easily accom- plished by frequently dropping lukewarm water into the ear, which has to be retained in it for some time. A polypus in the mea- tus may, if possible, be twisted or cut off; where this is not possi- ble, the polypus can gradually be caused to shrink, by touching it frequently with the half diluted tincture of Thuya. If the tym- panum is injured, a cure is, of course, impossible; in such cases the patients hear often much better by inserting a loose plug of cotton in the ear. This custom is so common with many people, that they are never seen without cotton in their ears. It is a bad habit, which favors more than any other proceeding the formation of little plugs of ear-wax; for, the nuclei of most plugs, which we have removed in large numbers, were found to consist of cotton-fibres. Still more hurtful is the habit of introducing medicinal substances into the ear. We are acquainted with a lady who has been using Camphor in this manner until her tympanum has become perforated in con- Coryza, Catarrh, Cold in the Head. 263 sequence. If little children are hard of hearing, we have to ascer- tain, in every case, whether they have not inserted some foreign body in their ears. Just as frequently, as upon changes in the external meatus, does hardness of hearing depend upon stricture or stoppage of the Eu- stachian tube. Such a defect may easily be caused by a severe catarrh of the nasal fossa, likewise by considerable hypertrophy of the tonsils. Here we have, of course, to employ the remedies that will be mentioned in subsequent chapters, when treating of the affec- tions of the nasal and buccal cavities. E. DISEASES OF THE NOSE. Coryza, Catarrh, Cold in tlie Head. Catarrh of the nasal mucous membrane is one of the most com- mon and most frequently occurring affections, is of very little in- herent importance, and is considered as a mere pathological trifle by our therapeutic opponents, not worth the trouble of having any- thine; done for it, although the real cause of this omission is that they really have no remedy for it. It is for this very reason that a catarrh is particularly interesting to us, the same as toothache, for which we have a good many efficient remedies; a lay person is often more astonished at the sudden cure of a catarrh or a toothache, by a few of our little powders, than at the most brilliant cure of a case of pneumonia. He has had catarrh often enough to be thoroughly acquainted with its course; hence he is surprised at seeing it short- ened by treatment. A simple catarrh arises from a cold. Individuals who watch themselves somewhat, know very well that, if they feel chilly from exposing themselves to a current of air after being heated, they will have a catarrh within twelve hours. Severe attacks always com- mence with a febrile sensation, lassitude, dull headache, especially above the root of the nose. At first the nose is drier than usual, sensitive to cool air, the smell is sometimes remarkably affected; there is a tingling in the nose and a desire to sneeze. If a dis- charge takes place at the commencement, it is generally very tena- cious, yellowish, or almost entirely watery. In most cases the ad- joining parts are involved, especially the tonsils, which are slightly reddened, and where a stinging pain is experienced. The larynx is 264 Diseases of the Nose. likewise affected, the speech being somewhat hoarse. A peculiar symptom is the remarkable frequency of the pulse, with which son e persons become affected at the commencement of a catarrh, and the striking elevation of the temperature. Among children particularly the constitutional symptoms are much more striking than among adults; whereas the latter continue in the enjoyment of a sound sleep, children, on the contrary, spend restless nights. Usually after the lapse of twenty-four hours a copious secretion of mucus takes place, after which the patient feels better and the constitutional symptoms disappear. Within nine days at most, the patient is completely restored to health, unless a relapse should have taken place. This very common fornj of catarrh scarcely requires to be treated medicinally. Cases may, however, occur, where the secre- tion remains copious and watery for three or four days, the patient feeling very much indisposed and very anxious to be freed from his complaint. Moreover, in the course of the catarrh, relapses may take place, in consequence of which the febrile exacerbations may increase to such an extent that a catarrh, which was at first quite unimportant, becomes a real torture. Under favorable circumstances, especially if the patient exposes himself to frequent relapses or is otherwise constitutionally pre- disposed to the complaint, the acute form passes into the chronic. Generally the chronic form consists in a profuse secretion of mucus, without any other trouble. Frequently, however, the profuse mu- cous secretion is accompanied by swelling of the mucous membrane and impeded respiration. After a number of relapses the swelling increases to such a degree, that breathing through the nose becomes impossible, which gives rise to a number of ailments: the speech has a nasal twang, the throat hurts in consequence of the dryness induced by breathing exclusively with the mouth open, and sleep is variously disturbed. These difficulties remain even after the mucous secretion has entirely ceased; in that case they are even more unbearable than before. If there is a peculiar predisposition, such as scrofulosis, the internal parts of the nose become inflamed side by side with the catarrhal irritation, and an ulcerative process sets in, which secretes a foul-smelling purulent matter, (ozaena.) A bad smell from the nose may, however, take place, without any ulceration. The structural changes in the mucous membrane fre- quently give rise to fungoid growths, polypus, etc. We may as well relate here a case of ozaena, which originated in a peculiar manner. On a certain occasion a farmer showed us his little three Coryza, Catarrh, Cold in the Head. 265 years old daughter, with the remark that she was always troubled with catarrh, aud that the discharge had a very bad smell. An examination showed that the left nostril was stopped up, with a partly whitish and partly blackish-gray substance. On removing it with a pair of pincers it proved to be a bean, which had swelled up very much and had become rotten. The ozaena, which had lasted upwards of six months, ceased at once. Of the catarrh caused by syphilis we shall treat in the chapters devoted to that disease. A catarrh is usually very seldom present during other inflamma- tory affections; if it exists before the latter, it generally disappears as soon as the latter affections break out. This circumstance, may have given rise to the story of retrocession of a catarrh, and is of particular importance in croup, where it is so easy, at the com- mencement of the disease, to make a wrong diagnosis. We can scarcely ever be mistaken if, in cases where the peculiar croupy sound of the cough, and other symptoms of incipient croup are accompanied by catarrh, we diagnose catarrhal croup, and promise a rapid improvement, which scarcely ever fails us. No more fre- quently, or scarcely ever, will catarrh be met with as an accompani- ment of pneumonia. Catarrh will only have to be treated medicinally, if it is accom- panied at the onset by symptoms of severe constitutional disturb- ance, or the catarrhal phenomena themselves are unusually violent. The symptoms during the first twenty-four hours generally demand Aconite ; Belladonna may have to be used, if the tonsils are inflamed. If the subsequent symptoms, except their intensity, are like those of a common catarrh, if the discharge is slimy, Mercurius solubilis is a distinguished remedy, which will scarcely be surpassed by any other. If the secretion is very copious, the lips and nose become rapidly excoriated, the headache is very violent, and particularly at the root of the nose a burning and stinging pain is felt, and the constitutional symptoms are very prominent and intense, Arsenicum acts almost instantaneously. The other medicines belonging to this series will be mentioned in the chapter on Influenza, since they will be found more particularly appropriate, if, beside the nose, the larynx, trachea and lungs are likewise affected. In the case of infants at the breast, a catarrh, even if it runs its ordinary course, becomes a source of distress, because it prevents them from nursing. In such cases Pulsatilla may afford more relief than any other 266 Diseases of the Nose. remedy; if the catarrh breaks out during the period of dentition, Chamomilla may be preferable. The chronic form of coryza is, under all circumstances, a very obstinate complaint. This is probably owing to the circumstance that such patients do not take the least care of themselves, and that the swelling of the nasal membrane is constantly increased by new relapses. The more the swelling increases, the more difficult it is to cure the complaint. In recent cases Mercurius and He par sulphuris may render good service. In neglected cases Sulphur and lodium often afford help; the latter especially deserves attention. Kali bichromicum has been praised beyond its due; it is useful only when the coryza is attended with soreness and ulceration of the nose. Calcarea carbonica is indispensable in cases depending upon scrofulosis, and where the discharge has a foul odor. In real ozama Aurum is by far the best remedy; we prefer Aurum muriaticum, the metallic gold is much less reliable. Alumen has likewise been recommended for ozsena. [In the 22d volume of the British Journal of Homoeopathy, the following interesting case of cure of ozrena with the Permanganate of Potash is copied from the Paris Gazette des Hopitaux: The pa- tient was an English young lady, at school in Paris. Her breath was so offensive, that her presence in the school-room had become unpleasant to her companions. Her approach caused nausea, and in one instance severe vomiting was induced. Cauterization, injec- tions of every description had proved unavailing. Sir I. Ollifte now resorted to injections of the Permanganate of Potash. They were repeated every three hours, and in the course of three weeks the offensive odor had entirely disappeared, and the patient was again able to associate with her companions. Alternate injections of the Permanganate and Chlorate of Potash were continued for some time longer, and the patient remained permanently cured. The Permanganate was likewise used internally, as follows: Thirty-six grains of the Permanganate to five drachms of syrup of orange-blossoms and six ounces of water, a tablespoonful three times a day.] In view of the obstinacy of chronic coryza and of the bad conse- quences it may entail, among which loss of smell is one of the most important, it is certainly advisable to devise a course of treatment that shall prevent relapses. One of the most useful means, to ac- complish this result, is a gradual hardening of the whole body by means of cold water. Cold water is altogether an important reme- Coryza, Catarrh, Cold in the Head. 267 dial agent in the treatment of catarrh. When drunk at the onset of an acute attack, in considerable quantity, it very soon moderates the most disagreeable sensations; and, in the chronic form, it ren- ders good service when drawn up into the nose several times during the day. This last-mentioned use of water likewise acts as an ex- cellent prophylactic. For catarrh, properly speaking, it is better to draw up tepid instead of cold water; tepid water loosens the tough mucus better than cold. In the chronic form, likewise, cold water is often much less suitable than warm water, which feels much more pleasant. That it has a favorable effect upon existing ulcers, is evident a priori, were it only by cleansing the suppurating surface and preventing the formation of crusts. It is well known that copious draughts of some lukewarm beverage are likewise recommended for catarrh; it is undeniable that it has an excellent effect in catarrhal conditions of the respiratory organs. This man- agement, however, seems so annoying to many persons, that only a few are willing to take this trouble. Of much more importance is the use of water in the epidemic catarrh of the respiratory organs; we shall revert to its use when treating of this disease. An ordi- nary proceeding in domestic practice is to excite a profuse perspira- tion. It is undeniable that this proceeding moderates the course of a catarrh, almost without an exception. Nevertheless serious doubts may be entertained against such a course. In the first place, sweat is sought to be excited by medicinal herbs. This con- duct is decidedly reprehensible, for the reason that the organism should never be drenched with medicinal decoctions without the most urgent necessity. And, in the second place, the skin is ren- dered more susceptible to cold, which is much worse than that the first cold should remain uncured. If the skin is to be excited to increased action, the best and least hurtful means to accomplish this, is a moderate vapor-bath; or, if we desire to excite perspira- tion in the bed, we may drink a glass of warm water with a little syrup. We have to devote a few remarks to polypi in the nasal fossa. If we except the cancerous growth, there are two distinct kinds of polypi. One is a simple fungoid growth of the nasal mucous membrane, and owes its origin to chronic catarrh; the other is rather an idiopathic growth with vessels and cellular tissue. These excrescences sometimes impede respiration to such an extent, that they have to be removed either by an operation, or by medicinal treatment. That the latter is sometimes adequate to their removal, 268 Diseases of the Nose. has been placed beyond all question by numerous successful results. In treating a nasal polypus, we use the following remedies: Teu- crium marum verum, especially for mucous polypi, to be used inter- nally and externally; as an external application we use the pulver- ized herb as snuff Calcarea carbonica, in the higher attenuations, is recommended by many authorities, likewise for polypous excres- cences of the Schneiderian membrane. We have never been able to obtain any good from its use in this disease. Against sarco- matous polypi we frequently find useful: Kali bichromicum, Phos- phorus or Sulphur. The result of the treatment, however, in such cases, is much less favorable than that of mucous polypi. Inflammation of the Schneiderian membrane generally occurs under the form of a more or less intense catarrh, of which it is very frequently a symptomatic manifestation. The ulcerative process to which attention has been called when treating of catarrh, depends upon this inflammation. The treatment is conducted with the same remedies that have already been indicated in the former chapter. There is another form of nasitis where single follicles are attacked, in consequence of which abscesses form. This disorder is very pain- ful, and it is desirable that its course should be shortened as much as possible. The best remedy for this purpose is Mercurius ; Hepar Sulphuris may likewise prove useful. In some cases, if the affec- tion is just beginning, it may be well to commence the treatment with Belladonna. The application of a warm fluid does the same good here as in any other abscess. Inflammations of the nose, which constitute partial manifesta- tions of other constitutional affections, will be spoken of in connec- tion with the latter, where the proper treatment will likewise be explained. A peculiar inflammation of the nasal mucous membrane, which bears the greatest resemblance to eczema of the external skin, and frequently spreads in the form of an eczematous process to the ex- ternal nose and to the lips, results in a continual formation of crusts and runs a very slow course, requires for its cure Mercurius, Kali bichromicum, or in more chronic cases, Graphites. Inasmuch as the cure does not take place very rapidly, it is well not to change the remedy too soon. [A case of phlegmonous nasitis, with a large ulcer at the tip of the nose, was radically cured in five days with the German tincture of Aconite. II.] 3. Inflammation of the Nose, Nasitis. Epistaxis, Bleeding at the Nose. 269 3. Epistaxis, Bleeding at tlie Nose. Bleeding at the nose is one of the most frequent occurrences; no organ is as easily inclined to bleed as the nose, the cause of which has to be sought in the peculiarly delicate structure of its mucous membrane, in its great vascularity, and in the circumstance that the nose is remarkably exposed to external influences and injuries. Bleeding at the nose generally sets in unexpectedly without any precursory symptoms, which, when existing, consist of congestion about the head, such as headache, vertigo, buzzing in the ears, etc., or fever. Generally the bleeding takes place only from one nostril, and, as regards quantity, varies from a few coagula, mixed with nasal mucus, to whole pounds. Sometimes it is a scarcely percep- tible flow of blood, sometimes a mere dribbling of a few drops, and sometimes, but very seldom, the blood rushes out in torrents. Ac- cording as the bleeding vessel is located, the blood is poured forth from the external nostrils, or else from the posterior nares into the pharynx. The latter result is apt to occur at night during sleep. On waking, the patient vomits up the blood, or, if it had run into the larynx, it is coughed up, leading both the physician and the patient to suppose that he had an attack of haemoptoe, so much the more when the other coexisting symptoms render this supposition more or less founded in fact. The bleeding may continue from a few seconds to whole days. If the single turns follow each other in rapid succession, it may often seem as if the bleeding continued for days. The causes are various; but if a good deal of blood is lost, it is always desirable to investigate them with accuracy. There undoubt- edly is such a thing as a constitutional predisposition to nose-bleed, in consequence of which the vessels are abnormally inclined to fill up and burst. This predisposition may even be hereditary, although it does not show itself in the looks of the individual. Besides this, a marked hypersemia of the nose, or even of the whole head, is one of the most frequent causes ; likewise mechanical impressions, ulcers of the mucous membrane, and finally a peculiar composition of the blood which favors the exudation of the blood, as in typhus, scurvy, anaemia, haemorrhoidal dyscrasia. The frequent appearance of nose- bleed at a time when the barometer is very low, causes us to adopt the theory that the atmosphere exerts a peculiar pressure, resulting more particularly in the production of congestions about the head. Although nose-bleed, as we stated above, is, generally speaking, 270 Diseases of the Nose. an occurrence of trifling importance, yet, under certain circum- stances, it acquires a peculiar significance. In the first place, the quantity of the blood that is lost by one or by a series of successive bleedings, may be so great that the most dangerous symptoms of anaemia may result from such a loss. In the next place, the hemor- rhage is dangerous in such conditions as anaemia and typhus, which do not bear any loss of blood. It is undoubtedly wrong to view the nose-bleed in such conditions as a critical endeavor of the organism, although such a view seems justified by a momentary amelioration of single symptoms, especially the congestive head symptoms. Such an improvement is very soon followed by a so much more disagree- able exacerbation. Nature thus points out the value we are to attach to artificial bleedings, and that they at most only palliate the distress at the expense of the general organism. In little children and old people, nose-bleed is always a dangerous occurrence. In treating this disorder, as a matter of course, the exciting causes are of great importance. Where the symptoms of violent conges- tion of the head are present, the remedies -which we have recom- mended for cerebral hypersemia, particularly Belladonna, Aconite, Nux vomica, [also Gelseminum and Veratrum viride~\, are especially to be kept in view. At the commencement of a general acute dis- ease, Bryonia alba is the best remedy; but it is not here alone that it is useful, but likewise in the bleedings depending upon strongly- marked venous hyperaemia of the brain, and belonging rather in the category of passive hemorrhages. If such bleedings set in without any other accessory symptoms or fever, we give Crocus and China, the last-named, more particularly, where distinct symptoms of anae- mia were already present previous to the hemorrhage. In the sub- sequent course of acute affections, with decomposition of the blood, Arsenicum, Lachesis and Secale cornutam are mostly to be com- mended. Hartmann has seen Moschus act with quick success in cases where jactitation of the muscles had already set in in conse- quence of the loss of blood. As a general rule the above-mentioned remedies will be found sufficient; in particular cases one of the following remedies may have to be chosen: Conium maculatum, Acidum muriaticum and sulfuricum, Arnica, Ferrum and Ipecacuanha; the last-mentioned especially in the case of little children. If the nose-bleed has become habitual, we should try to extirpate the disposition. If constitutional symptoms are present, we have to proceed against these; if the bleeding is an isolated symptom, Epistaxis, Bleeding at the Nose. 271 Sulphur, Lycopodium, Acidum nitricum, Ferrum have to be tried. With Hamamelis virginiana, which has been so universally recom- mended, wTe have never yet obtained the least result. The employment of medicines externally has two sides. The appli- cation of cold water to the nose may sometimes be very useful; on the other hand drawing up cold water in the nose will too readily prevent the necessary formation of thrombus. Hot hand-baths may be tried, but hot foot-baths are more hurtful than useful. In arte- rial hemorrhage we have often derived benefit from placing a piece of coarse filtering paper under the tongue. We do not know how to account for this result, but we do know that the result has been obtained and that the paper is frequently resorted to in domestic practice. F Tanacetum, our Tansy, often arrests epistaxis, when other reme- dies fail. II.] THIRD SECTION. Diseases of the Mouth, Fauces and (Esophagus. In no chapter of pathology does such a confusion of nomen- clature prevail, as among the diseases of the mouth and pharynx. There are scarcely two authors who use the same names for the same pathological processes occurring in these parts, and it takes considerable trouble to find one's way through this labyrinth. In homoeopathic literature the thing is still worse, for the reports of special cases are generally prefaced by an unmeaning diagnosis. What is the use of such reports ? They have no other use than to fill our periodicals. In spite of numerous and energetic remon- strances cases are reported in our Journals with the same superfici- ality as before. At the same time, as this is of very little use to ourselves, our opponents use this weak side in our literature as a point of attack, in order to prove the nothingness and erroneous- ness of our pretended cures, and in many cases we must admit that they are correct. The fact that reports of cures of the most im- portant pathological processes still continue to be dispatched in a few lines, shows a censurable ignoring of that which is most need- ful to us. A system of Therapeutics corresponding to the spirit of Homoeopathy, can only be built upon a large number of isolated observations. In the present condition of our School this end is still far from being attained, and the demand for an exhaustive system of Therapeutics is not founded in reason. In order to accomplish a work of this kind, all must co-operate, otherwise we cannot expect to succeed;-nor can we succeed unless all work to- gether according to the same plan. Who would undertake to pub- lish the results of our treatment of diseases of the skin, if one reports them under one name, and another under another ? The same criticism applies to diseases of the mouth and throat. We have premised these remarks in order to justify the apparently arbitrary classification we have adopted in the following para- graphs. We found it inconvenient to follow Hartmann's example; 272 Stomatitis. 273 his method of separating the affections of the same organ, presents many disadvantages, and the nomenclature he has adopted, is not at all positively acceptable to science. 1. Stomatitis. We comprehend under this name all the catarrhal affections of the mouth and fauces, from simple hypersemia to the formation of erosions, aphthae. The hypersemia of the mucous membrane of the mouth has, in most cases, neither a pathological, much less a therapeutic interest, and is, generally speaking, a mere symptom of some more general disease. In a few rare cases it is, to some extent, an idiopathic affection, shows a tendency to run a chronic course, and torments the patients to such a degree that it becomes necessary to proceed against it. In such cases we find certain places of the mucous membrane, most frequently the arch of the palate and the dorsum of the tongue, covered with spots of various sizes, of a uniform bright, and very seldom of a dark, redness, causing a feeling of in- tense burning, impeding mastication, and frequently disappearing very suddenly in order to break out again in some other part, and running altogether a very obstinate course. We have observed this not very frequent affection in two female patients, both of whom had cancer of the womb ; we have likewise noticed it in three ladies, members of the same family, who otherwise enjoyed perfect health, so that we could not help suspecting a certain degree of contagiousness. In these three persons the disease acted very capriciously ; sometimes the parts would remain perfectly sound for weeks, after which period the disease would break out again. There was no ptyalism, nor could the disease be traced to any definite cause; it was perfectly certain that syphilis and hydrargy- rosis were not the exciting causes. The more intense hypenemia of the mouth and fauces, which is very nearly allied to inflammation, is likewise rarely met with as an idiopathic affection, and is important in a practical point of view only in so far as ulcers are apt to form. It is always accom- panied by febrile motions. A catarrhal affection of the mouth and fauces accompanies the most diversified diseases of the digestive apparatus, as well as of the organs adjoining the mouth, and acquires importance not so much from its inherent dignity as from the fact that by it we deter- mine the condition of other organs. The coating of the tongue, for 274 Diseases of the Mouth, Fauces, and CEsophagus. instance, which depends upon the degree and form of stomatitis, is, undoubtedly, an important diagnostic sign. The main symptoms of catarrh of the mouth are painfulness, which is particularly prominent in the case of little children, altered taste, secretion of a greater or less quantity of tenacious mucus, attended with dimin- ished secretion of saliva, fetid smell from the mouth, sometimes frontal headache. If the fauces are prominently affected, we have the picture of angina catarrhalis, of which we shall treat more fully further on, in the chapter on Angina. The chronic form of catarrhal stomatitis is likewise characterized by an unusual secretion of mucus, altered taste and bad smell from the mouth, which is even perceptible to the patient. Of more importance is the chronic form of catarrh of the fauces, which is a source of great annoyance. It is generally met with among singers, smokers, drinkers, and is, like- wise, one of the remote consequences of syphilis. If the affection springs from the last-mentioned cause, it fills the patients with great anxiety, because they are in constant dread of a syphilitic affection in the mouth. It is generally confined to the posterior wall of the pharynx; the tonsils, however, are frequently involved in the mor- bid process. The affected part shows a somewhat deeper redness, is traversed with distinctly injected, varicose vessels, is more or less swollen, sometimes exhibiting granulations, and at times streaks of swelling, so that the mucous membrane seems divided in regular parallel puffy elevations, between and on top of which streaks of a very tenacious, yellow mucus are seen. This secretion of tenacious mucus is the greatest torture to the patients, for the affection is not painful of itself, but only becomes so when, by the constant efforts made to hawk up the mucus, the mucous membrane of the fauces becomes irritated. This trouble is always very obstinate. In one category with the catarrhal affection, we may range two processes which generally originate in it, and are of some interest to the physician, namely: the exfoliations and superficial ulcera- tions of the mucous membrane, and aphthae. The former pathological process, sometimes designated as stomati- tis or even diphtheritis, occurs both among children and adults ; its causes, however, are wrapped in obscurity. The disease begins with the symptoms of acute catarrh or hypersemia, sometimes with, but generally, without fever. Circumscribed spots are seen on the tongue or mucous lining of the cheeks, red, sensitive, and we soon discover that the epithelium at these spots is abraded. Sometimes the trou- ble does not progress any further, but generally the abraded spots Stomatitis. 275 change to ulcers of the size of split peas, and having an unclean asr pect; they heal very slowly. Some ptyalism and fetor from the mouth are generally present. This process which, if occurring but once, lasts from one to two weeks, frequently inclines to relapses, which succeed each other with more or less rapidity, and differ greatly as regards duration and intensity. At this point the dis- order becomes very obstinate. By aphthae we understand a peculiar vesicular disorganization of the buccal mucous lining. Aphthse generally set in with the symptoms of acute catarrh of the mouth, seldom without premoni- tory symptoms, having the appearance of small, watery or whitish vesicles on the lips, tongue or cheeks, surrounded by a narrow, red areola. They soon break, leaving small ulcerations of the epithe- lium, with a yellow or yellow-gray base, and a vividly red, sharply circumscribed border. With the outbreak of the vesicles, the fever often disappears, and only continues if the eruption, instead of breaking out all at once, makes its appearance in a successive series of crops. The single little ulcer usually heals very rapidly, and it is only under very unfavorable circumstances that more deeply- penetrating ulcerations and diphtheritic membranous formations take the place of the simple aphthae. Stomatitis proper, that is, inflammation of the mucous lining of the mouth, and pharyngitis, commences with the symptoms of a violent, more or less extensive hyperaemia, from which, however, it soon differs by the greater swelling of the more especially affected parts, particularly the gums. Every part of the mouth is very painful, not even the softest nourishment can be taken without in- tense pain; if infants are the victims of this disorder, they refuse the breast very obstinately. In the further course of the disease, the gums look dark-red, with whitish streaks, but, at any rate at the beginning, without any loss of substance. There is no increased secretion of mucus, but profuse ptyalism, with metallic taste and disagreeable odor of the breath. Fever is always present, some- times to a high degree, and attended with the most threatening cerebral symptoms. After a while the digestion becomes impaired, the deficient nutrition leads to a loss of strength, which is still increased by the fact that the sleep is usually very much disturbed. Tn the higher grades of the inflammation the salivary glands are always very much inflamed, swollen and painful. This disorder scarcely ever runs a rapid course; it lasts at least seven days, and may become very much protracted by secondary- 276 Diseases of the Mouth, Fauces, and CEsophagus. ulcerations and inflammation of the salivary glands. In this way the lives of little children may be placed in jeopardy, or by an ex- traordinary increase of the cerebral irritation and the appearance of convulsions. A number of observations in families where several children and adults were attacked by the disease, and where it could not be traced to any dietetic or hygienic irregularities, lead me to believe that it is contagious, if not in every case, at least in its most violent form It seems as though the more violent morbid processes of the buccal mucous membrane were, like other mucous membranes, possessed of a conditional contagiousness. The morbid processes of the buccal mucous membrane which we have enumerated so far, occur much more frequently and break out much more readily in the organisms of children than in those of adults. Whether this is owing to the greater delicacy of the infan- tile mucous membrane, or to deficient nutrition, is not very clear. Most diseases of this class, among infants at any rate, undeniably arise from the circumstance that the mouth is not kept sufficiently clean, whereas, on the other hand, stomatitis often attacks children where the utmost cleanliness is observed. One great cause of the disease is the pernicious habit of giving children the breast much too frequently; not only is the proper digestion interfered with by this pernicious habit, but the mouth cannot be kept clean when it is continually lined with milk. A mother cannot be too careful in this respect; a slight derangement in the functions of the mouth is sometimes sufficient to interfere with the assimilative process and to bring on a condition of things that must inevitably lead to the deterioration of the infantile organism. Treatment. We have placed these apparently different and yet in many respects homogeneous diseases together, because the remedies which they require are generally the same, and unneces- sary repetitions are thus avoided. Belladonna. What we have said of Belladonna, in speaking of its curative virtues in cerebral hypersemia, that they afford the most striking illustration of the truth of our therapeutic law, we apply these same remarks to the employment of Belladonna in the various inflammations of the mouth and fauces. Independently of the cir- cumstance that children are most liable to these inflammations and that Belladonna acts most powerfully in the infantile organism, certain abnormal changes in the buccal cavity constitute some of the constant, we might almost say characteristic, pathogenetic symptoms of this drug. It corresponds more particularly to stoma- Stomatitis. 277 titis proper at the commencement of the disease; likewise to the higher grades of acute catarrh. On the contrary, its usefulness in the exanthematic forms of the catarrhal process is very questionable, although we have frequently seemed to check the formation of aphthse by its timely use. The more marked the constitutional symptoms, the more specifically is Belladonna indicated. In chronic catarrh it wid probably never be of any use. Mercurius solubilis is as specific in certain forms of stomatitis as Belladonna is in others. Everybody knows how constantly Mer- cury causes stomatitis, and that this affection runs its course with certain definite phenomena. We would have described mercurial stomatitis when treating of the other forms of this disease, if we had not preferred, owing to the important position of Mercury as a remedial agent in stomatitis, postponing a description of the mer- curial form of this disorder until the opportunity of recommending Mercury as a remedial agent should naturally present itself. Mercurial stomatitis sets in with a more or less extensive hyperse- mia of the mucous lining of the mouth, which is generally most marked on the gums of the lower incisors. The simple engorge- ment is very speedily followed by swelling and sponginess of the gums. The gums are bright-red, separated from the teeth, bleed readily, and are extremely sensitive. The mucous lining of the lips and tongue swells likewise, the latter to such a degree that the tongue is pressed against the teeth, which make indentations in that organ. The posterior parts of the mouth are only attacked in the higher grades of mercurial action, more particularly the corner of the mucous membrane where the upper and lower jaws unite. The more violent the action of the poison, the more marked the swelling and the more intense the redness; the motion of the tongue and jaws is impeded not only because it is painful, but likewise because the tongue and corners of the jaws are very much swollen, so that the jaws can neither be completely closed nor separated. The saliva is secret el in larger quantity, and is mixed with a tenacious, very troublesome phlegm, and the odor of the breath is very foul; the taste is metallic, and is mixed with the same kind of foul taste that responds to the foul odor. During this whole process, sometimes at ^ts commencement and sometimes in its further course, there is a great disposition to the formation of ulcers. The ulcers generally break out first on the gums and on the lower lip. On the gums it is the free margin that is invaded, which frequently causes a con- siderable retraction of the gums. On the lips we observe flat, not 278 Diseases of the Mouth, Fauces, and CEsophagus. very large, spots, surrounded with red, sharply circumscribed bor ders, having a yellowish-white base, and being very sensitive, espe- cially when first breaking out. At a later period the tongue like- wise shows ulcerated places, mostly only at the margin, as if caused by the friction of the teeth, of irregular shape, and having an un- clean base. The most extensive and most destructive ulcerations take place in the corners of the jaws, whence they may spread to the pharynx and nose. The ulceration may even cause permanent adhesions of the jaws. In the preceding paragraph we have given a description of mer- curial stomatitis which does not contain all the symptoms of this disease. These, however, can be supplied from the Materia Medica. In completing our picture of the disease by these additional symp- toms, it is, of course, important to arrange every symptom in its right place. At all events, there is no medicine that furnishes such a complete image of the most violent form of stomatitis as Mercury; the resemblance is so great that without an exact investigation of the anamnestic circumstances of the case, we should, in many cases, be unable to decide whether the disease is mercurial or a simple form of stomatitis. What we have said renders all further indications for the use of Mercurius unnecessary; it is suited to every grade of the disorder, even to ulcerations of the mucous lining and to aphthse. It is not so certain whether its employment in chronic cases, especially in catarrh of the fauces, will prove equally advantageous. As we said before, this condition is frequently met with among individuals who had contracted syphilis and had been treated with Mercury ; in such cases Mercury should not be used. We have better medicines adapted to such individuals. Borax is not so much adapted to the aphthous form of stomatitis as it is said to be; it is frequently given without any result. On the other hand, it seems to be more effectual against thrush, of which we shall speak by and by. Of the other remedies which have been administered and recom- mended in this disease, the most important are: Nux vomica, Phos- phorus, Dulcamara, Acidum nitricum and Phosphoricum. These last- named remedies are, together with Belladonna, the best remedies for mercurial stomatitis. Acidum nitricum is particularly efficacious in this affection. In chronic stomatitis, the appropriate medicines have to be used for a tolerably long period. We recommend Acidum nitricum, lo- dium, Staphysagria, Kali bichromicum. Thrush, Aphthae of Infants. 279 Besides the remedies which we have mentioned, a number of other medicines may come into play, when the disease is not an idiopathic affection, but a sequel or complication of other derangements in the organism. Dietetic precautions are particularly important in the case of infants and children; the measures which have to be adopted in their case necessarily follow from what we have said in the para- graph concerning the etiology of stomatitis. A frequent cleansing of the mouth has a curative and palliative use, not only in the case of children, but likewise in that of adults. Warm water is the best means to cleanse the mouth with. The use of fat food has to be strictly forbidden; after eating fat food, every symptom of the disease becomes aggravated, without even any symptoms of catarrh of the stomach being present. 2. Thrush, Aphtha' of Infants. If we devote a special chapter to this affection it is in order to show the distinctive difference between it and the disorder which we have just now discussed, and with which thrush is generally considered identical. Thrush is a disease of the first months of infancy, or else becomes an affection of a threatening import in later years, during the last stages of very acute diseases, such as tuberculosis and typhus. It is characterized by the formation of fungi on the mucous lining of the mouth. Very rarely in perfectly healthy children, but mostly after the phenomena, which we have designated by the collective name of stomatitis, have existed for a longer or shorter period, scattered white spots make their appearance upon the mucous lining of the mouth, as if cream had been deposited there. They spread with great rapidity, sometimes grow in size quite considerably, and fin- ally may line the whole buccal cavity and extend even into the oesophagus and, under favorable circumstances, into the larynx. The spots consist of a tolerably firm, cheesy mass which is not easily detached and underneath which superficial ulcers form. At first they have a whitish look, which afterwards changes to a yellowish tint. In the course of their development the diges- tive functions become very deeply disturbed, which is undoubt- edly, in a measure, owing to the circumstance that the nutritive functions are very much interfered with by the disturbed diges- tion or nursing; but likewise to the passage of the fungi into 280 Diseases of the Mouth, Fauces, and CEsophagus. the intestinal canal. Under favorable circumstances the mucous membrane may be left perfectly sound after the superincumbent layers have become detached; on the other hand, if the exciting causes continue, the layers may constantly keep formin >• anew, and the disorder may thus become very much protracted. Of itself thrush is not very dangerous to children, except in cases where its outbreak indicates the near approach of death. The danger is' less in proportion as treatment almost always suc- ceeds in removing the morbid product and preventing its repro- duction. We know for certain that uncleanliness of the mouth is almost always the cause of thrush, although a vitiated, damp air likewise favors the outbreak of this disease, and sickly, weakly children are more liable to it than those whose constitu- tions are sound. In accordance with what we have said, the treatment requires, in the first place, that the mouths of the children should be washed after every nursing or feeding; moreover, if the children are brought up by the bottle, both they and their bottles have to be kept clean; if the children nurse, the nipple has to be care- fully washed before as well as after nursing, lest the thrush should be communicated to the mother. If possible the dwelling should not be neglected and always be properly ventilated. The mouth need never be cleansed with anything but water. The custom of some nurses to rub the mouth with -white sugar, is reprehen- sible, in so far as white sugar interferes with the digestion, and does not diminish the disposition of the particles of milk remain- ing in the mouth to become decomposed. It is of importance not to put the children to the breast too often, and not to let them hold their bottle in the mouth by the hour. That the formation of thrush is not alone owing to the above- mentioned causes, but very often to an inherent constitutional dis- position, is evident from the fact that thrush will sometimes per- sist, in spite of the most scrupulous cleanliness. For this reason we cannot always depend upon external treatment, and had better resort to internal treatment fiom the start. The chief remedy, which is sometimes sufficient without any other drug, is Borax, with which the diseased parts may be dusted by means of a camel's-hair pencil. The second trituration may be used. Beside Borax, Acidum sulphuricum and muriaticum have an excellent effect, the latter more particularly if there are distinct signs of decomposition of the blood. If thrush supervenes during the Angina Catarrhalis, Sore Throat. 281 presence of other morbid derangements of the mouth or the gen- eral organism, it is better to proceed against the primary affection exclusively, since the lesser grades of thrush are not, of them- selves, a threatening disorder, and the trouble is sufficiently attended to, if its further spread is prevented. 3. Angina. By this name we understand an inflammatory affection of the posterior parts of the mouth and pharynx. According as it con- sists only in a catarrhal irritation of the mucous lining or in actual inflammation of the parts, it is distinguished into catarrhal and tonsillary angina, which are two essentially distinct forms of the disease. a. Angina Catarrhalis^ Sore Throat. Angina catarrhalis is synonymous with acute catarrh of the pharynx and the posterior buccal cavity; but we have considered it in this chapter as something separate from the catarrhal pro- cess, because the treatment is rather identical with that of angina tonsillaris. The disease usually arises as independent of other affections, less frequently in the course of other catarrhal pro- cesses. Its most common cause is a cold; it likewise breaks out as a symptom of scarlatina, less frequently as a symptom of typhus, and sometimes it seems to spread even epidemically. Many individuals have from their youth a peculiar disposition to angina catarrhalis, without showing in their external appearance any signs of a peculiar irritability or weakness; on the contrary, they are persons of healthy-looking and vigorous constitutions. Symptoms, These vary according as children or adults are affected. In either case the disease usually breaks out suddenly without any premonitory symptoms. The children were quite cheerful the moment previous, and are suddenly attacked with all the symptoms of a very violent fever and marked cerebral congestion. The temperature of the skin is very high, the pulse disproportionately accelerated, that is in comparison with the trifling importance of the pathological process, the children want to lie down, and they sink into a soporous condition from which they are frequently roused by sudden exclamations or anxious fancies, which sometimes continue even after the patients are wide awake, so that they seem really delirious. All these symptoms are worse towards evening and attain their climax about mid- 282 Diseases of the Mouth, Fauces, and CEsophagus. night, after which they decrease in intensity. The cerebral symp- toms are so intense and, by their form and violence, cause so much anxiety, that it would seem at first sight as though the little patients were attacked with inflammation of the brain; there is but one certain diagnostic sign, which is the copious sweat that is scarcely ever wanting in this disease, and which always breaks out if the patients are covered ever so little, sometimes even if they are not covered at all, and which is never wanting if the patients are sleeping. The appearance of the tongue may be per- fectly natural; generally, however, it shows a thin whitish coat- ing at an early stage of the disease. The pupils are at times dilated, at times contracted. If the children are old enough to describe their morbid feelings, they complain much less frequently of pain in the throat than of pain in the pit of the stomach and in the ears. The pain in the latter may increase to a high de- gree of intensity, and may cause the patients to moan all the time. The apparently threatening intensity of these symptoms in the evening or at night bears no proportion to their striking de- crease in the morning, when the children are seen playing about very cheerfully, and perhaps, feeling a little more tired than usual. If left to itself, the disease does not terminate here, but soon after dinner a fever sets in which, however, d >es not attain the same degree of intensity that the fever had at the first outbreak, and ceases on the third, sometimes not till the seventh day. The appetite is very bad, the bowels constipated, thirst moderate. There is very frequently a peculiar odor from the mouth, which is not so much a foul smell, as rather like that of Phosphorus; and is always more marked in the more violent cases, perhaps because in such cases the stomach is generally very seriously in- volved. Angina catarrhalis is undoubtedly one of the most common causes of the cerebral congestions with which children are so often attacked, and is but too seldom recognized as their exciting cause. We are firmly convinced that many cases of supposed meningitis, where the remedial agent effected a complete cure in twelve hours, were nothing more than a catarrhal angina, on which account such an angina is of more practical importance to the physician than it would otherwise deserve. The above-mentioned diao-nostic siem has never left us in the lurch, and we deem it so much more im- portant as it is difficult, especially in the case of little children, to undertake an inspection of the throat. In children of six or seven Angina Catarrhalis, Sore Throat. 283 years, marked cerebral congestions do not usually accompany this form of angina, which runs the same course in their case as in the case of adults. Among older individuals angina catarrhalis generally sets in without any decided febrile symptoms; if they are present, they correspond to the febrile stage of every catarrhal fever, that is to say, they consist of alternate attacks of chills and heat, great lassi- tude, and rheumatic drawing and tearing in the extremities. At the same time they complain of disagreeable dryness in the throat, and painful deglutition, especially of the saliva, which is generally very tenacious, and secreted in small quantities. Drinking or swal- lowing solid food is generally much less painful. The fauces, especially at the arch of the palate, appear uniformly red, less fre- quently dark than bright red, the uvula is involved in the attack, looks swollen and elongated, so that its tip touches the root of the tongue, by which many patients are obliged to swallow all the time, and even causes an inclination to vomit. The tonsils are likewise somewhat swollen. If the disease is neglected at this first stage, or if the patient takes, perhaps, a second cold, the difficulty of swallowing increases a good deal, even to such an extent that the liquid returns by the nose, and the attempt to swallow solids causes actual paroxysms of suffocation. In such higher grades of the disease, even adults are affected with a very foul breath, the fever assumes a more contin- uous type, and violent headache, nausea and vomiturition are sel- dom wanting. On inspecting the mouth we find the whole of the posterior part of this organ dark red, sometimes we notice a few superficial ulcers; the mucous lining is very much swollen, and the tongue thickly coated. In children we have seldom an opportunity of watching these different degrees of the disease; on the contrary, they always feel sickest at the commencement of this pathological process. Amid a gradual decrease of all the symptoms, the patient generally recovers in seven to nine days, provided no untoward ac- cident interferes with the cure. Only in the lighter forms of the disease recovery may take place in three and even in two days. Angina catarrhalis is a prevailing affection of young people; however, where there is a constitutional disposition to this disease, its attacks continue to a late age; decreasing, however, in intensity. Before the first year it occurs less frequently, between the second and seventh it is one of the most common diseases. Whereas among young people it is very commonly an idiopathic disease: 284 Diseases of the Mouth, Fauces, and CEsophagus. among individuals between the ages of forty and fifty, on the con- trary, it is most generally a mere symptom of some general dis- order. The prognosis is always favorable, especially if the catarrhal angina is the only morbid symptom. Some profess to have seen death result from the convulsions caused by the cerebral hyperae- mia; in such cases, however, the cause of death has most likely been ascertained only superficially. Treatment. In its ordinary form there is no better remedy for this affection than Belladonna; when given every two or three hours, not too high, it hushes in twelve to twenty-four hours the most violent pains in the throat, removes the febrile and congestive symptoms, and leaves mostly only a little lassitude and an impaired appetite. This effect of Belladonna is almost constant among chil- dren, who are sometimes seen in the morning jumping about bright and cheerful, even if they seemed deathly sick the evening previous. In older persons, where the angina exists seldom as an idiopathic affection, Belladonna only removes the pain in the throat, whereas the other symptoms which correspond to the catarrhal process, remain unchanged, and require the remedies indicated by them. If Rummel (see Hartmann I., 418) tells us that in catarrhal angina Belladonna, and likewise Dulcamara^ act better after a dose of Mer- curius, we have to deny this statement, for the reason that we have seen Belladonna produce its favorable effects without a previous dose of Mercury. Hartmann quotes also Pulsatilla among the medicines belonging to this series. He gives the following symptoms as indicating this drug: the throat is dark-red, some of the vessels being engorged and very prominent; the general disturbance is not very violent, but violent earache and tearing-darting pains in the cervical mus- cles are generally present. As in the catarrh of the buccal cavity, so also in this disease may Mereurius be an appropriate remedy, especially if the tonsils are ulcerated, which is not unfrequently the case. Such anginas fre- quently assume an epidemic type of limited extent, in which case they become very obstinate. b. Angina Tonsillaris, Tonsillitis, Amygdalitis, Inflammation of the Tonsils. Quinsy. We designate by this name the parenchymatous inflammation of the throat, where the tonsils are generally most affected. Angina Tonsillaris, Tonsillitis, Amygdalitis, &c. 285 This affection is really met with only to the age of forty or fifty years, very seldom at a later period; most frequently between the years of seven and fifteen. Here too we find a disposition to pha- ryngeal inflammation, the same as in catarrhal angina, without any externally perceptible signs by which such a predisposition might be recognized; for, although we can always assert very positively that amygdalitis always arises from a cold, and we have, therefore, to believe in a certain predisposition to colds in those who are attacked with the disease, yet it is not clear why the same injurious influence makes some persons hoarse, causes a coryza in others, and an angina in a third party. What is certain is that persons who have to use their voice a good deal are more liable to an attack of angina, and are more generally affected with the chronic form. One attack of amygdalitis predisposes in a striking manner to relapses. Such diseases are more frequent in spring and fall than in summer and winter; their frequent appearance in the same locality at cer- tain periods, justifies the inference that this disorder is sometimes epidemic. Damp, gloomy, and badly-ventilated dwellings, are un- doubtedly very frequent causes of amygdalitis; we attend families in whom the children are very frequently attacked with this dis- ease, and where, in the absence of any other unfavorable circum- stances, the frequency of these attacks can only be accounted for by the unwholesomeness of their habitations. The peculiar relation of syphilis and Mercury to the tonsils, although as yet beyond the bounds of comprehension, is well known ; both these causes develop almost constantly a parenchymatous inflammation. In scarlatina we meet with amygdalitis as a characteristic symptom of the dis- ease ; in less frequent cases, amygdalitis likewise accompanies other exanthems, least frequently measles. Symptoms. Acute amygdalitis generally commences like all other acute affections, with a violent chill which is speedily fol- lowed by an unusual rise of temperature and increased frequency of the pulse, with violent headache and sometimes violent symptoms pf cerebral hypersemia; so that in the absence of local symptoms which have not yet made their appearance, we are easily led, espe- cially in the case of children, to suspect the invasion of some acute disease. Generally all the morbid symptoms which occur in catar- rhal angina make their appearance in this disease, only they are more continuous ; the fever, especially, is less remittent, on which account acute tonsillitis is more readily than catarrhal angina, con- founded with some violent acute disease, such as meningitis, even in 286 Diseases of the Mouth, Fauces, and CEsophagus. the case of adults. This is particularly owing to the fact that the local throat-symptoms do not make their appearance at once, but not till the fever has lasted already a whole day; in consequence of which we neglect to examine the throat at the onset of the disease. The throat looks generally redder, more so on one side than on the other. The vascular engorgement is very soon followed by a swell- ing of the tonsils; at first only one tonsil being affected, the other tonsil remaining either unaffected or being attacked subsequently to the former. The more rapidly the inflammatory swelling in- creases in intensity, and the higher the grade to which the inflam- mation is carried, the greater the danger of the inflammation ter- minating in suppuration. The swelling sometimes enlarges to such an enormous size that it is no longer possible to see the posterior wall of the pharynx. As the local symptoms increase, the general condition of the patient becomes more and more unfavorable; the fever remains at its height; deglutition is almost entirely impeded, and yet there is a constant urging to swallow. Speech becomes guttural, sometimes quite impossible ; the respiration is more or less impeded according as the posterior nares are involved in theinflam- matory process. During perfect rest the pain is not so great, but is excited or aggravated by every motion. The lassitude is continu- ally on the increase, partly owing to the violence of the fever, and partly to the deficient supply of solid, and more particularly of liquid, nourishment. The tongue is lined with a thick, tenacious phlegm, which is exceedingly troublesome to the patient, and seems to cause the urging to swallow, which frequently results in an incli- nation to vomit. The bowels are constipated, the urinary secretions diminished, and the urine is very thick. In this manner the disease continues about nine days, and sometimes increases to such a degree of intensity that the patient, the day previous to the opening of the abscess, seems to be like one near death. Very seldom the general condition improves during the formation of the pus. As soon as the abscess breaks, the threatening symptoms disappear almost im- mediately, so that it would seem as though the cerebral hypencmia, at least towards the end of the process, were in many cases conse- quent upon the impeded respiration, the same as in croup. That perfect recovery cannot take place at once, must be self-evident to any one who considers how much strength the body has lost by sleeplessness and deficient nourishment. Not in every case, and, as we shall show more particularly when speaking of the treatment of this disease, scarcely ever under Angina Tonsillaris, Tonsillitis, Amygdalitis, &c. 287 homoeopathic treatment, is the course of tonsillitis as acute as we have described. From the most violent fever, with sopor and deli- rium, to a scarcely perceptible disturbance of the general health, all sorts of degrees of constitutional malaise can be noticed, even though the local affection should be the same. If the inflammation is dis- persed, this result does not take place very rapidly ; on the contrary, in such a case the inflammation is very apt to pass into the chronic form, which is much more rarely met with when the inflammatory process terminates in suppuration. But even if the inflammation is dispersed, a febrile condition of the system, lassitude and loss of appetite, continue for some days, whereas the decrease in the inflam- matory symptoms ought to lead one to infer that the general well- being was much improved. The prognosis is almost always favor- able. Only in children the disorder may terminate fatally, either in consequence of cerebral difficulties, or by suffocation, or even, under certain unfavorable circumstances, by mortification of the parts. Among adults this danger need not be apprehended. Anginas initiating or accompanying exanthematic affections, have to be viewed from a different stand-point to that of idiopathic angina ; we shall treat of them in a subsequent chapter when speaking of exanthemata. The chronic form of amygdalitis arises in most cases out of the acute form, in consequence of the reabsorption of the inflammatory exudation only taking place partially, and the swelling of the tonsil remaining. It seems as though, independently of all constitutional predisposition, such remaining infiltrations superinduced a tendency to relapses. Every new attack increases the swelling, so that an hypertrophy may ensue, by which access to the pharynx may be almost entirely prevented. In the houses to which we have alluded, when speaking of the etiology of this disease, every child has such hypertrophied tonsils, even a girl of two years and a half; and every one of these children has twice a year a more or less violent attack of acute angina. After an abscess, hypertrophies of any size occur much less frequently. Without any previous acute attack, chronic amygdalitis may develop itself almost imperceptibly, in persons who have to exert their vocal organs a good deal, such as ministers, sing- ers, actors; but acute cases arising from such causes are not near as violent or important as cases arising from the previously mentioned causes. In chronic tonsillitis the swelling looks pale, with promi- nently engorged vascular ramifications. The surface is rugged, uneven, sometimes traversed by whitish cicatrized streaks. Some- 288 Diseases of the Mouth, Fauces, and (Esophagus. times the follicles are very much enlarged; they look like dark excavations between the protuberances on the tonsil, or like white points filled with a caseous substance, similar to acne. Ulcerations occur but rarely, and still less frequently for a long period. It is only exceptionally that the hypertrophy of the tonsils causes trouble to the patients. It is seldom that they experience any pain ; nor is the pain ever very acute, unless an acute attack has just taken place. The most common derangement is an altered tone of the voice, as in an acute attack, and a weakness of the vocal organs, in consequence of which the sufferer is easily attacked with hoarseness. In spite of the swelling, which is sometimes very large, the difficulty of swallowing is either trifling, or else there is no difficulty at all. Only in rare cases the patients complain of the swelling, as of a foreign body in the throat. It is a peculiar feature in such cases, that every cold brings on an acute attack of amygdali- tis, which is generally, however, confined to some fever with pain in the throat, and some difficulty of deglutition, with moderate red- ness of the tonsils. By neglecting such attacks, they may recur so often, and in such rapid succession, that the patient's health may remain disturbed for weeks. The hypertrophy of the tonsils is always a very obstinate diffi- culty, which it is so much more troublesome to remove, as the patients who feel tolerably well otherwise, do not feel disposed to take medicine. In an advanced age the swelling generally disap- pears spontaneously. Treatment. We are justified in regarding the treatment of angina faucium, no matter whether of the catarrhal or parenchy- matous type, as one of the most striking evidences of the superiority of the homoeopathic method of cure, for the reason that the disease precludes even the possibility of committing an error of diagnosis, and the affected organ is directly accessible to sight, so that we have it in our power to determine all changes with positive cer- tainty. Our successes in this direction cannot be slurred over on the score of a false diagnosis, and it may be well worth the trouble to briefly compare the different methods of treatment. It is scarcely to be believed, almost inconceivable, that legions of the most heroic remedies are advised and actually employed for a disorder which, although it may seem to run a threatening course, yet is really unimportant. One praises venesections, to be resorted to in rapid succession, as the best means of shortening a pathologi- cal disorder which reaches a spontaneous termination in nine days. Angina Tonsillaris, Tonsillitis, zAnygdalitis, &c. 289 One day is said to be gained by such treatment. To save one day, a dozen or more venesections are recommended, or at least a dozen leeches to the throat. From these violent means of cure, down to common ice-water, every thing is recommended, emetics, purga- tives, calomel, etc., local astringents, nitrate of silver, chlore, blis- ters, cold and warm fomentations. If this apparatus of violent remedies is not replete with the most absurd nonsense, it certainly shows an immense deal of unscrupulous recklessness, for the reason that every physician knows that the disease against which he plants such terrible batteries, beats a spontaneous retreat in a few days. Such heroic interference with the natural course of the disease, can- not, therefore, be justified on the score of necessity, owing to the dangerous character of this disorder, as in the case of internal organs, where an acute inflammation may readily terminate fatally. And after all, the result of such fearful therapeutic havoc is simply to abbreviate the course of the disease for one d ly, without how- ever, preventing suppuration, for all therapeutic manuals inform us that suppuration will almost regularly result. The expectant treat- ment has this advantage, that it does not impregnate the organism with deleterious medicinal substances; however, it likewise is una- ble to prevent suppuration. What now is the result of homoeopathic treatment? Under this treatment the formation of an abscess is a rare occurrence, espe- cially if the physician is called at the onset; even if suppuration takes place, he will scarcely ever have the patient under treatment nine days. This is a matter of common observation. Or is it more accident that every homoeopath is so fortunate ? Of course our op- ponents would much rather admit, if any thing at all, an unexam- pled good fortune than an efficacious treatment. An honest critic cannot help testifying to the great superiority of our treatment over any other in this disease. And with how few remedies do we achieve such success. Owing to our perfect knowledge of the posi- tive effects of our drugs in angina, a few only are sufficient to ena- ble us to effect a cure. As in other purely inflammatory affections of the mouth, so also in angina is Belladonna the chief remedy. We have mentioned this remedy so frequently in the gravest disorders, that anybody may infer from this circumstance the necessity of studying its phy- siological effects, even to their most delicate shades; for we do not possess a medicine that admits of a more diversified application. In angina tonsillaris Belladonna is only suitable at the commence- 290 Diseases of the Mouth, Fauces, and CEsophagus. ment of the disease, and in a form of angina which can scarcely be distinguished from angina catarrhalis. In general, however, it is scarcely possible in practice to establish a strict difference between these two forms of angina, nor is this essential to successful treat- ment. The darker the redness of the fauces, the more marked a bluish tint, the more considerable the inflammatory swelling, the less is Belladonna suitable; and even the presence of cerebral symp- toms would no longer justify its use. The presence of such symp- toms might tempt us to continue the exhibition of Belladonna, for the reason that we attach more importance to the congestive symp- toms than they really merit. In many cases Belladonna will suffice to control the disease, and prevent suppuration; this result ought to be obtained, however, in forty-eight hours at the longest, other- wise we cannot depend upon it. In other cases the febrile symp- toms disappear, but the tonsils remain red and swollen; in such cases the continued use of Belladonna would only involve a loss of time, for we should miss the favorable moment of preventing exu- dation. In the acute paroxysms of the chronic form, Belladonna removes with certainty the pain and the vascular engorgement, and in milder attacks suffices to restore the tonsils to their former con- dition. In view of the certainty with which we can cure an angina, in a comparatively short period, it is to be regretted that a physi- cian is not called to such a case at the very commencement of the attack, when the suitable period for the efficient exhibition of Bel- ladonna is not yet passed. Persons who are liable to attacks of amygdalitis, should be recommended to keep a vial of the proper medicine on hand, with a view of using it as soon as they begin to experience the symptoms of the trouble. Mercurius will rarely be suitable at the onset of the disease, unless it should be accompanied by violent catarrh of the buccal cavity, or originate in it. Usually, however, the physician is not called till the inflammatory swelling has reached a higher degree, in which case Mercurius is generally indicated. The more particular phe- nomena which indicate this remedy, are: The whole of the fauces have a deep-red or a bluish-red tint, more particularly the tonsils, which are darker than any other part, and usually show small ulcers, with pseudo-membranous exudations. The saliva is very tenacious and slimy, obliges the patient to swallow frequently, and the buccal cavity exhibits the symptoms of a highly developed catarrh, as we have described it in the chapter on stomatitis. The breath has a peculiar foul odor. The pains are generally less than Angina Tonsillaris, Tonsillitis, Amygdalitis, &c. 291 when Belladonna is indicated, but the general health is worse. All those symptoms are present, of which we can say, with positive cer- tainty, that they precede suppuration. Generally, however, unless the process is too far advanced, we succeed in preventing the forma- tion of an abscess. The most suitable preparation of Mercurius is the Mercurius solubilis in one of the lower triturations, frequently repeated. It should not be given up too soon if no striking im- provement sets in all at once, or the disease seems to increase in intensity, for not unfrequently the symptoms threatening suppura- tion recede, although this result seemed unavoidable. Hepar sulphuris calcareum is the most important remedy next to Mercurius; that is to say Hepar may be given when an abscess is evidently on the point of forming and we simply desire to hasten the suppurative process and the breaking of the abscess. The ab- scess is generally seen in one tonsil as a roundish prominence reach- ing beyond the swelling, having sometimes a dark and sometimes a lighter color. Sometimes, however, it is impossible to determine in the misshapen flabby swelling formed by the tonsils, the exact ppot of the abscess, which not unfrequently is located entirely on the side of the pharynx. Sometimes there are several abscesses, each abscess being small. In this case the morbid symptoms con- tinue for a longer period, because the abscesses discharge only little by little. That Hepar exerts an influence over the suppurative process and the emptying of the abscess, is evident from the fact that under its use the disease scarcely ever lasts eight days which is the common duration under any other treatment. Beside these three remedies, which will be found sufficient in all ordinary cases of amygdalitis, we have a few other medicines which are indicated by special symptoms and which we dare not pass over. Apis mellifica has more recently been warmly praised for amygda- litis; we confess we are not one of the admirers of Apis in this dis- ease, where we are yet to witness the first unequivocal effect from this agent. Besides the symptoms of Apis, which might possibly be twisted into indications for its use in angina tonsillaris, are not at all characteristically prominent in the American provings, more particularly if we separate the clinical effects which are taken from reports of cures. According to the simple physiological symptoms, Apis is better indicated in simple angina catarrhalis, than in the parenchymatous form. Why should we use such a vaguely defined drug where so many characteristic remedies are at our disposal ? 292 Diseases of the Mouth, Fauces, and CEsophagus. Lachesis deserves attention in the few cases where the fauces ex- hibit a livid redness, the inflammation has consequently reached a very high grade of intensity and gangrene seems to threaten. When this condition prevails, the constitutional equilibrium is very much disturbed: the respiration is labored, speech is impossible, the cerebral symptoms very marked. The internal swelling is associated with considerable swelling of the outer neck. The face has a very strikingly sick expression, and, instead of a vivid red- ness, exhibits a yellowish-gray pallor. This form is more frequently met with as an accompaniment of exanthematous fevers than in idiopathic angina. For Ignatia amara we transcribe Hartmann's own indications (I., 419): " The following symptoms of angina are characteristic of Ignatia, as has already been stated by Hahnemann in his remarks on this drug: stinging in the throat between the acts of degluti- tion ; sensation when swallowing as if the patient were swallowing over a bone, with a rolling sound; sensation of a plug or tumor in the throat, only between the acts of deglutition. Ignatia will never prove useful if the stinging is only felt during deglutition, but very certainly when the stinging is felt between the acts of deglutition, or when it passes off by continuing the act of swallowing; of course the other symptoms must likewise correspond to Ignatia. On look- ing at the buccal cavity the fauces look inflamed and red, the ton- sils are swollen and inflamed, covered with small ulcers. Another kind of angina which likewise yields to Ignatia, consists in a pain- ful soreness of the throat, which is only felt during deglutition; or in the sensation when swallowing as if a tumor had formed in the throat which hurts when swallowing. The sensation of a swelling in the throat, with painful soreness during deglutition, is therefore a chief criterium for the use of Ignatia." From these indications we infer that Ignatia must be particularly suitable for the acute paroxysms of chronic amygdalitis, which run their course without reaching a high degree of intensity and without showing any dis- position to suppurate. In the common form of amygdalitis, Bryonia alba will scarcely ever or perhaps never be suitable, but may be useful in cases where the tonsils are not very much inflamed, and where the cellular tis- sue of the throat is invaded, causing apprehensions of internal as well as external suppuration. Such forms generally occur in lim- ited epidemics, they run a very protracted course and involve the whole organism by causing a marked feeling of sickness. Angina Tonsillaris, Tonsillitis, A'nygdalitis, &c. 293 Aconite requires to be mentioned in a few words. It is frequently used at the commencement of angina, more, however, to moderate the fever than to counteract the local process, where it does not seem to be of much use. To persevere in the use of Aconite beyond this point, would imply a loss of precious time, in consequence of which the period when Belladonna manifests such striking effects, slips from us. Chronic amygdalitis is more or less easily controlled according to the time it has lasted, and to the character of the swelling. If we have to deal with a first attack of ano-ina where the exuded matter had not been completely reabsorbed, Sulphur is most usually the most appropriate remedy to promote absorption. If the tonsils have become entirely hypertrophied, we generally require a good deal of time to change this condition; moreover, every new acute attack may totally annihilate the advantages we have gained. The principal remedies in such cases are: Iodine, Baryta carbonica and Calc irea ; of course they have to be continued for a long time and in the higher attenuations. Where the swellino; of the organs is caused by the patient's mode of living and by excessive use of the throat, medicines will prove totally ineffectual, as long as the causes continue; in such cases, if the swollen tonsils really interfere with speech, they have to be extirpated with the knife. As regards other particulars connected with the treatment of acute amygdalitis, it seems scarcely necessary to allude to them. The patients being unable to swallow, nothing need be said about diet. The best gargle is tepid water, which is abundantly sufficient to clear the mouth of the troublesome phlegm as far as possible; generally the patients are unable to introduce a fluid into the mouth, much less into the pharynx, far enough to enable it to exert any salu- tary effect. Cold applications to the neck are much more hurtful than useful, even if they are continued for a long time. Usually the skin remains very active, and the patient perspires profusely; hence why should such applications be resorted to "I Where sup- puration cannot be prevented, it may of course be hastened by warm poultices. Opening the abscess with a bistoury is much more easily said than done; the patients being scarcely ever able to open their mouth sufficiently to admit a view of the parts We will conclude this chapter with a remark, which every home- opathic practitioner has undoubtedly been able to verify in his own practice, namely, that after the homeopathic treatment of an- gina, relapses are much less frequent than after any other treatment, 294 Diseases of the Mouth, Fauces, and CEsophagus. and that even the disposition to relapses seems to become extinct. This result strikes the patient much more forcibly than the phy- sician who apprehends the reason of this phenomenon, while it is of the utmost consequence to one who had been in the habit of passing through an attack of angina every spring and autumn. A similar result prevails with other affections where relapses occur quite frequently, particularly with erysipelas. [4. Retropharyngeal Abscess. Kafka has the following concise notice of this abscess: It is seated in the connective tissue between the pharynx and the anterior side of the vertebral column. An accumulation of pus on the posterior wall of the pharynx forms a swelling, which, by encroaching upon the pharyngeal space, narrows or totally closes the pharynx. The abscess either perforates the wall of the pharynx or gravi- tates downwards, and sometimes finds an outlet into the oesophagus or the thoracic cavity. Etiology. This abscess either occurs spontaneously from some unknown cause, under the form of a phlegmonous inflammation, or it is the result of a scrofulous or tuberculous, and in some cases even of a syphilitic, inflammation of the vertebrae; one or more verte- brae being swollen and painful, and causing stifl'ness or curvature of the neck, in consequence of a displacement of the spinous processes. This disease sometimes occurs as a secondary morbid process during the course of typhus, puerperal fever, pyaemia, etc. Symptoms. During the course of phlegmonous inflammation of the throat, without any simultaneously existing affection of the cervical vertebrae, febrile motions set in, which are sometimes very intense and attended with rather severe difficulties of swallowing. Gradually a swelling is seen on the posterior wall of the pharynx, bulging more and more from behind forwards, and showing signs of fluctuations. If the swelling becomes considerable, the velum and uvula are pressed forward more and more; if the swelling is seated further down, the larynx and the os hyoides are pressed for- ward, and if seated on one side or the other, it may be discovered at the angle of the lower jaw. The larger the swelling, the greater the difficulty of swallowing and breathing, the speech is altered, there is a hoarse cough, and the hearing is impaired. Little chil- dren distort their features when drinking or nursing, they cough some, or the liquids return again by the mouth and nose. If the Retropharyngeal Abscess. 295 pharynx is closed by the abscess, the breathing becomes extremely troublesome, the patients become cyanotic, bloated in the face, the eyes protrude from their sockets, the carotids pulsate violently, and there is danger of sudden suffocation. If the abscess is occasioned by some disease of the cervical verte- bra, they are generally very sensitive, swollen and displaced, the neck is stiff, the cervical muscles are in a state of tension, and the patients incline to hold their necks to one side. In either case, a careful examination of the neck, both on the inner and outer sides, is indispensable. Course, Terminations, Prognosis. A phlegmonous inflam- mation always runs an acute course. The retropharyngeal abscess, occasioned by a disease of the cervical vertebra, runs a chronic course, and sometimes remains hidden for a long time. For this reason, if children find it difficult to swallow, their necks are stiff, and they incline to hold their heads to one side, it is advisable to institute a careful examination of these parts. The secondary retropharyngeal abscess has the same symptoms as the phlegmonous form, except that many of the symptoms are modified by the character of the primary disease. These abscesses become dangerous by the circumstance that they may break dur- ing sleep or a state of partial unconsciousness, and cause danger of suffocation. In the phlegmonous and secondary form, the abscess always dis- charges either into the pharynx or the oesophagus. In spondylarthrocace the pus gravitates downwards into the lar- ynx or the thoracic cavity; in either case the result is attacks of suffocation or fatal inflammation, or else the suppuration continues and causes caries of the vertebra. In the phlegmonous form, the prognosis is favorable. If the cer- vical vertebra are inflamed and pyemic absces es occur, the prog- nosis is unfavorable. Treatment. The phlegmonous form requires the same treat- ment as acute quinsy. If fluctuation is perceived, the abscess should at once be opened; this will afford great relief to the patient, and obviate the danger of suffocation, or of a burrowing of the pus downwards. If the v rtebra are inflamed, the speedy lancing of the abscess may prevent caries. To restore the vertebra to their normal condition, we give Phos- phorus 6 to 30, or Natrum, mur. 6 to 30. If caries is present, we give 296 Diseases of the Mouth, Fauces, and CEsophagus. Silicea 6 to 30, or Asafadida 3 to 6. Country air and a strengthen- ing diet will help to mend the constitution. To prevent suffocation during sleep, in the case of little children, or while they are lying in a state of unconsciousness, it is of the utmost importance that the abscess should be opened as soon as its condition will admit of it. II.] Diphtheritic, Diphtheria. The diphtheritic process on the lining membrane of the mouth and fauces is in many respects enveloped in obscurity, whence the great confusion prevailing in its description, and consequently in its nomenclature. Small differences in the totality of the symptoms, or in the course or complications of the disease, have been taken advantage of to establish new species, without any practical advan- tage ; for the study of the pathological alterations characterizing this class of diseases, is rendered very much more difficult by such efforts at systemization. This work being designed as a guide in Therapeutics, we have kept aloof from all minute pathological dis- tinctions, and have ranged these allied processes under the name of diphtheritis, by which we mean all those processes in consequence of which exudations take place upon the lining membrane of the mouth and pharynx, without caring whether they are simply super- imposed upon the mucous lining, or constitute alterations of its tissue. Hence we mean all the different processes to which a vari- ety of names have been applied, such as: stomacace, croup of the mucous lining of the mouth and fauces, angina maligna or gan- graenosa, or pseudo-membranosa, fegar, garotillo, diphtheria epi- demica, etc. Such a comprehensive arrangement in one series and under one name has this great advantage: that, in the therapeutic chapter, many useless repetitions can be avoided, since the same remedies have to be mentioned for the different forms of the disease. The formation of membranous exudations upon the lining mem- brane of the mouth, is a very common occurrence, and may either be without any importance or entail the worst consequences. This prognostic can readily be determined by the character of the causes upon which the exudations depend, on which account the etiology of the disease is of the highest importance. In simple inflamma- tion of the mucous lining, the formation of pseudo-membranes con- stitutes an unimportant complication; it does not even at all times indicate a remarkably high degree of the inflammatory process. Diphtheritis, Diphtheria. 297 Membranous layers are likewise observed when the tonsils are very much inflamed. As a somewhat idiopathic affection, this patholo- gical process is seen in croup, where it spreads from the larynx to the fauces under conditions of which we are ignorant, but which seem to depend upon epidemic causes. It seems, moreover, as if there existed some peculiar predisposition for diphtheritic exuda- tions, and as if this predisposition were founded in a peculiar deli- cacy of the mucous lining, or in such general diseases as generally predispose to abnormal processes of exudation, particularly scrofu- losis and tuberculosis. The latter supposition is confirmed by the fact that unwholesome dwellings, deficient food, vitiated air, un- doubtedly occasion diphtheritis. Lastly, the disease is the result of epidemic influences; but even under these circumstances, attacks, more particularly, individuals who are exposed to the above-men- tioned obnoxious causes. The epidemic form is most likely conta- gious. Peculiar forms of the diphtheritic process are likewise met with in various exanthematic diseases, more particularly scarlatina, and in several derangements depending upon constitutional poison- ing, but we omit them in this place because special mention will be made of them in subsequent chapters. Symptoms and Course. In drawing a picture of the disease, it matters a great deal whether the pseudo-membranous process appears as ah idiopathic or a secondary disorder. In the latter case we suddenly find in the course of other diseases, upon circumscribed spots of the lining membrane, a whitish layer which rapidly thick- ens, and proves to be a firmly-adhering membrane. This membrane is either detached at an early period, while the affection which causes it decreases at the same time, in which case a mucous mem- brane is discovered in its place, which is slightly reddened, disposed to bleed, or sometimes, but less frequently, presents a normal appear- ance ; or else the membrane, favored by circumstances adapted to its growth, increases in thickness, becomes discolored, of a grayish- yellow hue, and shows a tendency to become decomposed, and to engender, upon the mucous lining, ulcers which generally remain flat, and only lead to considerable ulcerations when favored by cir- cumstances antagonistic to the patient. These phenomena have been generalized under the name of pharyngeal croup. This desig- nation is, in so far proper as the croupous process upon the mucous membrane of the larynx, is likewise without any tendency to cause more penetrating ulcerations. In opposition to this morbid process, there is a form of diphtheritis which attacks the mucous membrane 298 Diseases of the Mouth, Fauces, and CEsopnagus. in its whole thickness, and is characterized by a constant tendency to destroy it. This diphtheritis, properly so-called, has of late years made its appearance as an epidemic in England and America, and has likewise broken out in the north of Germany with such a fear- ful violence that it has become the terror of both physicians and the public. English and American physicians describe this epidemic form of diphtheritis under the name of diphtheria. The disease generally commences with unimportant febrile symp- toms, and most commonly without any local appearances. Only in a few cases we observe symptoms of a not very intense inflamma- tion of the tonsils. Hence the physician does not always have a chance to observe the course of the disease from the commencement, because neither the patient nor his family are specially disturbed by the morbid phenomena. At first there is slight redness of the fauces, the vessels in one or more places being considerably injected. It is here that, in a few hours only, we discover the. first traces of exudation. At the same time the redness increases considerably, without, however, spreading to the anterior portions of the mouth. One or more snow-white membranous patches seem to be laid loosely upon a deep-red, or even bluish-red; or violet base ; they have alto- gether the appearance of a layer of cream spread upon the mucous membrane. As yet the constitutional equilibrium is not very much disturbed; the fever is slight, the pulse not very much'accelerated, the skin not very dry, a slight perspiration even breaks out from time to time. Deglutition is not very much impeded, the pains at the affected part of the throat not very acute. Only a general las- situde shows that the local appearances have a much deeper signifi- cance than one would suppose. The affection may thus remain unchanged for the first seven days, only the exudation at most invades a few other parts in addition to the former. In the most fortunate cases the membranes become detached at the end of this period, leaving superficial ulcers with shaggy borders, which heal rapidly and leave the patient restored to perfect health. If the disease does not take this favorable turn, it then assumes a much more formidable form in the second week. The formation of the membranes keeps spreading; they assume a rather dingy- blackish hue. The constitutional disturbance is more marked, the pulse remaining about the same. The prostration increases, yet the patients, even in violent cases, are not always compelled to lie down. Sleep is generally very much disturbed. The pains in the throat are intense, deglutition and speech are very much impeded, the patients Diphtheritis, Diphtheria. 299 often complain of violent earache, which, however, is not constant, but comes in paroxysms. The alvine evacuations are normal, only diminished owing to the lessened quantity of nourishment. This stage likewise lasts a week, and may be followed by recovery ; the ulcerative process, however, is much more penetrating than at the end of the first week. The further progress of the disease in the third week consists in an increase of the constitutional phenomena, but principally in gan- grenous destruction of the affected parts in the fauces. There arise deep ulcers of various sizes, with a gray or blackish bottom, with shaggy borders, and havino- a horrid smell. The loss of substance may be very considerable. The ptyalism is copious and very fetid; the patients look very ill, although they may yet be capable of walk- ing about. The termination in recovery is a very slow process, in so far at least as recovery depends upon the healing of the ulcerated surfaces; for the constitutional symptoms already show a marked improvement, at a period when the ulcers still retain their malignant appearance. The return of the appetite is the most favorable symp- tom, likewise the decrease of the ptyalism and the fetor from the mouth. It takes several weeks before the ulcerated surfaces are completely healed. It is peculiar to this disease that, as the local symptoms disappear, a more or less universal paralysis sets in. This is not always the case, but very frequently, and it is inexplicable why, as in a case that came under our observation, an apparently trivial, local affection of the throat should be succeeded by paral- ysis of the arms, and an almost complete paralysis of the lower extremities. This paralysis disappeared very suddenly, after having lasted five weeks, subsequently to a slight attack of catarrhal angina. In the previous chapter we have furnished the description of an attack of moderate violence, and running a favorable, although very protracted course. This case may be regarded as a fair illus- tration of most cases of diphtheria. Under certain circumstances, however, of which mention will be made hereafter, the disease offers a very different group of symptoms, which the importance of the subject demands should be faithfully portrayed by us. In the more violent cases the preliminary stage is very often quite short. The disease sometimes invades the organism so rap- idly, and with such extraordinary intensity, that the patient is at once attacked with excessive prostration, a small, filiform pulse, cadaverous pallor, and death takes place as soon as the membranes 300 Diseases of the Mouth, Fauces, and CEsophagus. begin to form. In other cases the affection begins quite suddenly, with vomiting and an intense angina, violent fever, somnolence, stiffness and external swelling of the neck, and extraordinary fre- quency of the pulse. The speech is peculiarly altered, on account of the more difficult mobility of the tongue. The vomiting consists of a thin, yellowish liquid, and is very often accompanied by a sim- ilar diarrhoea. The exudation of the membranes takes place very rapidly, spreading almost simultaneously over the entire buccal and pharyngeal cavity as far as the nose. The swelling of the subjacent parts, and of the external neck, becomes quite considerable, so that it extends like a thick pad around the lower jaw At the same time the febrile symptoms are not very considerable, even if the fever had run ever so high at the commencement of the outbreak, but the strength decreases very rapidly. As a rule the urine now becomes more or less albuminous, and generally remains so during the whole course of the disease. When the attacks are so violent, the exudative process most commonly spreads to the respiratory organs, where it occasions all the symptoms of true croup, super- induces at an early period suffocative paroxysms and coma, and usually terminates fatally, death being frequently preceded by very violent vomiting. Very seldom consciousness remains undisturbed until the moment of death. After such violent attacks death gen- erally ensues in two to four days, so that a gangrenous decomposi- tion of the membranes and a more deeply penetrating ulcerative process is not readily observed in such cases. In the formerly de- scribed, more protracted cases, the ulcerative process is usually fully developed, and amenable to observation. In certain conditions of the system, the affection runs a chronic course, the membranous exudation being frequently detached and renewed again, and at the same time remaining confined within definite localities. In this way the strength of the patient vanishes by degrees, and death is almost always the end of this chronic form of the disease. If the constitution of the patient is, at the outset, thoroughly tainted with scrofulosis, tuberculosis, and other dyscrasias, the membranes evince from the commencement an extraordinary ten- dency to decomposition, and death results at an early period, although the extent and intensity of the disease may not yet seem very far advanced. Unfavorable external circumstances, such as damp dwellings, a crowd of persons living together in small rooms, insufficiency of fresh air, likewise exert a deleterious influence, on Diphtheritis, Diphtheria. 301 which account the worst forms of the disease are more frequently met with among the lower than among the higher classes. The causes of diphtheria, if we except the previously mentioned etiological influences, are enveloped in obscurity. The epidemic propagation of the disease, and its rapid spread in the organism, necessarily lead to the idea of a peculiar virus, whether of a vege- table or animal nature, is not certain. The contagious character of the disease, which no one will be bold enough to dispute, favors the assumption of a specific virus. Considering more particularly the peculiarities of the disease, we are compelled to adopt a general toxication of the blood, for the local process cannot possibly induce such a sudden and extraordinary waste of strength, without any corresponding increase of the secretions; moreover, as we stated above, a great many patients die at the very beginning of the exu- dative process. The supposition that diphtheria represents a masked scarlatina, is mostly derived from the circumstance that the fauces are mainly invaded by the diphtheritic process, and from its resemblance to the malignant angina of scarlet fever. The course of diphtheria, how- ever, is very different; moreover, we do not find in diphtheria, as a rule at least, the unusually high elevation of temperature, and the frequency of pulse, which are always present in scarlatina. Judging by all these various circumstances, diphtheritic angina is a plague whose behavior is, in all respects, similar to that of acute exanthemata and Asiatic cholera. Our first correct reports concerning the disease, date as far back as forty years ago, when the disease was prevalent in France. In England the spread of the disease, until the year 1856, was not very considerable, since which period, however, this plague has overrun the country with extra- ordinary rapidity, has migrated to Holland, thence in 1863 to the North of Germany, where it overran Ostfriesland, and likewise in- fected various localities in the interior of the country with its epi- demic taint. Peculiar states of the atmosphere and conditions of the soil do not seem to be necessary to further the spread of this epidemic; otherwise how could we account for the fact that Nor- derney on the North sea, Aurich in Ostfriesland, Seesen on the Hartz, and Muender in the Deister mountains, were visited at the same time. Except Aurich, the above-mentioned localities are the most salubrious in the country. In the city of Hanover we have, so far, only had isolated cases, almost all of which occurred in c pa- lent families. 302 Diseases of the Mouth, Fauces, and CEsophagus. We have to point out in a few words the difference between croup and diphtheria; so far as treatment is concerned this differ- ence is of the utmost importance. In croup the membrane is ap- parently of the same character as in diphtheria. The assertion that in croup the exudation is fibrinous and in diphtheria albuminous, is certainly unsupported. But it is an essential characteristic of the diphtheritic exudation, to be constantly tending to a gangren- ous decomposition, and to involve the subjacent mucous membrane in the gangrenous process; which is never the case with croup. So far there can be no question of transition-forms between the two processes; where such transition-forms have been supposed to exist, the diagnosis, which, in isolated cases, can only be established with certainty in the further course of the malady, has undoubtedly been premature. Besides all this, the constitutional symptoms are op- posed to the croupy character of diphtheria, more particularly the extraordinary, unusually rapid prostration, which mostly terminates fatally, whereas in croup death is caused by the mechanical obstruc- tion of the respiration with its subsequent influences on the compo- sition of the blood. Lastly, croup is almost exclusively a disease of childhood, and has never yet been suspected of being a contagious disease; whereas diphtheria, though it prevails more especially among children, spares no age in particular, and is a plague whose contagiousness cannot well be denied. The prognosis of diphtheria is always doubtful, for the disease may terminate fatally, no matter what course it may take. If the disease sets in accompanied by symptoms of violent constitutional disturbance, the danger of a fatal termination is very great, since we may almost be sure of a more general spread of the poison. The more rapid the prostration, the more unfavorable the constitutional and domestic conditions of the patient, the more considerable the gangrenous disorganization, and the sooner it takes place, the less the chances of recovery. The extension of the diphtheritic process to the larynx and lungs is almost always fatal. Nor should the protracted and mild course of the disease superinduce a feeling of security, for even then a malignant aspect may supervene. One of the most threatening symptoms is an albuminous deposit in the urine, especially if it is very copious. As sequelae of the disease we notice, more particularly, symptoms of paralysis, which may affect the extremities, or the cervical mus- cles, or even the pharynx; and is very obstinate. Deafness and amaurosis have likewise been noticed as sequelae of diphtheria. Diphtheritis, Diphtheria. 303 The cicatrization of the ulcers not unfrequently causes impediments in swallowing, talking and masticating. An unusual constitutional debility, which does not correspond to the grade of intensity of the morbid symptoms, and has the appearance of a general paralysis, sometimes remains for months, even if the appetite is completely restored and the waste of tissue has been repaired. Owing to the shortness of time that has as yet been vouchsafed to practitioners, in observing the course of the disease and investi- gating its causes and nature, we have not yet been able to determine the remedies that hold a positive and specifically-homoeopathic re- lationship to the disease. For the present, at least, it seems an established fact, that the selection of remedial agents in this disease cannot be strictly conducted in accordance with the law of symp- tomatic similarity, for the reason that we are not yet in possession of any proving embodying a full counterpart of this pathological series. All we can do is to mention all the remedies that have been recommended for diphtheria, and leave it to time and more exten- sive observation to determine which of these remedies are in specific curative rapport with this disease. Notwithstanding this incompleteness of our curative resources, we can boldly assert that the results obtained under homoeopa- thic treatment, are far more satisfactory than those obtained by allopathic practitioners. Even if we are not as yet in possession of full and accurate statistical tables, yet we know to a certainty that in many epidemics at least fifty patients out of a hundred have died under allopathic treatment, whereas, under similar circum- stances, the homoeopaths only lost ten per cent. Before enumerating the different remedies, we cannot forbear subjecting a very common proceeding in this disease, we mean local cauterization, to a brief critical examination. In England this proceeding has been very generally resorted to, even by homoe- opathic physicians, together with the exhibition of other remedies, and is generally recommended as indispensable. Nobody seems to have derived any real benefit from it, and several weighty author- ities reject it as prejudicial. The greatest contradictions are more particularly met with among the different escharotics employed for the purpose of local cauterization. One holds to the exclusive use of the Nitrate of Silver, another rejects this entirely, and relates wonderful effects from Chlorate of Potash or the tincture of Muri- ate of Iron. It is difficult to obtain light in this confusion; at the same time it is fortunately not very important. We assume 304 Diseases of the Mouth, Fauces, and CEsophagus. a priori that cauterization, if not positively hurtful, is at least use- less and therefore an unnecessary torture. Diphtheria is not a local affection, but a constitutional disease, a characteristic symptom of which is the exudation in the fauces. Of what use can the destruc- tion of the local symptom possibly be, since the disease continues on its destructive course? With the same propriety Variola pus- tules might be cauterized. Even if these local cauterizations were of some advantage, which, however, will always be trifling, is it not unreasonable to inflict this torture upon patients who are mostly children? We could never make up our minds to adopt this kind of treatment, and can excuse our English colleagues, only on the ground that they were not yet fully acquainted with the proper remedies for this disease, and therefore sought refuge in this exceed- ingly deceitful species of polypharmacy. Moreover, our English colleagues have been in the habit of giving two remedies in alternation, and, by this proceeding, obscuring the specific action of each. Hence their observations only constitute a very scanty foundation for further therapeutic experiments. We call attention to this defect with all becoming emphasis. If the incompleteness of our drug-provings, and the consequent uncertainty of the therapeutic effects of some of our remedies, render the alter- nate exhibition of two drugs an excusable practice, yet results ob- tained by such means should not be given to the public, for the simple reason that they cannot be accepted as reliable testimony. Belladonna has a sphere assigned to it in diphtheria; it is only indicated when the disease sets in with severe febrile motions and marked inflammation of the tonsils. After exudation has com- menced, it is no longer in its place. Mercurius. The pathogenesis of this drug evidently points to it, from the commencement, as a remedy for diphtheria. The results of its employment have not, however, been very favorable. An accurate comparison of its pathogenetic effects with the symp- toms of the disease, shows that this could not well be otherwise. Mercury has not the extraordinary and rapid prostration of strength and the complete suppression of cutaneous activity. These are two important and significant symptoms. English physicians have been in the habit of using the stronger mercurial prepara- tions, particularly the Iodide of Mercury, much less frequently the Corrosive Sublimate. No particularly rapid success has ever been achieved by either of these agents, nor can we boast of better sue- Diphtheritis, Diphtheria. 305 cess in our own latitude. It sometimes seems as though, the employ- ment of these agents involved an useless waste of time. Kali bichromicum is generally given in alternation with the Iodide of Mercury by our English colleagues. The symptoms of this drug undoubtedly point to its use in diphtheria, and assign to it an important rank among the remedies for this disease. Striking- therapeutic results have not yet been obtained with it. The same remarks apply to Bromine, which is recommended by Black for the more malignant forms of diphtheria. This drug has a characteristic symptom relating to diphtheria, namely: great debility and nervous prostration, remaining for a long time after all other morbid symptoms have disappeared. We have already stated that this symptom is characteristic of diphtheria. According to Black, Kali bichromicum is more particularly suita- ble, if the exudation is composed of loosely-adhering shreds, Bro- mine being more adapted to firmly-adhering, tenacious membranes. We may inquire, however, to what extent these two indications differ one from the other, since the membranes usually adhere very firmly at the commencement, and afterwards become like loose shreds. Acidum muriaticum. Most observers praise this remedy more than any other. It is scarcely ever adapted to cases having a rapid and violent course, but so much more to cases without much fever, but with marked lassitude and weariness, and having the appearance of lentescent typhus. The dose should not be too weak ; a few drops of the first or second attenuation in distilled water may be given. Children are generally too young to employ a solution of this acid as a gargle. Besides, there may be very little advantage, in such a proceeding. The same circumstances which recommend Muriatic acid, likewise argue in favor of Phosphoric and Nitric acid. The local symptoms of diphtheria are certainly to be found, in an emi- nent degree, among the pathogenetic symptoms of Nitric acid, and we do not comprehend why the preference has been given to Muri- atic acid almost to the exclusion of the former. The rapid progress of gangrenous disorganization has generally been opposed by Arsenic, probably more with regard to the consti- tutional than to the local phenomena. Symptomatically this remedy is scarcely ever indicated, nor can the employment of Ammoniu/o carbonicum be accounted for, unless the cerebral symptoms which sometimes set in justify its use. Besides the medicines which we have named, we find the follow- 306 Diseases of the Mouth. Fauces, and CEsophagus. ing remedies mentioned as adapted to this disease: lodium, Capsi- cum, Argentum nitricum, Kali ehloricum, Kali bromatum, Creasotum. Iodine most likely owes its recommendation to the eminent services it renders in croup; but such a recommendation by analogy is, as we have already stated above, not advisable, since the two processes are essentially distinct. Creasotum has no symptom in its patho- logical series that points to diphtheria, and has probably been selected only on account of its efficacy against gangrenous disor- ganizations. Nor is Capsicum homoeopathic to this disease. In opposition to the somewhat contradictory observations fur- nished by our English colleagues, Baumann's notice, in No. 9 of Vol. 62, of the All. Hom. Zeit., deserves the most attentive considera- tion. In a series of cases he only gave one remedy from the com- mencement, and, according to his statement, he obtained by means of it marvellous results. This remedy was Apis mellifica. If his expe- rience should be confirmed in other epidemics, we would have made a valuable discovery; we would have obtained additional evidence that mere drug-symptoms do not constitute a criterium for the homoeopathicity of a drug. However, the recommendation of this agent emanates from V. Meyer, who has called attention to it in Vol. 59 of the Zeitung, (see page 48.) Baumann gave one drop of the fifteenth attenuation, every two hours, in a little water. We mention this circumstance for the benefit of those who may desire to imitate this experiment, which we trust will be confirmed by numerous trials. Independently of this last-mentioned remedy, the rest would stand in the following order: At the commencement, Belladonna. After the membrane is formed, Mercurius iodatus, and afterwards, Kali bichr. or Bromine. In case of severe gangrenous disorganizations, Arsenicum or Creasotum. If the disease progresses more slowly after the exhibition of Mercurius, one of the above-mentioned acids. In slight cases, Kali chloricum. For the subsequent debility China has so far proved the best remedy. .Regarding the patient's diet, we must take care to supply a suffi- cient quantity of nourishing food, nor need we hesitate to administer small quantities of wine and water. Fresh air and cleanliness are a matter of course; the proper means should likewise be used to prevent contagion. The best local means of cleanliness is fresh water, which cleanses without doing any hurt. The patients need not be confined to their beds, but they must not be permitted to make any exertion. Noma, Cancer Aquaticus. 307 Against the secondary diphtheritic, or rather croupous, affection of the buccal and pharyngeal cavities it is not necessary to institute a special medicinal proceeding. The primary affection will suggest the proper remedy in such a case. It is only in exceptional cases that the membranous exudation, owing to its copiousness, will have to be considered in the first place. If the diphtheritic process spreads to the larynx, we indeed ob- tain all the symptoms of croup, but it would be wrong to employ for this form of the disease, the same remedies that are generally used in the ordinary form of membranous croup. [American practitioners have used, with much success, the poke- weed, or Phytolacca decandra; the Permanganate of Potash, of which Professor Allen, of the Chicago Hahnemann College, has furnished a very thorough proving, has likewise been recommended. Lachesis is recommended by its admirers; some employ it in every stage of the disease; others only when symptoms of gangrene are beginning to set in ; others again rely upon it principally in diphtheritic croup. We have several special treatises on diphtheria, among which the following deserve honorable mention: Ludlam on Diphtheria, Chicago; Helmuth on Diphtheria, St. Louis; and Neidhard on Diphtheria, Philadelphia. II.] 6. Noma, Cancer Aquations. We designate with this name a peculiar gangrenous destruction of the soft parts of the cheeks and mouth. It occurs almost ex- clusively among children between the ages of two and ten years, and befalls adults more frequently than children at the breast. It attacks exclusively children of unsound constitutions, who live in want and are deprived of the necessary supply of pure air and wholesome nourishment, or are brought up amid the privations of orphan asylums and foundling houses. Noma, properly speaking, is always a secondary affection breaking out after measles, less fre- quently after some other very acute disease, such as typhus, vari- ola, intermittens, etc. Where it is described as an idiopathic affec- tion, the diagnosis may be regarded as uncertain. The disease is of rare occurrence in practice. Why it only attacks the soft parts of the mouth, has not as yet been satisfactorily accounted for. Hartmann compares this process to pustula maligna. The resem- blance between these two diseases is undoubtedly very great. Symptoms and Course, Without being accompanied by con- stitutional phenomena, there appears, during the period of convales- 308 Diseases of the Mouth, Fauces, and CEsophagus. cence after some acute affection, upon the mucous membrane of the cheek, an aphthous vesicle or whitish-red pimple upon a dark-red, hard base, or without any abnormal surroundings. There is no pain either with or without contact. Very soon the vesicle bursts, or the little pimple scatters, and in its place we discover a more or less deeply-penetrating ulcer, which is speedily covered with a scurf. With the formation of the ulcer, the phenomena in the surrounding parts become more marked; the hardness spreads, the cheek and afterwards the whole face and even the neck, become oedematous. This cedema occurs less frequently, previous to the breaking out of the vesicle. Very soon the ulcer assumes a livid discoloration, which is soon after imparted to the whole of the surrounding mucous membrane. This is transformed into a yellow-gray or blackish pulpous mass, which is sharply separated from the normal parts of the cheek. The gangrenous disorganization continues to spread so rapidly, that, in a few days, not only the cheek, but likewise the eyelids and the maxillary bones, even the integuments of the neck down to the breast, are destroyed. It sometimes only takes three days for this disorganization to reach its climax. The odor from the mouth is extremely fetid, even the saliva has a cadaverous smell. The gangrenous parts are partially covered with a scurf, or in some places they are dirty-looking sores of great depth, even per- forating the cheek, with shaggy borders without a sign of reaction. Hemorrhagic effusions are, generally speaking, of rare occurrence, for the reason that the vesse.s are attacked last. At the commence- ment of the disease, or even after it has reached a considerable height, the general health is not much disturbed. The children are more languid than usual, have some fever, less appetite, sunken features; but these changes do not by any means correspond to the importance of the local process. Not till the integuments have been reached by the gangrenous process, do the constitutional symptoms assume a threatening aspect. The languor increases to a comatose sopor, whereas the nights are very much disturbed by delirium. The temperature of the skin becomes depressed or irregular, the extremities being cool and the trunk very hot. The pulse continues to increase in frequency, becomes more and more feeble, the thirst is intense. Vomiting and diarrhoea are of less frequent occurrence; it is remarkable that the appetite sometimes remains unimpaired even until shortly before death; a sort of canine hunger even often takes possession of the patients. Death takes place amid signs of perfect collapse with sopor. If the disease shows a disposition to Noma, Cancer Aquaticus. 309 terminate in recovery, which may take place at any stage of its progress, although the chances of recovery lessen in proportion as the gangrenous destruction spreads over a larger surface, the healthy parts become surrounded with a more vivid redness, and a circumscribed inflammation results, within whose boundaries tbe gangrened patches become detached, leaving a healthy looking ulcer with tendency to granulation. The healing takes place slowly, according as the loss of substance is more or less extensive. The prognosis is generally very bad, the patients being mostly children with such impoverished constitutions that the reactive energies necessary to a cure are almost always wanting. Regarding the treatment of noma we have no past experience to appeal to. The disorder is of such rare occurrence, and, if it lias at all been treated homoepathically, the case has most likely resulted so disastrously, that a case of noma has not yet been reported in our publications. Hence we can only point out the remedies which it may be necessary to employ, if a case should occur in practice. Among the medicines whose pathogenesis is known to us, there is but one that answers to the two characteristic features of noma, the gangrenous destruction with painlessness-we mean Secale cor- nutum. This remedy has been warmly recommended by Hartmann; instead of transcribing the highly-wrought text of his remarks, we refer the reader to the oft-repeated descriptions of ergotism in our Materia Medica and toxicologies. Although Secale, in this dis- ease, seems to have shown a preference for the extremities in de- veloping its gangrenous effects, yet this is no reason why it should not likewise be applicable in noma, since such conclusions from analogy are perfectly proper. A careful comparison of the patho- genetic effects of Secale with the phenomena of noma shows various other accords between the two series of symptoms. Gangrene after Secale is consequent upon a very different constitutional disturb- ance which disappears as soon as the gangrene breaks out. During the existence and the further development of gangrene the general health is not correspondingly disturbed, but the pulse is feeble, small and frequent. Without pointing out any other special symp- tomatic similarities, all we can say is that, for the present at least, Secale is our only known remedy for noma. Amorm the other medicines that have been recommended for this o disease, or seem otherwise indicated, we are not acquainted with any that seems to correspond to the essential characteristics of noma. These medicines are: Arsenicum, Acidum muriaticum, lodium, Kali 310 Diseases of the Mouth, Fauces, and CEsophagus. hydriodicum, Mercurius sublimatus, Ilelleborus niger, Chlore, Carbo vegetables, Creasotum. Whereas various accessory symptoms point to Arsenic, yet it is counter-indicated by the circumstance that the gangrenous destruction of noma goes on without any signs of reac- tion, whereas the destruction of organic tissue, caused by Arsenic, is attended with the most violent and most painful general and local symptoms. Carbo vegetabilis is much more specifically indi- cated than Arsenic, since the absence of organic reaction is much more marked under Carbo than under Arsenic. However, is such a symptom, in the absence of all other characteristic indications, sufficient to determine the selection of a remedy? Creasotum is not homoeopathic to this disease; but other physicians report good effects from it in this disorder, and, in the absence of more specific remedies, it may, undoubtedly, be tried. Doctor Hasbach, in the "Organ for Therapeutics," vol. II, 1853, recommends it as a local remedy for the purpose of promoting or exciting the detaching of the gangrened parts ; he paints them with the Creasotum by means of a camel's hair pencil. Whether its internal use produces favor- able effects, will have to be decided by further trials. We must repeat the statement, which we have already made else- where, that cauterization is just as improper in noma as we have shown it to be in diphtheria. The affection is no local process, how then can it be removed by local means ? Moreover, the strength of the patient being already very much reduced, the effect of a deeply penetrating cauterization should not be esteemed too lightly. • In view of the etiological as well as the special pathological con- ditions of the patient, the diet should aim at supporting his de- pressed vitality. A little generous wine is often better than the most nourishing food, which the stomach may be too weak to bear. The fact that the patients, in spite of the fearful havoc they are un- dergoing, are often tormented by a most devouring hunger to the last, shows that the diet is a matter of the utmost importance. We need scarcely suggest the propriety of seeing to the utmost cleanli- ness of the patient as well as the sick-room ; the ichorous discharge spreads such a pestiferous stench through the room, that ventilation and deodorizing agents have to be resorted to to keep the room sweet. The mouth should likewise be washed out as often as may be necessary, lest the children should swallow the ichor and the gangrened patches. Glossitis, Inflammation of the Tongue. 311 7. Glossitis, Inflammation of the Tongue. Although acute glossitis is of tolerably rare occurrence, this can- not be said of the chronic form of this disease, which has, moreover, a peculiar importance on account of certain diagnostic errors con- nected with it. The causes of acute glossitis are, in the first place, such delete- rious influences as have an immediate action upon the tongue, such as caustics, injuries, burns, stings of insects, drinking very cold water; in the next place, indirectly acting influences, such as the inflammation of adjoining parts, syphilis, suppression of an habitual perspiration of the feet, of piles and the menses. However, there are likewise cases that cannot be traced to the presence of any ex- citing cause. Acute glossitis generally sets in without any precursory symp- toms ; if induced by external irritants, the inflammation develops itself soon after they have begun to act. While a generally very violent fever is present, the tongue becomes painful, its mobility is very much embarrassed, and it swells so rapidly that the swelling sometimes fills the whole cavity of the mouth within the space of twenty-four hours, and even protrudes between the teeth. The tongue has a deep dark-red or even blackish hue, it is very hot and dry. The more the swelling increases, the more acute are the pains, and the more difficult the processes of mastication, deglutition and speech. In the higher grades of glossitis, even respiration is very much embarrassed, both by the tongue itself as well as by a readily supervening oedema of the epiglottis, and even of the larynx. The febrile symptoms are strongly marked, and the symptoms of consid- erable cerebral hypersemia are scarcely ever wanting. The inflam- mation easily terminates fatally, if the respiration is seriously inter- fered with. Otherwise the inflammatory exudation is gradually dispersed more or less completely, or an abscess forms, after whose discharge a rapid improvement takes place. The disease always runs a very rapid course. Chronic glossitis either remains after an acute attack, or else it develops itself gradually. In the substance of the tongue, one or nipre hard places are felt, not elevated above the surface of the tongue, and mostly painless on contact, but otherwise causing now and then dull pains. It is most generally caused by the irritating action of the sharp edges of some of the teeth, and is accordingly most frequently met with in the outer border of the tongue. Chronic glossitis is not very rare, and although patients do not often heed 312 Diseases of the Mouth, Fauces, and CEsophagus. the pain, yet they are very frequently tormented hy the apprehen- sion that their trouble might he of a carcinomatous nature. The circumstance of the swelling sometimes continuing for years with- out any apparent change, finally satisfies the physician that it is not malignant. This conviction is of especial importance, in so far as it often helps to prevent mischievous, or at least useless, surgical opera- tions. The termination of chronic glossitis in an abscess, does not often occur, except where the chronic form is the result of an acute attack, in which ease the formation of an abscess is much more common. Treatment. According to the statement of pathological trea- tises, acute glossitis is a very dangerous inflammation, which has often terminated fatally. When treated homoeopathieally, this in- flammation becomes a very mild affection for which we possess specific remedies, under whose influence the suppurative process is almost surely prevented. In most cases of glossitis, more particularly if the disease has an idiopathic character, Mercurius is the surest and most suitable remedy. According to Hartmann, it should be exhibited in the second or third trituration, with which he professes to have cut short recent cases that had not yet progressed too far. " I admit," he adds, "that the disease can be cured with a small dose of a higher attenuation; but in a case of so much danger, where experience and a reliable method of treatment have proved perfectly safe, mere theoretical experiments are out of place; so far as I know but few cures of glossitis have been reported by homoeopathic physicians in opposition to my own statements." That Mercurius is likewise the specific remedy in cases depending upon syphilis, should not be forgotten; only in such cases it is well to administer the more powerful mercurial preparations, the Corrosive Sublimate or the white Precipitate. Although Hartmann's statement, that a cure can be accomplished in a few hours, is somewhat extravagant, yet suppuration will scarcely ever take place after the timely use of this agent. If suppuration has set in, it is best to give Hepar sulphuris, without regard to the threatening symptoms which accompany this process. If the inflammation is caused by corrosive substances or a burn, it is speedily and safely removed by Cantharides^ whereas Mercury would have no effect. Inflammations of the mucous lining of the tongue, with the parenchyma being more or less involved, are generally more readily controlled by Belladonna than by Mer- cury, unless the inflammation should emanate from ulcers in the Glossitis, Inflammation of the Tongue. 313 lining membrane. Under these circumstances Acidum muriaticum and nitricum may likewise prove serviceable. During the further progress of the inflammation Arsenicum may still be resorted to as a last but very efficacious remedy, especially if the general organism seems to be very much prostrated. Where the inflammation had resulted from contusion or a mechanical injury of the tongue, Arnica is jumped at by many, in conformity with the general theory that Arnica is indicated by contusions and the like. The symptoms do not point to Arnica, nor have we any practical evidence for its appropriateness in such cases. According to Hartmann, Conium is the best remedy under such circumstances; indeed the symptoms point to its employment as a suitable agent. We will likewise mention Apis and Lachesis, which are useful in inflammatory affec- tions of the buccal cavity generally, and more especially in glossitis. There is scarcely a remedy that has such marked symptoms of glossitis as Apis. In one case of poisoning the inflammatory swell- ing was not the result of a sting in the lining membrane, or of the introduction of the poison into the stomach, so that the inflamma- tion might be accounted for upon the ground of local action; but the inflammation occurred after a'sting in the temple, showing that the virus has a specific effect upon the tongue. The symptoms of Lachesis are not nearly as clearly marked. In chronic glossitis we have to try Sulphur above every other remedy. In recent cases Conium is likewise indicated. In protracted cases we may expect aid from Aurum and lodium, and likewise from Silicea. Where the induration is situated under an ulcer dr sur- rounds it, we have to inquire in the first place whether carions teeth or other mechanical irritants are not the real cause of the trouble; in such a case a cure is obtained by removing them. It sometimes happens that such indurations have become so inveterate, that they continue even after the removal of the cause, in spite of persevering treatment. [In phlegmonous glossitis, with high fever, hot and dry skin, headache, slight delirium, etc., Aconite in the lower preparations of the root will be found an indispensable remedy. A drop of the tincture, or a few drops of the first decimal attenuation, in half a tumblerful of water, the medicine to be repeated every hour or even half hour, will be found the proper dose. II.] 314 Diseases of the Mouth, Fauces, and CEsophagus. We comprehend under this designation two tolerably distinct conditions which have, however, this in common: that the salivary glands are the seat, or rather the starting-point of the disease. Consequently we shall first describe parotitis proper, or an inflam- mation of the parotid gland, together with the non-malignant inflammation of the other salivary glands, and afterwards the malignant form of the disease attended with gangrene of the cel- lular tissue. 8. Parotitis. a. Parotitis, Inflammation of the Parotid Gland, Mumps, Angina Parotidea. This affection is at times idiopathic, and as such has received the above series of names; at other times it is a secondary disorder, to be regarded as a complication of other diseases. The symptoms differ accordingly. Idiopathic parotitis is generally preceded for a few days by febrile symptoms. The patients feel languid, sleep is uneasy, the appetite is gone; headache, with a feeling of stiffness in the posterior cervi- cal muscles is scarcely ever absent; a slight catarrhal irritation of the digestive tract is likewise generally present. After these pre- liminary symptoms have lasted for a short period, sometimes even for several days, the region below the lobule of the'ear on one side begins to swell, the swelling spreading very rapidly over the cheek and the submaxillary region ; in a short time the face looks very much disfigured by the swelling. The swelling is not very painful even to rather hard pressure; the color of the swelling does not differ from that of the surrounding integuments, except sometimes a slight redness; the swelling is at times of a stony consistence, at times it is soft, and at other times has an uneven feel. The move- ments of the head, more especially of the jaws, are very much im- peded. With the appearance of the swelling, the general symptoms usually improve, the fever abates rapidly, and the patients, in spite of their great disfigurement, feel tolerably well. In most cases the swelling spreads to the other side in one or two days, but here never attains the same size as on the former side. If the swelling runs a normal course, it generally reaches the climax on the fifth day, after which it gradually begins to disperse, so that between the tenth and fourteenth day no trace of the swelling remains visible. With a higher grade of inflammation, or under otherwise unfavorable cir- cumstances, the redness assumes an erythematous character, and Parotitis. 315 suppuration may take place, which, in comparison to the size of the swelling, remains inconsiderable, but protracts the course of the disease very greatly. The swelling takes this course more frequently in the case of adults than in that of children; in the case of the former, an inflammatory hardness of greater or less extent some- times remains for some time. Only in rare cases, or if the affection assumes a certain degree of malignancy, as it sometimes does in certain epidemics, the brain may become involved in the process. What is more frequently the case is, that the testicles, or the labia majora, swell suddenly, while the swelling of the parotid gland dis- appears ; both swellings may, however, coexist, and the supposition of a metastasis should not be entertained too lightly. Secondary parotitis occurs in the course of many acute diseases, particularly typhus; in some typhus epidemics it is a constant sequela of the disease, whereas in other epidemics it is entirely absent. The appearance of the swelling is not bound to any definite period of the disease; at times we see it break out at the commence- ment, at other times during the period of convalescence. It is gen- erally preceded by local pains, increased congestions of the head, even delirium and chilly creepings; its rapid development is seldom attended with abatement of the fever. The further course of the local process is similar to that of the idiopathic disease; the swell- ing either scatters or else it terminates in violent inflammation with suppuration, which, during a state of great constitutional prostra- tion, may assume a malignant form, with the discharge of ichor. Whereas, in the former case, parotitis always indicates a favorable course of the general disease ; the formation of pus, on the contrary, always portends danger, and is at least a disturbing complication. It is difficult to determine a priori, of what character the swelling will be; but when parotitis sets in at the acme of the disease, it is always more dangerous than when it occurs at the commencement or during convalescence. Here, too, as in the case of mumps, an induration may be left behind for a long time. In isolated cases of either variety the ear seems to be affected, hardness of hearing and purulent otorrhoea remaining after the disappearance of the swelling. The etiology of parotitis is involved in obscurity, in so far as we are unable to determine by what atmospheric or other influences the disease is caused. Its epidemic character leads us to adopt the existence of some peculiar miasm, similar to the miasm of typhus, cholera, etc. We know, moreover, that the common epidemic mumps prevail most frequently in the transition-seasons. But it is 316 Diseases of the Mouth, Fauces, and CEsophagus. a mystery why the parotid gland should be invaded in acute dis- eases of the general organism, in one epidemic quite frequently, in another scarcely ever, or why at one time it should be harmless and at another time a phenomenon portending great danger. This difference accounts for the circumstance why some consider this form of parotitis a dangerous, and others a trifling, disease. An inflammation of the other salivary glands often accompanies parotitis as an accessory disorder, and may likewise break out in an idiopathic form. Numerous facts lead us to believe that each separate salivary gland may become the seat of an affection like mumps. After very acute diseases we have often noticed stony swellings of the lesser salivary glands of a very obstinate character, and running their course amid a general prostration of strength. Treatment. In ordinary mumps, which run a very rapid and painless course, it makes very little difference what medicine is given; indeed, the affection might safely be left to take its own course. However, inasmuch as we cannot well know what the final termination of the affection may be, it is best to always give the suitable remedy, since wo can rest assured that under its use suppu- ration will only take place exceptionally. The best remedy is Mer- curius. The specific action of Mercury upon the salivary glands is well known. It not only increases the secretions of these glands, but likewise causes a real inflammation in the body of the glands which may readily terminate in suppuration, as is often seen in the violent treatment of diseases with large doses of Mercury. No remedy prevents suppuration as certainly as Mercurius. Belladonna deserves a preference if the constitutional symptoms are very severe, and the swelling assumes an erysipelatous character. Rhus toxico- dendron rivals Mercurius in efficacy ; for a more accurate description of their distinctive pathogenetic symptoms, we refer the reader to our Materia Medica. We content ourselves with mentioning in this place that Rhus, independently of the symptoms of typhoid parotitis, is more suitable to a kind of mumps where the inflamma- tory swelling is not very hard, not very red, and not very painful. These three remedies will always prove sufficient in mumps; in typhoid parotitis other remedies will likewise have to be used, for which we refer to our article on typhus. The induration remaining after typhus is often very obstinate, and only yields gradually. In such a case, Baryta carbonica is the best remedy, provided it is con- tinued for a sufficient length of time. Besides these remedies, Co- Parotitis Maligna. 317 nium, Aurum and Silicea may be thought of. The metastasis to the genital organs is best met by Pulsatilla [and Belladonna. II.] As regards general hygienic measures, we are decidedly opposed to the abuse of external warmth, of which both physicians and patients are guilty, in the supposition that they will by this means prevent a metastasis. This abuse is of no sort of advantage to the course of the disease; but it is a source of great discomfort to the patients if they are compelled to envelop their heads with a quan- tity of covering. The headache is always increased by such a pro- ceeding. If suppuration threatens, and the swelling is very painful, lukewarm, moist cataplasms not only afford relief, but they likewise promote the dispersion of the swelling. b. Parotitis Maligna. We apply this name to a specific inflammation of the cellular tis- sue surrounding the salivary glands; it is characterized by a ten- dency to gangrenous disorganization. Synonymous appellations are : Cynanche cellularis maligna, angina externa, metaphlogosis or gan- grenous inflammation of the cervical cellular tissue. The reason why we mention this affection in this place is, because the disease always starts from the lesser salivary glands, and seems to have a preference for their locality. Upon the whole, parotitis maligna is a very rare disease that has so far been chiefly observed in the South of Germany. We know that it makes its appearance more particularly in the fall and win- ter ; attacks chiefly individuals of the lower classes with impover- ished, dyscrasic, scrofulous constitutions; and occurs most frequently in low lands, marshy districts, and damp dwellings. The real cause of the disease, on looking at its whole course and essential charac- teristics, seems to be a peculiar toxication of the blood, such as occurs in typhus and diphtheria. When cynanche maligna was prevalent some time ago, typhus, with tendency to putrid decom- position, was likewise very frequent. Symptoms and Course. The disease commences at once at the affected part, without any preliminary symptoms. Accompanied by febrile symptoms, consisting of alternate chills and flashes of heat, with general languor and prostration of strength, dulness of the head, loss of appetite and coated tongue; the patient experiences slight difficul- ties of deglutition, with dull pain in the lower maxilla and teeth, and a feeling of stiffness in the articulation of the lower jaw of the affected side, which is generally the right side. The saliva is secreted 318 Diseases of the Mouth, Fauces, and CEsophagus. in somewhat larger quantity, the buccal cavity shows no abnormal symptoms. While the constitutional symptoms are increasing in in- tensity, we notice on the third day, and, in violent cases, often in a few hours, a swelling in the region of the submaxillary or sub- lingual, much less frequently of the parotid gland, which keeps on increasing and spreads over the whole side of the neck. The swell- ing is of a stony consistence, sharply circumscribed, lies close to the bone, does not feel very hot, is not red, nor very painful to contact. As the swelling increases in size, the process of deglutition becomes more and more difficult and the opening of the mouth almost im- possible: The general condition of the patient becomes worse and worse; he has restless nights, his pulse is small and quick and the skin inclines to perspire. All the symptoms increasing in intensity, the disease reaches its acme about the tenth day. The face and neck are terribly disfigured, the swelling occupying the lower part of the face and the submaxillary region as far as behind the ear, sometimes extends even down to the clavicle, and looks like a thick pad laid around the neck. The mouth now can no longer be opened, deglutition has become next to impossible; the voice is rough and without resonance; a quantity of tenacious mucus flows out of the mouth. The fever is intense. If, as is possible, but not very prob- able, the inflammation should disperse at this period, the difficulty of swallowing decreases in the first place, the swelling diminishes from the.periphery towards the centre, the fever moderates, the sleep becomes quieter, the cutaneous transpiration takes place easily and affords a feeling of ease and comfort. The process of reabsorp- tion goes on very slowly. Generally, however, suppuration takes place at the acme of the disease, with speedy transition into ichorous decomposition and gangrenous destruction. At the same time the fever increases, after which it rapidly assumes an adynamic character. If the pus is evacuated in good season, an immediate improvement may set in, or else the septic character is too far advanced, the ichor is formed again and again, and the symptoms assume the appearance of ma- lignant typhus. The extremities grow cold and the scene ends with delirium, subsultus tendinum, unquenchable thirst, miliary eruptions, paroxysms of dyspnoea and finally paralysis of the lungs. In the case of adults a fatal termination may be reached between the eleventh and twentieth day, children sometimes die as early as the third day If the disease runs a favorable course, there frequently remains Salivatio, Ptyalism. 319 for some time, besides disfiguring cicatrices, and on account of the destruction of considerable portions of the integuments, an indura- tion at the lower jaw, which at times involves a salivary gland, and at other times the periosteum of the jaw-bone. Beside the gangrenous destruction on the neck, which may not only have invaded the cellular tissue, but likewise the muscles, bones and even the cartilages of the larynx, a post-mortem examination very frequently reveals signs of pulmonary stasis, softening of the spleen, and typhoid degenerations in the bowels. The prognosis is very unfavorable, the disease being one of the most fatal diseases known. In describing it we have followed almost literally Schweickert's detailed delineation of cynanche maligna in the " Hom. Viertel- jahrsschrift," (Hom. Quarterly,) vol. XIII, 1; he proposes the fol- low! no- treatment: As soon as the inflammatory swelling makes its appearance, warm poultices are applied to it without intermission; as soon as we dis- cover a trace of fluctuation, a deep incision is made in order to secure an outlet to the ichor and to prevent its gravitating down- wards. The wound has to be cleansed with water, as often as neces- sary, and in order to facilitate the discharge of the ichor, a hori- zontal posture should be maintained. In one case Schweickert gave internally Aconitum, Belladonna, Rhus tox., Mercurius, Baryta, carbonica, Silicea, without the least success. In three other cases he gave Anthracin 9th and 30th attenuation, and effected a cure in every instance. These results may perhaps be confirmed by further trials. Somebody has recommended Bryonia for this dis- order. Why Arsenicum was not given in the first-mentioned case, we are unable to say. For the remaining indurations Aurum muriat. natr., and Silicea were found the most efficient remedies. There is a less malignant inflammation of the cellular tissue of the neck, which runs a more subacute course. It arises like the malignant form of this disease and seems to depend upon at- mospheric influences. We have treated three cases of it within the last three weeks, the patients belonging to the poorer class. The /constitutional symptoms are not very striking, but there is great prostration of strength. Poultices and the internal use of Mercurius and Baryta carb, effected a cure in every case. 9. Salivatio, Ptyalism. An increased secretion of saliva is not often an idiopathic affec- tion; it generally is a symptomatic occurrence in the course of 320 Diseases of the Mouth, Fauces, and CEsophagus. some more general disease, and constitutes, moreover, a very un- important complication. There are cases, however, where saliva- tion is a very serious disorder, and we have deemed it necessary to devote a short chapter to it. The causes of salivation are either an irritation of the mucous lining of the mouth or of the salivary glands themselves, or it may result from affections of other organs, such as the stomach, pancreas, liver, uterus, or from paralysis of the tongue, the muscles of the mouth and pharynx, or the salivation may be a consequence of the toxical action of Mercury, Iodine, Gold; or finally it may be caused by other general influences, a cold for instance. Salivation arises gradually, very seldom suddenly; the quantity of the secreted saliva may amount to several pounds a day. At first the saliva contains a good deal of mucus, is tenacious, insipid; but if the secretion increases in quantity, it acquires a sweetish taste and is attended with fetor from the mouth. Ulcerations of the mucous lining of the mouth, catarrhal symptoms of the digest- ive tract, and febrile motions likewise supervene. Sleep is frequently interrupted by the necessity of swallowing the profusely secreted mucus. The constitutional equilibrium is always considerably inter- fered with after salivation has lasted for some time, nutrition being very much impaired, not only by the loss of fluids, but likewise by the imperfect admixture of saliva with the food and its consequent imperfect digestion. The affection is scarcely ever painful, but there is the tormenting sensation of a constant afflux of saliva in the mouth. Only exceptionally the salivary glands are painful and swollen. The duration of the disorder varies from a few days to several months and even years, according as it may have been caused by one circumstance or another. Sequelae are: Catarrhal puffing up of the lining membrane of the mouth, ulceration of this membrane, caries and looseness of the teeth, and, moreover, the phenomena of altered digestion. Treatment. Ptyalism being generally a symptom of some constitutional derangement, we refer the reader to the chapter where these derangements are treated of, and shall here mention only such medicines as may be required when ptyalism has reached such a degree of intense virulence that the first attention in the treatment of the case has to be devoted to it, or perhaps in the few cases where it occurs as an idiopathic disease. Where it is a mere partial manifestation of a more general constitutional disorder, the remedies for the latter will likewise remove the ptyalism. Salivatio, Ptyalism. 321 The most important remedy for this affection is, under almost all circumstances, Mercurius, except where the ptyalism had been caused by the abuse of this drug. Its specific action upon the salivary glands necessarily implies its great efficacy as a curative agent in this disease. It is not only suitable in salivation pure and simple, but likewise in salivation depending upon affections of the mouth, fauces, stomach, liver and pancreas. Recent cases, or such at least as have not yet become inveterate by age, yield more readily to its curative influence. The tenacious and ropy saliva must have a sweetish, metallic, insipid taste, accompanied by a putrid-sweetish odor from the mouth. The best mercurial preparation in such cases is Mercurius vivus, lower triturations; next to it Corrosive Sublimate. lodium is not only valuable against mercurial salivation, but likewise in salivation depending upon other causes; more partic- ularly upon affections of the stomach or pancreas. It is preferable to Mercurius in cases where the assimilative energies have become very much depressed by the protracted duration of the disease. Acidum nitricuni is likewise an excellent remedy for mercurial ptyalism, but, like Iodine, may likewise be applicable in other forms of this disease. The saliva has a marked sweetish taste, is tena- cious, although not very copious; the lining membrane is very much affected, the sme'.l from the mouth very bad. Acidum sulphuricum has almost the same symptomatic indications as the former acid; indeed, it would be a difficult matter to draw well defined lines of demarcation between the two. According to Hartmann, Colchicum is particularly adapted to ptyalism, caused by suppression of the perspiration, and accompanied by all sorts of rheumatic ailments whose increase is attended with a corresponding increase of the ptyalism. When swallowing the saliva, it causes nausea and a desire to vomit; notwithstanding the quantity of secreted fluid, the patient experiences a troublesome feeling of dryness in the throat. Dulcamara is likewise urgently recommended by Hartmann, who seems to think a great deal of it in a variety of complaints. Judging by the symptoms we certainly have better remedies; of practical results none are as yet recorded. Belladonna is far superior to Dul- . camara, both in mercurial and other forms of ptyalism. Without continuing our list of remedies, we now add a few that deserve particular consideration in cases where ptyalism is a mere symptom; they are: Nux vomica. Capsicum, Sulphur, He par sal- 322 Diseases of the Mouth, Fauces, and CEsophagus. phuris, Baryta carb., Staphysagria, Mezereum. Of course this is not the whole list of remedies that may be employed against ptyalism; we must remember that almost every drug in our Materia Medica induces an increased secretion of saliva. In the rare cases where ptyalism develops consumptive symp- toms, Natrum muriaticum may deserve attention. [Rheumatic inflammation of the gums and sublingual glands is not an unfrequent occurrence. In such cases the saliva sometimes flows out of the mouth in a continuous stream. It seems to be mere water, without much taste or bad smell from the mouth. Chilly creepings and slight flushes of fever are likewise present. We have cured such cases in a very few days, sometimes in a single day, by mixing one or two drops of the Tinctura Aconiti Radiris in half a goblet of water, giving a dessertspoonful of this solution every half hour or hour, and widening the intervals in proportion as the patient began to improve. II.] [10. Scorbutus. Scurvy of the gums. According to Kafka scurvy of the gums usually commences with a red border along the upper margin of the gums; their indenta- tions between the teeth become bulbous, spongy, and sometimes recede from the teeth; the gums are swollen, spongy, and look bluish. The gums sometimes overhang the teeth in palmated ex- crescences, or bulge out here and there in thick, spongy, pad-shaped swellings. As the disease progresses in intensity, the swellings on the gums and the gums adjoining the teeth soften, become discol- ored and ulcerate. In case of improvement, the swellings decrease, the gums again adhere closely to the teeth, recover their firmness and normal color. Scurvy of the gums is caused by bad and improper nourishment, want of fresh vegetables, fresh water, or by the continued use of salt meat, or by a deficiency of nourishment; or, it may be occa- sioned by excessive bodily labor, with an insufficient supply of food, by an utter neglect of all bodily exercise; by bad, damp, cold, foul air, marshy emanations, or by continued depressing moral emotions. Disease of the gums is always the first sign of incipient scurvy, and is not so much caused by an abnormal condition of the blood, as by a peculiar disease of the walls of the capillaries, upon which the hemorrhages, the swellings and the rest of the morbid phe- nomena depend. Scorbutus, Scurvy of the Gums. 323 Scurvy of the mouth is exclusively seated in the gums. It is a remarkable fact, that persons who have lost their teeth are not at- tacked by this disease. Mastication is painful, sometimes even impossible. At every attempt to masticate, or on pressing upon, or cleaning the gums, or even when talking, the gums bleed more or less. In the further course of the disease, the continued decomposition of the blood and the necrosed tissues, cause a penetrating, repulsive fetor from the mouth ; the secretion of mucus and saliva is considerably increased. Necrosis and consequent loss of the gums may cause the roots of the teeth to become denuded, the teeth become loose, and finally fall out. Course, Terminations, Prognosis. Scurvy of the mouth, if neglected, or if the influences that occcasion it are permitted to continue, is an exceedingly chronic and obstinate disease. This form of scurvy is curable in the majority of cases; if neglected, it may cause considerable destructions of the gums, and the loss of teeth. The prognosis, although generally favorable, yet, in the presence of considerable destructions in the mouth, and a deep in- volvement of the constitution, may become very dubious. P eatment. As long as the disease is purely local, the gums bleed, are swollen, loose, bluish, tuberous, a local treatment, with spirituous or astringent washes is sufficient. For this purpose we cause the mouth to be gargled with brandy or vinegar diluted with water. If these means should prove insufficient, we resort to a weak solution of burnt alum, in the proportion of ten grains to six ounces of water, or to a mixture of dilute muriatic or sulphuric acid, in the proportion of ten to twenty drops to six ounces of water. If the gums ulcerate, the fetor becomes excessive, the salivation increases in quantity, and the affection is still confined to the gums, we give Nitri acidum 3, internally, and have the mouth gargled with the same acid, as recommended previously; or else we give Corrosive Sublimate 3, internally, and for a gargle we prepare a solution of one grain of the sublimate to four ounces of water; Creasotum 3, internally and externally, the same as Nitric acid, is likewise excel- lent. Nux vomica 3, internally, and ten drops to eight ounces of water as a gargle, is sometimes very appropriate. Ammonium car- bonicum used in the same manner, may prove serviceable. As a matter of course, everything that tends to keep up and de- velop the scorbutic disease, has to be avoided, and all pernicious influences have to be absolutely removed. The general mode of 324 Diseases of the Mouth, Fauces, and CEsophagus. living in regard to diet, habitation, cleanliness, etc., has to be regu- lated with strict care and attention. If the disease should progress and develop itself into a general constitutional disease, we shall then have to institute an anti-scorbutic treatment, which will be de- scribed in the article on Scurvy. II.] [11. Ranula. Kafka has treated several cases of this disease internally with perfect success. This swelling may be located in the excretory duct of the submaxillary glands, the Whartonian duct. It is soft, fluc- tuating, almost transparent. The orifice of the duct is closed, in consequence of which the saliva accumulates, becomes inspissated, and the duct enlarges and finally forms a sacculated swelling. Ranula may likewise constitute a hard and firm swelling under the tongue, either in consequence of calculi stopping up the ducts, or in consequence of the ducts having become inflamed. It is with this latter class of ranulae that the physician has to deal; the former belong to the domain of surgery. At the commencement of the disease the patients complain of a pain under the tongue, which is made worse by chewing and talk- ing. Upon examining the mouth at this period, we find the Whar- tonian ducts swollen, somewhat hard and red. These phenomena increase gradually, both in intensity and extent; sensitive patients commence to experience febrile motions, the slowly increasing swelling becomes more painful, and interferes with the motions of the tongue quite considerably. Gradually the sublingual cellular tissue becomes infiltrated, and a swelling forms, which, if left to itself, frequently attains to a con- siderable size, until it fills the larger portion of the buccal cavity, in consequence of which the tongue is pressed upwards towards the fauces, the respiration is impeded, and speech and deglutition become impossible. Or the swelling may form under the chin, and bulge more and more towards the outside, in which case the tongue is much less involved in the pathological process. In either case the pain and constitutional disturbance are very great. If we do not succeed in effecting a reabsorption of the swelling, chills set in and throbbing pains in the swelling ; these symptoms point to the formation of an abscess which will have to be treated by surgical means. The abscess either perforates the anterior side of the neck, or else, "which is of more frequent occurrence, the base of the buccal cavity. Ranula. 325 Course, Terminations,, Prognosis. The course of this swelling is either acute or chronic. In the former case the inflam- mation sets in suddenly; pain, redness and swelling come on at once, and the dispersion of the swelling or its termination in suppu- ration likewise occurs at a much earlier period. If the swelling reaches a considerable size, (sometimes it attains the size of a hen's or goose egg,) the pressure of the tongue upon the pharynx and larynx, and consequently hypersemia of the brain, may result fatally In the chronic form the pain is at first imperceptible, so that the patients often wait a long time before sending for a physician. The swelling develops itself very gradually, nor do the single symptoms reach a very high degree of intensity. If suppuration cannot be prevented, the swelling becomes more and more inflamed, and it is at this stage that the previously described threatening disturbances arise, and do not cease until the abscess has either found a natural or artificial outlet. After the swelling has changed to an abscess, dispersion is no longer possible. On account of the danger that may arise before and during sup- puration, the prognosis should be very guarded. Treatment. In treating ranula, the question is, in the first place, whether the course of the disease is acute or chronic. In the former case, if the pain is intense, and the swelling red, hard and inflamed, we give Belladonna 3, in solution, and at the same time apply cold compresses under the chin; or, if the inflammation is intense, wrn resort to applications of ice. The cold water compresses have to be renewed every five minutes. As a rule, the violent pain abates in a few hours; at the same time the redness decreases, and talking- is much less difficult. Under the influence of Bella- donna, retrograde metamorphosis progresses very finely for two or three days; about the fifth or sixth day it seems to stop. The redness and pain, are indeed much less, but the swelling remains hard, and interferes with mastication and speech. In such a case we give every day three to four doses of Mercurius solubilis 2, after which the hardness decreases in a very short time, the swelling becomes smaller and softer, and finally disappears altogether. In three cases that we have treated in this manner, suppuration was entirely prevented. If suppuration sets in, the abscess should be opened as soon as fluctuation is perceived. An incision may be made ejther in front or at the base of the mouth. In the chronic form of the swelling we commence the treatment with Mercurius solubilis 2 or 3, two or three doses a day. If there 326 Diseases of the Mouth, Fauces, and CEsophagus. is no decrease of the swelling in six or eight days, and the swelling is not any softer, we give Calcarea 6, a dose morning and night. In one case this remedy alone effected the complete absorption of the swelling. If no absorption had taken place, we should then have given SiUcea 6 and Thuya 3 or 6. If no dispersion is brought about by internal treatment, the swell- ing gradually shows signs of inflammation, which becomes more and more acute until an abscess forms, when surgical means have to be resorted to. As long as mastication and deglutition are difficult, we feed the patients on milk, soft-boiled eggs without salt,mush,and the like. II.] 12. (Esophagitis, llysphagia Iiitlammatoria, Inflammation of the (Esophagus. An inflammatory affection of the oesophagus may simply consti- tute an acute catarrh of the mucous lining of the oesophagus, in which case it is accompanied by a catarrhal inflammation of the mouth and fauces, or of the stomach, and is without any impor- tance, or even without any more prominent symptoms than charac- terize the accompanying affection of the other organs. In oesophagitis proper, it is not only the mucous membrane that is attacked, but likewise the subjacent tissue; hence the symptoms are much more violent, and seem more marked, for the reason that oesophagitis occurs much more frequently as an idiopathic affection. The causes of the disease are almost always of a mechanical or chemical nature, foreign bodies, acids, corrosive substances, or exces- sive heat of the ingesta; without such demonstrable causes the inflammation is of much less frequent occurrence. Owing to the slight sensibility of the oesophagus, the symptoms, if the attack is not too acute, are not very marked. Patients com- plain of a dull pain, according as the inflammation is seated near the throat, or between the shoulder-blades; it is much aggravated by every effort at swallowing. Deglutition is more or less inter- fered with, the food regurgitates, and at intervals a tenacious mucus, which is sometimes streaked with blood, is hawked up with a great effort. In acute cases, however, the pain becomes intense and even intolerable, deglutition is almost impossible, and the least attempt is so painful that the patients do not even dare to gratify their burn- ing thirst. The mucus, which is hawked up with an agonizing distress, is of a purulent character; speech is almost impossible, and the breathing is oppressed even to suffocation; fever is almost CEsophagitis, Dysphagia Inflammatoria. 327 always present, and signs of cerebral congestion may occur. If an abscess forms, every symptom increases with the fever until it reaches a most threatening height. The violence of the symptoms abates as soon as the pus is discharged. Where no abscess occurs, the symptoms disappear more slowly and almost imperceptibly. (Esophagitis acquires particular importance through the conse- quences which it sometimes entails upon the patient, more particu- larly stricture. It does not set in at once alter the disappearance of the inflammatory process, but develops itself very gradually. At first the patients only experience at times a difficulty of swal- lowing, or, when attempting to swallow large pieces, they do not seem to descend readily into the stomach, and arrive at their place of destination only after a time, or after drinking a little water. These difficulties increase very gradually, until deglutition has be- come so difficult that all kinds of solid food are rejected again. With the stricture there generally supervenes a dilatation of that portion of the oesophagus lying between the stricture and the pharynx. In consequence of this alteration, the food remains for some time in the oesophagus before it is rejected. In treating oesophagitis we have in the first place to inquire into the causes of the disease Foreign bodies have to be removed with- out any loss of time. If the trouble has been caused by corrosive substances, a lukewarm, slimy beverage should at once be drank in large quantities; dilute lukewarm milk may likewise be taken. The principal medicines are: Arnica, if the injury was produced by foreign bodies, Cantharides, if caused by burns, and Rhus tor., if caused by corrosive substances. If the disease cannot be traced to any definite cause, we may give Mercurius preceded by a few doses of Belladonna. Beside these medicines Hartmann mentions Coc- culus, Sabadilla, Arsenicum, Secale corn alum, Mezereum, Laurocer- asus and Carbo vegetabilis. The thirst of the patients is best quenched by little bits of ice in the mouth. Strictures can only be reached exceptionally by internal remedies, and then only in recent cases. If the stricture is owing to the pres- ence of a cicatrix, no internal treatment is of any avail, any more than in a case of dilatation or cul-de-sac. Only where the stricture is owing to an hypertrophied condition of the mucous lining, the following remedies may be administered with a reasonable hope of relief' Salphur, lodium, Mercurius, Hepar sulphuris and Arsenicum. (Considering what excellent effects have been obtained by means of the introduction of a graduated sound, internal treatment should 328 Diseases of the Mouth, Fauces, and CEsophagus. never be exclusively depended upon, but surgical treatment should at once be resorted to. [Spasmodic dysphagia may yield to Tartar Emetic, Aconite, Nux vomica. IT.] 13. Odontalgia, Toothache. Toothache is such a stumbling-block for authors of therapeutic manuals, that no mention is made of this distressing affection, which is, by tacit consent, assigned to the domain of the dentist. This is natural enough, owing to the fact that the Old School never has had any real remedies for toothache, except perhaps a dose of Opium. Common practice, however, is not bound by therapeutic compendia; what is most needed in practice, is often not to be found in printed treatises. This is the case with toothache. With our present mode of living, no pain is more frequently complained of than toothache, and nothing is more urgently demanded by the patient, and at the same time more embarrassing to the truly rational physician, than to find a sure remedy for this complaint. On the other hand there is no derangement more calculated to place the advantages of homoe- opathic treatment in more brilliant relief than the management of toothache. How many sceptics have been converted into zealous adherents of Homoeopathy by the relief from toothache which a few small powders had afforded them as if by magic ; for were not the powders taken internally ? What homoeopathic physician can- not relate a number of such cases ? On this account we cannot conceal our opinion that toothache has a practical significance for the homoeopathic physician as well as for his patients. The case is with toothache as with many other iso- lated morbid phenomena. Homoeopathy alone is in possession of a definite method of curing this complaint, and we regard the suc- cessful treatment of toothache by homoeopathic means as a greater triumph for Homoeopathy than the cure of a disease in which the whole organism was involved. The evidence of the cure having been effected by internal treatment, is too striking not to overcome the most inveterate scepticism. We do not mean to assert that we succeed in curing every case of toothache; we know very well that homoeopathic remedies have no magical power and that we may be deceived in the selection of a drug. We certainly can boast of curing at least one-half of all our cases, which is a great deal more than the Old School can brag of. We need not analyze the causes of toothache. A remedial agent had generally better be chosen in accordance with the Odontalgia, Toothache. 329 symptoms; it is only in a few cases that the remedy will have to be selected from a higher and more universal stand-point. For this reason a Repertory is nowhere more useful than in a case of tooth- ache; we can only regret, however, that a number of remedies have been received among the list of curatives for toothache, which have, indeed, toothache symptoms, but have no specific reference to the teeth. This circumstance diminishes the value of a carefully con- structed Repertory, so far as toothache is concerned. The better way would be to construct a Repertory of the few remedies for toothache, from which we have already seen definite curative re- sults. In affections of the stomach we do not make use of every drug that has symptoms of gastric derangement among its patho- genetic effects, but only those which produce derangement of the stomach as a constant result of their pathogenetic action. This remark applies to all affections confined to one definite organ. Those who wish to become acquainted with every medicine that has some sort of toothache among its pathogenetic symptoms, and may possibly cure a case of toothache some time or other, will therefore have to consult a Repertory, whereas in the following paragraphs we only indicate the principal remedies whose curative powers in toothache have been verified by actual observation, and which will be found sufficient to cure most every case of toothache that may be met with in practice. Mercurius is placed at the head of the list because no remedy has such constant effects upon the teeth as Mercurius. Mercurius is particularly adapted to ailments from carious teeth. The pains are stitching, tearing or boring, are not limited to the point they start from, but radiate to the ear, forehead and even occupy the whole side of the head. They are aggravated by the warmth of the bed, by a horizontal posture, by eating and drinking, and are moment- arily relieved by the application of cold water. Their regular period of exacerbation is from evening till midnight, when they sometimes become unbearable without afterwards abating altogether. The contact of warm substances with the tooth increases the pains, whereas warm applications to the cheek relieve them. External coldj a draught of air, etc., are particularly aggravating. At the same time we cannot possibly overlook an inflammatory affection of the surrounding soft parts; the gums are red, swollen, sensitive, the glands are engorged with blood, the secretion of saliva is in- creased, the constitutional condition is feverish, with disposition to perspiration that affords relief, constant anxiety and restlessness compelling the patient to resort to a frequent change of posture. If 330 Diseases of the Mouth, Fauces, and CEsophagus. the pains last much longer, the gums become spongy, recede from the teeth, bleed readily, and show ulcerated spots, especially at the margins. Moreover we have the symptoms of catarrh of the mouth; abscess at the root of the tongue. The best mercurial preparation is Mercurius solubilis, next to which ranks metallic quicksilver. Belladonna. The pains are very violent, rather throbbing, but sometimes digging or jerking. They break out in paroxysms, are worse towards evening, are aggravated by contact, access of at- mospheric air and eating; they abate by the application of cold water and by complete rest. They are attended with marked red- ness of the gums, erysipelatous redness of the cheeks, but without any marked swelling, with violent congestions of the head, alter- nate chills and heat, violent thirst, and are apt to assume the char- acter of prosopalgia, by simultaneously invading several branches of the fifth pair, or by migrating to some other region while the toothache ceases or only abates. Nux vomica in its action upon the teeth is very similar to Bella- donna. The pain is drawing, tearing or jerking, mingled with violent, short, keenly-acute stitches or with throbbing pulsations. It attacks the patient at any time of the day, but is most violent early in the morning; the pain is not continuous but consists of detached paroxysms. Warmth neither aggravates nor decreases the pain; rest induces an improvement; mental efforts, chewing, drawing in cold air, coffee and spirituous beverages cause a severe aggravation of the pain. Marked congestive symptoms are gener- ally present, but the pain may be purely nervous, and, as in the case of Belladonna, may shift to other branches of the trigeminus. Swelling, redness and painfulness of the gums do not counter-in- dicate Nux. A choleric temperament, abuse of coffee or spirits, are a recommendation for its use. Bryonia is particularly adapted to a toothache to which the ap- pellation of rheumatic is generally applied. Redness, inflammation and swelling of the gums are absent. The prevailing pain is a tearing distress, accompanied by stitches and a sensation of looseness and elongation of the teeth. It sets in or is aggravated in the evening or at night, and is likewise aggravated by warm drinks, warm food, chewing motions, lying upon the non-affected side, whereas it abates by lying upon the affected side, by contact with cold water, or by continued exercise in the open air. The pain shifts easily and readily from one tooth to another, not only in the same row, but likewise from the lower to the upper jaw. Touching the affected tooth is not usually very painful. Odontalgia, Toothache. 331 Chamomilla corresponds most specifically to the toothache which is most violent at night, more particularly when the person sleeps on a feather-bed. It comes in paroxysms, does not attack any particular tooth; in its milder form the toothache is a formicat- ing, jerking pain, in its more violent form it is a tearing pain, which, in its highest degree of intensity, darts into the ear. It is aggravated by warmth, also by eating and drinking, and by cold water; swelling of the cheeks, profuse secretion of saliva, heat and redness of one cheek, excessive nervousness and restlessness, disposition to weep, and in some cases swelling of the gums, loose- ness and a feeling as if the teeth were elongated, generally ac- company the toothache. (Hartmann.) Pulsatilla. The pain is tearing, extending throughout one-half of both jaws, less frequently through the whole row of teeth; or else the pain is jerking, lancing, a maddening pain, or as if the nerve were violently put upon the stretch and then suddenly let go again, in no case is it possible to point out a definite tooth where the pain is localized. An aggravation takes place at night, also in the evening, after warm eating or drinking, by the warmth of the bed or in a warm room, or by picking at a tooth. The tooth- ache moderates by contact with cold, especially with cold water ; or, in the open air, with sudden aggravation when entering a warm room; it is likewise moderated by the application of vinegar and by sleep. The pain inclines to shoot into the ear, eye and temple, is often accompanied by hemicrania, otalgia, chilliness. The com- plexion is pale, at any rate it must not be of a vivid redness if Pulsatilla is to be used. Chlorosis, anaemia, pregnancy, are addi- tional indications for Pulsatilla. Pulsatilla is likewise an excellent remedy in toothache preceding or accompanying the menstrual period. The presence of inflammation and swelling is not adapted to this remedy. Spigelia. We have already spoken in praise of this remedy when on the subject of prosopalgia, and we likewise recommend it for toothache, with the following symptoms: The pain is not seated in one tooth, but in an indefinite number of teeth, especially in the anterior row ; the pain is a flashing, not throbbing, pain, darts even into the face, is generally felt only in the day-time, less frequently at night; is aggravated by air, cold water, eating, heat, and abates during rest, or when tepid warmth is applied ; it is attended with pallor and bloat of the face, chilliness, palpitation of the heart, neu- ralgic pain in the face. 332 Diseases of the Mouth, Fauces, and CEsophagus. Staphysagria affords help when the pain attacks sound as well as carious teeth; it is ag-oravated by the ingestion of food and drink; it is a tearing pain emanating from a carious tooth, and extending throughout the whole side as far as the pes anserinus, where it excites the most violent pains, which are aggravated by a light touch, but diminished by hard pressure; when the pain is a gnaw- ing pain in a decayed tooth, with a drawing distress in other teeth; it is particularly violent early in the morning, is aggravated by chewing, open air and cold beverage, improved by warmth. The gums bleed easily, are swollen and painful. (Hartmann.) Rhus toxicodendron is suitable in cases of toothache caused by rheumatic exposure and by getting wet. The prevailing pain is a tearing or jerking pam, or like the pain of a sore; has prevailing evening and night exacerbations; always affects a number of teeth ; is aggravated by both warm and cold substances in the mouth, whereas it is often diminished by the application of external warmth; the warmth of the bed is intolerable; the teeth feel as if loose and elongated; indeed, they sometimes really are. Severe exercise affords great relief. Sepia is more particularly efficient in chronic toothache, especially in the obstinate and violent toothache of pregnant females. It is generally attended with severe congestions, is worse at night, and sometimes intermits entirely in the day-time. Every motion of the mouth, the contact with cold things in the mouth, fresh air, or the passage from the open air into a room, aggravates the pain. The toothache to which Sepia corresponds is, as we have already stated when speaking of prosopalgia, no characteristically definite pain; almost any kind of pain is to be found in the pathogenesis of Sepia. Sepia is still more specifically indicated if the teeth decay very rap- idly. There is not much swelling, but a more or less violent proso- palgia is apt to accompany the toothache. Mezereum is suitable if the pain is characterized by violent burn- ing, stitching or boring. It is worse in the evening and at night, and is aggravated by motion. The pain is apt to occur paroxysm- ally, with perfectly free intervals between the paroxysms. A general chilliness, with heat about the head, great restlessness, ill-humor, and an extreme sensitiveness of the external parts of the head, accompany the toothache. One of the most efficacious remedies for toothache, which is sel- dom mentioned among this class of remedies, is Arsenicum. No medicine relieves more surely than Arsenic, a toothache which reaches its climax about midnight or immediately after lying down, Odontalgia, Toothache. 333 and becomes so intense that the patients are unable to describe it, who tormented by anxiety and restlessness, run about, uttering moans and groans. Sleep sometimes sets in after the patients have taken a single dose of the remedy, which sometimes acts with such magic effect that they vow they have been given a dose of Lauda- num. If the cheek is swollen, the remedy has no effect. If palpi- tation of the heart is present, or if the toothache is in relationship with the approach or the appearance of the menses, the good effects of Arsenic are so much more certain. Beside the above-mentioned remedies, which will generally prove sufficient, the following medicines, although less definitely indicated in affections of the teeth, may likewise render good service: Acon- itum, Baryta, China, Coffea, Hepar sulphuris, Ignatia, Opium, Phos- phorus, Platina. In conclusion, we beg to protest against the assumption that homoeopathic medicines can cure any species of toothache in a short period of time. Where an abscess has already formed, where the root of the tooth is carious, where the periosteum is affected, or where the pain is excited by foreign bodies in the tooth, any remedy is either useless, or a favorable effect can only be obtained very grad- ually This remark is intended for malicious opponents or for over- sanguine friends. It is an essential requisite to the cure of tooth- ache that the use of coffee should be strictly avoided. If, in order to effect a cure, it should be necessary to remove the tooth, no rea- sonable physician will waste time with useless attempts at healing the disorder by the administration of internal remedies ; the forceps is the only reliable remedy. Nevertheless, we dare assert, that, in the majority of cases, an operation is rendered unnecessary by the timely and proper use of our specific remedies. [Aconite deserves a much higher rank among the remedies for toothache than Baehr has assigned to it. In congestive toothache, with violent throbbing pain, sensation as if the tooth would be shattered to pieces, excessive soreness and sensitiveness of the tooth, flushed face, sparkling eyes, headache, chilly creepings, alternating with flashes of heat, etc.; a dessertspoonful of a solution of a drop of the tincture of Aconite root in half a tumbler of water will some- times scatter the pain as if by magic. If the tooth is decayed, a small plug of cotton, soaked with a little tincture of Aconite, inserted into the cavity of the tooth, will sometimes remove or, at least, suspend the pain in an instant, as it were. In many cases of this kind, Aconite is preferable to Belladonna. II.] FOURTH SECTION. Diseases of the Stomach, Intestines, and Peritonaeum. A. DISEASES OF THE STOMACH. 1. Catarrh us Ventriculi A cut us. Acute Catarrh of the Stomach. Acute Indigestion. Acute Dyspepsia. To this morbid condition of the stomach, according as it is more or less intense and complicated with affections of the intestines, liver complaint, etc., such a variety of names have been applied, that it is quite a task to indicate all its synonymes. Nevertheless, this seems indispensable, for the reason that those names are still in use, without, however, possessing any scientific value. In this respect we refer to a subsequent chapter, where the affections of the stomach and intestines are to be treated of under the general desig- nation of gastro-intestinal catarrh, by which arrangement numerous repetitions will be avoided. In this place we will content ourselves with discussing the condition which is often alluded to as gastricism, status gastricus, derangement of the stomach, and, in a higher de- gree, febris gastrica simplex. The causes of catarrh of the stomach are of special importance, both as regards prognosis and treatment. We may, therefore, be excused if we dwell upon the etiology of this disease with more than ordinary minuteness. The boundary line between the normal and abnormal functional activity of the stomach, cannot be definitely drawn, owing more particularly to the physiological incorrectness of our present habits of living. Even ordinary digestion becomes, in some respects, anal- ogous to a morbid process, through the febrile symptoms which we experience after a copious meal. In the case of one person the same phenomena may appear normal, which in other persons might look like morbid appearances, the distinction being determined by their duration. If this does not exceed the duration of the digestive 334 Catarrhus Ventriculi Acutus. 335 process generally, we do not interpret them as abnormal conditions; such an interpretation is only put upon them, if the disturbance continues until the next meal, or even longer. If a person, after partaking of a large quantity of fat food, is attacked with heart- burn, we do not regard this as a disease; but if every time we par- take of a little fat, we are attacked with a sour stomach, and the acidity continues, we conclude that there is functional derangement of the stomach. Now, it is well known that the capacity of the stomach to digest certain aliments, and to equalize disturbances, differs greatly in different individuals. Hence so far as catarrh of the stomach and other disturbances of this organ or of the intestines are concerned, we have to infer that there exists an inherent dispo- sition to derangement, the degree of which can only be determined by experience. We need not call attention to the important influ- ence which this inherent disposition exerts in the management of gastric derangements; it is upon a correct knowledge of this dispo- sition that the possibility of preventing the recurrence of functional disturbances depends. This knowledge is of particular importance in the case of little children, in whom inattention to constitutional tendencies results in impoverishment of the organism, whereas a compliance with its inherent demands leads to vigor and health. A constitutional abnormal disposition need not always be congenital, but may be acquired. Catarrh of the stomach, for instance, may become habitual: strength of body and the functional activity of organs may become impaired by bad or deficient nourishment, or even by an excess of dietetic regularity, or the avoidance of stimu- lants beyond the normal limits established by our recognized and generally adopted mode of living. This last-mentioned point is strikingly illustrated by children who are brought up without the use of mixed food, and whose stomachs consequently become so sen- sitive, that the least change, which does not disturb children who are brought up with less uniformity in diet, at once causes gastric derangements. Beside a constitutional disposition, catarrh of the stomach may be caused by overloading the stomach with food, which we have . frequent opportunities of witnessing in the case of children. The quality of the food likewise plays an important part, the heavier and more indigestible the food, the more easily the stomach is de- ranged, even by a small quantity. Even an otherwise readily digested aliment may become indigestible, in consequence of not being sufficiently masticated, and thus being introduced into the 336 Diseases of the Stomach. stomach in a state where the gastric juice cannot act upon it. The temperature of the food likewise has great influence; we frequently notice this by the effect, upon the stomach, of ices, cold fruit, cold beer. On the other hand, a very high temperature may likewise prove hurtful. Beside these more normal substances of not unfrequent use, a quantity of other articles which are introduced into the stomach, either as articles of diet or as medicines, may cause catarrh of the stomach. Among the former we place, in the front rank, alcohol in its different forms and degrees; the excessive use of coffee is another cause of catarrh of the stomach. Tea has the same effect as coffee, but not in the same degree. Every smoker knows that tobacco is very apt to cause derangements of the stomach. All these sub- stances have the peculiar effect of retarding digestion; hence the action of such medicinal substances as impede the functions of the intestinal canal, resembles that of large doses of Opium. Beside these material causes of catarrh of the stomach, we have to mention several important immaterial etiological causes of this disorder. First, depression of cutaneous temperature. Usually this causes catarrh of the respiratory organs; but in many individ- uals, and more particularly in children, a cause of this kind leads frequently, and even most commonly, to catarrh of the lining mem- brane of the stomach; or else the respiratory organs and the stomach are both affected with catarrh, and thus it happens that catarrh of the stomach very often accompanies a simple catarrh, angina, bron- chial catarrh, etc. In this category belongs the influence exerted by certain epidemic conditions of the atmosphere, etc., so that we may have an epidemic influenza with a normal state of the stomach, whereas, on the other hand, epidemic influenza may be accompanied by the most violent catarrh of the stomach. In conclusion we call the attention of homoeopathic practitioners to an important point. Every febrile affection superinduces a higher or less degree of catarrh of the stomach. Under Old-School treat- ment this catarrh is generally made worse, and becomes so obstinate that it outlasts the primary disease and is one of the chief causes of a retarded convalescence. This circumstance should not be over- looked, in cases that come to us for treatment, after the disease had been running its course for some time. Violent mental disturbances or disagreeable emotions of any kind, anger, mortified feeling, etc., are very apt to induce a catarrhal irri- tation of the stomach. Catarrhus Ventriculi Acutus. 337 Symptoms. The phenomena of this affection vary in accord- ance with the intensity of the local affection and with the individu- ality of the patient; we will therefore describe the various degrees of the affection in the case of adults and the gastric catarrh of children. A few hours, perhaps, after one of the above-mentioned disturbing influences has been able to act, a feeling of pressure and heaviness is experienced in the region of the stomach, which the patient fan- cies is bloated. Local pressure, even of the clothes, is painful and causes anxiety. The appetite is gone, the very thought of food causes a feeling of aversion. In cases where a certain kind of food had caused the disease, a loathing is felt against this very article of diet. These incipient symptoms become very soon associated with phenomena depending upon incomplete or otherwise abnormal di- gestion and consequent decomposition of the food. On account of a copious development of gas, the epigastrium becomes more or less puffed up, and the sensitiveness of that region increases; the gas which is belched up, is either inodorous or else has a fetid smell; an excess of acid may likewise be secreted in the stomach, and heartburn may arise, with sensation as if a fluid were ascending in the throat. The aversion to food increases even unto loathing;, nau- sea and vomiting, the food being vomited up with mucus and water and with an admixture of acid and, finally, bile. These phenomena of gastric derangement are always accompanied by symptoms of a general constitutional irritation. First, the patients feel unusually languid and depressed, an extreme irritability and ill-humor are accompanied by flying heat alternating with chilly creepings; the head feels heavy and dull, a pressure in the frontal region is partic- ularly annoying (cephalea gastrica); on stooping and moving about rapidly, a feeling of dizziness is experienced, or the sight is ob- scured. The tongue is lined with mucus, although not in every case; the taste is insipid or slimy, pasty, acid, putrid, and the breath has generally a bad, sulphurous smell. Usually the urine is turbid, mixed with mucous flocks. The bowels may remain constipated during the whole course of the disease; this is more particularly the case when the disease was not caused by dietetic transgressions; where it was induced by improper nourishment, the nausea and vomiting are generally accompanied by soft stool and lastly diar- rhoea, which, however, never becomes excessive if the stomach is the only suffering organ. The slight attack of gastric catarrh sometimes gets well in half 338 Diseases of the Stomach. a day; it seldom lasts longer than a few days. Whether it lasts a few days, may depend upon the intensity of the attack, and upon the admission of hurtful articles of diet in the course of the dis- ease. Where dietetic precautions are not observed, the acute form may easily run into the chronic form, or the genuine chronic catarrh of the stomach; or the intestines may become involved, giving rise to the gastro-intestinal catarrh of which we shall speak afterwards, or else the complaint may increase to a higher grade of intensity, giving rise to the so-called gastric fever. Gastric fever, if it is not the result of an increased intensity of common catarrh, usually commences with violent febrile phenom- ena, alternate chill and violent heat, accelerated pulse, etc. The local symptoms of the stomach are scarcely distinguished from those of the milder form of catarrh, not even as regards intensity: sometimes they are even less marked; the vomiting, for instance, being wanting, the nausea slight, the phenomena of reaction of the stomach against its contents being generally trifling. The constitutional symptoms, on the contrary, are more prominent; the lassitude, for instance, being so great early in the morning, that the patients feel compelled to remain in bed ; the legs refuse to support the body. The headache is distressing, the sleep is disturbed and restless, the patients are tormented by a craving for fresh water, the tongue is very much coated, and the taste in the mouth very bad. The disease never terminates in one day; the fever very soon assumes the type of a continuous remittent, with evening exacerba- tions, increases in intensity, though not regularly, during the first week, and gradually decreases in the second week. Where the stomach is alone affected, and the bowels do not become involved, they sometimes remain constipated for days. The urine is satu- rated. In violent attacks, with immoderate fever, especially if the patients are young, symptoms of considerable cerebral congestion with delirium, develop themselves. Recovery takes place gradu- ally ; convalescence is a slow process, with great tendency to re- lapses, so that the disease may become protracted for several weeks, and may entail great debility and emaciation. The acute stomach-catarrh of children offers deviations in the course and consequences of the disease, only in so far as it attacks children who are chiefly confined to milk as an article of diet, con- sequently children under one year. Although the lighter grade of the disease may be safely considered an entirely unimportant de- rangement, yet the higher and highest grades constitute the most Catarrhus Ventriculi Acutus. 339 dangerous diseases of childhood. Before describing the symptoms, we will mention, somewhat in detail, some of the etiological causes of the diseases. Since this form of catarrh of the stomach only occurs among infants, very seldom, at least, after the first year, we have, as a mat- ter of course, to trace the causes of the disease to faulty nutrition. The great and frequent transgressions of which parents are guilty in this respect, may be inferred from the frequency of this disorder. Whore children are simply brought up on milk, the causes may be of two kinds : The milk is either bad, or else the good milk is given the child in improper quantity and form. The milk is bad when it comes from women who are again menstruating, or who are sick, or are laboring under the effects of some severe mental or moral dis- turbance, or who nurse their children too long. This last cir- cumstance is a main cause of the frequent attacks of illness of children, of one or two years old, among the poorer classes; more particularly of peasant wives, who sometimes nurse their children to the age of three or five years, in order to prevent conception. That this supposition is correct, is evident from the fact that chil- dren improve as soon as they are weaned and properly fed with more appropriate nourishment. Cow-milk may likewise be bad food for children who are brought up by hand, more particularly if it comes from a diseased cow or from a cow whose milk is too old. The sec- ond point is still more important, for the reason that it occurs more frequently; if we do not dwell upon it more fully, it is because we cannot spare the space for such a disquisition. It is highly improper to feed the child too frequently: as soon as the child stirs, it is put to the breast, or the bottle is given. Now we know that it takes two full hours to digest milk. If the child is fed again before this period has elapsed, the fresh supply is added to the half-digested contents, so that neither portion is properly digested, and the con sequences of catarrh of the stomach very soon make their appear- ance. That this must be so, every adult person may observe on himself; let him take nourishment for a few days every hour or two hours, and he will soon experience symptoms of gastric catarrh. If bad milk is added to the excessive feeding, illness must necessarily result. Beside the above-mentioned circumstances, want of attention to cleanliness constitutes another cause of sickness. The milk is not fresh enough, or the bottles and nurslings are not kept clean, or the mother forgets to cleanse the nipple before the child is put to it, so 340 Diseases of the Stomach. that the child draws in the decomposed milk, that may have re- mained adhering to the nipple, with the fresh milk from the breast; and we know full well that the stomach of the child is not capable of resisting the deleterious influence of this spurious nourishment. It is a peculiarity of some children's stomachs to reject fresh cow- milk, whereas boiled milk agrees with them ; yet the reverse is com- monly the case. Where the child is not exclusively fed on milk, the gates are wide open to an attack of sickness. For children who have no teeth, milk is the only proper food, in spite of everything that may be said to the contrary. All slimy, farinaceous or sweetened articles of diet are generally hurtful. If the bad effects are not seen at once, let us watch children that have been brought up on such food, in their second year, and we shall find that their apparent embonpoint is not natural, and that they are troubled with a disposition to derangement of the stomach. Usually, however, this result is observed in the first months after this method of feeding the chil- dren has been commenced. The mixed food is assimilated so much the less readily, the younger the child; this truth is so firmly estab- lished that it is inconceivable how experienced practitioners can recommend slimy decoctions for children immediately after birth, together with a small quantity of milk, and how they do not even seem to suspect that the sickliness of children with whom this sys- tem is pursued results from improper nutrition. Instances of this kind are of daily occurrence. The only food, beside milk, which agrees with the digestive organs of children, is the extract of beef, prepared cold, of which we shall speak more fully when describing the treatment of this affection. If the child, with its stomach pre- served in its normal condition by means of adequate nourishment, has arrived at the period of dentition, it has to encounter other dangers in the next following period, which includes two great changes in the infantile development, namely: the cutting of the teeth and the beginning of a mixed diet. The last-mentioned change is either initiated too soon, that is, before at least four teeth are through, which fact is generally a sign that other food besides milk may be introduced into the stomach; or else the transition is too sudden, and we expect the infantile stomach, which has had nothing but milk so far, to digest, the very next day, all kinds of farinaceous food. Such irrational changes beget an impoverished condition of the tissues, and we often see children who had become robust and fleshy at the mother's breast, emaciate shortly after they are weaned. Catarrhus Ventriculi Acutus. 341 Ordinary people, so far from noticing this change, do not even sus- pect its real causes, namely: improper food and disturbed digestion. They even smile if they hear a physician volunteering such state- ments. Besides the above-mentioned circumstances in the mode of nutri- tion to which children are subjected, we will mention another cus- tom which met with a great deal of favor in former times, and' which has been the certain cause of a great many cases of catarrh of the stomach-we mean the so-called bibs. The decomposition of the remaining particles of milk which such a bag causes in the mouth, and the almost invariably following derangement of the stomach, show that it is no superfluous precaution to carefully cleanse the bottles, nipples, and the mouth of the child, in order to prevent the decomposed particles of milk from getting into the stomach. Symptoms, The first morbid symptom generally is vomiting. We know that a certain kind of vomiting is one of the phenomena of health, in a little infant, provided the infant is without fever and grows fat, and unless the milk which is discharged immediately after nursing is not curdled, whereas the milk which is thrown off some time after nursing should be curdled. Where these symptoms are not present, the vomiting has an entirely different significance, and leads us to infer the presence of gastric catarrh. As a general rule, the morbid vomiting takes place some time after nursing, the little patient throwing off milk which is either uncoagulated or only partially curdled, and shows an admixture of mucus after the disease has lasted for a short period. The milk which is thrown off shortly after nursing is less frequently completely curdled, and has a very sour smell. The children do not seem to suffer much at the commencement; they look a little paler and more sunken than usual; their appetite is good, sometimes it seems even better than usual, which, however, may be owing to the circumstance that the children are very thirsty and may want to drink rather than eat; at any rate, they swallow with great avidity small quantities of fresh water, and the mouth is evidently very dry. Very soon the vomiting is followed by increased restlessness; bloating of the region of the stomach, which seems very sensitive; drawing up of the lower extremities, and crying immediately after partaking of food. The skin feels hot and dry, and less elastic. This increase of morbid symptoms is attended with irregularity of the alvine evacuations. They are loose, of irregular color, yellow, green or brown; they 342 Diseases of the Stomach. contain undigested milky coagula, sometimes of large size, and resembling stirred eggs; their odor is very much changed, at first sometimes sour apd afterwards fetid. Such a slight attack of gastric catarrh sometimes terminates in recovery in a few days, although an unusually rapid emaciation is always a striking symptom. On the contrary, if the disease turns but unfavorably, the most threatening symptoms set in very rapidly. The vomiting occurs less frequently, for the simple reason that much less nourishment is introduced into the stomach, but it has an in- tensely sour smell, and contains a large quantity of mucus. The diarrhoea increases, assumes a liquid consistence, of a lighter color, so that the main portion of the evacuations is colorless, and only contains a few isolated yellow or greenish cheesy coagula; their odor continues sour, but has a peculiarly disagreeable smell. The evacuations are seldom more consistent, gray or entirely white, but very fetid. With these very violent symptoms in the digestive range, the greater intensity of the constitutional symptoms corre- sponds. The children sink very rapidly, and their features acquire a peculiar expression of suffering, with the folds in the face deepen- ing more and more. The temperature of the trunk is raised above the normal standard, while the extremities feel cold. The appetite vanishes, the children refuse the breast or bottle, and only draw very feebly, if they touch the bottle at all; on the contrary, they swal- low cold water with great avidity ; hence they are very thirsty. The restlessness yields to sopor, during which they lie with their eyes half closed, and often squinting. Their ordinary crying ceases, they merely utter plaintive moans, more particularly about the time when they soil their diapers. If the disease has progressed thus far, there is the greatest danger that convulsions and other cerebral symptoms may terminate the patient's life. In case of a favorable turn, the vomiting gradually ceases, the diarrhoeic stools become less frequent, have a better color, and the appetite returns. Con- valescence progresses very slowly, and relapses are readily brought about by the slightest errors in diet. The disease is sometimes of very short duration, even in fatal eases, but it may extend beyond several weeks. Gastric catarrhs running a very rapid course are always attended with violent intes- tinal symptoms, and will be treated of more fully in the chapter on gastro-intestinal catarrh, under the appellation of cholera in- fantum. The pathologico-anatomical changes, produced by gastric catarrh Catarrhus Ventriculis Acutus. 343 in the case of adults, are too unimportant and unessential to require a more special description at our hands. On the contrary it be- hooves us to add a few remarks on the post-mortem appearances in the case of children. In their case the stomach is often found soft- ened, a change that so far has given rise to many differences of opinion. According to some, gastromalacia is an idiopathic morbid process, observing its own laws, and running its own specific course; according to others, it is a post-mortem appearance, which begins when gastric catarrh assumes its most violent form, and can, there- fore, be diagnosed with perfect certainty in some particular cases. The latter supposition is undoubtedly the best founded, and is more especially corroborated by experiments made upon the exsected stomachs of animals. If such stomachs are filled with milk, and are placed for a short period near a warm place, they show all the anatomical signs of gastromalacia. In a similar manner gastroma- lacia is said to develop itself in an infant, if, shortly before death, milk is introduced into the stomach, and fermentation takes place during the fatal hour. This view is confirmed by the fact that the stomach has been found softened, in the case of children who did not show a single sign of the disease while still alive, and who par- took of a little milk shortly before death. It being of the utmost importance, in a therapeutic point of view, that this disorder should be diagnosed with perfect certainty, we will add a few additional remarks. The lower grades of acute gastric catarrh cannot easily be confounded with other affections, except with gastric fever. This fever but too often has the ap pearance of typhoid fever, and it is of the utmost importance for a physician, that he should not diagnose falsely at the onset, and in a few days should have to give a different prognosis. The most essential characteristics of typhus are: the breaking out of the dis- ease without any demonstrable exciting causes, especially errors in diet; a higher temperature of the skin, and an increased frequency of the pulse. In the further course of the disease, so many pathog- nomonic signs turn up, that it is scarcely possible to confound the two diseases. The existence of herpes labialis positively precludes the idea that the disease before us is typhoid fever. Treatment. Although it may be impossible, in the case of adults, to ward off gastric catarrh by means of an energetic prophy- lactic treatment, we should not lose sight of it whenever repeated attacks, or other reasons, have satisfied us of the existence of a pre- disposition to this disease. It is more particularly in the case of 344 Diseases of the Stomach. persons who are convalescing from an attack of gastric fever, that the greatest caution has to he observed in the use and selection of articles of diet, lest a relapse should take place by the use of inap- propriate nourishment. In the case of children the employment of prophylactic means is not only more important, but likewise much more gratifying. By imparting proper instructions to the parents, and exerting a proper control over their management, a physician has it. in his power not only to .protect the infant from many an attack of illness, but also to save himself a good deal of trouble. The main points have already been stated in the paragraph on the etiology of acute gastric catarrh, and what has not been said in that place, can easily be inferred from the remarks there made. Before mentioning the remedies belonging to this class, we beg leave to cast a glance at the ordinary method of treating this dis- ease. The most common prescription is an emetic. Is this treat- ment proper or not ? It is known that the stomach has been made sick and irritated by the use of hurtful or too copious quantities of food, and it is undoubtedly natural to jump at the conclusion that the noxious material must be removed, in order to restore the nor- mal condition of the stomach. We sometimes succeed in accom- plishing this result. More frequently, however, the emetic adds an additional irritation to that which is already existing, and, instead of abbreviating the affection, its duration, on the contrary, is lengthened, and with the duration its intensity. Hence this method is more or less hazardous, so much more as we are in pos- session of easier means to reach the same end. The use of tepid water, in case a desire to vomit should be felt, is a much safer emetic than Tartar emetic or Ipecacuanha. Next to the emetic, a purgative is most thought of. Now, we have no purgative that does not more or less irritate the stomach, and after that the intes- tinal canal; hence the gastric disorder is increased first, after which the intestine, which is so very greatly disposed to sympathize with the condition of the stomach, becomes still more disposed to become involved in the gastric derangement, so that, instead of abbrevi- ating, we, on the contrary, prolong the suffering. In the place of such violent means, Homoeopathy possesses remedial resources that act much more rapidly and safely than any others. However, soon after exhibiting the suitable remedy, we often provoke vomit- ing and diarrhoea ; but these are simply critical evacuations, and of good omen. In such cases it will not be necessary to change the medicine. Catarrhus Ventriculi Acutus. 345 As regards the selection of the proper remedy, we have already given our reasons why it is a difficult and often deceptive task. In every pathogenesis we find, under the head " Stomach," all the symp- toms of catarrh of the stomach, and yet not every medicine of this kind is on that account a remedy for gastric catarrh. As in the case of toothache, experience has had to confirm the practical value of the symptoms, and has thus pointed out a small number of med- icines that have reliably curative effects in this disease. Here we have another proof that the superficial selection of a remedy, in accordance with mere symptoms, will often deceive us, and can only lead to good results if the origin and combination of every symptom in the provings have been logically stated. We will first give a cursory view of the chief remedies for gastric catarrh, and shall afterwards endeavor to bring them into homoeopathic accord with each form and stage of the disease. To judge by the success that has been obtained with Bryonia alba, this medicine is the leading remedy in this disease. The symptoms having special reference to the stomach, are full of meaning, and are, moreover, supported by corresponding symptoms in other sys- tems and organs. The aggravation of the symptoms by eating, the sensitiveness and bloating of the prsecordial region, the painful sen- sation of swelling in this region, the nausea with disposition to vomit up the ingesta, point more particularly to catarrh of the stomach. Besides these symptoms, the following deserve particular attention: nausea, with feeling of coldness and chills, soon after midnight, followed by vomiting of the ingesta, which, in its turn, is succeeded by vomiting of mucus and bile; sweetish, insipid, pappy and nauseous taste; sensation of hunger, with complete ab- sence of appetite, or even loathing of food. To these symptoms we add the following passage from Hartmann : Bryonia is a distin- guished remedy in gastric fevers which emanate from a twofold cause, a cold, and mortified feelings. The gastric symptoms are attended with severe feverish heat mingled with chills, lassitude, aggravation of the symptoms at night, irritable nervousness and frontal headache, as if the forehead would split open ; constipation and rheumatic distress generally. Belladonna has no less marked symptoms than Bryonia, the local symptoms, however, being much more violent and the fever more intense. The pain in the stomach is very violent, stinging, cutting, contracting, with prevalence of violent pressure, aggravated by eat- ing any kind of food, with distension of the epigastrium. Great 346 Diseases of the Stomach. nausea results in difficult vomiting with straining, the patient brings up mucus and bile rather than food. The appetite is gone, the thirst intense, but only for sour and piquant beverages. Charac- teristic indications for Belladonna are gastric catarrh accompanied by catarrh of the mouth and pharynx, and evidently owe their ori- gin to a severe cold. With such catarrhs the fever is always very acute, the skin, however, is moist in spite of the heat, the head feels dull and tight. Such conditions are mostly met with only in the case of children, for whom this medicine is a real panacea in such affections. The breath has a foul or sulphurous smell. Ipecacuanha is a chief remedy for gastric catarrh, without fever, or when the fever is very slight, more particularly if the catarrh had originated in overloading the stomach or eating fat food. The stomach symptoms are: feeling of emptiness, pressure, stitches, pinching pains, with bloating of the pit of the stomach. Other characteristic symptoms are: insipid, bitter or rancid taste, as from spoiled oil, no appetite, or only a desire for sweet and delicate things, a symptom which is frequently met with in the case of children ; vomiting of the ingesta, afterwards of bile and quantities of mucus, accompanied by diarrhoea. The gastric catarrhs corre- sponding to Ipecacuanha generally occur in the hot season, it is sel- dom indicated in gastric catarrhs of the winter-months. Pulsatilla is in many respects similar to the previously mentioned remedy. It is likewise adapted to gastric catarrhs brought on by eating fat food, but likewise to catarrhs caused by cold fruit, ices, or acid food. There is no fever except chilliness or chilly creepings. A characteristic symptom is the sensation as if the food were lodged undigested above the stomach. The taste is greasy, rancid, bitter or very slimy, the eructations arc bilious or acrid: there is no appetite, warm food is especially repulsive. The tongue has a thick white or yellowish coating. Other characteristic symptoms are the complete absence of thirst, and the irritable, whining mood, like- wise the aggravation of the symptoms during the hours preceding midnight. According to Hartmann, Pulsatilla is likewise suitable for the subsequent nervousness, prostration, chilliness and loss of appetite, which symptoms sometimes remain after gastric fever. Nux vomica is particularly adapted to catarrhs arising from the excessive use of spirits or coffee, or from a fit of chagrin. In attacks arising from other causes, it is often suitable at a later period of the catarrh after the fever has entirely disappeared. The stomach symptoms are not very intense. The region of the stomach is somewhat sensitive, but not a great deal, nor does it correspond Catarrhus Ventriculi Acutus. 347 to the bloat; the sensation of fulness is somewhat troublesome, and the prevailing pain is a severe pressure. The taste is sour or bitter or sulphurous, the tongue is thickly coated. Symptoms of marked prominence, are the continued frontal headache, especially during the morning hours, with sensation as if the brain were loose; and the aversion to bread and milk. Antimonium crudum is one of the chief remedies for gastric catarrh without fever. It is most suitable if the catarrh is caused by over- loading the stomach; the contents of the stomach have been re- jected, but great nausea is still remaining. The region of the stomach is not very sensitive, the pain is principally a clawing or pressing pain and comes on in paroxysms. The tongue has a thick whitish coating, the breath has a foul or unpleasantly sweetish odor; the mouth is slimy, the appetite is not entirely gone, or else there is a sensation of hunger with loathing of food; the thirst is tormenting, with eructations without any particular taste. The general condi- tion of the system is unfavorable, the patient feels very languid. The bowels are torpid; there is never any very troublesome diarrhoea. Acidum phosphoricum is an excellent remedy if the characteristic local symptoms are entirely wanting; there is no fever, but ekces- ^ive debility with complete loss of appetite. Conditions of this kind sometimes occur somewhat epidemically, having the appear- ance of typhoid fever. These remedies will generally suffice to cure any attack of gastric catarrh; of other medicines that may likewise prove serviceable, we will give a cursory list in accordance with Hartmann's example. In the lower grades of gastric catarrh, it is of importance to be acquainted with the exciting cause, in order to be certain of the specific remedy. If arising from overloading the stomach, hunger is certainly the best remedy. Only gruel should be allowed, and a little black coffee at the commencement, which is apt to result in a critical discharge from the bowels. If there is a marked disposition to vomit, coffee is of no avail, because it makes the vomiting more difficult; a little tepid water had better be drank first, in order to facilitate the vomiting, and afterwards a little coffee may be used. If fat food is the cause, we give Pulsatilla or Ipecacuanha; after cold fruit or ices, Arsenicum or Pulsatilla; after a fit of anger or chagrin, Chamomilla or Bryonia; after spirits or coffee, Nux vom- ica ; after mental or bodily efforts immediately after a meal, Nux vom- ica ; after continued grief and chagrin, Ignatia and Staph ysag ria ; in the case of debilitated individuals, China is recommended; to anaemic females we give Ferrum, Pulsatilla or Arsenicum. 348 Diseases of the Stomach. The higher grade of gastric catarrh, or the gastric fever proper, seldom follows immediately, as soon as the influence of the exciting cause is perceived ; there generally occurs a preliminary gastric derangement, unless, perhaps, some atmospheric or other cause, not amenable to observation, should induce a sudden breaking out of the fever without any special precursory symptoms. Many physi- cians recommend Aconite for the incipient fever, if it is sufficiently marked; but we confess we look upon this use of Aconite as a loss of time. If the fever is violent, which is not often the case in the gastric fever of adults, Belladonna does more efficient service than Aconite, more particularly if the region of the stomach is very painful and puffed up. If the fever is not very violent, the local symptoms less prominent, the symptoms of a general constitu- tional disturbance are threateningly conspicuous, and there is a resemblance to incipient typhus, Bryonia will be found the most suitable medicine. Ipecacua,nha is preferable to Bryonia if the gas- tric symptoms are very violent, and there is great loathing of food, continued nausea and frequent vomiting, without the tongue being much coated. Beside these two remedies, Pulsatilla and Tartar emetic may be found suitable at the commencement of the attack. In the subsequent course of the disease, when the urging to vomit, has completely disappeared, and there only remains great weakness of the stomach, Nux vomica deserves our highest attention; after taking which, the appetite sometimes returns with remarkable rapidity, and convalescence takes place. Acidum phosphoricum and Antimonium crudum. may deserve attention at this period of the disease. For the frequently remaining debility, China is the chief remedy; Ferrum may likewise do good, especially in the case of chlorotic individuals; so may Arsenicum, especially if the debility is accompanied by severe pains in the stomach. Colocynthis is less a remedy for genuine gastric catarrh,than fora peculiar condition of the stomach that can be traced to a cold as its exciting cause. The appetite is not entirely gone, nor do they greatly complain of nausea or aversion to food; but the region of the stomach is sensitive, and, after eating, the patients complain of raging crampy pain, which can only be moderated by warm appli- cations ; there is neither bloat nor belching up of wind. Evidently the pain chiefly resides in the muscular fibres of the stomach, and has very much the character of colic pains. These symptoms yield to Colocynth very soon. Such conditions are generally met with only during the transition-seasons when the air is cold, but the sun Catarrhus Ventriculi Acutus. 349 is still powerful enough to heat the blood; they likewise occur in summer, in consequence of sudden changes in the weather. In ordinary cases of infantile gastric catarrh, the above-mentioned remedies are undoubtedly applicable ; but it is often difficult to dis- cover the right remedy, for the reason that the patients are too young to explain their distress. For this reason it is well, if no improvement takes place after a time, to frequently change the medicine, for it is more than likely that it is not adapted to the case. As we said above, the first symptom is vomiting. If vomiting takes place soon after feeding, and the milk is thrown off unchanged, Ipecacuanha should be the first remedy given. After Ipecac, the normal condition of the stomach will soon return, provided the proper dietetic measures are resorted to in other respects. If the vomiting is excessive, the child seems very sick, and a rapid col- lapse takes place, Veratrum album is preferable to Ipecacuanha; it is likewise indicated by the absence of diarrhoea. If, soon after nursing, the milk is rejected in a curdled state, if it has a sour smell and is, as usual, mixed with a good deal of mucus, Pulsatilla is pre- ferable, provided there is little or no diarrhoea; Chamomilla, on the contrary, if copious greenish diarrhoeic stools are present. Veratrum may be suitable in such cases, especially if the evacuations contain only a very trifling admixture of bile. If the vomiting takes place a long time after nursing, and the milk is not decomposed, Nux vomica is the very best remedy. This last-mentioned form of vomit- ing is generally the most dangerous, and is easily succeeded by the most threatening phenomena, so that Arsenicum and Creasotum may have to be administered. In such a case we have no longer to deal with the simple gastric catarrh, but with the gastro-intestinal catarrh, of which we shall treat in a subsequent paragraph. If the disease sets in in a rather mild form, and the little patients pine away slowly, Cuprum is entirely in its place, likewise China. If the trouble arises from sickness of the mother or nurse, we have to inquire carefully into the causes and circumstances, and it is well to give the nursing female the same medicine that is taken by the child. If a sudden emotion is the cause, Ignatia may be the right remedy; after a violent fit of chagrin, we give Chamomilla ; after fright and a subdued but violent mortification of the feelings, we give Opium; after drinking spirits, Nux vomica or Tartar emetic; after partaking of other kinds of food or drink, we give the reme- dies that have been mentioned previously. If the affection threat- ens to become chronic, we give the medicines that will be mentioned in the next chapter. 350 Diseases of the Stomach. As regards the most suitable diet for children, we have also stated all that need be said on the subject, in a former chapter; we will here simply add a description of the method in which the extract of beef should be prepared. Take lean meat from a recently killed ox that is not too young, cut it fine and pour four times its weight of cold water upon it. Stir occasionally and let it draw for three- quarters of an hour or a whole hour, add a very small quantity of kitchen salt, allow the whole to boil up once over a good fire, and sift through a strainer. This extract is well-tasting, strong and adapted to the weakest organs of digestion; according to circum- stances it may be mixed with milk, or sweetened with a little sugar, and the little patients may drink of it at least twice a day. The extract has to be made fr 'sh every third day. Any other decoction of meat is averse to the child's taste, or agrees less or not at all with its stomach. This remark is particularly applicable to veal-broth, which is still preferred by many physicians and lay-persons to beef- tea, both for children and debilitated adults, although everybody might easily understand that it is rather indigestible and not very nourishing. Further remarks on this subject will be deferred to the next chapter in order to avoid unnecessary repetitions. 2. Catarrhus Ventriculi Chronicus, Chronic Catarrh of the Stomach. Dyspepsia. Both the acute and chronic catarrh of the stomach are very common complaints. Like the acute catarrh, so is the chronic form a very common accompaniment of other diseases, but likewise occurs quite frequently as an idiopathic affection. It is the frequency of its occurrence, together with its great importance, either as a complication or an independent disease, that has induced us to de- vote a special chapter to its description and treatment. Chronic catarrh of the stomach often arises from the acute form, in consequence of its not being completely cured, or, by repeated attacks causing a deep-seated alteration of the lining membrane of the stomach, or in consequence of the morbid condition being kept up by improper diet. In this respect all the deleterious influences of which mention was made' in the previous chapter, are to be re- garded as etiological causes of the disease. Besides these different originating circumstances, the chronic form may likewise arise from the commencement as an independent disease; it maybe caused by frequent derangements of the digestive process, in consequence of Catarrhus Ventriculi Chronicus. 351 mental exertion, emotions shortly after a meal, too frequent eating, or by continued depressing affections, and, finally, by the habitual abuse of spirits, more particularly spirits containing a large percent- age of alcohol. Chronic catarrh of the stomach likewise occurs as a coexisting complication in a variety of other diseases, such as anae- mia, hydrsemia, tuberculosis, liver complaint, affections of the spleen, pancreas, heart disease, pulmonary catarrh, etc. The in- fluence of pregnancy upon the stomach likewise occasions, in many instances, a very obstinate and severe catarrh of the stomach. The symptoms of chronic catarrh of the stomach are very vari- ous, on which account it is exceedingly difficult to furnish a com- plete picture of the disease, including its origin and course; hence it is preferable to treat of each particular phenomenon as a detached manifestation of the ailment. Among the local symptoms the pain in the epigastrium occupies the first rank, as regards frequency. It is seldom violent and mostly amoun's to a painful sensation of pressure in the region of the stomach, which is either distended in reality, or feels as if it were. The pain is scarcely ever a stinging or burning pain, nor does it break out in distinct paroxysms like cardialgia. It is almost always aggravated or excited by the digestive process, or may likewise be increased by external pressure. It is characteristic of this disorder to be variously excited by various substances. Whereas one person cannot bear rye-bread, another eats fresh bread with perfect im- punity. With others meat, milk, beer or cold food, do not agree. Scarcely any one afflicted with chronic gastric catarrh, is able to partake of acrid, sour or fatty substances, without experiencing dis- tressing results. So far it has been impossible, even to chemistry, to account for these differences. To judge by the local pain, a dis- turbance of the digestive process is evidently the most constant symptom. The food is digested very slowly, sometimes remains in the stomach for days, thereby causing a variety of striking symp- toms, among which heartburn and flatulence are most prominent. The latter may exist to an excessive degree, causing a distinct puffing of the epigastrium. The gas is either belched up with a feeling of relief, or else it passes off by the rectum with a great deal of trouble from the flatulence; at times it has no smell and at other times the odor is very fetid. Although the acute catarrh is often attended with vomiting, yet it is seldom present in the chronic form. If vomiting occurs, the ingesta are seldom included ; where this is the case, there is every reason to suspect the existence of a 352 Diseases of the Stomach. very troublesome and dangerous alteration of the coats of the stom- ach. Most generally the vomiting is slimy, tenacious, ropy, insipid, attended with great straining, and commonly takes place in the morning or after the digestion is accomplished. In other cases it is more like a frothy, liquid saliva, with an occasional admixture of bile or acids from the stomachs, that are constantly brought up with an extremely tormenting effort. The mere ascension of the fluid as far as the pharynx, is much more frequent than actual vomiting; this commonly imparts to the patient a sensation as if a worm were crawling up the oesophagus. These more local symptoms are never isolated, but are generally accompanied by more or less considerable changes in other organs, or in the constitutional state of the patient. A common companion of chronic gastric catarrh, is the catarrhal affection of the buccal cavity. The tongue is covered with a thick coating, especially at the root, the whole of the mucous lining is swollen, the breath has a disagreeable smell. At the same time the taste is generally insipid, slimy, or is entirely suspended, or perverse; the saliva is secreted in increased quantity. The appetite varies; at times it seems quite normal, at other times it is increased, usually it is less or even extinguished. The patients have, it is true, the sensation of appetite which is sometimes increased even to canine hunger, but all desire to eat has vanished. The increase of appetite is sometimes only apparent, the patients often eat sparingly, finding it impossible to eat larger portions at one time. Almost all such patients are devoured by a desire for sharp or piquant aliments, which, however, are relished only for a short time and are rapidly exchanged for others. The thirst is seldom increased. The stools are either as usual, or less, and, in consequence of the participation of the intestinal canal in the catarrhal process, are lined and per- meated with mucus. Even in the lesser degrees of the disease, headache is seldom wanting; most frequently it is a dull pressure in the forehead, with dulness of the whole head, ill-humor, hypochondriac mood, irri- table temper, want of disposition to work, drowsiness in the day- time and sleeplessness at night. If the disease lasts any time and acquires a higher degree of intensity, the assimilative functions become rapidly and severely depressed, the countenance assumes a yellowish-gray hue, the expression is that of suffering and mental and moral disturbance. At this stage the liver and pancreas become Catarrhus Ventriculi Chronicus. 353 readily involved, the urinary secretions become morbidly altered, urates being secreted in more copious quantities. If left to itself, the course of the disease is, under all circum- stances, a very protracted one. Under proper management most cases terminate favorably. If certain deleteriou influences continue to affect the stomach, gastric catarrh may, without any other com- plication, lead to gradual emaciation and death, or certain degener- ations of the mucous lining may result, that may finally terminate fatally. Among these, the chronic ulcer of the stomach is the most dangerous, next to which we class hemorrhage from the stomach, and lastly hypertrophy of the mucous membrane. The last-men- tioned disorganization leads to stricture of the pylorus and conse- quent dilatation of the stomach, which usually results fatally, although after a long period. In this case there is constant vomit- ing, which has the peculiarity of occurring a few hours after eat- ing, when the stomach digestion is entirely completed. The food is vomited up completely digested, with an admixture of water and mucus. The vomiting is exceedingly distressing and occurs at regular intervals. Although this state of things exerts a most deleterious influence upon the assimilative powers of the organism, yet the patients may drag their miserable existence along for eight years and more. The anatomical changes in this disease, provided it has not run too protracted or too violent a course, usually consist in an insular or unequally distributed puffing of the mucous membrane of the stomach, either of a very pale, or dark-red or gray color. The ves- sels at these places are injected, varicose and prominent. In violent cases of long duration the other membranes are likewise very much thickened, but not throughout; only in part and most prominently at the pylorus. In such a case the folds of the mucous membrane are more distinct, the single follicles project, so that in some cases they form a shaggy surface. The extensive hypertrophy of the coats causes a stricture of the pylorus, and vice versa, the stricture of the pylorus leads to dilatation of the stomach. Superficial erosions and ulcers are frequently met with. We will treat of the diagnosis of gastric catarrh when we come to treat of the affections with which it is easily confounded. Treatment. As in the acute form, so in the chronic, the diet plays an important part, since it has to be regulated not only with a view of meeting the cause but, likewise, the characteristics of the disease; hence we prefer devoting a more extended chapter to its claims. 354 Diseases of the Stomach. Of course the habitual use of hurtful substances has to be strictly avoided. Spirits containing a good deal of alcohol are to be entirely prohibited, in the case of persons who are made sick by such things. In other cases, on the contrary, the moderate use of good wine, even of rum or cognac, improves and even removes the dis- ease, as is often witnessed among farmers' wives, who use the two last-mentioned beverages as domestic medicines, and sometimes with excellent success. The use of coffee is sometimes the sole cause of the disease; it is more hurtful in the shape of a powerful extract and adulterated with surrogates, than when drank strong and properly filtered. For this reason we see women made sick by the use of coffee much more frequently than men, and country people more frequently than the inhabitants of cities; that this observa- tion is correct, follows from the circumstance that the patients get well as soon as they leave off the use of coffee. The peculiar power of coffee to retard digestion-lay persons generally believe the con- trary-renders even the best quality of coffee a prejudicial article of diet to all patients whose digestion is naturally very slow; it is more particularly immediately after a meal that coffee must be avoided, for at such a time it might excite the rising of sour water and increase the pressure. The pleasantly stimulating and thirst- quenching effect of coffee is only momentary and should deceive no one, for the malaise induced by coffee, generally, is not experi- enced until half an hour or more has elapsed. Tea has pretty much the same effect as coffee, except that it agrees much better with some, and proves an excellent sedative to others. At all events it is not a reliable beverage, for we are scarcely ever perfectly sure of obtaining it unadulterated and suitably prepared. Fat is to be avoided, particularly boiled or fried fat, whereas small quantities of raw fat are easily digested. To this class belong all kinds of fat meat, all kinds of baked or farinaceous dishes pre- pared with fat, all kinds of vegetables boiled with a great deal of fat, and finally the different kinds of fat gravies. All do not comprehend why this kind of food should hurt them, although their own feelings might tell them that it does. Finally we have to oppose the abuse of spices with all firmness, however such advice may be disliked by patients who love spiced food for the reason that it stimulates their bad appetite. Next to these articles of diet which are hurtful under all circum- stances, the manner in which food is to be eaten, likewise deserves our attention. We cannot enumerate all the bad habits which are Catarrhus Ventriculi Chronicus. 355 indulged in at table, on the contrary we prefer to show how the meal should be partaken of. Above all, the food has to be properly masticated and eaten slowly, nor should it be swallowed when yet very hot. After eating, the stomach must not be pressed upon by an inappropriate posture of the body, nor is a recumbent posture advisable; severe bodily exercise is as prejudicial as hard mental labor; a reclining-sitting posture is the most suitable. A single deviation from these rules is often sufficient to render chronic catarrh of the stomach a permanent disease, and, inasmuch as the physician does not always become acquainted with the dietetic trans- gressions of his patients, the best rule he can adopt is to give posi- tive instructions regarding the diet to be observed and the manner of eating. However, it is impossible to indicate positive general rules by which the patient can be bound in all cases. The patient has to find out what ao-rees with him, and all we can do is to see to it that he does not commit any positive infractions of dietetic rules. We shall scarcely ever be able to determine a priori whether the one or the other regime will have a favorable influence upon the patient. What is pleasant to one person, is often repulsive to another. A great deal evidently depends upon our former habits; Whereas simple food agrees much better with a person who has been ac- customed to luxurious habits, others require the most invigorating nourishment. One cannot bear milk, whereas another thrives under its use. The same is true with regard to meat, to some it does good whereas it is hurtful to others. This shows that the plan of pre- scribing fixed dietetic rules is not feasible; and in no affection has the individuality of the patient to be regarded with so much care as in chronic catarrh of the stomach. We will mention, however, a few more general points of view. As a rule, physicians dread to allow the use of fruit in affections of the stomach. These apprehen- sions and doubts may be well-founded, if the acid of the fruit de- composes, or interferes with the action of certain medicinal sub- stances ; or if the stomach has become so sensitive, in consequence of the abuse of drugs, that it cannot bear the most harmless article of nourishment. Under homoeopathic treatment such cases never occur, and inasmuch as good fruit is most excellent to regulate di- gestion, the use of it should be encouraged instead of being forbid- den. Fruit is, moreover, very refreshing to the patient. Few per- sons only do not readily digest it, only we may try to find out in what shape it agrees with them best, fresh or stewed, or dried fruit 356 Diseases of the Stomach. stewed. In corroboration of these views we refer the reader to the well-known grape-cures. Beer likewise is a beverage, the use of which is sometimes denied and at other times highly praised. The mod- erate use of ale has often a surprisingly good effect in the case of women; we do not know any good reason why such a beverage should be prohibited. The case is different with beer-drinkers. In- asmuch, however, as beer seldom causes catarrh of the stomach, it is not well that beer-drinkers should be forbidden the use of their favorite beverage at once, without rhyme or reason. There may be differences of opinion regarding the use of ale, but our sweet-beer deserves favorable consideration on the part of all physicians. When not spoiled, it is undoubtedly the best artificial beverage; its use is not only urgently to be recommended in catarrh of the stomach, but likewise in all febrile affections. When used in the latter, it is a good plan to add a little sugar and to allow part of the car- bonic acid to escape. This course should likewise be adopted in acute gastric catarrh; beer, however, should not be drank if the patient has to vomit a great deal. If beer does not agree with a person cold, it frequently does the same amount of good if boiled with a little sugar, except that in such a form it is not near so refreshing. • In conclusion we have again to call attention to milk in a few words. We have already shown that a rigorous milk diet is suffi- cient to cure gastric catarrh. With many it does not agree at all, with others only when recently drawn, others can only use it when boiled. This knowledge has to be acquired by cautious experi- ments ; the patient must not be injured by obstinately insisting upon a preconceived method on the part of his medical adviser. Many experience the greatest amount of comfort from drinking sour milk, but this is less fre mently the case. Fresh buttermilk agrees with persons more generally than any other kind of milk. If we desire to institute a milk cure, it is best to begin with butter- milk, if we have a favorable opportunity of obtaining it. It need scarcely be observed that the balance of the patient's physical conduct must not be neglected, and that every thing con- cerning it must be regulated in accordance with sound principles of health. Since it cannot be denied that catarrh of the stomach is not only caused, but likewise maintained, by a disposition to take cold, cold ablutions of the trunk, together with a reasonable amount of clothing, are of essential benefit. In enumerating the medicines belonging to this class, we meet Catarrhus Ventriculi Chronicus. 357 with several difficulties. In the first place, it is impossible to make use of the existing literature with any certainty, for the reason that we find gastric catarrh described under a variety of names, accord- ing as one or the other symptom is more prominent, sometimes as vomiting, or at other times as heartburn, or weak stomach, or car- dialgia, chronic gastritis, etc. Since all these symptoms may occur without the existence of chronic catarrh of the stomach, we find a reference to our existing literature an uncertain business, so much more as the diagnosis is very often incomplete. The changing forms of the symptomatic combinations, likewise render it difficult to indi- cate remedies for the main group of symptoms constituting gastric catarrh. Hence, in special cases, the reader will have to institute frequent comparisons with the Materia Medica, which are so much more necessary, as the number of the remedies we shall have to mention is necessarily large. Nux vomica. We frequently meet in our literature with the statement that Nux is only adapted to nervous affections of the stomach, not to affections with a material basis. Even in the ab- sence of other satisfactory reasons, experience ought to be sufficient to upset views of this kind. For gastric affections arising from the use of spirits, coffee, wine, etc., we scarcely know of a better rem- edy than Nux vomica; and it is a well known fact, that these sub- stances engender gastric catarrh in its most prominent form. In making this statement we do not mean to deny that Nux vomica is likewise adapted to neuralgia of the stomach, but we must not too hastily assume the existence of pure cardialgia, which is un- doubtedly a somewhat rare disease. The stomach-symptoms of Nux are very numerous. This fact shows the characteristic rela- tion of Nux to affections of the stomach, and justifies us in giving prominence to the phenomena in which Nux has evinced a specific curative power. The taste is either bitter or sour, so that the food seems to have an altered taste. Coffee is repulsive, likewise tobacco and rye-bread. The appetite is gone, yet there is a sensation of hunger, which even increases to canine hunger. The symptoms are either excited or made worse by eating. After every meal there are violent, or even painful, bitter or sour eructations. Nausea and a disposition to vomit are not strongly marked; there is not much vomiting, and then only of water and mucus. The region of the stomach is sensitive, especially after a meal, and generally distended. The pains in the stomach are more especially a hard pressure, less frequently tearing or crampy pains. The buccal cav- 358 Diseases of the Stomach. ity shows symptoms of an intense catarrh. Stool is hard and re- tarded. No other pathogenesis contains the symptoms of gastric catarrh more fully than Nux. However, it is more suitable in recent cases without any marked symptoms of material changes. As we have stated before, the remedy is of particular advantage in cases resulting from excessive mental labor and sedentary habits. Bryonia is, in many respects, closely related to Nux. Both reme- dies correspond more particularly to chronic catarrh that had developed itself out of an acute attack, and not so much to chronic catarrh setting in gradually and imperceptibly. The prevailing Bryonia-pain is likewise a hard pressure, as from a stone; it sets in soon after eating, is caused by gas in the stomach, and is relieved by frequent eructations. These eructations, however, are not like those of Nux, at times bitter, at other times sour, but having rather a foul and spoiled taste, and are apt to result in the spitting up of food,' or in vomiting of the ingesta mixed up with bile and mucus. The taste is a spoiled bitter and pappy taste. Bryonia differs from Nux by exciting a violent and continued desire for copious quanti- ties of cold drinks, and by causing a depression of the temperature. Antimonium crudum has already been mentioned under acute catarrh; it is especially suitable in cases of protracted or misman- aged acute catarrh, if the tongue has a thick yellow or whitish coating. Pulsatilla resembles Bryonia in many respects, except that there is great chilliness without thirst, and the symptoms do not show themselves at once, but some time after eating, and are diminished by exercise, whereas exercise aggravates the pains of Bryonia. Pulsatilla deserves particular attention if the stomach symptoms are accompanied by uterine derangements; against the gastric ail- ments of pregnancy it is utterly powerless. Cocculus acts similarly to Nux in gastric affections; it is particu- larly useful if the patient is troubled with flatulence that gives rise to colicky pains. Beside these remedies we have to mention: Ipecacuanha, Vera- trum album, Ignatia and Staphysagria, which complete the list of remedies in cases of more recent origin, whereas the following list of remedies is more adapted to more chronic and more deeply-seated cases. China has several very definite symptoms; the taste is bitter or else it is entirely absent. The local pains are not very violent but continued; the appetite is gone, the stomach is altogether very in- Catarrhus Ventriculi Chronicus. 359 active, so that the food either remains for a long time in the stomach, and causes a feeling of fulness, or it passes otf with the stool, either partially or completely undigested. This remedy is particularly suitable for gastric derangements that have remained after severe diseases. Sepia is more particularly, although not exclusively, adapted to the chronic gastric catarrh of females. The catarrhal symptoms are attended with a variety of nervous pains, especially with pain- fulness of the back, which sometimes has the appearance of spinal irritation. The appetite is perverse, the patient craves pungent food. There is considerable acid in the stomach, which causes a disagreeable burning some time after eating, especially at night, that can be relieved by eating a little solid food. Sepia sometimes removes very rapidly, or at least mitigates, the gastric complaints of pregnant females. In a certain condition of the system, which we have so far only noticed in females, it affords considerable aid. After the exacerbation of chronic gastric catarrh has lasted a few days, with intolerable burning pains, the renal region, more partic- ularly on the left side, becomes painful, a violent burning pain is felt in this region, and a quantity of saturated, highly-colored urine is discharged, which deposits copious quantities of urates, or else a clear urine, with a copious sandy sediment, loaded with uric acid. After this discharge the pains generally abate, and only return again if the stomach has not yet been fully restored to its normal condition. In this affection the pains are generally very fierce, and may readily be confounded with simple cardialgia, if the changes in the urine are not attended to. Phosphorus renders excellent service in chronic catarrh of the stomach. Its symptoms are more like those of chronic inflamma- tion than of simple catarrh, in the lesser degrees of which it will scarcely ever be found suitable. Phosphorus likewise has a ten- dency to the excessive formation of acid, except that the eructations and the vomiting have an oily taste. The pains are intense, and are aggravated by eating. This circumstance, in addition to the other phenomena, points to considerable alterations of the mucous membrane, on which account we employ Phosphorus with success in ulceration and hemorrhage of the stomach. Lycopodium is one of the most frequently used medicines in chronic catarrh of the stomach. It is not so much adapted to the lower grades of the disorder, nor where the local symptoms are very prom- inent; it is more particularly in its place where the constitutional 360 Diseases of the Stomach. equilibrium is very much disturbed and the patient grows thin. The face has a grayish hue and an expression of suffering, so that we are led to suspect the presence of malignant disorganizations of the stomach, under which head we shall again refer to it more espe- cially. Where Lycopodium is suitable in gastric catarrh, we gener- ally have structural changes in the spleen or liver. The symptoms referring to the mental and sensorial range are characteristic, and, thereto e, of special importance in determining the selection of Lycopodium. Arsenicum album is known to us as one of our leading stomach- remedies. In a general sense, it corresponds more especially to an inflammatory affection of the mucous membrane of the stomach, bur likewise, as we know from experience, to catarrhal symptoms in their higher grade of development, as we observe them more particularly in the case of drunkards. Characteristic indications are: the local pains are a violent pressure alternating with burning, or a burning distress exclusively ; the thirst is intense and torment- ing ; the taste is bitter, sour or foul; the vomiting is very hard, and attended with excessive pain; the desire to vomit is felt after every meal. Arsenicum is likewise indicated for the peculiar, painless torpor and inaction of the stomach of long duration, and leading to a gradual decay of the tissues. Here, too, we have to point to the condition of the urine, wLich, after Arsenic, has a larger quantity of uric acid. Violent cardialgic pains are an additional indication for this drug. The symptomatic indications of Sulphur are so numerous that it is difficult to point out the whole list. Almost all of them corre- spond to chronic catarrh of the stomach and its disastrous conse- quences. More than all theories does experience confirm the use of Sulphur in chronic gastric catarrh, for it cannot be denied that it has often given a favorable turn to the disease when other remedies had been used in vain. Chronic vomiting is arrested by Sulphur more surely than by many other drugs. Experience has taught us, that large doses of the lower triturations are not near as useful and eflective as not very frequently repeated doses of the higher attenu- ations. We cannot point out a single exception to this rule. The adherents of the fabulous psora-theory, praise Sulphur in all possible diseases; likewise in the gastric complaints of individuals who have had the itch once in their lifetime. A complication with liver affec- tions and piles is an additional indication for Sulphur, as we shall show more fully by and by. Gastritis, Inflammation of the Stomach. 361 Calcarea Carbonica is scarcely ever indicated in the chronic gastric catarrh of adults. The gastric complaints of chlorotic females are an exception, for in these Calcarea may render good service. In such cases the remedy is more particularly indicated by the follow- ing symptoms: A strong desire for acidulated drinks, and a good deal of thirst generally ; excessive secretion of acids; perverse long- ing for very sharp, sour substances; aversion to animal food, with copious use of farinaceous diet; canine hunger, without the least appetite ; disposition to diarrhoea. Calcarea is particularly suitable for children under two years ; adults require it much less frequently Simple gastric catarrh is very seldom met with in the case of chil- dren, for the whole of the intestinal canal very soon becomes in- volved in the morbid process, on which account we shall have to recur to this drug in our chapter on gastro-intestinal catarrh. Dis- turbances of the gastric functions, which constitute the impercepti- ble commencement of gastric catarrh, such as vomiting, loss of appetite, or else an excessive avidity for food, especially farinaceous food ; flatulent distension of the abdomen, sour smell from the mouth, disposition to catarrh of the mouth, yield most promptly and safely to Calcarea. Beside these remedies, the following deserve our attention: Plum- bum, Ferrum, Cuprum, Carbo vegetabilis, Podium, Natrum muriaticum. It would take up too much space if we would write out a complete symptomatology of each of these drugs; moreover, the full patho- genesis of each can be found recorded in the Materia Medica. We wish, however, to mention one remedy of which we have no very extensive provings, but which has already shown its valuable cura- tive powers in practice-we mean the Sulphate of Atropine. It is particularly suitable where violent local, intermittent pains are com- plained of; they are ameliorated by vomiting up mucus with a good deal of straining, or they are momentarily suspended altogether, and are felt principally at night. We have never effected a com- plete cure with this salt, but have always afforded partial relief, after which the cure was completed with a few doses of Sulphur. 3. Gastritis, Inflammation of the Stomach. Acute gastritis is a pathological process concerning which the views of pathologists differ as yet a great deal. Some even go so far as to suppose that this inflammation, in so far as it originates spontaneously, is identical with acute catarrh of the stomach. This view rests upon a one-sided comprehension of the post-mortem ap- 362 Diseases of the Stomach. pearancos, without at the same time interpreting them with refer- ence to the morbid symptoms. It cannot be denied that the same post-mortem changes may result from acute catarrh and from gas- tritis, but their meaning differs according as the generating cause is of a different nature. We must not forget that in dealing with the stomach, we deal with a highly complicated organ and not with a mere mucous membrane. Inasmuch as the phenomena during the lifetime of the patient do not always indicate, with unmistakable accuracy, the tissue where the inflammation is seated, we do not deem it essential to dwell any further upon uncertain differences. Owing to the different views entertained by pathologists regard- ing the nature of gastritis, the etiology of this disease must neces- sarily be involved in a good deal of obscurity. Among its causes we have to mention, in the first place, the various circumstances which have already been alluded to in the chapter on acute catarrh, namely, the introduction of excessively hot or cold articles of diet into the stomach, and violent colds. Besides these causes the stomach may become sympathetically involved in other acute diseases. That excessive moral emotions, especially of a depressing kind, may cause acute gastritis, has been shown by striking examples. Mechanical injuries by foreign bodies, such as glass or needles, are not very un- frequent causes of gastritis. The most frequent causes of this dis- ease are violently-acting poisons, either vegetable or mineral, among which alcohol occupies a prominent rank. And, finally, we may state that cooks, whose abdomens are exposed the whole day to a high degree of radiant heat, are frequently attacked with affections of the stomach, and generally with gastritis. The symptoms of this disease change according to the degree of the local affection, or the irritability of the individual attacked by the disease. From these symptoms we cannot draw any reliable inferences regarding the actual character of the local changes. In a few cases the inflammatory affection does not develop any marked symptoms, the patient sinks all at once, and a post-mortem exami- nation reveals the phenomena of inflammation, which had resulted in ulceration and perforation. In the milder cases we merely find the symptoms of an acute gastric catarrh, only the sensitiveness of the region of the stomach to external pressure is generally more in- tense, nor is the pain exclusively a painful pressure; the pulse is likewise more hurried than during the existence of catarrh. In a practical and therapeutic point of view it is, of course, important that the diagnosis should be correct; in some cases, however, this Gastritis, Inflammation of the Stomach. 363 seems impossible, and the only certain diagnostic sign is the appear- ance of the tongue. In acute catarrh of any intensity, the tongue has a whitish or yellowish coating, whereas in gastritis it is gener- ally clean, dark-red, or more smooth and marked with red spots. The most violent attacks of gastritis occur after the ingestion of intensely-acting poisons, without any premonitory symptoms and very suddenly. If the disease sets in idiopathically, it is no less violent and begins with a violent chill, which generally ushers in all very acute diseases. The first sure diagnostic sign is a raging pain which seems intolerable, and is generally burning, less fre- quently a tearing or crampy pain, which at times is limited to a small spot, and at other times extends over the whole region of the stomach. This region is often so sensitive to contact that the weight of the bed-quilt cannot be borne. Very soon it becomes dis- tended. The pain is likewise apt to spread over the abdomen and chest, and the pain caused by the depression of the diaphragm im- pedes the breathing even to the most violent dyspnoea. In one case which we had to take charge of, after it had been under allopathic treatment, the pain in the stomach became associated with an ex- ceedingly violent, stitching pain in the right side of the chest, which the attending physician interpreted as pleuritis, and consequently treated with leeches applied to the right side of the thorax. A post-mortem examination showed the pleura and lungs perfectly sound. The mistake was the more easily made, as the patient was tormented by a distressing cough, setting in shortly previous to an attack of pain in the right side. As a rule vomiting sets in at the onset, even if no poisoning had taken place, in consequence of which the rest of the food is ejected from the stomach, and afterwards a watery or tenacious and, in the higher grades of the disease, a bloody mucus. The blood and mucus are more particularly thrown up when a corrosive poison has been swallow'ed. Every ingestion of food or beverage excites the vomiting, so that the patient scarcely dares quench his horrid thirst even by small quantities of water; solid food is not retained at all. The bowels are constipated as a matter of course. The participation of the general organism in the morbid action is first manifested by a more or less intense fever, with a small, feeble but frequent pulse; the urine being at the same time diminished. The pains either continue unabated or increase gradually; the countenance which has an expression of suffering from the start, soon assumes a cadaverous pallor and looks disfigured, the extremities are cool, the skin is covered with a cold 364 Diseases of the Stomach. sweat. An inexpressible anguish causes an unceasing restlessness, and deprives the patient of all sleep. In proportion as the disease approximates to a fatal termination, the strength sinks with an un- usual rapidity, hiccough, fainting fits, delirium, etc., set in, until death terminates the scene. In other cases the patients die suddenly without any alarming symptoms. This picture of acute gastritis of course admits of certain modi- fications, if the disease is caused by a poisonous substance; for in such a case the peculiar effects which this poison produces in other organs, have likewise to be considered. In all somewhat acute cases the disease always runs a rapid course, so that death sometimes sets in in a few hours; sometimes the disorder continues to the fourth week, or it assumes the form of chronic catarrh of the stomach, which has already been de- scribed. It is a subject of great importance to know the exact character of the anatomical appearances in this disease. Recovery scarcely ever takes place suddenly, and it is easily disturbed by the least error in diet. Beside the termination in chronic gastritis, the trouble may continue as suppuration of the mucous membrane, together with its consequences, a statement of which will be fur- nished in a subsequent chapter. The post-mortem changes do not always strictly correspond to the symptoms observed during the lifetime of the patient. The mucous membrane appears red over a greater or less extent; it is at times of a lighter and at other times of a darker hue; sometimes of unequal thickness, softened or eaten away in some places, or per- forated in consequence of a more deeply-penetrating ulcerative pro- cess. These changes, of course, differ if they are caused by the action of poisons , but these differ ences need not be described more minutely m the present instance. The prognosis is uncertain, especially in cases running a slow course. Acute idiopathic gastritis is one of the most fatal affec- tions, whereas toxical gastritis is much more promising as regards a final cure. A good deal depends upon the conduct of the patient during convalescence, for we need scarcely state that the peculiar structure of the stomach is very favorable to relapses, and that, independently of such considerations, the ulcerative process, if it should have commenced, requires the greatest care. Treatment, We have already stated that gastritis, in its dif- ferent degrees of intensity, assumes different forms of symptomatic manifestation. The milder forms often resemble an acute gastric Gastritis, Inflammation of the Stomach. 365 catarrh to such an extent that it is impossible to distinguish one from the other. On this account the remedies mentioned under catarrh of the stomach will likewise have to be used against gas- tritis. In the more violent forms of this inflammation we have, in the first place, to determine the cause. This, of course, cannot be done when the disease originates spontaneously; but it is perfectly feasible if the inflammation was caused by poison. In such a case, we must not only try to remove the swallowed poison by an emetic, but we may likewise have to employ the stomach-pump or neutral- izing antidotes in o der to prevent absorption of the poison, and thus render it less dangerous, and perhaps harmless. We omit the mention of the antidotes to the various poisons, for the reason that they can be found fully recorded in any toxicological treatise. We may observe, however, that in every case where vomiting is attended with violent symptoms of gastritis, the vomited substance should be carefully preserved for examination; chemical analysis is the only certain means of making sure of the fact of poisoning in a given case. That which still remains to be done after the first manage- ment of the case, which is common to all schools, has been attended to, becomes properly the subject of homoeopathic treatment. It is likewise of importance, in a case of poisoning, to consider whether the ingestion of copious quantities of cold water, for which the patients long, on account of the burning distress in their stomachs, may not have a prejudicial effect by promoting the solution of the swallowed poison. Where there is any uncertainty, we give the preference to slimy decoctions, oily substances, milk which is not too much diluted. Regarding the treatment of gastritis, it would seem that it can- not be very difficult to enumerate a multitude of remedies for this disease. Almost every drug in our Materia Medina has symptoms resembling the symptoms of gastritis ; and, according to the law of similarity, must therefore prove curative in this disease. This view, however, is based upon entirely false notions. With most poisons, inflammation of the stomach is not caused by the same property that renders them valuable and useful as remedial agents; but it is generally the consequence of a purely chemical and mechanical action, and, for this reason, without any practical value for homoeo- pathic treatment. In some respects our inability to discriminate between the toxicological and pharmaco-dynamical effects of a poison, interferes very much with a successful homoeopathic treat- ment. In this respect we have to act by the rule, that only such 366 Diseases of the Stomach. poisonous substances can be regarded as remedial agents as have simulated a state of gastritis, in consequence of the absorption of small doses into the general organism. Following this rule, we can only select a small number among the whole list. Arsenicum produces, more specifically than any other poison, the symptoms of gastritis, whether by its direct introduction into the stomach, or by its absorption by the skin when applied to this organ in form of an ointment, or by the inhalation of arsenical dust. This statement is corroborated by several very striking observations. One is the case of a young woman living in a room, the walls of which were covered with a green paper containing Arsenic ; she passed through the different degrees of gastritis up to the blood- streaked, distressing vomiting. The cause of these toxical symp- toms was the more easily accounted for, as the symptoms dis- appeared on the third day after she had changed her domicile. Here the poisonous dust had been absorbed through the respiratory organs. Cases where the external application of Arsenic in the form of a solution or ointment causes the phenomena of arsenical poisoning, are not very rare. This shows that the stomach-symp- toms belong to the most constant and characteristic symptoms of Arsenic, and that we are fully justified in regarding Arsenic as one of our most efficient agents in the treatment of gastritis. Owing to the importance of the remedy, we here range the symptoms in one series: Violent pressure in the stomach; distressing burning in the stomach; extreme sensitiveness of the region of the stomach to the least pressure; swelling of the pit of the stomach; gag- ging and painful vomiting after every meal, even after drinking liquids, particularly after eating sour substances or rye-bread; un- quenchable thirst, with longing for cold drinks, with inability to swallow more than a small quantity at a time; the respira- tion is embarrassed; horrid anguish and restlessness, the patient has to be in constant motion; retention of stool and urine; cold- ness of the extremities, with burning heat of the trunk; sweat from sheer anguish; frequent, small, easily compressible pulse; dis- torted, cadaverous expression of the countenance. This list of the most prominent symptoms may suffice. Strangely enough, our lit- erature does not contain a single cure of gastritis by Arsenic. Some gastric affections, which are reported under the name of cardialgia, do not seem to have been anything else than cardialgia; but it is difficult to establish a correct diagnosis from the reports as furnished in the journals. This gap in our literature, may be owing to the circumstance that gastritis resulting from other than toxical causes Gastritis, Inflammation of the Stomach. 367 is a very rare occurrence, and that the lesser grades of gastritis have been reported under other names. According to the above-men- tioned symptoms, Arsenic would seem to be adapted only to the most violent forms of gastritis ; but a cursory perusal of the patho- genesis of Arsenic in our Materia Medica will suffice to show that this agent is suitable in every form of gastritis, from the mildest to the most violent. Phosphorus has the symptoms of gastritis neither as completely and prominently, nor as intensely as Arsenic. Beside the burning distress in the stomach, Phosphorus has likewise a cutting pain as a prevalent symptom ; the heat'of the trunk is very great, the ex- tremities are cold, the patient has frequent attacks of chills, the power of reaction sinks very speedily, and convulsions set in. In a given case, a good deal of attention and careful comparison will be required to establish the difference between Phosphorus and Arsenic. Belladonna is scarcely ever appropriate in the more advanced stages of gastritis, but is quite in its place at the onset, if the attack is not too violent. If our diagnosis is firmly established, the ques- tion is, whether it is not better to give at once the medicine that is the simillinum for the disease from its first outbreak to its final termination. At all events Belladonna is preferable to Aconite. We do not see upon what grounds Aconite is recommended as a remedy for gastritis. The fever is not such as corresponds to the Aconite fever ; it is a wrong method to undertake to give a remedy for the whole complex of the symptoms in a strictly local affection. [In rheumatic gastritis, with great tenderness of the region of the stomach, distension of this region, a burning and throbbing or stinging and tearing distress in the stomach, raising of blood from the stomach, synochal or even moderate fever preceded by a more or less violent chill or a succession of slight chills, and general con- stitutional symptoms, such as weariness, expression of distress in the countenance, thirst, constipated bowels, dyspnoea, etc., Aconite is an indispensable remedy, as we can assert from experience. It is particularly the muscular coat which is the seat of the disease. We mix one or two drops of the tincture of the root in half a tum- bler of water, and give a dessert-spoonful of this mixture every half-hour or hour, until the patient is better. The attenuations in such cases are either useless or insufficient. II.] Camphora is not in curative rapport with the whole pathological process of gastritis, but is exhibited with great benefit, if the dis- ease breaks out suddenly with great violence. The attack is very 368 Diseases of the Stomach. similar to the stage of invasion of Asiatic cholera ; the strength seems paralyzed all at once, the circulation stops, and the skin is icy-cold. The symptoms of Cantharides that seem to have reference to gastritis, are very questionable; they are probably the effects of the local action of the poison. What Hartmann relates concerning Nitruin is so indefinite, that we hesitate to repeat his remarks. Many other remedies have single symptoms that seem to belong in this category, but the indications are very imperfect. The most noteworthy among them are: Bryonia, Digitalis, Mercurias, Meze- rcum, Tartarus stibiatus, and Ayitimonium crudum. The two last- named remedies deserve particular consideration in the deceitful and not very intense gastritis of drunkards. Moreover, we refer the reader tc the treatment of acute catarrh. The diet fills an important place in the treatment of this disease. When the disease is at its height, it is not necessary to prohibit any kind of food, for the patients do not desire any; and it is, moreover, impossible for them to eat anything; all they care for are refresh- ing drinks, and since quantities of fresh water would be out of place, the best method of alleviating the craving for cooling bever- ages, is to allow a few small pieces of ice to dissolve upon the tongue, and to satisfy the want of something liquid by means of some mild slimy decoction. During convalescence the greatest cau- tion should be observed in regard to the use of solid food, which should be given in very small and gradually increasing quantities. That an ulcer may not form even at this period, is not certain; moreover, the stomach has become so irritable by the long depriva- tion of solid food, that if given in too large a quantity, it may either cause a relapse, or at least superinduce a condition resembling acute or chronic catarrh. A gastritis which runs its course without causing much trouble to the patient, likewise requires the most careful management regarding the diet to be observed. 4. Ulcus Perlbrans Ventriculi seu Rotundum. Chronic Ulcer of the Stomach. Every mucous membrane, and particularly that of the stomach, inclines to ulcerate. In a subsequent chapter, when treating of hemorrhage from the stomach, we shall speak more fully of ulcera- tive processes in general. Here we shall simply treat of a peculiar form of ulcer, recognized by unmistakable characteristic symptoms. In order to prevent all misapprehensions, we will commence with the anatomical description of the ulcer. Ulcus Perforans Ventriculi seu Rotundum. 369 The perforating ulcer generally occurs as a single ulcer in the stomach; only in rare cases we meet with several together. It is almost exclusively situated near the small curvature, the pylorus, and in the posterior wall of the stomach, very rarely in the fundus of this organ. At first it is a sharply circumscribed hole in the mucous membrane, of the size of two inches in diameter and up- wards, without any inflammatory infiltration or coloration of the surrounding parts. In the further course of the ulcer the base, as well as the surrounding parts, may become corroded by the ulcera- tive process, imparting to it a more oval or even elongated form. If the muscular and afterwards the serous coat become involved in the ulcerative process, the ulceration of these coats never spreads as extensively as that of the mucous coat, so that the profile of the ulcer acquires a flat funnel or terrace-shaped appearance.- The ulcer inclines very much to perforate all the coats of the stomach; this, however, takes place slowly, and is preceded by the formation of adhesions, which prevent the escape of the contents of the stomach into the cavity of the abdomen. Where this course does not take place, the perforation with immediately following fatal peritonitis, is the usual termination of this process. The healing of the ulcer takes place by means of a ray-shaped cicatrix, and consid- erable contraction of the cicatrized part. These anatomical peculiarities show that the perforating ulcer must depend upon characteristic pathological changes, and that it cannot result from any of the processes which we have described in previous chapters. Among the numerous hypotheses that have been offered in explanation of this very peculiar form of ulcer, the most probable is, undoubtedly, the theory, that the occlusion of an arterial vessel of more or less size had caused the death of a circum- scribed piece of mucous membrane, and that consequent absorption and ulceration had been set up by the action of the gastric juice. In this way the round form of the ulcer is most easily ac- counted for. The etiology of this process is almost entirely enveloped in ob- scurity, although this disorganization is by no means a very rare occurrence. Most diseases occur among persons of middle age. Tuberculosis, carcinoma, and other deep-seated affections are fre- quently met with among individuals affected with this ulcer, but whether they are the cause of the ulcer, and how, is questionable. It is said that much exposure in front of a big fire, during work, often causes the disease. 370 Diseases of the Stomach. Symptoms and course. The circumstance that cicatrices of the round ulcer are often met with in persons who have never complained very particularly of gastric derangements, must satisfy us that this ulcer sometimes runs its course without any striking symptoms. It likewise happens that an individual dies of peritonitis consequent upon perforation of the stomach, without any signs of disease of the stomach having been perceived during the lifetime of the patient. We have already shown that gastritis may exist without any striking symptoms. It is difficult to say with what phenomena the round ulcer generally commences; the characteristic pain is the first symptom of which the patient complains, he may at most have experienced slight disturbances of the digestive func- tions. The pain caused by the ulcer is very peculiar; although spread over a large portion of the region of the stomach, yet the pain seems to be located at a definite spot, and is very much aggravated by external pressure. Beside this pain, which is roused by pressing on the parts, the patient complains of other more intense pains which are either excited or very much aggravated by the ingestion of solid or stimulating food. These pains often seem like cardialgia, with which they are easily confounded, for the reason that they are apt to occur in paroxysms. The patient traces them very positively to the place where the ulcer is located. They are felt during the first two hours of the digestive process, but may last much longer. They are generally burning pains, or cutting as with many knives, seldom lancing as with a single blade, they radiate more particularly toward the back, likewise into the ab- domen, are aggravated by external pressure sometimes to an alarm- ing degree, and generally cause a great deal of dyspnoea. In some cases they have complete intermissions, in others they have a remit- tent type. Not unfrequently the pains occur so perfectly free from other complications that they seem more like an attack of pure neu- ralgia ; generally, however, they are attended with signs of gastric derangement, and increase in intensity in proportion as the char- acteristic symptoms of the ulcer become more prominent. The appetite is less, the patients complain of distension of the stomach, violent eructations, heartburn, waterbrash. The bowels are torpid, and sometimes obstinately constipated. This mild commencement of the disorder is sooner or later asso- ciated with vomiting. The vomiting is most usually connected with the paroxysms of pain, which it generally winds up and there- fore relieves. It is exceedingly distressing, and, as a general rule, Ulcus Perforans Ventriculi seu Rotundum. 371 causes at least a partial expulsion of the food that had been par- taken of last, as mixed with water and mucus, has an acrid-sour taste, and always occurs a few hours after partaking of the food. Sometimes no food is vomited up, but only mucus and sour water. As the ulcerative process spreads, t;ie vomiting is apt to become mixed with blood. If no large vessels are corroded, the vomited material is only streaked with blood; but if an important artery should be destroyed, the hemorrhage is more copious and may even terminate fatally. We have seen several quarts of blood vomited up in twenty-four hours. Independently of the consequences of such hemorrhages, which of course superinduce hydrsemia, the ulcer exerts a depressing in- fluence upon the assimilative functions, which is so much more penetrating, the more considerable are the disturbances caused by the sore. As we have already stated, the course of the ulcer may be very rapid, provided we do not mistake the date of its origin; more commonly, however, the ulcer runs a chronic course, even for years, with more or less protracted intermissions. These often depend upon the cure of one ulcer, whereas a second attack indicates the formation of a second ulcer. In the smaller number of cases the termination of the disease is death, which either takes place in consequence of the disturbed nutrition, or hemorrhage, or perforation with consequent rapidly developed peritonitis and sudden death. Recovery may be com- plete ; but if the ulcer was very large, the cicatrized part very much contracted, and the contraction is situated in the region of the pylorus, the consequent encroachment upon the capacity of the stomach may induce more or less important derangements. Some- times perforation may take place quite suddenly even after complete recovery seemed to have been achieved; the reason is that when penetrating to the subjacent tissues, the disturbances caused by the ulcer are less striking than when the ulcer spreads superficially. Hence the prognosis is pretty uncertain; as a general rule not very bad, but in case of frequent hemorrhages, very doubtful at all events. If a majority of the above-mentioned symptoms are present, the diagnosis of ulcer of the stomach is not very difficult; in other cases, on the contrary, where the symptoms are not very striking, a diagnosis cannot be made with certainty. It is more especially of importance where carcinomatous degenerations are suspected, or 372 Diseases of the Stomach. where tne symptoms justify the suspicion that cardialgia is the character of the existing disturbance. We shall revert to these distinctions in a subsequent paragraph. Treatment. This is another of those pathological processes, concerning whose treatment our literature has nothing to show, and where again the fact is demonstrated, that the report of a case, without any special diagnosis, is of no use to us. Many of the cases reported as cardialgia, undoubtedly come under the category of perforating ulcer, likewise some of our reported cures of carci- noma of the stomach; more particularly the latter, for the reason that the cure of a real carcinoma is, if not questionable, at any rate very uncertain and doubtful. As far as a rigorous discrimination is concerned, the most necessary points of comparison are wanting. In looking at the symptoms in our Materia Medica, we meet with considerable difficulties in selecting a remedy, namely the absence of objective phenomena and of such as have been con- firmed by post-mortem examinations. On the other hand some of our provings are so characteristic that the selection of a suitable remedy cannot be very difficult in all cases. Moreover the slowness of this pathological process and the comparative absence of im- mediate danger, enable us to devote a reasonable amount of time to a careful comparison of the pathogenetic with the pathological Bymptoms, and to cautiously institute therapeutic experiments. In searching for a simillimum we must not forget that, although the round ulcer is character!steric of the pathological process of which we are treating, yet it alone does not constitute this process, but forms the terminal solution of a whole series of morbid develop- ments; and that therefore a medicine may be specifically ho- moeopathic to an affection, of which we are not as yet able to de- monstrate the round ulcer as the final pathological result. In selecting our remedy it is likewise important to remember that ulcer of the stomach is a very chronic affection, which is best treated with medicines that have a slow, deeply-penetrating, continued action. In our chapter on hemorrhage of the stomach, we shall have to mention the remedies that are in homoeopathic rapport with perforating ulcer, and therefore refer the reader to that chapter. Atropine. It may seem strange that we should open the list with a remedy of which we have no full provings, but the striking results that have been obtained with this remedy, in perforating ulcer, com- pel us to confer this distinction upon Atropine. We know from ex- perience that no medicine is better calculated to subdue the fright- Ulcus Perforans Ventriculi seu Rotundum. 373 ful cardialgic pain of ulcer of the stomach than the Sulphate of Atropine. At the same time we know that this medicine alone is not sufficient for a complete removal of the difficulty, for all it accomplishes is to effect a temporary palliation of the distress. Hence the medicine can only be administered as an intercurrent remedy. The fourth trituration is most advisable; the third is still apt to develop medicinal symptoms. The improvement caused by Atropine is best continued by Sulphur, giving a dose of a higher potency at prolonged intervals. Atropine generally arrests the vomiting. Baryta carbonica possesses among its pathogenesis all the symp- toms that characterize ulcer of the stomach. In Hahnemann's record we find: Ulcerative pain or a feeling of soreness in the stomach after external pressure, or when drawing breath ; a painful writhing sensation in the stomach when swallowing a morsel of food, as though the food had to be forced through a stricture and came in contact with sore places. These, in connection with other symptoms, must necessarily suggest Baryta to us as a specific rem- edy. Our own practical observations have confirmed these expecta- tions. But a curative action only took place if no vomiting was present, or only vomiting of a small quantity of mucus, and if the cardialgic pains did not occur in distinctly separate paroxysms, but were rather of a remittent type. Carbo veg etab ilis is more important than Baryta, although the local symptoms may be less distinct. At any rate, they are suffi- ciently distinct to show its homceopathicity to ulcer of the stomach. It is a distinctive symptom of Carbo not only to excite the pains by eating, but they are likewise felt when the stomach is empty, espe- cially when the stomach is very sour; but it is likewise appropriate in cases where this symptom is wanting, and where no other reason exists to account for this exceptional circumstance. In many regions of country, vegetable charcoal is a much employed domestic remedy for cardialgia, though the vomiting, which is never absent, shows that the name is wrongly applied. We are acquainted with a gen- tleman who was cured of a gastric affection that evidently depended upon perforating ulcer, and had continued with uninterrupted vio- lence for three years, by means of the pulverized young shoots of the common poplar. We are unable to decide whether the poplar has any curative virtues inherent in it, or whether the charcoal alone exerts the curative influence. It is certain that our own char- coal likewise has an excellent effect. 374 Diseases of the Stomach. Argentum nitricum, although its pathogenesis is not yet very thoi- ough, yet has been variously exhibited in affections of the stomach, and has been found more particularly useful in the complaints arising from perforating ulcer. This likewise corresponds to what Hart- mann has stated regarding its employment in cardialgia. We trans- cribe his remarks literally: " My experience with Argentum nitri- cum is as follows: I have only had occasion to make use of it in the case of females; menstrual irregularities have always consti- tuted my chief guide, more especially premature and profuse men- ses, developing an impoverishment of the constitution and conse- quent nervous irritability. The violent, spasmodic pains in the stomach, obliging the patient to bend double, do not intermit with any degree of regularity, but occur early in the morning as well as in the afternoon and evening, or even at night, attended with vio- lent retching, resulting in the expulsion of a fluid having an acrid, sour, or bitter taste like bile, and having a yellowish-green color, and of a tenacious consistence.'' This is not a true picture of car- dialgia. Otherwise Arg. nitr. acts just as well upon the stomachs of male as upon those of female patients. Hartmann recommends the first three decimal triturations. Everybody can easily convince himself that Arg. nitr. in the higher potencies is entirely powerless, or that it acts, at any rate, with much less efficacy than in the lower. Beside these most prominent and most important remedies, the following deserve particular consideration: Arsenicum, Phosphorus, Plumbum, Natrum muriat., China, Secale cornutum, Veratrum, Calca- rea carb, and Lachesis. Of these, Arsenicum, as well as Phosphorus, have already been mentioned in the chapter on gastritis, where they are much more appropriate than in the chapter on ulcer of the sto- mach, especially Phosphorus. As regards Arsenic, we can show such a number of fine results that it deserves to be classed in the foremost rank among the remedies for perforating ulcer, except that the symptoms will not always be found to correspond with the pathological phenomena. Arsenic is particularly indicated, together with China and Calcarea carb., where the ulcer is consequent upon previous emaciating morbid processes or occurs with them simul- taneously , for instance, after intermittent fever or in amemic indi- viduals. Natrum muriaticum likewise deserves our attention under such circumstances. Concerning the appropriate diet, we have only a few remarks to otter. Of course the stomach has to be managed with great deli- Carcinoma Ventriculi. 375 cacy; overloading the stomach, or indigestible substances, stimu- lating and irritating articles of diet, or such as cause an excessive secretion of gastric acid, such as fat, are to be strictly avoided. We do not mean to say that it would be a good plan to restrict the pa- tient to a scanty and poor diet; this neither advances the cure nor helps the patient. We have to see to it, that the strength is upheld by a light, nourishing diet, since marasmus is too apt to set in. The slow course of the disease and the inability to effect a rapid cure, should teach us not to change our remedies too frequently; hence it is best to exhibit them at rather long intervals. The fre- quent and violent a'tacks of cardialgia are apt to induce us to pursue the contrary course, in order to afford speedy relief to the patient; but these kind intentions do not lead to any good results. We should have placed this form of cancerous disease in the category of carcinoma, if the importance of this pathological pro- cess, and the facility with which it is confounded with other pathological processes of the stomach, did not bespeak for it more particular consideration. The etiology of cancer of the stomach, belongs, in most cases, to the domain of hypothesis; all sorts of causes are accused of the dis- ease, but with what right is questionable. It is admitted that this affection seldom occurs before the fortieth, and scarely ever before the thirtieth year, and that it is more frequently met with among men than women. There is no doubt that this form of carcinoma, as well as any other form, is hereditary. Moreover, we have to repeat the causes which we have assigned to chronic catarrh of the stomach, more particularly the habitual abuse of strong alcoholic beverages. Want and poverty, continued grief, constant care and mental depression, tend to develop cancer of the stomach. The last- mentioned cause is the more active, if the stomach inclines to be attacked with acute or chronic catarrh, in which case carcinoma originates very readily in the disorganized mucous membrane. Carcinoma of the stomach is most usually a primary disease, with reference to other cancerous disorganizations, but may readily give rise to cancerous formations in other localities. Inasmuch as an intelligent comprehension of the symptoms of carcinoma of the stomach implies a knowledge of the anatomical structure and locality, we here furnish a short view of its patho- 1 >gical post-mortem degenerations. Carcinoma of the stomach has 5. Carcinoma Ventriculi, Cancer of the Stomach. 376 Diseases of the Stomach. most generally the form of scirrhus, the fibrous carcinoma, less fre- quently that of medullary fungus, and still less frequently of any other form; in exceptional cases these two forms may occur in com- bination. The seat of carcinoma, from where it generally starts, is, in the majority of cases, the pylorus ; next to that the cardia ; after that, the small curvature, and very seldom the fundus. Carcinoma prefers spreading like a ring, in opposition to the longitudinal axis of the stomach. The disposition to decomposition, and the dissolu- tion in ichor, is greatest in the case of medullary fungus, taking place with more or less rapidity, whereas the parts not destroyed by dissolution are sometimes simultaneously metamorphosed into fungoid growths. The secondary alterations, caused in the stomach by the carcinomatous process, differ according as their locality differs. If the carcinoma is seated near the cardia, we have stric- ture and shrinking of the parts; if near the pylorus, the stomach becomes dilated. In the former case the oesophagus is apt to be- come involved in the disorganization, in the latter the duodenum. If the disorganized portion of the stomach does not form any adhe- sions with adjoining parts, as is often the case, the carcinoma is apt to draw the stomach downwards, out of its normal situation. It is easily seen that the symptoms of carcinoma of the stomach must vary a great deal. A precursory stage, properly speaking, can hardly be supposed to exist. If the carcinoma develops itself out of other diseases, they cannot well be regarded as an ordinary preliminary stage of the disorganization, but the carcinoma and this disease coincide accidentally, and without obeying any fixed law. As soon, however, as the carcinoma begins to form, the signs of a chronic gastric catarrh at once make their appearance. The patient experiences a pain after every meal, the prevailing character of which is a hard pressure; digestion takes place slowly, a quan- tity of gas forms, whence distension of the pit of the stomach, eructations, etc.; moreover, heartburn, nausea, waterbrash. These symptoms are not characteristic of carcinoma, and they may con- tinue for a long time, even if the carcinoma should continue to grow all this time; a perfectly certain diagnosis, at this stage of the dis- ease, is impossible. As soon as a reliable diagnosis can be made, we meet with the following symptoms: A spot in the region of the stomach becomes painful, both when pressed upon or without press- ure, the pain being worse after every ingestion of food. The pain is at times like a hard pressure, at other times burning, and very often lancing or cutting, which is so often characteristic of cancer. Carcinoma Ventriculi. 377 Food does not cause as intense a pain as in ulcer of the stomach, but the pain lasts longer. Generally the pain is associated with vomiting, at first rather of water and mucus, and afterwards of the ingesta. The vomiting does not occur at regular periods, at the commencement, particularly, the paroxysms may be separated by longer intervals. At a later period, the time when the vomit- ing sets in, depends upon the seat of the cancerous degeneration. If the cardia is the locality of the disease, the vomiting takes place soon after eating; if seated around the pylorus, a few hours may elapse before the vomiting takes place. Vomiting may likewise occur early in the morning, before any food has been swallowed; this accident, however, apparently does not occur unless blood has become effused into the cavity of the stomach, in consequence of the ichorous dissolution or separation of the diseased mass. It being speedily decomposed by the gastric juice, the blood, when vomited up, looks like coffee dregs, grumous, having a chocolate color, which is pathognomonic of cancer. This metamorphosis of the blood occurs only when it oozes from the capillary vessels, ramified over the lining membrane. If a larger vessel is destroyed by the ichor- ous process, the blood is vomited up in the shape of a black mass,, and in large quantity. This last circumstance does not often occur in carcinoma. When the pain and vomiting set in, the constitution begins to show the disastrous inroad of the disease. The body begins to waste away, and the strength becomes very much im- paired. The appetite is entirely gone, or, if there is a little appetite left, the patient dares not gratify it on account of the pain caused by the food. The alvine evacuations are, of com se, very scanty, sometimes black, if blood accumulates in the stomach. This fact can often be inferred from the character of the stools, provided the blood is not evacuated by the mouth. At an early period of the disease, the face assumes an expression of suffering, the corners of the mouth become depressed, and the face assumes a dingy yellow- ish-gray or livid hue. The spirits are always very much depressed, and an irresistible hopelessness adds to the patient's tortures. The emaciation becomes excessive; oedema of the extremities super- venes, less frequently ascites. If the cancer is located in the neigh- borhood of the cardia, the sufferings of the patient are the most acute. The inability to swallow food, condemns the sufferer to die of starvation; and the certainty of having to meet such a terrible end, frequently drives him to commit suicide. We do not always succeed in verifying the existence of carcinoma by palpation or per- 378 Diseases of the Stomach. cassion; sometimes we fail even in the most characteristically marked cases. Scirrhus, in the region of the pylorus, is most easily diagnosed as a solid bunch in the pit of the stomach ; or, if the stomach had gravitated downwards, near the umbilicus. The vom- iting may sometimes abate, or even be suspended for some time, without any corresponding improvement. If the tumor becomes detached, or melts away into ichor, the patient may experience a corresponding degree of ease, in consequence of the passage through the cardia, or the pylorus, having become temporarily freed. These phenomena are not always found united, otherwise the diagnosis would be very easy. Sometimes one, and sometimes anothei symptom is absent, and there are cases where the pains are comparatively very slight. This last-mentioned circumstance is often witnessed in the case of old people, who barely complain of the symptoms of a slight catarrh of the stomach, while they are rapidly wasting away under the cancerous disease. A few circumstances modify very essentially the course of the disease. The wasting of the strength goes on more rapidly when the cardia or pylorus is attacked, than when the disease is located in the curvatures. Scirrhus grows more slowly than medullary fungus, nor does it encroach as much upon the cavity of the stom- ach. Hemorrhages, of course, complicate the prognosis; the same takes place, if, side by side with the local carcinomatous affec- tion of the stomach, carcinomatous tumors and excretions are dis- covered in other organs, as is very frequently the case in the further course of the disease. Unless serious untoward circumstances arise, the disease runs a somewhat protracted course, at least for several months, and sometimes even for years. Of all carcinomatous de- generations, the medullary fungus runs the most rapid course. One of the secondary accidents, which sometimes puts a sudden end to the sufferings and life of the patient, is the perforation of the coats of the stomach consequent upon the decay of the scirrhous tumor, with rapidly following and fatal peritonitis. Death generally takes place amid the most marked signs of general prostration and decay, which is most generally indicated by the appearance of more or less extensive dropsical symptoms. Without determining whether a remedy for this disease has been properly chosen, the diagnosis of carcinoma of the stomach is of particular importance, in so far as it enables us to decide whether the disease can be acted upon by internal treatment, and whether the reported cures really were carcinoma. The importance of a cor- Carcinoma Ventriculi. 379 rect diagnosis is particularly interesting in our relations towards our professional opponents, and, we are sorry to confess, is very much underrated in this respect. The most important points for a correct diagnosis of the disease are: In the first place, the distinctly per- ceptible swelling somewhere in the region of the stomach, which does not change its location. A iter wards the peculiar color of the vomit; this, however, may likewise occur in slow and scanty hem- orrhages of the stomach from other causes, but is especially copious from perforating ulcer of the stomach. The pains likewise may contribute to corroborate the diagnosis. In cancer they are mostly constant, somewhat aggravated by the ingestion of food; whereas, in the case of ulcer, the pains have sometimes complete intermis- sions, but are excited to a high degree of intensity by eating. The age of the patient and the duration of the disease constitute im- portant diagnostic aids; for, whereas nutrition is not much inter- fered with by other chronic affections of the stomach, even after they had lasted a long time; in the case of carcinoma, the strength vanishes rapidly and very soon. Moreover, other affections of the stomach have occasional, although very trifling, remissions; carci- noma progresses steadily without any interruption. Treatment. In the presence of a disease which is considered incurable by every physician, we are bound to ask ourselves, very seriously, what is the extent of our means, and how far we can hold out the hope of curing a patient who is willing to trust himself into our hands. We have no right to promise the cure of carcinoma by homoeopathic means, with the same readiness as we promise a cure of cardialgia, or some other chronic affection. That there are homoeopathic physicians who make such rash promises without meaning to do wrong, can easily be proven. But if we inquire whether a case of carcinoma of the stomach, that had been diag- nosed with undeniable accuracy, has really been cured by homoeo- pathic means, we have to deny the correctness of such a statement. In taking charge of such a patient, we have to confess our inability to promise anything, at the same time that we resolutely and consci- entiously undertake to afford him relief. For the circumstance that a reliable cure of carcinoma has not yet been reported, does not show that we may not, at some future time, be able to achieve such a success, and then we may be fortunate enough to discover new and better remedies that may finally conquer the disease. In such desperate cases we have to follow strictly the law of similarity, with so much more boldness, as we are convinced that the patient's dis- 380 Diseases of the Stomach. tress will never be increased by such a course. A correct selection of the remedial agent affords us an advantage, that no other cura- tive method can boast of; we sometimes succeed in mitigating and even suspending symptoms that are peculiarly tormenting. Such palliative effects have occurred in the practice of every homoeo- pathic physician, and, although they may only occur exceptionally, yet they are an abundant reward for the trouble it cost to find a remedy capable of producing them. Hartmann introduces the treatment of carcinoma of the stomach with the following remarks of Canstatt: " To check the further development of the threatening destroyer is a much more thankful task than to undertake to remove the fully-developed, incurable degeneration." From this quotation, and from his subsequent re- marks, we infer that Hartmann adopts the existence of a precursory stage. This theory is antagonistic to practical observation, and the measures proposed in accordance with it, deserve but little consider- ation. It seems to us that Canstatt's opinion would be more prop- erly enunciated in this wise: Considering the great difficulty of distinguishing an incipient carcinoma of the stomach from other, even chronic, derangements of this organ, and in view of the per- fectly correct supposition that chronic inflammatory affections of the stomach favor the formation of carcinoma, it becomes a sacred obligation for every physician to watch and to treat every affection of the stomach with the greatest care. It is exceedingly doubtful whether the retrograde metamorphosis of an incipient carcinoma is at all possible; but we must admit that, if a cure is possible, it can best be achieved during the incipiency of the cancerous growth. From this stand-point, the treatment of cancer includes all the rem- edies that have been recommended for chronic catarrh of the stom- ach, and perforating ulcer, and will afterwards be recommended for cardialgia. Our previously expressed reflections will, moreover, induce us to attend to the diet, in affections of the stomach, with the utmost attention, since every dietetic transgression, every im- proper habit in our mode of living, may entail the most disastrous consequences. Although this kind of prophylactic treatment may not be sufficient to prevent carcinoma, yet, if such a misfortune should occur in spite of all dietetic care, it is a consoling thought that nothing had been neglected on our part to prevent it. Further particulars concerning diet are not necessary, since they have been fully explained in our article on chronic catarrh of the stomach. Particular care must be had, to spare the patient all depressing or Carcinoma Ventriculi. 381 exciting mental emotions, since every symptom becomes aggravated immediately after such an occurrence. If called upon to treat a fully-developed, undoubted case of car- cinoma of the stomach, every homoeopath will undoubtedly first think of Arsenic as a sheet-anchor. It cannot be denied that the pathogenesis of Arsenic contains very accurately the symptoms characterizing carcinoma of the stomach, for which we refer the reader to our Materia Mcdica the more urgently, since Arsenic is one of our best stomach remedies. We do not know of any cure of carcinoma by means of Arsenic, but we do know that in a num- ber of cases Arsenic has arrested the progress of the disorganization for weeks, and even months, and has effected a consequent suspen- sion of the patient's sufferings. Among the latter, we notice more particularly the vomiting and sleeplessness; altogether, Arsenic often acts like Opium. On the other hand, we must not expect too much of this drug; the vomiting, for instance, which is caused by stricture of the orifices of the stomach, cannot possibly be arrested by any kind of medicine. We infer from a number of observations that the higher attenuations of Arsenic, in this disease, palliate the pains more certainly and permanently than the lower, and that the dose should not be repeated too often. Nux vomica is another of those medicines that palliate many of the distresses in carcinoma of the stomach. It has a favorable effect in the excessive acidity of the stomach, the distressing heartburn early in the morning, vomiting of mucus when it does not occur immediately after eating, the painful flatulence, and finally the obstinate constipation. The last-mentioned symptom is relieved by NUX, as by magic; likewise if the constipation had been caused by the excessive use of Opium. Lycopodium bears great resemblance to Nux. In the chapter on catarrh of the stomach we stated that Lycopodium is particularly indicated, if the symptoms lead us to suspect the presence of some malignant disorganization. It is especially suitable if the patients are much distressed by sour stomach and heartburn, accompanied by burning pain in the pit of the stomach; if the vomiting con- sists of mucus, takes place at night or early in the morning, or if the constipation is very obstinate and the faeces are enveloped in mucus. Lycopodium is likewise specially indicated by the condi- tion of the mind and feelings. Veratrum album is only useful for the vomiting of the ingesta. It has afforded relief even in cases where Arsenic seemed powerless. 382 Diseases of the Stomach. For occasional attacks of vomiting, especially vomiting of mucus, it is of no use. Mezereum is recommended for carcinoma of the stomach; whether such a recommendation is properly based upon symptomatic simi- larity is very doubtful. Kallenbach reports two cases where the vomiting was arrested by this medicine. Our objection to such cases is, that the dissolution of the cancerous growth had most likely cleared the passage in or out of the stomach; for in Kallen- bach's cases, both patients died soon after the cessation of the vom- iting. The symptoms seem to point out Mezereum as a more appropriate remedy for perforating ulcer, and hemorrhage from the stomach, than for carcinoma. Plumbum does not seem entirely homoeopathic to carcinoma of the stomach; the local symptoms do not indicate it. On the other hand, the manner in which the vomiting takes place, the excessive an- guish during the vomiting, the nature of the vomit, the obstinate constipation, the emaciation like that of a skeleton, the condition of the mind, are well calculated to recommend this medicine as an excellent palliative. A very striking case, related by Widumann, in the Hygea VII, should invite similar experiments with Plum- bum. We have to observe that Widumann employed the Acetate of Lead, not metallic Lead. Hartmann mentions, beside these remedies, Carbo vegetabilis and animalis, likewise Comum, but a merely superficial perusal of their pathogenesis, shows that not one of them fully corresponds to the pathological series of carcinoma, and they at most cover a few single symptoms, hence cannot be properly assigned a place in the front rank of cancer-remedies. Creasotum is recommended by some homoeopathic physicians, the same as by physicians of the Old School. The pathogenesis of Creosotum is, however, very imperfect, but, inasmuch as any remedy that may possibly be of some use in the treatment of carcinoma of the stomach, ought to be received by us with a hearty welcome, we deem it our duty to give it a place in our list. For other medicines that might possibly be of some use in carci- noma, we refer the reader to chapters 2 and 4. A precautionary rule, that cannot be too often or too earnestly enjoined upon begin- ners, is not to change the medicine too often, nor to indulge in too frequent a repetition of the dose. By the former mistake we are led to be deceived regarding the efficacy of our remedies, and to abandon a good remedy because it has not yet had time to display Haematemesis, Hemorrhage from the Stomach. 383 its effect. In this as in other similar affections, where we are con- stantly obliged to prescribe a remedy without the least hope of do- ing the patient any good, we often have to resort to a simple powder of sugar of milk in order to appease the sufferer's im- patience. [Cuprum acetumm will sometimes relieve the distressing vomiting in carcinoma of the stomach. II.] This is scarcely ever an idiopathic affection, but almost always symptomatic of some other disease. If we devote a special chapter to this accident, it is because vomiting of blood always excites our most serious apprehensions, and, therefore, is of great importance in a therapeutic point of view. For this reason we place this subject immediately after those processes which mostly occasion the dis- order. Hsematemesis may depend upon a variety of pathological causes, and if it inclines to become profuse and threatening, it is of the ut- most importance in practice to investigate with accuracy and care the precise etiological causes in each attack. Bleeding may occur, even if the vessels of the stomach are all left intact, even if a post- mortem examination does not reveal the least rupture of any blood- vessel. As a complicating symptom bleeding occurs, more partic- ularly, in diseases characterized by a peculiar alteration of the whole mass of blood, such as typhus, scurvy, yellow fever, etc. The hem- orrhage may be very copious, although none of the Larger vessels are ruptured. A second cause of the bleeding is a rupture of the walls of vessels. It may be caused by excessive accumulation of blood in the stomach depending upon disturbances, engorgements, etc., of the vena porta, liver, spleen-hence it is not of unfrequent occurrence in the case of individuals afflicted with piles; or the hemorrhage may be caused by menstrual suppressions and stop- pages, on which account it occurs more frequently at the climacteric age; it sometimes seems as if the hemorrhage took place as a vica- rious substitute for the menstrual discharge. The vomiting during pregnancy is very frequently stained with blood. In the cases we have mentioned the bleeding is very copious, and generally takes place'from the ruptured capillaries. Hemorrhages depending upon an impeded circulation of the liver, spleen, etc., mostly arise from varicose distension of the veins of the stomach, and incline to be very copious. The worst kind of bleeding arises from injuries of 6. Hsematemesis, Hemorrhage from Ilie Stomach. 384 Diseases of the Stomach. the vascular walls, consequent upon ulcerations of the mucous mem- brane. It is met with in chronic catarrh of the stomach, as well as in cases of perforating and carcinomatous ulcers. If there is an idiosyncratic disposition to bleeding, it may be provoked by a blow upon the stomach, a fall, or a violent emotion. The symptoms of hsematemesis differ, according as the bleeding is more or less copious, and arises from different causes. If the bleeding is but slight, and the blood is not vomited up, the accident remains sometimes entirely unnoticed. If the vomited substance only contains a few streaks of blood, it has no particular signifi- cance at the time, but the patient has to be watched with more care, because we can never be sure whether a more dangerous hemor- rhage is not threatening. The blood should likewise be examined, with a view of discovering pathological changes that had remained latent heretofore. The bleeding likewise acquires importance from the circumstance, whether the blood is discharged with violent strain- ing, or is vomited up easily; in the latter case the bleeding is much more significant, on account of its indicating ulceration of the mu- cous membrane, or some important change, dilatation, etc., of the vessels, whereas a little blood may be discharged in consequence of violent straining, even if the vessels are perfectly intact. As soon as a somewhat considerable quantity of blood is vomited, a series of characteristic symptoms are evolved. The morbid symp- toms that already happen to be present, become associated with a constantly increasing dull pressure in the pit of the stomach, and a distressing feeling of distention of the stomach, generally attended with nausea. If the bleeding takes place slowly, the preliminary symptoms may be confined to these few; on the contrary, if the blood is expelled with rapidity and force, the patient experiences the usual symptoms of a considerable loss of blood, such as anxiety, paleness, cold sweat, cold skin, vertigo and even fainting. A large quantity of blood is vomited up at once, and with great force. The action of the gastric juice imparts to it a blackish hue, and has the consistence of coagulated sour milk. The quantity discharged at one vomiting often exceeds one quart, so that it seems scarcely possible that the stomach could have contained such a large quan- tity at once. Immediately after the vomiting the patients feel faint and exhausted, and are tormented by an almost unquenchable thirst; at the same time a visible throbbing occurs in the pit of the stomach, of which the patient himself is conscious. After this par- oxysm, a period of rest and comparative ease sets in, until another Haematemesis, Hemorrhage from the Stomach. 385 attack of bleeding occurs. The interval to the next bleeding, lasts from a few hours to several days; in violent cases four or five attacks may occur on the same day; of course in such a case, severe symptoms of anaemia may set in even unto convulsions, and death may be the immediate consequence. If so much blood is expelled from the stomach, the stools are likewise black as coal, and very thin; it may even happen that the blood is not vomited up first, but that the black stools may be the first sign of the bleeding. Regard- ing a return of the bleeding, we cannot speak with certainty, it de- pends entirely upon the primarily exciting cause. If there is a fre- quent return of the bleeding, anaemia and dropsy are unavoidable results. Recovery from a single attack usually takes place slowly, the patients being at the same time tormented by a variety of gas- tric disorders, such as a burnin2: distress in the region of the stom- ach, foul taste, sweetish or foul eructations, horrid thirst, and by a long-continued abdominal pulsation. Under all circumstances there is great danger lest the bleeding should return, hence the patient cannot be too careful in not overtaxing the stomach. Bleeding re- sulting from ulceration may not afford much relief, but in cases of luematemesis, of which we are unable to discover the exact cause, or which depend upon the suppression of other hemorrhages, the re- lief afforded by such bleedings may be quite considerable. As regards diagnosis, two circumstances may deceive us. In the first place a violent paroxysm of haemoptysis may be mistaken by patients for vomiting of blood, and the deception may be kept up if the physician does not himself examine the vomit, since pa- tients, often, are so overwhelmed with anxiety that they lose all calmness and presence of mind. In other respects the black color of the vomit, and the absence of the bloody expectoration, which always follows a paroxysm of bloody cough, furnish the surest in- dications reo-arding the true character of the attack. It likewise happens that a person may have a violent attack of nose-bleed over night, and that the blood may be swallowed : if the quantity of the swallowed blood becomes excessive, it awakens the person, and the blood is then vomited up, and may look precisely as it does when true haematemesis takes place. It is difficult to distinguish one from the other; our diagnosis has to be more particularly deter- mined by the absence of all precursory symptoms and subsequent gastric derangements. The use of whortle-berries and similarly- colored fruit may likewise occasion a momentary deception, more particularly if the patients are very anxious. 386 Diseases of the Stomach. As a general rule, the prognosis in all ordinary cases, is favorable, except where the hemorrhage is at once so excessive that death results from the mere loss of blood. The prognosis, however, is always doubtful, in so far as a first bleeding leaves an inclination to a renewed attack, and the bleeding always indicates the presence of dangerous alterations in the stomach. Hence a permanent cure is never absolutely certain. Treatment. Hartmann (Vol. II. 183) relates a case from his own practice, which we transcribe literally, with so much more pleasure as it suggests many interesting observations. "My patient was a man of about sixty years, of a plethoric, atra- bilious constitution, who, on previous occasions had several attacks, but none equalling the present one in violence. I arrived at the moment when the patient was vomiting up a quantity of dark- colored carbonized blood, after which he sank back on his couch in a fainting condition. Shortly after, another attack took place, after which the weakness became excessive; the blood which had been vomited up in three attacks, filled half a chamber, yet the disease did not yet seem disposed to intermit, for the horrid visibly percep- tible throbbing in the pit of the stomach, perceptible even to the patient, the nausea, eructations, and the other precursors of a re- newed attack, continued; the patient's skin felt cold; the features were sunken and he moaned and groaned while drawing breath. No remedy seemed better indicated than China, of which he took a drop of the 18th attenuation. In three hours, another but milder paroxysm set in, and on the next morning the patient had recovered so far as to be able to exchange a few words with me; he likewise complained less of the feeling of qualmishness in the pit of the stomach, in the place of which he experienced a burning distress; the sighing inspirations had disappeared, but the visible throbbing in the pit of the stomach with anxiety was still present; the least motion aggravated the nausea, which likewise became worse at night, together with all the above-mentioned complaints. The appetite was entirely gone, the bowels constipated, the patient was tormented by great thirst. Although I allowed the China to act for four days, yet upon the whole there was no improvement; on the contrary the attacks returned every day twice, and the patient had likewise several stools a day, which weakened him still more. The burning distress in the region of the stomach, the unquench- able thirst, the increasing pulsations in the pit of the stomach, to- gether with intense attacks of anxiety, etc., were sure indications Haematemesis, Hemorrhage from the Stomach. 387 for the exhibition of Arsenicum album, which I administered on the fourth day early in the morning, after which such a steady improve- ment set in, that on the fifth day after the patient took the Arsenic, he was able to leave his bed. The bloody stools continued for two days after the Arsenic had been taken, after which they gradually changed to fecal evacuations. The throbbing and the burning distress in the pit of the stomach continued unchanged for a fort- night after the Arsenic was taken, so that I was led to suspect the existence of an aneurism in the aorta descendens. Calcarea car- bonica had a good effect, but Carbo vegetabilis removed the whole of these symptoms." A superficial comparison of this case with the above-mentioned symptoms, shows that it took a course as though no remedy had been given. It would seem as though Hartmann had treated but few cases of melaena, otherwise he would have held different opin- ions regarding the correctness of his choice of remedies. Hartmann seems to think, for instance, that Carbo vegetabilis, in arresting the abdominal pulsations, likewise arrested the whole trouble, because an apparent feeling of comfort succeeded its administration. But we know that this result takes place in the majority of cases, and that the vomiting of blood occurs again for all that. At all events Hartmann ought to have informed us how many years, after this cure was accomplished, the patient's health remained good. This whole report shows us how cautiously we have to proceed in taking it for granted that a certain remedy had effected a cure. The treatment of luematemesis has to proceed from a twofold point of view, first to arrest the hemorrhage and provide against its immediate consequences, and afterwards to prevent the return of the accident. Our best plan will be, not to give the pathogenesis of each remedy separately, but to group the remedies with ref- erence to the above-mentioned indications. For the hemorrhage itself we know of no better and more effica- cious remedy than Ipecacuanha, unless very peculiar accessory symptoms should render some other medicine necessary. Hence it is indicated against a first attack, rather than against the sub- sequent and alarming symptoms of anaemia. The less the hem- orrhage is depending upon some anterior pathological disturbance, the more efficacious Ipecacuanha will prove. But it is necessary to give large doses and frequently repeated; triturations of the root are, moreover, preferable to the tincture. Nux vomica is more suit- able for hemorrhages accompanied by vascular excitement, they 388 Diseases of the Stomach. are not very copious, and the vomiting is accomplished with dif- ficulty, and attended with severe retching; Nux is more partic- ularly indicated in hemorrhage arising from some acute affection of the stomach. Under such circumstances the dose has to be adapted to the vascular excitement, lest it should be increased by too powerful medicinal action. It is emphatically suitable in cases where the hemorrhage is but trifling, and the blood bright-red. In such cases Belladonna will prove serviceable. If we are called to the patient after he has vomited several times; if the above- described symptoms of anaemia are very prominent; the pulse quick or thready, the skin cool and the nausea unceasing, Veratrum deserves a preference. Secale cornutum competes with this remedy; Secale, however, is decidedly preferable if convulsions have set in, whereas Veratrum is required rather by the fainting sort of weak- ness, or by actual syncope. On the contrary Arsenicum album is preferable if the anguish is very great, the thirst unappeasable, the restlessness extraordinary and the skin is not too cool. The above-mentioned remedies will prove generally sufficient to arrest the hemorrhage. We will add that Arnica is recommended for hemorrhage caused by mechanical injury. We should likewise state that haematemesis, and ordinary bleeding from the stomach, frequently occur in the case of new-born infants, for which Aconite is the chief remedy [The sphere of Aconite in this disease is much more extensive. It will be found generally adapted to hemorrhage with great vascular excitement, quick and small, but hard and jerking pulse, or else the pulse is full, bounding, and accelerated, the skin is warm and dry, the face flushed, there is vertigo and head- ache, the extremities are cold, epigastric region bloated and sore, with pulsative throbbing in the same, nausea and sometimes even palpitation of the heart, great thirst. In Hartmann's case, we should have given Aconite, instead of tampering with other medicines. Aconite would have arrested the hemorrhage at once, and would have effected a cure of the case. Arsenicum was not indicated as the leading remedy in this case, because one of the most character- istic indications for Arsenic in haematemesis, is trembling of the lower extremities, with violent chilliness, even in front of a big fire. H.] China, is generally indicated for the secondary phenomena suc- ceeding the bleeding. It is only exceptionally, however, that the symptoms will be found to be strikingly similar. Nux vomica is undoubtedly more suitable, provided the hemorrhage had not been Haematemesis, Hemorrhage from the Stomach. 389 too profuse, or else Veratrum and Arsenicum, the former particularly if the black stools occur very frequently. Not till the more threat- ening symptoms have abated, is China in its place. Hemorrhages depending upon decomposition and fluidification of the blood, will be mentioned when the various affections to which they are related as effect and cause, are treated of. Such hemor- rhages require to be managed from entirely different points of view. Where the bleeding is caused by suppression of the menses, we have to think first of Pulsatilla ; not so much for the purpose of arresting the hemorrhage, as for the purpose of restoring the men- strual flow. If congestive symptoms are present, Belladonna is pre- ferable ; likewise, if the arrest of the menses is incidental to the climacteric period. Under such circumstances, Lycopodium may prove useful. If the primary affection, upon which the vomiting of blood de- pends, can be correctly diagnosed, it is not so very difficult to oper- ate against it; the treatment is the same as that of chronic catarrh of the stomach, perforating ulcer, carcinoma of the stomach, or such affections of the liver and spleen as may have caused the disturb- ances of the circulation. If the fundamental trouble cannot be found out, we have to confine ourselves, almost entirely, to rigid dietetic and hygienic instructions, and we should try to remove every little irregularity in the digestive functions as speedily as possible by appropriate remedies. Nux vomica, most generally de- serves a preference; if the symptoms do not point to any exception- ally characteristic affection of the stomach, it may be well to con- tinue the use of Nux for a long time at distant intervals. In order not to omit any remedy that may afford relief in such an important accident, where speedy help is sometimes absolutely required, we add the following remedies to our list as worthy of mention: Plyoscyamus is said to be particularly useful in arterial hemorrhage; Phosphorus, Carbo vegetabilis, Mezereum. Of the last- mentioned remedy, we have never seen the least effect in hsematem- esis. Hartmann likewise mentions Millefolium, (because it is said to be useful in any kind of hemorrhage ?) Cantharides, Natrum muri- aticum, Zincum, Sulphur, Cicuta virosa. It is true Cantharides cause vomiting of blood, but most likely, only by their intensely irritating, local action, not by virtue of their constitutional effect. In melsena proper, they are not specifically appropriate. [Among the remedies that have been introduced into American practice in the last few years, Erigeron, or the Canada fleabane; 390 Diseases of the Stomach. Eryngium, or the button snake-root; Hamamelis^ or the witch-hazel, and Sanguinaria, or the common blood-root, have been used by American homoeopathic physicians with more or less success. Of Hamamelis especially, a number of excellent cures of epistaxis, hsematemesis, and hemorrhage from the intestines, have been reported. H.] It can easily be imagined, that in a disease of this kind, the desire to afford help as rapidly as possible, and to quiet the apprehensions of surrounding friends, lest their impatience should prove injurious to the patient, should induce us to resort to external applications in connection with internal treatment.. The most usually employed external means are cold applications, and counter-irritants. It is hard to decide whether a bag of ice laid upon the stomach, exerts a truly favorable effect upon the bleeding. What is the object of such .a proceeding ? Certainly not to effect a direct deviation of the blood from the vessels of the stomach, since the cold repels the blood from the place where the ice is applied. Hence the driving away of the blood from the skin, would only tend to accumulate this fluid in the vessels of the stomach. That the most intense cold does not act upon the stomach directly, admits of no doubt. But even if no favorable effect can be expected from the ice-bladder, let it be laid upon the stomach, were it only to quiet the family. Only let the patient be protected from excess. We cannot speak much more favorably of the different cutaneous irritants. Among them, dry cupping has most in its favor, and least against it It should not be tried, however, if striking signs of anaemia are already present. It is of particular importance that the general dietetic and hygi- enic habits of the patient should be carefully regulated. As soon as hemorrhage sets in, the patient should remain in a state of per- fect bodily and mental rest. A strictly horizontal posture is indis- pensable, and every motion that is not absolutely necessary should be avoided. The horrid thirst of such patients presents some difficul- ties. To quench it, small pieces of ice should be swallowed, or should be allowed to melt in the mouth; this is much better than to swallow liquids. Ice is certainly very refreshing to the patient, and he may partake of it safely, whenever it can be procured; the dread of cold water, which seems to control some people, is ill- founded. It may be that drinking large quantities of water, pre- vents the formation of a thrombus in the stomach, but the frequent use of small quantities of this fluid has no such effect. We know that in cases of severe hemorrhages, the organism desires to repair Cardialgia, Spasm of the Stomach. 391 the quantitative loss of vital fluids by absorbing water, hence the agonizing thirst, hence nothing better can be done than to give the patient, very frequently, a small quantity of fresh, cold water. There can be no harm in reasonably gratifying a natural desire that is so pointedly, and so emphatically expressed. Even the most generous wines are given, if the weakness becomes excessive, simply because Nature seems to require this kind of treatment. There are circum- stances when wine is, indeed, the only means from which a favorable effect can be expected, as rapidly as the imminent danger seems to require. We can testify from experience that wine, if properly administered, is not by any means hurtful. As long as there is danger of a return of the bleeding, the patient has to be kept on a low diet, or, if he has no desire for food, he may safely be allowed to do without it. Otherwise, slimy soups are his best nourishment, only they must be eaten when quite cool. As soon as the hemorrhage is arrested, the waste should be repaired as speedily as possible by giving the patient more invigorating nour- ishment. As long as there is any sign of abdominal pulsation, solid food had better be avoided; not till every trace of pulsation has disappeared, can the ordinary mode of living be resumed 7. Cardialgia, Spasm of the Stomach. With a view of facilitating the comprehension of the following chapter, we will state that our remarks apply to all the various conditions that have been designated as gastrodynia neuralgica, gastralgia, neuralgia coeliaca. By these expressions we understand a very painful affection of the stomach, existing without any material changes in the tissues of this organ, and which, on this account, we regard as simply emanating from the nerves of the stomach. Regarding the nature of this pathological process, we have not as yet arrived at any very definite explanation. Cardialgia is, at times, a primary, at other times a secondary affection. The causes of idiopathic cardialgia are : A generally in- creased sensitiveness and irritability of the nerves of the stomach, without any definite dietetic transgressions being discoverable as the primary cause of the disease. Such an abnormal irritability does not continue uninterruptedly, it appears in paroxysms, without any demonstrable cause, so that at certain times the distress is ex- cited by a variety of articles of food, which at other times can be eaten without the least inconvenience. One cause of cardialgia is 392 Diseases of the Stomach. the disproportion between waste and supply; hence we find this affection prevailing among persons leading a sedentary life, or in- dulging in excessive living. In many individuals, especially in the summer season, a common cold is very apt to cause cardialgic pains. The chief causes of the primary disease, are medicinal arti- cles of diet, and medicines themselves. We see cardialgia remain after other severe diseases that had been treated with a quantity of violent drugs; this is known to every homoeopathic physician. The disease is likewise caused by abuse of spirits and green tea. Coffee, however, is the beverage to which most individuals owe their attacks of cardialgia-we mean badly prepared coffee. Ac- cording to our experience, strong, filtered coffee, that has not been boiled, and is free from adventitious admixture, scarcely ever causes gastric derangements, provided it is not partaken of in too large a quantity. This, however, is very seldom the case; and, if it does produce gastric derangements, it is not cardialgia, but such disturb- ances as we have described under the general designation of catarrh of the stomach. For this reason, women are much more frequently attacked with cardialgia than men. Hartmann may be correct when he says that the sedentary mode of life to which women are so frequently condemned, prevents them from neutralizing the dele- terious effects of coffee by plenty of exercise; but this is not the only cause, in proof of which we point to the frequent occurrence of cardialgia, among country women of the -poorer class. That coffee is the sole cause of cardialgia among them, has become evi- dent to us by abundant experience, for we have cured many cases of this disease, in a very short time, by means of a few powders of sugar of milk, simply recommending strict avoidance of coffee. But if we do not wish to be deceived, we should proceed very cau- tiously in examining the patient concerning the use of coffee; for women do not mind telling a falsehood if their favorite beverage, coffee, is at stake. More than one woman has confessed to us that she would have resorted to homoeopathic treatment, if it had not been for the dread of having to do without her coffee. We would advise the physician to visit his patient unexpectedly, at the time when she is in the habit of sipping her coffee, in order to satisfy himself what horrid brew she calls by that name, and, at the same time, to become convinced that this so-called coffee, with its admix- ture of chicorea and the like, is sufficient to cause sickness. An- other drug, which, however, does not cause cardialgia as certainly as coffee, is tobacco. The pains caused by tobacco are of a peculiar Cardialgia, Spasm of the Stomach. 393 crampy kind, and often continue the whole day, but do not become seated as easily as the pains caused by cotfee. Whether cardialgia can be caused by tight dresses alone, without any other injurious influence, is difficult to determine, for the reason that women who wear such dresses are, generally, predisposed to derangements which culminate in cardialgia. As a secondary affection we meet with cardialgia in various con- ditions of the organism which produce nervous debility as a leading result, such as anaemia, chlorosis, leucorrhcea, and affections of the sexual organs generally, likewise onanism, spermatorrhoea, and finally during convalescence from very severe diseases, such as typhus. That hysteric women frequently complain of cardialgia, is well known. Affections of the spinal cord are likewise to be sus- pected, but it is difficult to determine whether the spinal irritation is the cause, or effect, of the cardialgic disorder. The supposition that the suppression of habitual foot-sweats may cause cardialgia, is likewise very hypothetical. The most violent attacks of cardialgia which we have yet seen, in the case of two female patients, were evidently caused by an excess of uric acid, for during the attacks, which came on periodically, a sandy sediment was discharged with the urine, or very copious crystals were deposited in this fluid. The connection between the two orders of phenomena is not very clear. Regarding age and sex we meet with cardialgia more frequently among women, very seldom before the age of pubescence, most fre- quently between thirty and fifty years. The mode of living does not seem to exert a prominent influence, except in so far as the substances, to which we have called attention in previous para- graphs, may give rise to the disease. In view of the changeable character and multiplicity of the symp- toms of cardialgia, we are unable to exhibit them in a connected series, and we, therefore, prefer describing them in detail. The pathognomonic symptom, of cardialgia, are pains, the principal seat and starting point of which is the region of the stomach, and which break out at intervals, at least at the commencement of the dis- ease. The chief character of the pain, is a constrictive, crampy, twisting pain ; the pain is likewise tearing, boring, burning, cutting, throbbing, gnawing; indeed, it may assume every possible shape. In the lesser forms of cardialgia, the patient does not suffer much, since the pain is nothing more than a dull painful pressure. Gen- erally, however, shortly after a sensation of malaise, eructations, a 394 Diseases of the Stomach. feeling of goneness or weariness in the pit of the stomach, the pain suddenly increases in intensity to such a degree that the patient is compelled to cry out. It is characteristic of cardialgia that slight pressure should cause pain, whereas hard and continued pressure is not only easily borne, but affords relief, hence we see the patients pressing their stomachs against the edge of the table, or bending double over the back of a chair, in order to obtain relief from their distress. The pain either remains confined to the region of the stomach, or else it radiates towards the back, the chest, or the ab- domen. The respiration is frequently interfered with, hence we often hoar cardialgia described as a spasm of the chest. The par- oxysm is excited by certain kinds of food and certain emotions, or it may occur at regular intervals, or without any apparent cause or periodicity. Some individuals are attacked early in the morning, when they have nothing on the stomach; others late in the even- ing or at night, or after a meal. At one time the pain is excited by everything that is taken into the stomach; at other times it is ameliorated by eating. These differences in the time of the appear- ance of the paroxysms, and in the effect of external circumstances, are not only met with among different individuals, but likewise in the same patient. The morbid phenomena which may manifest themselves during the intervals of the paroxysms, are exceedingly variable. One of the most common is vomiting; there is seldom vomiting of food except when it occurs shortly after a meal, most generally the patient brings up a slimy-watery fluid. The vomiting usually ter- minates the paroxysm, it is very rare, that the pains continue after the vomiting. Beside the vomiting we frequently meet with an excessive development of gas in the stomach, which sometimes takes place all at once; the gas distends the stomach so that the patient is obliged to loosen his clothes, belching up a quantity of wind affords relief and even arrests the distress. Heartburn, nausea and canine hunger, frequently accompany cardialgia, not so much as constituent symptoms of this affection as accidental symptoms of some other affection of the stomach. Beside these derangements emanating from the stomach exclu- sively, we have disturbances in other organs. During the attacks we frequently meet with palpitation of the heart, colicky pains, convulsive motions, debility even unto syncope, etc. After the attack the patient complains of great weariness, the urine is se- creted in large quantity and clear as water, very seldom saturated, Cardialgia, Spasm of the Stomach. 395 and the region of the stomach remains sensitive for a short time after. A single paroxysm, when the disease first commences, seldom lasts longer than one hour. If the disorder increases, the attacks may succeed each other so rapidly that the pain seems to be contin- uous, with only short remissions, and raging for days. In some cases the general organism does not seem to be affected by the car- dialgia, between the paroxysms the patients seem quite well; usually, however, nutrition suffers, especially if the spasm is pro- voked by certain kinds of food, so that the patients are afraid of eating. But even without this inconvenience the digestive powers gradually become weaker, the alvine evacuations are retarded and difficult, the face puts on an expression of suffering and acquires a pale and livid hue. A transition into other complaints does not take place. Where such a transition is supposed to have been witnessed, it was not cardialgia, but some other affection that the patient had to deal with. That any interference with the functions of the stomach may, under certain circumstances, give rise to chronic catarrh of the stomach, is self-evident; we can likewise readily admit that genuine cardialgia may become combined with some other morbid process, and that both may coexist for a certain period. It is not always possible, either at the commencement or at the very height of the disease, to diagnose cardialgia with absolute certainty. If the disease is comparatively recent, the paroxysm may be mistaken for an acute attack of gastritis, this mistake is very soon discovered by a cessation of the pains. Beside gastritis it is with the round ulcer that cardialgia may be confounded. The absence of a circumscribed, localized painfulness; the circumstance that in cardialgia the ingestion of food either ameliorates the distress or, at any rate, does not excite the attack; the circum- stan.ce that cardialgic pains usually develop themselves gradually, that they disappear without any regularity, and that they are diminished by hard pressure, are pretty safe diagnostic indications in almost every case. With carcinoma, cardialgia can only be con- founded if the cardialgic distress continues without interruption, however, the fact that cardialgia does not result in emaciating the system, generally removes all uncertainties regarding the distinc- tive differences between carcinoma and cardialgia. Treatment. We are justified in asserting that the rapidity and safety with which cardialgia yields to homoeopathic treatment, 396 Diseases of the Stomach. constitute one of the bright points of Homoeopathy. We lay so much more stress upon this advantage, as every other method of treatment generally consumes years in combating this disorder without success. Moreover, in the case of a chronic trouble like cardialgia, the result of the treatment is much more indisputable than in acute affections, where all sorts of imaginable objections are made against the method of treatment, in order to evade the logical necessity of having to admit the reality of the cure by medicinal means. Hence the sure cure of one of the most common and most obstinate affections, is better evidence in favor of Homoe- opathy, than the most evident success in treating an acute disease. The treatment of cardialgia is one of the least difficult problems for a homoeopathic practitioner, since we have only to deal with subjective symptoms, and hence the selection of the proper remedy depends entirely upon a very careful comparison of the symptoms. Detached suggestions derived from practice, are easily made avail- able in a given case, and constitute in this very affection the safest guides; another reason why cardialgia is easily cured, is that phy- sicians are so frequently called upon to treat it. Of the large number of remedies most of which have been tried practically, we give the more important ones with all their leading indications; the balance can only be mentioned very generally. Nux vomica. We may safely assert that a majority of all the cases of cardialgia are suitable to this remedy and either yield to it entirely or partially. It is characteristic of Nux to cause pains when the stomach is empty, which afterwards are moderated by eating; on the other hand there are pains caused by Nux which are either excited or aggravated by eating. The early morning- hours are generally the time when the pains to which Nux is homoeopathic, are either excited or aggravated; although pains which are felt during the day, are likewise adapted to the curative action of Nux. The circumstances under which cardialgia is either excited or aggravated, are exceedingly varied, likewise the time of their occurrence. In addition to such general indications which are, however, very important in selecting a remedy for cardialgia, the more special symptoms furnish a striking picture of cardialgia, especially of that form the diagnosis of which cannot easily be doubted. Hartmann furnishes the following apt description of the disease: "The characteristic pains are: Contracting, pressing, crampy, tearing pains in the stomach, with sensation as if the clothing were too tight in the region of the stomach and caused Cardialgia, Spasms of the Stomach. 397 an oppression, a sensation that is somewhat like the sensation as if flatulence were pressing against the hypochondria; this sensation as well as the cardialgia itself, are generally aggravated after a meal and by drinking coffee; it is associated with a feeling of oppression and constriction of the chest, spreading in many cases as far as between the shoulders and the small of the back, or causing a sensation as if a tight band were encircling the chest. If the pain is already felt early on rising, if the patient is awakened by it, the curative power of Nux may be certainly depended upon. But Nux is likewise indicated when the following phenomena of reflex-action and synergy are associated with the pain in the stom- ach: Nausea, especially during the attack, waterbrash, rising of a sour-bitter fluid with or without heartburn, vomiting of the ingesta or of mucus, also ineffectual retching, palpitation of the heart with anxiety, sour-putrid taste in the mouth, constipation, flatulent distension of the abdomen, occasionally hemicrania, press- ing pain in the forehead. Nux is likewise indicated m the case of women whose menses are profuse, the pain setting in with partic- ular violence about the time of the catamenia. " The more delicate and more sensitive the individual, the weaker may be the dose; the more robust the individual, the stronger should be the dose. So far I have never been obliged to give below the third attenuation; if I have once become satisfied that Nux is the remedy in a given case, I do not hesitate to repeat it; nor have I seen any ill effects in the few cases where I have given Nux morn- ing and evening, although I mostly give it only in the evening." We will add to this characteristic picture that Nux is particularly adapted to men and to women of a sanguine and quick temperament, also to individuals who are troubled with symptoms of impeded circulation in the digestive apparatus. Nux vomica is specifically adapted to cardialgia, caused by the use of coffee, spirits, and the abuse of chamomile tea. It is less frequently suitable in cases arising from some violent emotion ; again, on the other hand, it is indicated if the attacks set in after severe diseases, or in consequence of self- abuse. Arsenicum album. In treating of other affections of the stomach, we have had occasion to point out the strikingly specific action of this drug upon the stomach, and we feel likewise bound to place it in the front rank of our remedies for cardialgia. Hartmann has described the cardialgia, to which Arsenic is homceopathic, under the name of neuralgia cceliaca, and we here transcribe the most 398 Diseases of the Stomach. essential parts of his statements, because they embody the essential characteristics of the pathogenesis of Arsenic in their corresponden- tial relation to this disease. The real paroxysm is preceded by a certain restlessness for a longer or shorter period ; next, the patient experiences, all at once, a pain under the ensiform process, of a burning, tearing, stitching or press- ing nature, as from an incandescent coal, or as if the parts were violently torn asunder. The pain is sometimes so intense that ro- bust persons become raving mad, delicate individuals faint away. After the pain has lasted at this circumscribed spot for half an hour, it leaves this part and, like a flame, shoots upwards under the ster- num towards the neck, or-else it divides in two currents, ascending towards the neck on both sides of the vertebral column, following the tract of the sympathicus, or finally it scatters suddenly in all directions, more particularly towards the hypochondria, in the direc- tion of the plexus lienalis and hepaticus. Towards the end of the paroxysm the patient generally belches up wind, or water accumu- lates in his mouth. After the attack he experiences a feeling of emptiness in the abdomen, lassitude and a feeling of weary exhaus- tion in the whole body. The tongue remains quite clean, the appe- tite normal, the digestion likewise. The majority of cases occur at night or early in the morning, more frequently among men than women. For attacks of this kind the best remedies are Arsenicum and Nux vomica. Hartmann establishes the following contrast between the two: " Nux vomica is more frequently suitable for the male, Arsenicum for the female sex; if the male individual is of a delicate and sen- sitive frame, Arsenicum may likewise be appropriate. Nux, as is well known, is adapted to a lively, sanguine temperament, an irri- table disposition ; it is indicated, if the attack is in a measure owing to suppressed hemorrhoids, and if the pain is so acute that the patient is driven by it to madness. It is likewise indicated where sedentary habits, mental labor, have favored the outbreak of such a disease. Arsenicum, on the other hand, is especially suitable in the case of melancholy or nervous temperaments, and the pains are so intense that they cause the patient to faint. Nux deserves a preference if the paroxysm occurs in the morning hours; after it stops, the patient sinks into a heavy slumber, disturbed by dreams, from which he wakes more tired than he was the evening before; during the paroxysm the patient feels more relieved in a recumbent posture than when standing up or walking about. Arsenicum is Cardialgia, Spasms of the Stomach. 399 required if the paroxysms set in about midnight, awaken the pa- tient from the soundest sleep and abate somewhat when he walks about. The burning pain corresponds more to Arsenic, the tear- ing, stitching, pressing pain to Nux, both kinds of pain are attended with anguish which, when excessive, decides in favor of Arsenic." Cardialgias characterized by such symptoms, are not very fre- quent, nor is Arsenic the only remedy in such cases. This agent plays an important part in cases where the diagnosis is uncertain. It is the acute burning pain that points to Arsenic, so much more when it is accompanied by great restlessness, nervous excitability, palpitation of the heart, and an unequal temperature of the body, and the attacks set in more particularly at night. Chamomilla. According to Hartmann's excellent description of the curative sphere of this drug, it is particularly suitable for irri- table dispositions that are disposed to Hare up, and if the attack is provoked by a fit of anger. The pain is a hard pressure, as from a stone in the pit of the stomach, and painful bloating of that region and of the left hypochondrium; the pain is attended with shortness of breath and anxiety, is worst at night,' so that the patient is beside himself with anguish and restless tossing about; a throb- bing headache in the vertex sometimes supervenes, obliging the patient to get up. It is only during rest and when the body is doubled up, that some ease is obtained. It is important to know that such an attack is mitigated by drinking coffee, whereas the cardialgia to which Nux is suitable, is aggravated by coffee. On account of this circumstance Chamomilla may be required in car- dialgias caused by coffee, more particularly if Nux alone is not sufficient to a cure. Belladonna is not often suitable to cardialgia, more particularly to cardialgia of a more violent degree of intensity. The symptoms are very much like those of an incipient acute gastritis, the pain is a gnawing pressure or a tensive pain, is relieved by stretching the region of the stomach when reclining backwards, arrests respira- tion, spreads over the adjoining parts, is excited or aggravated by the ingestion of warm food, and is so peculiarly intense that it causes syncope. This form of cardialgia is usually caused by a severe cold and on this account breaks out quite suddenly. It is generally attended with colisiderable accumulation of gas. As far as the origin of the disease is concerned, Belladonna is nearly related to Colocynth. This remedy is more suitable if the attacks set in in rapid succession, the pains are crampy and caused as by a twisting 400 Diseases of the Stomach. of the stomach, oblige the patient to bend double, abate by external warmth, are aggravated by the ingestion of any kind of aliment; there is nausea, but scarcely ever any vomiting. Eructations afford much relief. The pain is attended with chilliness and even a cold perspiration. Such cases are scarcely ever met with except in warm months about the time when colicky pains are common. If the car- dialgia to which Coloc corresponds, occurs in a more chronic form, Cocculus is the best remedy. It is more particularly indicated when the cardialgia is accompanied by the accumulation of gas in the intestines, crampy pains and obstinate constipation. Ignatia is like Nux vomica, characterized by a painful pressure in the region of the stomach, as from a stone, which is excited by the ingestion of any kind of food, and, as a spontaneous distress, occurs principally at night. It is attended with a feeling of hunger and aversion to food. If grief and care are the cause of the disease, Ignatia is said to be the more indicated. [A characteristic indica- tion is a feeling of goneness in the pit of the stomach, with sensation as if a number of needles were pricking the inside of this region. II.] Sepia has a pain similar to that of Ignatia; here, too, it is apt to set in after eating, but seems to prevail early in the morning before breakfast, and between breakfast and dinner. The characteristic distinctions of both drugs are particularly seen in the accompanying mental conditions • Ignatia is more especially adapted to delicately- organized, sensitive, hysteric individuals, upon whom depressing emotions exert an overpowering influence; Sepia, on the contrary, to individuals with sanguine, excitable temperaments, and inclined to congestions. Both remedies are more especially suitable for females; Sepia is more particularly depending upon the accompany- ing symptoms of the sexual range for its homoeopath! city to cardi- algia. Argentum nitricum has already been mentioned in our chapter on perforating ulcer. We there stated that Hartmann's enthusiastic recommendation of this remedy cannot well be applied to its rela- tion to simple, uncomplicated cardialgia. Considering the large number of well-proved and practically tried remedies which we pos- sess for cardialgia, it would be ill-advised to place an uncertain agent, like the Nitrate of Silver, with uncertain indications in the rank of our remedies for cardialgia. It remains for us to mention three remedies, which we class to- gether, because their action coincides in one important particular. They are Pulsatilla, Ferrum, and China. We have stated above Cardialgia, Spasms of the Stomach 401 that cardialgia is frequently met with in individuals who are afflicted with chlorosis, or generally with anaemia or hydrsemia, and that it likewise does not unfrequently occur in the stage of conva- lescence from severe acute diseases, such as typhus. We cannot as yet, show how the altered composition of the blood is related to the nervous derangement of the stomach; that such a relation exists, admits of no doubt. Pulsatilla is particularly adapted to the cardialgia of chlorotic pa- tients, provided it is of recent origin, more particularly if the spas- modic distress breaks out early in the morning, when the stomach is yet empty. It abates for a while by eating, but afterwards re- appears with so much more intensity; it is accompanied by nausea and a desire to vomit, but there is scarcely ever vomiting of water. The symptoms of this form of cardialgia vary a good deal, and have a multitude of secondary or accessory ailments, which are embodied with great completeness in the pathogenesis of Pulsatilla, and to which we refer in our Materia Medica. Ferrum is likewise, though less exclusively, adapted to the cardi- algia of chlorotic females. This remedy corresponds more particu- larly to the higher grades of the disease; its selection is not very difficult, because the symptomatic indications are very uniform and precise. Ferrum corresponds to cardialgia with violent pressure or a crampy pressure, which is excited or aggravated by the ingestion of the least quantity of aliment, and during which the region of the stomach appears decidedly distended. At the same time there is nausea and vomiting of mucus and water, especially early in the morning before breakfast, another characteristic indication is the excessive and insipid eructations after every meal. China is particularly appropriate, if the cardialgia depends upon a general weakness caused by loss of animal fluids, or by the exces- sive use of cathartics, after copious artificial or spontaneous losses of blood, after a protracted diarrhoea. The pain always is like a hard pressure or a crampy pain, and is either mitigated or aggra- vated by eating. Bodily rest relieves the distress. Beside spas- modic eructations, we likewise have an excess of acid in the stomach; vomiting constitutes the exception. We do not mean to assert that these remedies are the only ones capable of curing cardialgia; they are the leading remedies in this disease. In the cardialgia of chlorotic patients, Arsenicum and Cal- carea carbonica act an important part, Arsenicum particularly, if we 402 Diseases of the Stomach. suspect the existence of perforating ulcer. Next to China, Nux vomica deserves special consideration. Phosphorus is likewise recommended for cardialgia, to which, however, it is not homoeopathic symptomatically. The successful cures of this disease with Phosphorus, were not, in our estimation at least, cures of genuine cardialgia. Carbo vegctabilis likewise is no remedy for pure cardialgia, but is better suited to affections of the stomach, attended with material alterations. Its use in the cardialgia of nursing females is undoubt- edly problematical; China and Nux vomica are preferable. Beside the remedies we have mentioned, the following likewise deserve our attention: Platina, Secale cornutum, Lycopodium, Plum- bum, Coffea cruda, Magisterium Bismuthi, Staphysagria, Stannum. [Acidum hydrocyanicum is likewise an important remedy for cardi- algia. In some of the last numbers of the New England Medical Gazette, some highly interesting cures of cardialgia by subcuta- neous injections of Morphia are reported by Doctor Gallinger of Concord, N. II. H.] Diet does not require any special remarks at our hands. The same rules are to be observed here that we have laid down for chronic catarrh of the stomach. The cause of the distress has to be carefully considered. If the disease arises from weakness of the stomach, all strong, substantial nourishment should be avoided. Fat food is hurt- ful altogether. That coffee should be avoided, may be inferred from what we have said on the subject of coffee in a former paragraph. The dread of an attack of cardialgia induces many patients to pre- scribe for themselves a series of privations, so that their assimila- tive system and general constitution suffer more in consequence, than they would have done under the tortures of simple cardialgia, so that the diagnosis becomes exceedingly uncertain. To such pa- tients, simple, substantial, easily assimilated food is indispensable ; cardialgia is not benefited, much less cured, by a regular starvation diet. A marvellously favorable effect is often obtained by the methodical application of cold water. Nothing facilitates the cure of cardialgia as much as a daily ablution of the whole body with cold water, or at least of the trunk and head. The favorable effect of this proceeding is most strikingly visible in the female sex, but likewise in men who do not take much exercise, and have to un- dergo exhausting mental labor. These categories of diseases of the stomach, are not sufficiently exhaustive to enable us to assign a place to every possible derange- Cardialgia, Spasms of the Stomach. 403 ment of the stomach in one of them. It is impossible to furnish such a comprehensive exhibition of all such diseases, at any rate less possible than to range the affections of other organs in such a general series. The stomach is exposed to the action of external in- fluences more than any other important organ. If we understand by health, the power inherent in a healthy organ or organism to equalize all external influences without any striking or lasting dis- turbance, we may well say that a sound stomach is a rare occur- rence in the present condition of civilization. We are satisfied with a moderate degree of normal equilibrium in the functions of the stomach, and do not regard an unimportant disturbance of this organ as anything very abnormal, provided the disturbance does not continue too long, or increases by decrees. It is, indeed, as difficult to draw a sharp line of demarcation between the health and disease of this part, as it is impossible to set up a fixed normal line for the process of nutrition. All these transition forms, from health to disease, the different forms in which a disturbance of the process of digestion may appear, cannot possibly be indicated with approxi- mate completeness, with a view of pointing out the correct treat- ment. In order to hit upon the proper remedy in all such cases, we must either possess a perfect knowledge of the appropriate remedies, or else consult a Repertory, where the correct remedy will be found, the more readily, the more disconnected the symptom to be re- moved, appears in the series. Pathology unites all these conditions under the common name of dyspepsia, and by thus classifying the most diversified conditions in one series, shows how little the practical wants of the sick are responded to by a pathological scheme. It is dyspepsia, if the digestion takes place too slowly, but likewise if it is too fast. The same name is applied to a too copious, as well as to a too scanty secretion of the gastric juice, a disposition to excessive development of gas, etc. Now, can such a designation be expected to be of any use therapeutically? We shall find that physicians who regulate their Therapeutics by pathological categories, fare badly when, in face of such trifles as are met with every day in practice; and we ought to be grateful to Homceopathy for her safe guidance in such cases, giving us more reliable means of cure than mere dietetic rules. On the other hand we should do wrong were we to lose sight of the necessity of dietetic restrictions, and simply depend upon medicine. A simple suggestion regarding the diet, will, some- times remove an obstinate gastric trouble; we must only take care 404 Diseases of the Intestinal Canal. to be thoroughly acquainted with the patient's mode of living. How many recover their health simply by eating slowly, and mas- ticating their food with care, or by not eating it too hot, or not smoking immediately after a meal. Such habits have to be in- quired into with great care; no medicine can afford help, if the vicious habits which cause the disturbance are kept up. The medicines that may afford aid in all such cases, are those that have been recommended for acute and gastric catarrh of the stomach ; in most cases of gastric disturbance, these medicines will be found sufficient; all we have to do is to carefully compare their pathogenesis with the phenomena of the pathological series, and to impress them well upon the memory. This is so much the more advisable, as the gastric difficulties occur in so many different shapes, and so frequently, that it is impossible to consult the Mate- ria Medica in every case where our assistance is sought. B. DISEASES OF THE INTESTINAL CANAL. 1. Catarrh us Intestinalis, Intestinal Catarrh. If it is difficult to present the different forms of the diseases of the stomach under a few heads, in such a manner that the series shall present corresponding advantages in a therapeutic point of view, it seems still more difficult to thus range the diseases of the intestinal canal, for the following reasons: In the case of the stom- ach, the anatomical disturbances can be harmonized, without much difficulty, with the nomenclature that a simple symptomatology had suggested to former schools ; whereas, the affections of the in- testinal canal present such a chaos of names and definitions, and such an uncertainty regarding the diagnosis of the diseased locality, that we hardly know what road to pursue in order to write intelli- gibly from the stand-point of the old-fashioned pathology; and, on the other hand, to satisfy the demands of the more modern classifi- cations. Neither one nor the other is a sufficiently safe guide alone. In order to anticipate the hasty censure of critics, we will state that we have adopted our present plan for the purpose of responding fully and satisfactorily to the necessities of the practical physician; not to gratify a dogmatic pathology. By following the latter, we should have to confine ourselves to discussing higher and lower Catarrhus Intestinalis. 405 grades of catarrh, so that the essential distinctions which often separate these grades, together with their most common complica- tions, might be overlooked, to the great disadvantage of the thera- peutical part, where the practical treatment of these derangements is exhibited. With a view of showing the fundamental process un- derlying the forms of disease that will be discussed in the subse- quent paragraphs, we have deemed it advisable to group the whole under the general denomination of intestinal catarrh, and to desig- nate them as so many subdivisions, whereas in the older treatises on Pathology they constitute so many leading heads. By pursuing this course, the reader will obtain the desired information, in what- ever direction he may look for it. In order to avoid repetitions, it is advisable to separate only the symptomatic indications;the etiology,and the most prominent ana- tomical conditions, being the same for all. As regards etiology, we refer the reader to our statements in the chapter on catarrh of the stomach. The deleterious influences which cause catarrh of the stomach, may likewise affect the intes- tinal canal, either alone or together with the stomach. A few cir- cumstances, however, deserve particular mention. Many substances that are not apt to cause catarrh of the stomach, very readily dis- turb the intestinal canal. Among them we mention more particu- larly fruit, wine that has not been thoroughly fermented, and sour beer. Some persons are affected by coffee, which acts upon them as a very mild cathartic. All sorts of purgatives belong in this category; they not only cause transitory catarrhal symptoms, but likewise more acute intestinal catarrhs, that may interfere with the good effects of homoeopathic treatment, and may lead astray in making up our diagnosis, which is, in any case, a subject of consid- erable difficulty- In some individuals, every cold, whether general or local, causes intestinal catarrh; in others, on the contrary, the catarrh is only excited at certain periods, so that the catarrhal irri- tations assume the form of an epidemic. Such catarrhs have been traced, perhaps with reason, to a peculiar genius epidemicus gas- tricus. Generally, however, such epidemics depend upon certain definite atmospheric conditions, only we are not able to account for the connection between cause and effect. What is the reason that in a warm spring, catarrhs of the respiratory organs prevail, where- as in the fall we have more particularly catarrhs of the intestinal canal ? Why are the violent catarrhs of the summer season char- acterized by a deficient, and, sometimes, all but suspended secretion 406 Diseases of the Intestinal Canal. of bile ? Observation, likewise, seems to have established the fact that in the summer season the catarrhal irritation seems to be located more particularly in the upper part of the bowels, whereas in the fall season it seems to prefer the larger bowels and rectum. Persons are apt to account for the summer and fall catarrhs by reasons suggested by the dietetic habits of the season, more espe- cially the use of fruit. There is no denying that the abuse of fresh fruit may easily cause irritations of the intestinal canal. That there must prevail a special atmospheric tendency in this direction, is shown by the fact, that persons who have not eaten the least parti- cle of fruit are attacked with intestinal catarrh. As a complica- tion, it supervenes during the most varied morbid processes, some- times as their regular companion, and at others as an exceptional occurrence. It scarcely ever has a critical significance, which has been taken for granted, rather by the force of habit than that of sound reason. The anatomical changes superinduced by intestinal catarrh, are so insignificant in a majority of cases, that they need not be ex- patiated upon in this place. The changes which occur in the intes- tinal canal during the course of other diseases, will be described when these diseases are treated of. It may suffice in this place, to call attention to the fact, that violent diseases of the intestines, especially if they run a protracted course, may easily lead to ulcer- ations of the mucous lining. This circumstance must not be lost sight of, otherwise convalescent patients might prematurely indulge in the use of quantities of substantial food, and the copious and solid feces might easily occasion the discharge of an abscess into the abdominal cavity. This circumstance will be more fully dwelt upon in the chapter on typhus. a. Simple Intestinal Catarrh. The ordinary acute intestinal catarrh, generally commences with a short preliminary stage of a few hours' duration, consisting of a disagreeable uncomfortable feeling, aversion to food, general chil- liness, sometimes vertigo, and dulness of the head. If the attacks are more violent, the affection sometimes sets in at once with a copious, diarrhoeic evacuation mingled with a quantity of gas. At the same time, the symptoms of constitutional disturbance increase in intensity, among which a sudden disproportionate general debil- ity, holds a prominent rank. Fever is very seldom present at the commencement, but the temperature rises somewhat later. The Simple Intestinal Catarrh. 407 tongue is, and remains clean, as long as the intestine is the only part affected. The diarrhoeic stools come on repeatedly at irregular intervals; three or four stools may occur in the course of a single day, and again in the course of an hour. The more frequent and copious the discharges, the sooner they become watery, and the less fecal matter they contain. At first the color is normal; it is only at a later period that it becomes lighter, mingled with greenish streaks and small somewhat darker fecal lumps. At first they smell like ordinary faeces, after lasting some time the evacuations almost become inodorous. Local pains are almost always present; at times they are crampy, at others cutting, at times a simple press- ure, at others they are felt before or after the discharge, and again they continue all the time. The appetite is less, but never entirely suspended. This form of catarrh seldom lasts longer than a few days, pro- vided the patient does not commit any serious dietetic mistakes. The discharges become less frequent, and the pain abates. The complete cessation of the diarrhoea, is often succeeded for some days by constipation, the health being otherwise perfectly good. Under particularly unfavorable circumstances this acute form may pass into the chronic. The treatment is not quite as simple as it might seem at first sight, because it is of importance not to omit even the most trifling circumstances in our choice of the right remedies, of which the number and changeable character of the symptoms suggest a goodly supply. In every case of importance it is best to consult the Materia Medica. Rheum is suitable in the intestinal catarrh of full-grown persons, as well as of children; more particularly, however, in that of children, especially when caused by a cold. The discharges are not quite watery, usually only papescent, having a sour smell in the case of little children; they are frequently mingled with mucus, and have a dark color. Gas is developed in large quantity, the abdomen being perceptibly distended, with pinching pains before and during stool; these cease for some time after the bowels are relieved. The urging to stool is felt very suddenly. Dulcamara acts very similarly to Rheum; it is particularly suit- able to summer-diarrhoea, with colicky pains around the umbilicus, which are only relieved, not arrested, by an evacuation. The dis- charges have little color, are mixed with green streaks, papescent, and occur mostly in the afternoon or at night. Dulcamara is partic- 408 Diseases of the Intestinal Canal. ularly suitable, if the colicky pains and the accumulation of gas have preceded the diarrhoea for a day or more, so that the seat of the derangement is properly traced to the lesser intestines. Chamomilla is adapted to catarrhs caused by violent emotions, such as anger or chagrin, also to the diarrhoea of children, espe- cially during the period of dentition. The evacuations are papes- cent, mixed with mucus, green, (in the case of children,) of the consistence of stirred eggs, excoriating the anus, smelling sour or like ro'ten eggs. The stools do not follow each other in very rapid succession, are accompanied by severe colicky pains; sometimes however they are painless and occur principally at night. Mercurius solubilis is particularly suitable for children during the period of dentition; in the intestinal catarrh of adults this remedy is less frequently indicated. There are only a few evacuations in the twenty-four hours; they are not very copious, mixed with mu- cus, portions of them are tinged dark-green, contain fecal matter, excoriate the anus, and have a sour smell. The pains are cutting or pinching, and precede the diarrhoea, attended with chilliness. Ipecacuanha corresponds more particularly to the intestinal ca- tarrhs of the summer-season, more especially to the most acute forms thereof. The discharges occur frequently, they are thin, have a foul smell, little color, are rather painless, but accompanied by frequent and sudden prostration. Colocynthis has not very frequent, papescent stools with a marked bilious tinge, attended with much gas, and paroxysms of severe crampy pains. The flatulence escaping with the stool is very fetid. The patient complains of chilliness. Colchicum is related to Ipecacuanha; the stools are watery, have little color, are not very copious and painless, it is particularly suitable to individuals who are attacked with intestinal catarrh, from every trifling provocation. Pulsatilla has nightly diarrhoea without much pain, the discharges are slimy, tinged with green, attended with chills, and succeeded by pinching colicky pains which last some time. For this milder form of intestinal catarrh, the above-mentioned remedies will generally be found sufficient; for more acute forms, the medicines mentioned in the following chapter may have to be resorted to. b. Cholera Sporadica seu Nostras, Cholerine. This pathological process is a union of a high grade of intestinal catarrh, with a violent catarrhal affection of the stomach. Cholera Sporadica seu Nostras. 409 Cholerine either takes place only in isolated cases, or as a mild epidemic, in which case it always depends upon peculiar atmo- spheric influences. It seems to be favored, not so much by warm weather, as by an excess of atmospheric electricity, on which ac- count, cholerine may likewise occur in the fall and winter. Single cases may depend upon previously mentioned etiological influences. Generally the disease has precursory symptoms, such as a general feeling of malaise, weariness, nausea, aversion to food, cephalaea gastrica, pains and rumbling in the bowels, pressure and a tight feeling in the region of the stomach, and diminished secretion of urine. Violent attacks occur suddenly. The disease generally breaks out at night; the patient is awakened by a feeling of op- pression in the pit of the stomach, which is soon followed by copi- ous and repeated vomitings, even to such an extent that the patient sometimes imagines the vomiting uninterrupted. At first the food, which had been partaken of last, is thrown up, after which the vomited substance becomes more or less watery and copious, and is so much the less mingled with remnants of food, or tinged with bile, the longer the vomiting continues. Diarrhoea sets in, either at the time the vomiting occurs, or it supervenes soon after. At first the stools have more consistence; soon, however, they become watery and lose their color, so that in very violent attacks, the evacuations by the mouth as well as by the rectum may assume a rice-water appearance, as in Asiatic cholera. Local pains, (even in the most acute attacks,) may be entirely absent at the commence- ment, or there may be colicky, crampy, or cutting pains in the um- bilical region, which are always heightened by the vomiting. Vomiting is excited by the ingestion of the slightest quantity of food into the stomach; moreover, the patient is prevented from eating, by a distressing aversion to food. Sometimes in a few hours the intensity of the pains abates, and the patient gradually becomes quiet. If the disease lasts any length of time, a number of dis- tressing difficulties supervene. In consequence of the constant efforts to vomit, the stomach becomes very painful, as in cardi- algia, the abdomen is meteoristically distended, or else is spas- modically drawn in, and the patients are tormented by agonizing anguish and an unquenchable thirst. The skin becomes remark- ably cool, is even covered with a cold sweat, the pulse is less per- ceptible, the respiration is embarrassed, the features are unusually sunken, and the face has a cyanotic hue. In these higher grades of the disease, muscular spasms are not wanting; they first affect the 410 Diseases of the Intestinal Canal. lower extremities like tonic spasms. The weakness finally becomes so great that the patients have not strength enough left to vomit, and the expulsive action of the stomach is limited to a mere hic- coughing. With these phenomena death takes place very rapidly, although the consciousness sometimes remains undisturbed, even to the last moment. In case of recovery, the urging to vomit first ceases, the skin resumes its functions, and the pulse increases in volume. The evacuations resume a normal color at a later period, convalescence is very slow; very frequently the affection changes to another form which we will designa'e as mucous fever. In the case of children, the symptoms and course of this disease are somewhat altered ; in their case the affection has even been des- ignated as cholera infantum. Cholera infantum never attacks as suddenly as the cholerine of adults , on the other hand the disease is of longer duration and intensity, hence the danger is more threat- ening. As in the case of adults, so in that of children, the affection usually breaks out at night, excepting, that either the vomiting or diarrhoea is more prominent. If the vomiting is more frequent, the diarrhoea is less so, and vice versa. There is always fever. The substances evacuated from the stomach or bowels have almost al- ways more color than in the case of adults; the quantity and num- ber of the evacuations are likewise proportionally smaller. A single paroxysm is not dangerous; the danger consists in the continuance of the exacerbations and remissions of the disease, which are gen- erally more marked at night, the symptoms abating somewhat dur- ing the day. The strength departs very strikingly and rapidly, and the bodily weight diminishes greatly in a few days. Recovery is indicated by a gradual abatement of the evacuations, more gradual than in the case of adults. A fatal termination, which is not unfre- quent, is announced by excessive prostration, the supervention of convulsions, delirium, sopor, and the fetor of the evacuations, which become foul and decomposed, and are sometimes mixed with blood. The transition into another form of the catarrhal disease is propor- tionally of rare occurrence. The danger is the more imminent the younger the infant, it is greatest in the case of infants at the breast, whose feeble existence is so easily extinguished, even by a simple attack of catarrh of the stomach. Treatment. Since this disease runs its course within very de- finite boundaries, the number of remedial agents which we employ against it is limited, and our practical knowledge of their action is much more certain and comprehensive. Whereas there is very little Cholera Sporadica seu Nostras. 411 danger for adults in the treatment of their cholerine by other than homoeopathic means, and this danger seems confined to children and very old persons, we may, on the contrary, be sure of a success- ful termination of the disease under homoeopathic treatment, ex- cept, perhaps, in the case of old and decrepit individuals, and feeble children disposed to convulsions, to which they succumb, rather than to the cholerine, as in the case of any other very severe disease. The leading remedies against cholerine are: Ipecacuanha, Vera- trum album, and Arsenicum ; it is not a very difficult task to dis- criminate between the respective symptomatic indications of these drugs. Ipec. corresponds to the less violent attacks, as long as the discharges have a bilious tinge, and the vomiting and retching are very severe. Hence it is one of the leading remedies for cholera infantum, because the stools scarcely ever become colorless, and is likewise suitable for adults if there is little or no diarrhoea. Ipec. is not counter-indicated by a cold skin, cold sweat, anguish, rest- lessness, or cramps of the extremities. Veratrum album is particu- larly adapted to a case where the evacuations are colorless; these are always the most difficult to manage. This characteristic of the evacuations may be expected with tolerable certainty, if the disease sets in at once with violent, copious and frequent vomiting, and the accompanying diarrhoea is equally violent. Under such circum- stances, it is advisable to at once give Veratrum instead of Ipecacu- anha. The greater the resemblance of this disease to Asiatic cholera, the more urgent the necessity of giving Veratrum. To substan- tiate this, we refer the reader to the chapter on Asiatic cholera. In the case of children, Veratrum will seldom be found the most suit- able specific. Arsenicum album is never indicated at the commence- ment of this pathological process; it is only suitable when, in the further course of the disease, the pains in the stomach and bowels become unusually severe, the vomiting has been replaced by a dis- tressing retching, the diarrhoea is indeed less copious but more fre- quent, and is more or less tinged with blood. These symptoms of the intestinal tract are always associated with extreme anguish, embarrassed respiration, inextinguishable thirst, collapsed features, and a small or even imperceptible pulse. As a general rule, Arseni- cum is more suitable after Ipecacuanha than after Veratrum. In cholera infantum it is one of our main specifics, if the diarrhoea threatens symptoms of decomposition, such as a gray or black color, admixture of blood, and putrid odor. In the case of adults, chol- 412 Diseases of the Intestinal Canal. erine scarcely ever has this termination, more especially if it had been treated homoeopathically from the start. Beside these three remedies, others may be required under certain circumstances. Chamomilla is often a good remedy at the com- mencement of cholera infantum, only it is difficult to decide whether the disease is cut short by the medicine. In the case of adults, we must not expect a striking effect from Chamomilla, although it is constantly recommended for this disease, if mortified or vexed feel- ings were the exciting cause. The last-mentioned cause seldom occasions an attack of cholerine, but may produce simple catarrh of the bowels. Colocynthis is suitable in a proportionally rare form of cholerine, where the patient vomits but a few times, and after that experiences a fearful nausea with paroxysms of retching, which at most results in the expulsion of some phlegm; the stools are diarrhoeic, but not watery; they have a marked bilious tinge; are not very frequent, on an average, and are always preceded by intol- erable colicky pains. The disease is generally. caused by a cold, sometimes by chagrin. Colchicum autumnale deserves a preference over any other remedy, if, after one or two, or, at all events, scanty vomitings, the diarrhoea increases to a violent degree, the stools assume a watery consistence, are not entirely colorless, and even take place without warning. If recovery has fairly commenced, if, after the diarrhoea has ceased, the patient still complains of lassitude and want of appetite, Nux vomica sometimes has a surprising effect. Against a protracted diarrhoea, Acidum phosphoricum is a most efficient remedy, unless severe pains continue to be present; in such an event, Phosphorus is more suitable. If chronic intestinal catarrh should result, the rem- edies proposed for this condition are to be used. A transition into the febrile form of intestinal catarrh requires the medicines indi- cated in the subsequent chapters. As regards dose, most physicians agree that the lower attenua- tions are most efficient; we need not, on this account, go below the second. Considering the rapid course of the disease, the medicine may be repeated as often as every half hour; in moderate cases, the dose may be repeated every two hours without incurring any risk. The root of Ipecacuanha seems to act more positively and decisively than the tincture. The diet need not cause any serious thought, for the reason that the patients have an aversion to all kinds of nourishment at the onset of the disease. Small quantities of thin, slimy decoctions, Catarrhus Intestinalis Chronicus. 413 alternated with very cold, fresh well-water, likewise in small quan- tities, are alone admissible. After the attack is over, the stomach has to be exerted very sparingly for some days; solid food should be allowed only in the smallest quantities, nor should aught but the simplest kind of nourishment be partaken of. In cholera infantum the diet is of more importance. This has generally a number of attacks, and inclines to relapses. The slightest dietetic transgres- sions and irregularities are strictly to be avoided. The children need not starve ; they bear very well beef-tea, milk, good bread, and light soups, only the quantity has to be regulated w'ith great care. If the patient is much emaciated and exhausted, small quantities of a generous sweet wine are very appropriate: in teaspoonful doses it may be given even to children of one year old without the least risk ; even at this early age, it sometimes effects a sudden and strik- ing revolution in the digestive functions. [The Iris versicolor, or blue-flag, is used by American homoeo- pathic and eclectic physicians, as a very efficient remedy in cholera infantum. Some use the lower attenuations, others the tincture. The discharges are greenish, worse at night, or they occur princi- pally at night; in severe cases they even resemble the rice-water discharges of Asiatic cholera. In our own experience, and that of many of our friends, Iris has not led to the satisfactory results ob- tained from it by other practitioners. Acute attacks of cholerine, with slight febrile excitement, prostration, and watery discharges without any, or having a fetid smell, have been arrested promptly and permanently, by means of the lower attenuations, or even one or two drops of the tincture of the root of Aconite. II.] c. Catarrhus Intestinalis Chronicus, Chronic Intestinal Catarrh, Chronic Diarrhoea, Cholera Infantum, Summer Complaint. This form of disease is observed as an accompanying complica- tion in a number of other pathological processes, especially in affec- tions of the liver, spleen and stomach, and very prominently in tuberculosis. Chronic intestinal catarrh develops itself as an idio- pathic affection, out of acute attacks of the disease, either because they had been neglected, or else frequent relapses had caused obsti- nate alterations in the intestines. The affection may likewise, be a purely primary one of gradual growth, and which had finally acquired a higher degree of significance. The symptoms and meaning of this affection differ in the adult and child, and, therefore, require to be described separately. 414 Diseases of the Intestinal Canal. The intestinal catarrh of adults, at times, is attended with obsti- nate constipation, at others with diarrhoea. In the former case, the faeces consist of hard dark-colored, little lumps, resembling sheep's dung, which are covered with a viscid, glassy mucus, sometimes mingled with a few streaks of blood. The diarrhoea is either con- tinued, or alternates with constipation. The fecal matter is not very thin, or else it consists of a slimy watery fluid, mixed with a few lumps of hard fecal matter; the peculiar glassy or jelly-like mucus, is always found in them. If the diarrhoeic stools occur alternately with obstruction of the bowels, the former generally have a very fetid smell. If considerable alterations in the struc- ture of the intestines are present, we find an admixture of pus or blood from the ulcerative surfaces. The stools in one day are never as frequent as in cholerine. With these symptoms of disturbed digestion, a variety of other ailments are always more or less ob- served. The tongue has usually a thick coating, especially at the root, the appetite is either gone or perverted; in a few cases there is excessive hunger. If the bowels arc constipated, there is always an accumulation of gas, if they are loose there is much less of it. The presence of this flatulence often distresses patients in an extra- ordinary degree. This distress is generally attended with pains at the anus, caused by hemorrhoidal tumors. The temper is always affected by chronic intestinal catarrh ; the patient is gloomy, some- times even desperate, like an hypochondriac. Symptoms of irregu- lar circulation supervene, such as cerebral congestions, continued headache, palpitation of the heart, abdominal pulsations, and cold- ness of the lower extremities. If the stomach sympathizes with the disease, as it always does if the disease lasts any length of time, a loathing of food is experienced, and the patient has perverted desires for unnatural substances, with retching, vomiting of water and mucus, and vomiting of food. In most cases the disease is one of the most obstinate, without being particularly dangerous. Naturally enough, in view of such a persistent derangement of the digestive faculties, the patient gradu- ally loses flesh and strength. In spite of this, the patients may live to an old age. If the diarrhoea prevails, emaciation sets in very rapidly, marasmus results, and towards the end an effusion of serum into the cellular tissue and the abdominal cavity occurs. If the duration of the disease is determined by intestinal ulcers, the patient's prospect is much worse, because the wasting of the vital strength goes on so much more rapidly. Speaking of ulcers, their Catarrhus Intestinalis Chronicus. 415 existence may be suspected in chronic diarrhoea generally, for as chronic ulceration feeds the catarrh, so does the catarrh feed the ulcerative process. Another malignant complication which is not very un frequent, is the contraction or stenosis of the intestinal tube, which may occur in consequence of cicatrization, as well as through a bend in the gut, or in consequence of hypertrophy of the inucous membrane. This accident is the more important, as a sure diagno- sis is only possible exceptionally, and the treatment may conse- quently be conducted upon a mistaken basis. Obstinate constipa- tion, and the small size of the discharged feces, justify the inference, that stenosis may exist. This diagnosis becomes the more certain if, by some means or other, the contraction of the intestine becomes so great that an antiperistaltic movement arises, with consequent- fecal vomiting, without any signs of intussusception. Moreover, the continued arrest of the feces at one place in the intestines, may cause an incidental catarrhal irritation, readily resulting in ulcera- tion. As an excess of flatulence may disturb the circulation, and cause cerebral congestions, so it may likewise derange the functions of the liver and spleen ; nevertheless, the phenomena on the side of the liver may likewise be accounted for, by the changes in the diges- tive functions, and the consequent anomalous direction of the bile. Among the constitutional complications of other affections, diar- rhcea, as a representative of intestinal catarrh, is one of the most significant, since nothing consumes the strength of the patient more rapidly than a persistent case. Above all, it is tuberculosis whose fatal termination is threatened by diarrhoea. It may, however, happen that intestinal catarrh, as an accompaniment of acute affec- tions, may run into the chronic form, on which account convales- cence is very much retarded. A result of this kind is more particu- larly met with in typhus, and likewise in various other diseases. It is always a disagreeable sign, because intestinal ulcerations are very apt to occur under such circumstances. The chronic intestinal catarrh of children has more definite symp- toms than that of adults. If there is no invasion of the stomach by the catarrhal irritation, the leading symptom is an obstinate diar- rhoea, with hourly or less frequent discharges. The evacuations are at times very copious, and not so frequent; or else they are scanty and more frequent. At first there is considerable admixture of bile, and the color, after a short exposure to the air, is green ; afterwards the discharges assume a lighter color, until finally they often resem- ble clay. As regards consistence, they are not entirely watery, 416 Diseases of the Intestinal Canal. sometimes papescent and semi-liquid, until the fecal matter gradu- ally disappears. The smell is generally sour, and there is always more or less admixture of bile. The other symptoms vary; there is either an entire loss of appetite, or else a ravenous desire for food; such kinds as the little patient used to be very fond of arc re- fused, and others are grasped at with avidity. If the stomach is involved, all the symptoms of stomach catarrh show themselves, and the diarrhoea is mixed with remnants of undigested food, or flakes of milky coagula. The strength vanishes very rapidly. If the diarrhoea continues any length of time, the patients are reduced to mere skeletons, with the skin dangling loosely around, and their hollow eyes sending forth an erring and confused look from among a multitude of wrinkles. The causes of this very dangerous affection of childhood, are all those circumstances that have been indicated as the causes of stom- ach catarrh in the case of children, and to which we refer the reader. The more frequent appearance of this disease among chil- dren that have just been weaned, is owing to the peculiar nature of the teething process, as well as to the change of diet. Among children over two years of age, the disease is met with only excep- tionally. Lest this disease should be confounded with the intestinal tuber- culosis of children, the so-called tabes meseraica, the diagnosis should be made with the greatest care, for the tubercular disease requires a different kind of treatment. If there is no swelling of the mesenteric glands, and no sign of tubercles in the lungs, it will be found very difficult to draw a line of distinction between the two diseases, with reliable certainty. The probabilities are in favor of intestinal catarrh, if the new diet, or a change of diet for the worse, or the cutting of the first teeth, usher in the first signs of the disease. Under homoeopathic treatment, the prognosis, as long as the dis- ease has not reached its highest degree of intensity, is favorable, although this disorder, as managed by the adherents of other schools, is generally considered a very fatal disease. Of course no successful result of the treatment can be expected unless the strict- est diet is observed. In the case of adults as well as children, the first object of the treatment should be the enforcement of strict dietetic rules. The rules for children, and partially for adults, have been laid down in the chapter on catarrh of the stomach. We must always see that Catarrhus Intestinalis Chronicus. 417 the nourishment can easily he assimilated, it must not be of a stimulating kind, or of one that will throw down much fecal mat- ter; the children should be fed with the most perfect regularity and never to excess. In the case of convalescents, the greatest caution has to be observed in eating; quantities of solids have to be avoided, food should be partaken of frequently, but not in copi- ous quantities. Nux vomica is the chief remedy for the chronic intestinal catarrh of adults, especially if the stomach is involved in the disease, like- wise if it is not. The most important symptoms are: constipation, if not too obstinate and long-lasting, with discharge of small, dark- brown, very hard lumps with mucus or blood, likewise constipation alternating with frequent papescent stools, stitches, painful con- striction of the rectum, hemorrhoidal tumors of the rectum, urging to stool; a great deal of flatulence, with difficult stool; pains in the liver; congestions of the head. Compare, moreover, the symptoms referring to the stomach, likewise the symptoms of the emotive sphere. Numberless observations have satisfied us that Nux alone is sufficient to permanently cure, in a short space of time, almost every case of moderate intensity. Lycopodium acts in this disease with scarcely less certainty than Nux, and has been tried with equal success. It is more appropriate to inveterate and more advanced cases. The moral symptoms, and the looks of the patient, constitute a very safe line of demarcation between the action of Lycopodium and Nux. The mind is very much depressed; the patients have lost all hope; they seem a prey to the deepest hypochondria; their complexion is of a jaundiced, yellowish-gray, or di igy-sallow hue. The constipation is obstinate and long-lasting; there is frequent and ineffectual urging; hemor- rhoidal tumors, with secretion of blood; the fieces look like sheep's dung, encircled with mucus. There is a great deal of flatulence, the expulsion of which rarely affords relief. The liver, stomach, and even the spleen participate in the affection. The coating on the tongue is not very thick, or the tongue is even quite clean. The effect of these two remedies upon the alvine discharges is some- times very rapid; we have often relieved a constipation of years' standing with a single dose on the very first day, so that the diet could not possibly have induced the curative change. Lycopodium likewise affords rapid aid against a distressing flatulence, but it is only palliative, since it is impossible to arrest the tendency to an excessive development of gas, with a few doses of this remedy. 27 418 Diseases of the Intestinal Canal. Sulphur is a specific in inveterate cases, when affections of the liver are present. The stools are dry, hard as stone, of small size, and a dark color, lined with mucus, accompanied by frequent in- effectual urging, pains in the anus, swelling of the hemorrhoidal tumors. The moral symptoms and the symptoms of the stomach and abdomen are like those of Lycopodium. Sulphur likewise corresponds to constipation alternating with diarrhoea, or to evac- uations composed almost exclusively of mucus, as sometimes oc- cur side by side with the most obstinate constipation. There is always a great deal of bile in the secretions. It is only exception- ally that Sulphur will develop its curative effects in a very short time. This agent suits children, if the stools are mixed with a quantity of mucus or even with some pus. Altogether, if there are traces of ulceration in the intestines, we have to think in the first place of Sulphur. Graphites acts so similarly to Sulphur, that, instead of repeating our remarks on Sulphur, we prefer referring the reader to our Materia Medica. The remedy is often effective in cases where Sulphur seemed suitable, but did not show any effect. Natruru muriaticum also acts similarly to Sulphur, only the accessory symp- toms have to determine its appropriateness in a given case, since the local symptoms are not sufficiently decisive. [Regarding the treatment of intestinal constipation as a symp- tom of intestinal catarrh, Kafka offers the following remarks: "If a diminution of the peristaltic motion is associated with obstinate constipation, and it is evident that the fecal masses have accumu- lated in the intestinal canal, all that is left for us to do, is to re- move this mechanical obstacle by exciting the peristaltic motion, by means of some suitable cathartic, which w.H cause a secretion of serum in the bowels, by which means their contents will be dis- lodged. According to the teachings of physiological pharmaco- dynamics, Rheum fulfils these requisites more completely than any other drug. It is not well to administer this remedy in massive doses, for the reason that they cause an excessive secretion of serum without touching the fecal masses. "When administered in small quantities, at the rate of five grains per dose, giving a dose every two or three hours, it excites the peristaltic motion. This effect is evidenced by the pinching and rumbling in the abdomen, and emission of fetid flatulence. At the same time serum is secreted in the intestinal canal, after which a few liquid, fetid evacuations take place. After the remedy has been Catarrhus Intestinalis Chronicus. 419 taken two or three days, lumps of fecal matter are passed; under the continued use of the drug, these discharges of lumpy faeces have to be kept up, until no lumps can be felt in the bowels. "If live grains are not sufficient to produce the desired effect, the quantity may be increased to ten grains; in most cases, how- ever, five grains will be found sufficient. "If the torpor of the intestinal canal is very great, and Rheum has no effect, we recommend Aloes, from two to three grains per dose, a dose every two or three hours. Both remedies may be taken in the form of pills, or enveloped in a wafer. The passage of the stagnant fecal masses can be powerfully aided by means of stim- ulating injections of soap-water, with a little sweet or castor-oil and common salt; if the fecal mass is lodged in the upper part of the intestinal tract, it may be reached by fastening to a suitable injection-pipe, a long, elastic tube. " In the first years of our homoeopathic practice, we repeatedly tried to overcome an obstinate stasis of the faeces by homoeopathic treatment. Several failures on our part drove the patients back into the hands of allopathic physicians, who, although they treat this condition empirically, yet, as a rule, meet with more success in relieving the patient. In a case of constipation of this kind, we do not hesitate to advise the avoidance of all round about attempts at relief with the usual homoeopathic means, and the use of such medicines as we are taught by physiological pharmaco-dynamics will most speedily and safely secure the desired end. "Many of our readers will undoubtedly find it strange that meas- ures should be recommended in a treatise on homoeopathic thera- peutics, which are indeed derived from the domain of physiological pharmaco-dynamics, but in reality belong to that of the empirical School. But we have stated at the commencement of our work that we occupy a practical stand-point. At the sick-bed it is often impossible to succeed with theories. Whether a certain method of treatment is correct, feasible, and useful to the patient, has to be decided by experience, and the weight of experience should never be underrated. The sick-bed is the touch stone for our theories; these will survive, if they stand the test of a practical trial; their uselessness in practice is their doom. " Moreover, it is our duty to deliver our patients from their suf- ferings by the shortest and safest road. We shall adhere to these motives, and are not afraid of proclaiming the fact, that the infinitesi- mal doses of Homoeopathy are incapable of removing the accumulation of indurated masses of faeces in the intestinal canal. 420 Diseases of the Intestinal Canal. "If, upon examination, fecal masses are no longer accumulated in the bowels, we return to the homoeopathic treatment, and remove the intestinal catarrh and the continued torpor of the bowels by means of Nux vomica, Natrum muriaticum, etc. "If these remedies should not have the desired effect, we send our patients to Karlsbad, Marienbad, Kissingen, or Homburg. The two first-named springs are particularly efficacious." In our own coun- try, the Congress and Rockhill springs of Saratoga have a distin- guished reputation for their excellent effect in habitual constipa- tion. II.] Phosphorus and Acidum phosphoricum correspond to intestinal catarrhs, having taken the form of chronic diarrhoea, both in the case of children as well as adults. Whereas the stools to which Phosphorus is adapted always contain faeces and a considerable ad- mixture of bile, with rather copious traces of blood, and are attended with severe colicky pains, the faeces for which Phosphoric acid is suitable are lighter colored, or even colorless; there are no pains in the abdomen, but a good deal of flatulence. Phosphorus is, more- over, the main remedy for ulceration of the intestinal mucous mem- brane ; next to which, Nitri acidum deserves a preference. This remedy is likewise adapted to chronic diarrhoea, more particularly if the faeces contain pus and blood. In chronic diarrhoea, associated with lienteria, China, Ferrum, and likewise Phosphorus, are the main remedies, Arsenicum being less frequently indicated. China, together with Nux vomica, or Phosphori acidum, corresponds most nearly to the intestinal catarrh of convalescent patients; China deserves attention in all diarrhoeas of long duration, only it is difficult, in view of the extraordinary diversity of the symptoms, to determine the cases to which it is specifically homoeopathic. Sepia is efficacious in the chronic intestinal catarrh of females. Obstinate obstruction is occasionally interrupted by papescent stools without much bile Plumbum has such characteristic symptoms that it would seem specifically, and, as it were, exclusively adapted to certain forms of chronic intestinal catarrh. The obstinate constipation caused by lead-poisoning is well known as a pathognomonic symptom, likewise the peculiar colic. We desire to call attention to the fact that Plumbum corresponds very prominently to the symptoms of steno- sis of the intestine and of atonic ulceration of the bowels. In offering a concluding remark concerning the chronic intestinal Catarrhus Intestinalis Chronicus. 421 catarrh of children, we have to call attention to one other remedy beside Sulphur, Phosphorus, Phosphori aciduni, China and Acidum nitricum: we mean Calcarea carbonica. As yet, the therapeutic lines between the different kinds of Calcarea have not been dis- tinctly drawn by adequate provings; we do not know how far the Carbonate of Lime is distinguished from the Acetate or Phosphate. Nor has the practical experiment shed sufficient light on these dif- ferences. Without any special reasons, one prefers this, another that preparation of Calcarea, the Carbonate being most generally employed in practice. It might be difficult to show what symp- toms in chronic intestinal catarrh indicate Calcarea. The whole process, including all its various modifications,, is adapted to the action of this drug, and any homoeopath who does not avail him- self of this agent at the very beginning of the treatment, would commit a very great wrong. The very first dose of this remedy is apt to produce a change in the whole vegetative activity of the childlike organism, without it being possible to attribute the ameli- oration to a mere change of diet. Such a remedy should occupy a prominent place in the memory of every physician; hence, instead of giving the whole pathogenesis of the drug, we indicate only two leading points that argue in favor of Calcarea: we mean excessive acidity of the stomach and a partial or total deficiency of biliary secretion. We have frequently verified the fact in our own prac- tice that Calcarea carbonica acts better in the form of a liquid atten- uation than a trituration of the same number. We cannot account for this circumstance, although there is no doubt that our observa- tion is correct. Arsenicum album is rarely ever indicated at the commencement of the disease ; in cases where the continued exhausting evacuations, and the intensity of the disease, have superinduced septic symptoms, this medicine sometimes affords speedy help, even in cases that seem hopeless. Under such circumstances, Arsenicum is likewise suitable in the case of adults; in their case, however, Arsenicum produces curative effects less frequently, for the reason that symptoms of de- composition do not set in until all help is impossible. In the case of children, however, the disease is still curable even after it has reached the climax. The selection is determined much less by the peculiar nature of the evacuations than by the rapid prostration, the oedematous swellings, the constant anguish and restlessness, the fearful thirst and the extreme emaciation. In the presence of such general symptoms, the stools may be light-colored like those of Cal- 422 Diseases of the Intestinal Canal. carea, nevertheless Arsenicum may be indicated; of course, if the stools are dark-colored, mixed with blood and purulent mucus, hav- ing a pungent, putrid smell, Arsenicum is the only remedy of which a curative effect may be expected. In the lesser grades of the disease, where there are but four or five diarrhoeic stools a day, papescent, of a light-yellow color, with occasional watery discharges, the evacuations being largely mixed with mucus, the stomach being excessively sour, without any great signs of emaciation, Borax is decidedly in its place. Beside these remedies, Argentum nitricum, Ziwum, Cuprum, and Nitrum deserve attention. We have no prominently characteristic indications for Arg. nitricum; it may be tried where Calcarea is suitable. Zincum and Cuprum are indicated where the symptoms of chronic intestinal catarrh are attended with general convulsions. Beside these remedies, those indicated for cerebral anaemia are like- wise appropriate. Nitrum acts very similarly to Borax; if, in this lesser grade of the disease, the discharges are mixed with blood, Nitrum deserves the preference. [P tdophyllum, 6th to 12th, and Croton tiglium, 6th to 18th attenuation, have had good effect in chronic diarrhoea. II.] Inasmuch as it is very important that the strength of the little patients should be raised as soon as possible, and yet it is very diffi- cult, on account of the deficient activity of the stomach, to accom- plish this end, we have to try very carefully what kind of food the stomach can best bear. A very common domestic remedy are raw eggs without the white, but there are many children who cannot bear them. On the other hand, finely shaved raw beef is highly to be recommended, because it is very nutritious and easily digested. If it is not readily digested, we recommend the broth that we have indicated in our chapter on gastric catarrh, which suits even the most debilitated stomach. Particular attention is due to ablutions of the skin, especially among the poorer classes, that consider water rather hurtful than useful as a remedial agent. Very cold ablu- tions, however, should not be resorted to at once, but gradually from a higher to a lower degree. d. Febris Gastrica Catarrhalis, Mucosa et Biliosa; Gastric Fever. These forms of fever have a large number of synonymes, of which the principal are: febris saburralis, gastrico-venosa, pitui- tosa, splanchnica; mucous fever, and bilious fever. We compre- Febris Gastrica Catarrhalis, Mucosa et Biliosa. 423 hend them in one series, because by so doing we avoid a great many repetitions in the therapeutic section. The following forms of disease belong all to the catarrhal intes- tinal affections, which generally make their appearance over a large region of country, and hence depend upon peculiar atmo- spheric conditions, and cannot be demonstrated as the results of dietetic transgressions, which only furnish the first impulse towards the breaking out of the disease. It is undeniable that severe de- pressing emotions may give rise to such diseases. A catarrhal gastric fever is distinguished from a simple gastric fever, of which mention has been made in the chapter on diseases of the stomach, by the fact, that the intestinal canal is involved in the pathological process. The disease scarcely ever begins suddenly, but has precursory symptoms. These consist in the symptoms characterizing the lesser grade of acute catarrh of the stomach. Gradually, seldom suddenly, these symptoms become associated with fever, the patients frequently complaining of chilliness fol- lowed by heat. Little by little the fever increases until it becomes continuous, generally with unimportant evening exacerbations. The headache, which at first is dull, now becomes more violent, the thirst very severe, the pulse hurried; the nausea increases unto vomiting; water and mucus, which is at times sour and at other times tasteless, being thrown up. The patients feel so languid and exhausted, that with the best will they are unable to remain out of bed, more particularly in the morning and evening. The evening exacerbation continues till far in the night, so that the sleep, if it is not entirely wanting, is very much disturbed. Morning is the best time for the patient, although even then the fever is not en- tirely absent. Upon the whole, it slowly increases during the first week. The appetite is entirely lost, the tongue has a thick, white coating, the taste is insipid, pappy, slimy; the region of the stom- ach and afterwards the whole abdomen, becomes sensitive to the touch; at the commencement of the disease the bowels are some- what constipated. The symptoms increase in number and inten- sity, sometimes to the fifth and even to the ninth day. In violent attacks the tongue becomes dry, also brownish, the abdomen is dis- tended, so that the idea of typhus suggests itself, the more as a mild delirium is not unfrequent; the skin is very dry and the urine saturated to excess. If the febrile symptoms abate after the fifth day, more particularly if up to this period they have continued in all their intensity, the evacuations become softer, and finally diar- 424 Diseases of the Intestinal Canal. rhoeic; however, they do not occur in rapid suecession. For all that, convalescence does not date from the period when the fever abates. The patients, overcome with an intense feeling of illness, have to keep their beds, and now only begin to realize their weakness. The tongue remains coated and the appetite is entirely gone. The former exacerbations and remissions of the fever still continue, in the shape of evening-aggravations of the symptoms. Tt is mostly only at the end of the second week that convalescence fairly commences; however, it may not begin till the fifth week and even later, if the natural course of recovery is interrupted by wrong management. Increased action of the skin an I a copious sediment in the urine are the surest signs of the real beginning of recovery ; the appetite may not return until some time after; not as in typhus, where with the first signs of recovery the patient is sometimes devoured by an unappeasable hunger. If, on recovering from this fever, the patient should experience a strong appetite, he runs great risk of having a relapse which may prove more danger- ous, and last much longer than the original disease; for every error in diet, were it even trifling, is apt to cause an aggravation of the disease, which is sometimes so violent that it is scarcely possible to distinguish it from typhus. The diarrhoea sometimes continues for a longer period, it may even change to chronic intestinal catarrh. If the disease terminates favorably, the organism gradually resumes its normal state. It is characteristic of this fever that it takes a long time, sometimes even months, before the patients recover their strength. Bilious gastric fever is generally nothing more than a higher grade of the pathological process we have just now described, the phenomena of a disturbance of the biliary functions being particu- larly prom nent. Like the former, the affection sets in with the symptoms of gastric derangement; sometimes even before the fever sets in, the symptoms of disturbed functions of the liver supervene, the patient feeling exceedingly languid, depressed in spirits, the ap- petite, especially for meat, being lost, and the patient, with a bitter taste in his mouth, craving particularly sour food. The invasion of the disease is generally announced with a chill, followed immedi- ately by great heat; like the gastric fever this form of fever gener- ally sets in in the evening, except that the febrile symptoms are much more intense, and the morning and day-remissions are much less distinct. If the skin had not yet assumed an icteric hue, it now shows itself in the eyes and face. The patients are tormented Febris Gastrica Catanhalis, Mucosa et Biliosa. 425 by a violent boring headache that almost drives them to madness. The pnlse is accelerated, the temperature perceptibly heightened. The tongue exhibits a yellowish-white coating, is hot and dry; thirst very great, the patient craves sour drinks. The region of the stomach and liver is sensitive. The nausea and loathing- increase to bilious vomiting, which occurs more frequently than in gastric fever, and alternates with retching, accompanied by a feeling of intense anguish. The vomiting consists of green masses, having a bitter and rancid or sour taste. The bowels are constipated; the scanty fteces are tinged deep-brown. The urine shows a bilious pig- ment. The patient is tormented by an unceasing restlessness, and is very irritable and low-spirited. In this disease likewise, the ap- pearance of diarrhoeic stools denotes the beginning of an improve- ment. The evacuations are sometimes so deeply charged with bile that it seems as though nothing but bile came from the bowels. They are almost painless, are attended with an abatement of the fever, and an increase of cutaneous action; thus convalescence runs its course, as in the former fever, unless interfered with by impro- per management or dietetic transgressions. In case the disturbance of the hepatic functions is deep-seated, the diarrhoea may not only continue for a longer period, with a corresponding increase of the general languor and weariness, but we likewise perceive the pres- ence of an excess of bile in the blood. The skin remains inactive, the icteric hue becomes more prominent, the patient feels very lan- guid, drowsy, and the pulse becomes sluggish. This condition of things naturally retards convalescence beyond the usual period. This bilious-gastric fever sometimes bears a closer resemblance to typhus than the.catarrhal fever, and there is the more danger of a severe attack of illness, as bilious fever, together with typhus and intermittent fever, generally sets in under the influence of some miasm. It frequently happens that bilious fever runs into intermit- tent fever, and vice versa; as we have had occasion to observe quite recently in a region of country where the flood of last summer had given rise to a prevalence of these two fevers. The same, however, may be said of gastric fever, so that the affection of the liver does not seem the cause of a transition into intermittent fever. It is more difficult to show a transition into typhus, for the reason that both these fevers commence with nearly the same initial symptoms; there is no reason, however, to suppose that such a transition is im- possible, since both diseases originate under the same influences, except that one is more local, the other more general. Under the 426 Diseases of the Intestinal Canal. continued action of the causative miasm, the lighter disease may easily assume the more aggravated and more general form. Of these three forms of fever, the gastric mucous fever, febris gastrica mucosa, is the most dangerous and most inveterate, and the more to be dreaded, as it attacks more particularly old or enfeebled individuals. A characteristic feature of this fever is the accumula- tion of quantities of mucus upon the mucous membranes of the digestive tract. Like the other two forms, the mucous fever likewise usually de- velops itself out of a simple gastric derangement; the transition, however, is less marked, for the reason that the febrile phenomena do not set in all at once. There is a more gradual increase of the symptoms. The appetite soon vanishes; an irresistible aversion to all kinds of food is present; the languor and prostration increase from day to day; the tongue shows a thick coating of mucus. Sooner or later these symptoms become associated with fever, which, however, never reaches the high degree of intensity as in the other forms. At first the chilliness prevails, after which the heat becomes continuous but moderate. The pulse is never much accelerated; in cases where the heat is wanting, it is even slower than the normal pulse. Very rarely the fever has distinct periods of exacerbation, especially at the commencement; whereas, in the later course of the disease, a tertian type becomes more or less prominent. With the fever, all the symptoms increase; the coating of the tongue becomes thicker, and incommodes the patient still more, because the mouth and pharynx are likewise lined with mucus ; the taste is flat, pappy, offensive. The region of the stomach is seldom sensitive; as soon, however, as a little food is partaken of, it becomes distended, the patient experiences a feeling of anguish and restlessness, and with much retching the patient vomits up the ingesta, with a quantity of mucus. Even without eating, the patient in the morning may be troubled with retching and vomiting of mucus. The bowels are very torpid; only in the subsequent course of the disease the evac- uations are occasionally soft, and mixed with large quantities of mucus; the stools may likewise consist of pure mucus. The urine is diminished in quantity, has a loam color, and is thickly clouded with mucus. In more acute cases, the respiratory organs partici- pate in the secretion of mucus. What imparts to this disease a very peculiar character, is the constitutional condition of the pa- tients ; they lie in a state of sopor and apathy; it seems as if the organs of sense had less power to perform their respective functions; Febris Gastrica Catarrhalis, Mucosa et Biliosa. 427 they do not seem to notice the surroundings ; yet they are seldom delirious, and the consciousness remains undisturbed ; it seems as though the patients had sunk into a state of utter discouragement. At an early period, the strength is reduced entirely; the patient does not complain of pain, properly speaking; his head feels dull, and there is buzzing in the ears. In this way the disease continues unchanged for weeks, sometimes abating a little, and at others in- creasing. Among older persons the tongue is apt to become brown and dry; with younger ones, the tip and edges become red and dry, or smooth and red. In the end, the vomiting becomes less frequent; the skin remains almost uniformly dry. As the whole course of the disease is so remarkably protracted, recovery takes place but slowly, imperceptibly as it were, interrupted by the least error in diet, by the least unusual physical or mental effort. Not until the produc- tion of mucus diminishes very sensibly, can we hope for recovery. Convalescence is generally slow; it sometimes takes months before the patients recover their former condition. The cause of this, next to the extraordinary prostration, is, that the appetite returns only very gradually, and the patient cannot bear any considerable quantity of food. It is only exceptionally that the occurrence of diarrhoeic stools denotes a change for the better; as a general rule, diarrhoea aggravates the disease by consuming the strength. Only where a general improvement occurs, after a copious discharge of mucus by the anus, can such an evacuation be looked upon as a favorable crisis. The danger to life in mucous fever is not so great as the complexity of the symptoms would seem to indicate. It is considerable in cases of old or debilitated individuals, and if continual relapses take place. No disease is more frequently and more easily confounded with typhus than mucous fever. In this fever the shortness of its course is not, as in the other two forms, decisive of its true character. The difference between febris nervosa lenta and febris mucosa will be shown more fully in the chapter on typhus; we here content our- selves with stating, that the mucous fever is scarcely ever epidemic, hence, less depending upon atmospheric conditions, whereas it arises more readily in consequence of depressing mental emotions, grief, care, and excessive mental labor. Usually the persons who are attacked by this disease have been suffering for a long time with digestive derangements, catarrh of the stomach, constipation, etc., in consequence of which, their constitutions have become debilitated 428 Diseases of the Intestinal Canal. and impoverished. Robust individuals are scarcely ever attacked with mucous fever. Treatment. Since we have to deal with processes whose course is by no means regular, but exhibits a variety of modifications and transitions, our best plan is to describe the various remedies each by itself, instead of indicating the possible course of the treat- ment in a continuous series. A general view of the remedies ap- pertaining to this group is the more necessary, as it affords us the means of meeting more easily the relapses and incidental complica- tions occurring in this disease. Among these different remedies, Belladonna is almost the only one suited to the breaking out of the first and second class of these fevers, if, after a severe chill, violent heat is felt in the evening, .which increases as night approaches. Its effect is particularly strik- ing on women and children, yet it has an equally good effect on men. This remedy usually moderates the fever and arrests the vomiting and retching. As soon as the heat and redness of the face and the restlessness have abated, other remedies had better be employed. We cannot well recommend Aconite at the commence- ment of gastric fevers; we doubt whether Aconite has ever pro- duced a o'ood effect under these circumstances. In mucous fever, o which has scarcely any fever from beginning to end, neither one nor the other remedy is appropriate. If Aconite can be used at all, it will be more particularly at the commencement of bilious fever, if it sets in suddenly without any precursory symptoms. Mercurius vivus generally is applicable in bilious fever during the best part of the disease. Characteristic symptoms of Mercurius are, the intense fever-heat which sets in in the evening, and is most violent at midnight; the raging, mostly boring headache, which does not permit the patient to lie down ; the sensitiveness of the region of the liver and stomach; the yellow tinge of the eyes and skin; the bitter taste and loathing; bitter eructations, vomiting of bile, an intense desire for sour drinks, an excessive restlessness and anguish. If in the subsequent course of the disease, the evacu- ations contain a large quantity of bile and some mucus, this would be an additional indication for Mercurius. Hartmann recommends Mercurius for mucous fever in the following words. His remarks, however, apply more to bilious fever than to what we have de- scribed as mucous fever. " It corresponds to the precursory symp- toms, as well as to the more fully developed disease; the appetite decreases more and more; the tongue is lined with a whitish Febris Gastrica Catarrhalis, Mucosa et Biliosa. 429 mucus; the throat and pharynx are distressingly dry during deglu- tition ; foul taste and smell; loathing and nausea, with tearing, burning pains in the temples , pressure and tension in the pit of the stomach, region of the stomach and liver; rising of an acrid fluid into the mouth ; turbid, slimy, sedimentous urine; irregular stools, with frequent urging ; pale, sallowq yellowish complexion ; debility, apathetic mood. Characteristic indications are more particularly a thick, dirty, slimy coating on the tongue; flat, pasty, soapy taste; great desire for piquant articles of diet; dryness in the mouth and throat; torpor or entire suspension of the alvine evacuations, or else slimy, diarrhoeic, fetid stools; considerable mental and physical prostration of strength." Of course the patient must not have taken large doses of Mercury just previously, or even some time before his sickness. Bryonia resembles Mercurius in many respects, but has a much larger sphere of action in these fevers. It is not only suitable in bilious and catarrhal, but likewise, although less frequently, in mucous fever The origin of the fever in a cold, or in an error of diet, a fit of chagrin, and during the heat of the summer, points to Bryonia. We cannot enumerate the whole series of the sympto- matic indications, which can better be studied in the Materia Medica. The distinctive differences between Bryonia and Mercu- rius are: The Bryonia-fever generally commences in the afternoon, has slight remissions, but is, at the same time, less intense. The headache is a painful pressure, or a tearing pain, and is considerably relieved by lying down quietly Patients do not exclusively crave sour or piquant things. The tongue is thinly lined with mucus, and the taste is rather flat and pasty, than intensely bitter. The bowels are constipated, or else the alvine evacuations consist of not very frequent diarrhoeic discharges, of a deep brown color, and mixed with a good deal of mucus. The cases of mucous fever where Bryonia is to be used, have distinctly marked febrile mo- tions ; it will be found particularly suitable during the first eight days of the disease. Pulsatilla is suitable in the first and second class of these fevers, principally in the second. There must be an increased secretion of bile, if Puls, is to be depended upon. It does not so much corres- pond to cases with violent fever, as to those that run a slow course, It is more suitable for children and women than for men. The most noteworthy symptoms are: bitter taste and bitter eructa- tions ; vomiting of mucus and bile; irresistible aversion to animal 430 Diseases of the Intestinal Canal. food; absence of thirst, or else a desire for sour and piquant bever- ages ; sensitiveness of the region of the stomach and liver; bilious diarrhoea, mixed with mucus; severe evening-exacerbations of the fever, with chilliness prevailing during the day; whining mood, restlessness, with lowness of spirits. Antimonium crudum is the chief remedy in the genuine mucous fever, especially if the fever is very slight, or has passed off in a measure. It is indicated when a good deal of mucus is secreted on all the mucous membranes. Among the symptoms we have: A great deal of mucus in the mouth, and especially in the fauces; vomiting of mucus ; stools consisting of pure, tenacious mucus ; co- pious slimy sediment in the urine; cough, with expectoration of tenacious mucus. In addition, we have: lying in a state of apathy; chilliness, thick coating on the tongue; feeling of hunger, without any appetite; distension of the abdomen after every meal; desire to vomit; obstinate constipation, or else alternate mucous diarrhoea and constipation ; excessive debility, prostration. Such a complete image of mucous fever is not to be found in the pathogenesis of any drug; moreover, the curative power of this agent has been verified by a number of practical observations. Only the medicine should not be given up too soon; the long duration of mucous fever ren- ders a sudden cure impossible. Tartarus stibiatus acts, in many re- spects similarly to Antimonium crudum, but it is not a very suitable remedy for mucous fever, for the reason that Tartar emetic does not prostrate; on the contrary, it elevates the reactive powers of the organism. The catarrhal affection is characterized rather by the production of balls of mucus, which is not viscid, and is first seen in the respiratory organs, and afterwards, but much less intensely, in the digestive organs. All local affections to which Tartar Emetic is homoeopathic, have an inflammatory character; whereas those to which Antim. crudum is adapted, are distinguished by the character of torpor. Veratrum album manifests curative virtues more particularly in cases where copious vomiting and diarrhoea are chief symptoms. It is not only an excellent remedy for these symptoms, but is likewise suitable where Ant. crudum seems indicated. Like this remedy, so has Veratrum album the secretion of excessive quantities of mucus upon every mucous expanse, the rest of the symptoms likewise cor- respond. The more specially distinctive characteristics may be studied in the Materia Medica Pura. We content ourselves with stating, in this case, that the Veratrum album disease is much more Febris Gastrica Catarrhalis, Mucosa et Biliosa. 431 acute and searching, whereas the action of Antimony is slow, and imperceptibly increasing in intensity. Veratrum is generally pre- ferable, if the respiratory organs participate in the pathological process. Phosphori acidum is very seldom indicated in genuine febris mu- cosa, because it lacks, in some degree, the chief symptom, the char- acteristic secretion of mucus. However, it is indicated above all other remedies, if the disease resembles lentescent typhus, and con- sists principally in a soporous condition of the patient, who is lying down overwhelmed with a general debility, without any marked local symptoms. If these symptoms become associated with other alarming symptoms portending a fatal termination, such as complete inactivity of the skin and of the secreting organs, a very small and feeble pulse, complete prostration, real sopor, Carbo vegeta.bH.is may be tried. AVe have already stated that such symptoms only occur among old and decrepit or much enfeebled individuals; otherwise, the diagnosis must have been erroneous, and the typhoid character first manifests itself at a late period. Digitalis purpurea is likewise an appropriate remedy in mucous fever, but of great significance in this disease, much greater than the present limited use of this medicine would seem to imply. Independently of the other symptoms belonging to this group, all of which are embodied in the pathogenesis of Digitalis, it is, more particularly, the condition of the pulse that points to Digitalis. It is not so much the very slow pulse that furnishes the most im- portant indication, but the alternate acceleration and slowness of the pulse, with weakness of the impulse, that constitute the chief indications for Digitalis. If the patients, while lying in their beds, show from 40 to 45 pulsations, and, on raising themselves, the pulse, at once rises to one hundred and more beats; if the pulse is at the same time intermittent and irregular, Digitalis is eminently in its place. Even without any marked change in the pulse, the remedy is adapted to cases for which Acidum phosphoricum has been re- commended, if there is obstinate constipation. It is one of the most remarkable peculiarities of the action of Digitalis, that, with- out any increase of the secretions and excretions of the body, the weight of the body and the strength, decrease with extraordinary rapidity. There is another remedy which, in this respect, bears great resemblance to Digitalis, it is Cuprum. Since the effects of this poison vary so very greatly, according as it acts with more or less rapidity, and since the nat- 432 Diseases of the Intestinal Canal. ural groups of symptoms can only be learned imperfectly from our Materia Medica, we here subjoin a number of cases of poisoning by copper, which furnish a picture of the Cuprum-disease as it was observed by Frerichs in the well-known case in Mengershausen, near Goettingen, where a whole village was poisoned by soup that had been boiled in copper kettles. The first effect of the poison was a gradually increasing lassitude and prostration in the whole frame, attended with a feeling of weight in the head, and after- wards vertigo. In addition to this cephahea gastrica, there was complete loss of appetite, constipation, and now and then fugitive, drawing pains in the abdomen. Very soon the features became collapsed, and the patients tumbled about like shadows. The sub- sequent symptoms were- Excessive dulness of the head, vertigo which did not even permit them to sit up in bed; headache; rest- less sleep, disturbed by dreams, also with bland delirium, or else continued sleeping almost like coma, in the case of some, complete sleeplessness; great pallor of the face with an expression of ex- cessive prostration, and stupidity; the eyes had lost their lustre and were deeply sunken in their sockets. Excessive languor and weariness, a fainting fit, whenever they tried to move about; the tongue looked pale, not much coated, was moist, but in the case of some red, dry, and rough ; thirst considerable, aversion to all kinds of food. Abdomen soft and painless; occasionally a slight colicky drawing pain; the pulse was somewhat accelerated and small, the urine turbid and cloudy. This condition lasted at least six days and only disappeared gradually, the weariness and languor passing off last. Frerichs himself compares this Cuprum-disease to a light typhus, except that the characteristic diarrhoea, which is seldom wanting in typhus, was not present, so that the symptoms resem- bled more nearly an attack of mucous fever. We shall revert to this point afterwards when speaking of typhus. China is an important remedy for both bilious and mucous fever. In either disease it will berarely found indicated at the commence- ment ; in bilious fever if, in spite of bilious stools, no improvement takes place; on the contrary, the disorder seems to increase, and shows more or less distinctly an intermittent type; in mucous fever, if the disease approximates convalescence, without any decided critical change seeming rea ^y to make its appearance. Nux vomica is one of the few remedies that are equally appro- priate in the three forms of fever In the simple gastric fever, the best period for its employment is the time when an improvement Febris Gastrica Catarrhalis, Mucosa et Biliosa. 433 seems to set in, and the pains decrease very slowly, with poor appe- tite, the diarrhoea having either ceased or occurring only at times; the greater the disposition to relapses, the more we may expect of the curative action of Nux. In bilious fever this remedy occupies a high rank as a curative agent, in consequence of its relation to the biliary functions. In view of the multitude of symptoms it is almost impossible to furnish only an approximative list of the symptoms that belong to this group; all we can do in this place, is, to indicate the difference between this remedy and Bryonia. In the Bryonia-fever, the patient lies quietly, the mental and sensorial functions are inactive, whereas Nux vomica has an excessive irri- tability of the mind as well as of the senses, together with a strik- ingly rapid decrease of strength. Bryonia has a pale complexion, Nux vomica a bright-red complexion, with a yellowish tinge. The symptoms of buccal catarrh are much more significant under Nux vomica, the tongue is somewhat dry, or coated white, with bright- red edges. The taste, besides being bitter, is sour or putrid, whereas Bryonia has more especially a flat, pasty taste. Nux vomica has aversion to certain kinds of food, Bryonia to all kinds. Bryonia has a marked disposition to perspire, Nux vomica a dry and hot skin. These are a few salient points; for more detailed contrasts the Materia Medica will have to be consulted. In mucous fever, Nux vomica is indicated under similar circumstances as China; it frequently removes very rapidly the peculiar remaining atony of the digestive organs, and regulates the action of the bowels, not unfrequently by first superinducing a few diarrhceic stools. It is well, in selecting a remedy, not to lose sig't of the more general conditions of the system. Nux vomica is suggested by an irritable, sanguine, excitable temperament, hemorrhoidal symptoms, derange- ments of the digestive organs of some standing, origin of the dis- ease in a fit of anger or chagrin. Nux is likewise required in the bilious fever of drunkards, persons living luxuriously, and of indi- viduals exhausted by mental labor or leading a sedentary mode of life. It is generally more suitable for men than women. Ammonium muriaticum according to Hartmann, corresponds per- fectly to the symptoms of a status pituitosus. The tongue is lined with a white mucus; there is constant hawking, on account of a quantity of tenacious mucus in the throat; disagreeable, pappy taste, with accumulation of water in the mouth, aversion to food, empty eructations, gulping up of a bitter-sour fluid, feeling of emptiness and hunger in the stomach, malaise and warmth in the 434 Diseases of the Intestinal Canal. stomach, discharge of a glassy, tenacious mucus by the rectum; these are some of the leading indications for this drug. For all that, striking cures by it are not recorded in our publications. With these remedies, all ordinary cases of bilious-gastric fever can be cured. Hartmann gives a number of other remedies without any precise indications, which we here transcribe, because the symp- tomatic differences of these three forms of fever may require a more extensive list, from among which the right remedy can be selected. The catarrhal form may require Colchicum, Capsicum, Cocculus and Staphysagria ; bilious fever, Chamomilla, Ignatia, Ipecacuanha, also Cocculus; mucous fever, Dulcamara, Rheum, Sepia, Rhus toxicoden- dron, Spigelia, Mezereum, Baryta, Arsenicum, Senega. As a genera] rule, a larger dose of the medicine may safely be given in these fevers than in other acute diseases. For the catar- rhal and bilious fever, stronger doses of the remedy are necessary, because there is a well founded prospect that larger doses will pro- duce a crisis in a shorter space of time. However, if, as in mucous fever, the disease runs a slow course, it is not well to give large doses, or to repeat them too frequently. This rule is the more urgent the longer the disease has lasted. During the fever it is not very difficult to regulate the diet, the patients not showing any desire for any kind of food. Piquant and sharp articles of diet have to be forbidden, although patients may evince an extraordinary craving for such things ; after eating them, the condition of the patients is always worse. The best beverage is pure, fresh water; a little milk and water is good nourishment. Where it can be had, sweet beer is not only a refreshing and benefi- cent beverage, but likewise an excellent means of promoting the appetite. Neither diarrhoea nor vomiting need prevent its use; only, if the beer contains a great deal of carbonic acid, it is well to add a little sugar and to first allow the gas to escape. In mucous fever, especially, this beer is excellent, and patients generally crave it. Fruit, especially when stewed, agrees with the patients, and is very refreshing. During the period of convalescence, small quan- tities of wine often do more good in stimulating the activity of the stomach than medicine. Inasmuch as every error in diet is apt to cause a relapse, it is of the utmost importance to make a proper selection of the food, and to increase the allowance very gradually. On the other hand, the patient, for fear of a relapse, should not be kept too long on lean soups; this would retard convalescence unnec- essarily. Enteritis, Inflammation of the Bowels. 435 3. Enteritis, Inflammation of the Bowels. We apply this designation principally to an inflammation of the smaller intestines, and more particularly to the most frequently occurring form of this inflammation, ileo-co'itis, or inflammation of the ileum and colon. It is difficult to sharply separate the inflam- mations of the various parts of the bowels, because the different parts are almost always inflamed together, nor would this separation be of much practical value. Duodenitis scarcely ever occurs alone, but almost always as the companion of gastritis. Moreover, it is almost impossible to diagnose this disease, and hence we omit it entirely. The causes of enteritis are mostly the same as those of intestinal catarrh, dietetic transgressions ; the use of irritating, readily decom- posed, sour substances; overloading the stomach ; abuse of spirits ; a cold. In addition, we have poisonous substances; mechanical irritation by fecal matter, the progression of which in the bowels is arrested, in consequence of which the vessels become compressed, or finally, though rarely, the inflammation may be caused by entozoa. Besides these causes, enteritis occurs as a continuation of other inflammatory processes, gastritis, peritonitis, and as a form of reac- tion against ulcerations of the intestinal mucous membrane. The anatomical changes differ in accordance with the degree, extent and duration of the affection, and likewise with the consti- tution of the diseased organism. The inflammation is, at times, very diffuse, or affecting only scattered portions of the intestinal canal; or the whole thickness of the bowel may be invaded by the inflam- matory process, or only the mucous membrane. The affected parts are injected and more or less red, or mixed with dark-red extrava- sations. The mucous membrane is puffed up, interstitially dis- tended ; in the later stages of the disease it may become infiltrated with pus, and sometimes falls to pieces in shreds. Ulcerations may likewise occur, but really only under the influence of some constitu- tional disease, in which case they may spread over a larger surface, whereas, in individuals free from any constitutional taint, the ulcer- ation is confined to single follicles. In very acute cases, a thin, croupous exudation is sometimes seen on the free surface of the mucous lining. If the serous membrane is involved, a thin layer of exudation is likewise observed on its free surface. The appearances in the colon are the same as those in the ileum, except that follicular ulceration is met with more frequently and is more numerous. 436 Diseases of the Intestinal Canal. If the inflammation is not spread over a large surface, and com fined to the lining membrane, the symptoms are not very grave. There are few local pains, little fever, loss of appetite, constipation, feeling of fulness in the umbilical region; nausea occurs very sei- dom; there is never any vomiting. In this manner the affection may exist for a short time and disappear again almost impercepti- bly, or it may increase and continue to spread; very rarely the dis- order breaks out at once in all its violence. The pains now become intense, burning or tearing, or cutting like colic, until they some- times grow intolerable; they spread over the whole abdomen; are generally most violent in the umbilical region, where the least pres- sure causes an intense aggravation of the pain, which is increased even by the act of breathing; coughing causes extreme pain, which is likewise intensely aggravated every time the patient attempts to turn the upper part of his body, on which account he remains lying motionless on his back. At all times the pain has more or less pro- longed exacerbations like colic, evidently caused by the progressive descension of the contents of the bowels. At the same time the abdomen is distended, but not to excess, as if tympanitic. Where the ileum is alone affected, there is obstinate constipation; where the colon is involved in the inflammation, we have sometimes, not always, diarrhoeic, colored, frequently bloody stools, not unfre- quently attended with tenesmus, or alternate constipation and diar- rhcea, or, finally, obstinate constipation. In such cases the colicky pains are more frequent and extensive, the distension of the abdo- men more considerable. In violent attacks of this disease the con- stitutional symptoms are always very marked. A general chill only precedes a very sudden invasion of the disease. The patient feels the heat more perceptibly than others; he is constantly com- plaining of an intolerable thirst; the pulse is accelerated, even to one hundred and twenty beats, small and contracted, not seldom unequal and intermittent; the skin of the body is hot and dry ; the extremities are frequently cool; the forehead is covered with a per- spiration as from anguish ; the appetite is entirely gone ; the tongue has at times a light coating, at times it is clean and very soon be- comes dry. If the affection increases in violence, the first symptom generally is nausea, which soon becomes associated with retching and vomiting. At first, bile and mucus are vomited up with the food; but if the inflammation is extensive, even fecal matter may be thrown up; the vomited matter very soon acquires a smell like that of ffeces. The signs of collapse now become more apparent; Enteritis, Inflammation of the Bowels. 437 the face has a cadaverous appearance, expressive of deep suffering, with, elongated features and sunken eyes. Under such circum- stapces, the patient often wanders, the skin becomes cool, and is covered with a cool perspiration. Convulsions and fainting fits occasionally complicate these symptoms, and death may ensue under such circumstances. In enteritis this is rarely the case in the first days of the disease, as in peritonitis; the disease does not so often terminate fatally, by virtue of its own inherent intensity, as by the morbid derangements which it causes in other respects, and, accord- ing to their nature, more or less rapidly ; a supervening peritonitis leads the more rapidly to a fatal termination, ulcerations of the intestines more slowly. A rapid and complete recovery only takes place exceptionally. The prognosis is always uncertain, because the disease is apt to pass into insidious chronic complaints, even after recovery seemed to be fairly under way; at all events, enteritis always constitutes one of the more important diseases. The diagnosis of enteritis, although somewhat difficult, vet, with proper care, can be made in the majority of cases with positive cer- tainty. The disorder is most easily confounded with incarcerations^ simple cholerine, colic. The last two can become dangerous, if the trouble is esteemed too lightly, and, as is often the case, is treated with deleterious domestic remedies, among which we class the use of strong alcoholic beverages, and wine. Since it is not always pos-t sible to make a sure diagnosis until the disease has run along for a time, the employment of irritating domestic remedies cannot be sufficiently guarded against in cases of colic and cholerine. T eatment. Hartmann begins this section with the following remarks : " Concerning the treatment of enteritis, I flatter myself, that I have been one of the first homoeopathic physicians who pro- posed to continue the use of Aconite in enteritis, until every trace of, inflammation had disappeared; of course, the dose is not to be repea- ted until the former dose has exhausted its effect. This period cannot be indicated with positive certainty, since it does not even remain the same in the same individual, lasting at times four, at other times twenty-four hours. The more acute the inflammation, the sooner the medicine exhausts its action; on the contrary, the more the inflammation decreases, the longer the medicine acts, so that at first it may be necessary to administer the medicine three or four times in the course of twenty-four hours, whereas afterwards one dose may be sufficient in the twenty-four hours. I have never re- 438 Diseases of the Intestinal Canal. peated the medicine more than six or seven times in a case of enteritis, nor do I believe that it need be given more frequently at any time. We may observe that the constipation attending the enteritis does not counter-indicate Aconite, nor does it require another remedy, since it disappears of itself, as soon as the inflam- matory symptoms begin to abate. Under this treatment the dis- ease generally passes off without danger, and within a much shorter period of time. There is no remedy that corresponds to enteritis as perfectly as Aconite, in all the finest shades- of the disease." It would seem to have been hazarding a great deal, if Hartmann had undertaken to recommend an uncertain remedy with so much positiveness; a number of cures have more or less demonstrated the correctness of his statements, and our Materia Medica shows that the law of similarity justifies the selection of Aconite in this dis- ease. Nevertheless, not all forms of enteritis correspond with Aco- nite, and Hartmann should have restricted bis recommendation of Aconite within narrow limits. His advice, not to repeat the dose until the previous one has exhausted its action, is mere theory, for at the commencement of the disease the symptoms but too often increase in intensity up to a certain point, and yet Aconite will at last produce a most satisfactory change in the disease. How are we to wait, under these circumstances, for the completion of drug- action ? Aconite corresponds perfectly to the form of enteritis de- scribed by Hartmann, but he has only described one form of the more acute disease, namely: where constipation is a prevalent symp- tom. If, as is not unfrequently the case, the inflammation is at- tended with profuse diarrhoea, Belladonna is much more appro- priate ; however, this remedy will be rarely found sufficient, which is likewise the case in regard to Aconite. It is particularly two remedies that are most frequently required after either Aconite or Belladonna, namely: Bryonia and Colocynthis. The former is gen- erally suitable after Aconite, much less frequently after Belladonna; it is obstinate constipation that most frequently points to Bryonia. Uolocynthis, on the contrary, is preferable if the diarrhoea is less frequent, the colicky pains continue intense, and the bowels are very much distended with gas, so that their convolutions can be felt through the integuments. Bryonia is, moreover, adapted to the scarcely apparent inflammations, setting in without violent pains or marked fever, and likewise to enteritis involving the peritoneum, so that a layer of exuded fluid is distinctly perceptible. These four remedies will be found sufficient in all cases of enteri- Enteritis, Inflammation of the Bowels. 439 tis that run a somewhat regular course, and have no dangerous complications, and were treated homoeopathically from the com- mencement. Instead of Belladonna, Mercurius may sometimes be more appropriate; Nuz vomica is likewise deserving attention in the later stages of the disease. If the disease reaches its climax, Arsenicum is the only remedy of which help can be expected, pro- vided help is still possible. Intestinal inflammations, occurring as a consequence of other dis- eases, present peculiar difficulties. As a general rule it is advisable, under such circumstances, to regard enteritis as the most important disease, and to direct our treatment against it in the first place. If the disease assumes the form of a lentescent fever, which is very seldom the case under homoeopathic treatment, Phosphorus and Sulphur will prove the most efficient remedies to secure a favorable turn. Phosphorus will be found necessary if there are unmistakable traces of ulceration of the bowels. We have to revert once more to the constipation, which is such a common accompaniment of this disease. It is an object of terror to lay-people, and even to many, or rather a majority of physicians. Nevertheless, it is of no essential importance, and is much less dan- gerous than the means which are generally used to remove it. If these means had no other effect than to cause an increase of the peristaltic movement of the bowels, their employment might be pardonable. In this respect simple injections of water are com- mendable. But if medicines are used, we not only hasten the action of the bowels, but have to apprehend other hurtful effects, for the reason that we are dealing with a diseased organism. Moreover, we do not always succeed in opening the bowels by cathartic drugs. Homoeopathic physicians know better than any others how unneces- sary all such violent means of treatment are, for as soon as the in- flammatory symptoms have subsided under homoeopathic treatment, the constipation ceases of itself. Embrocations of tepid water, ap- plied to the abdomen, and not changed too often, are an excellent palliative. Dry warmth does not act well in enteritis. In enteritis, as in all other intense diseases of the bowels, the diet has to be regulated with the greatest care. In the first days of the disease, the patients do not eat anything; if they begin* to feel hungry, a weak broth is better than lean watery soups. The pa- tient's own desire to partake of a little broth, is the best indication for giving it. Solid food must only be given in gradually increas- ing quantities. 440 Diseases of the Intestinal Canal. 3. Typhlitis, Perityphlitis, Inflammation of the Caecum. This inflammation is one of those that occur most usually as an uncomplicated and idiopathic disease. Sometimes the intestine alone is involved, sometimes only the parts surrounding the intes- tine, and sometimes both. The etiology is uncertain; what is certain is, that the peculiar anatomical relations of the csecum have a great share in the dispo- sition of this intestine to become inflamed. The retarded or im- peded passage of the faeces is most frequently accused of having caused the inflammation, whence the disease has been named typh- litis stereoralis. It remains, however, a question, which was the cause and which the effect. Ulcerations of the vermiform process, which are easily caused by foreign bodies that had remained lodged in it, incline to spread to the caecum. Typhlitis not unfrequently occurs as a complication in inflammations of the female sexual or- gans, more especially if these arise from puerperal causes. It is dif- ficult to show how far a cold, or the use of sour or easily spoiled food, may be instrumental in producing this disorder. Idiopathic perityphlitis seems to be easily caused by a cold attended with vio- lent exertions, and is principally observed in young persons; where- as typhlitis stercoralis only occurs in advanced age. Nor is typh- litis of rare occurrence in a high grade of tuberculosis, and, in that case, is probably the result of intestinal ulcerations. The most important anatomical changes caused by typhlitis, are: More or less considerable interstitial puffing of the mucous lining, with infiltration, or in the further course of the disease, with lique- faction and ulceration of the same; the vermiform process is full of pus; ulcerated perforations, with adhesions to the ad.oining parts, or having caused peritonitis by opening into the peritoneal cavity, or fistulous openings through the integuments; inflammatory infil- tration in the cellular tissue: inflammatory affection of the serous coat and peritoneum. In wide spread perityphlitis we discover de- positions of pus in the parts adjoining the intestine, with descen- sion of the matter towards the thigh. According to the degree of intensity, locality and extent of the inflamnTation, the symptoms of typhlitis vary considerably; this circumstance renders a separate description of the disease indis- pensable. The most violent acute attacks of the disease begin at once, with- out any precursory symptoms, with violent, cutting, colicky pains Typhlitis, Perityphlitis. 441 in the right iliac region, which are considerably aggravated by con- tact. From the commencement of the disease the alvine evacua- tions are entirely arrested. The whole abdomen gradually becomes much distended, and is more or less painful. The appetite is en- tirely gone; there are frequent and painful eructations, soon fol- lowed by retching and vomiting which, in violent cases, may even contain fecal matter. The fever is high, the skin hot, the pulse accelerated and small; the tongue, although generally clean, soon becomes dry, not unfrequently the extremities are cool, and the face is covered with cool perspiration. The anxiety is very great, pros- tration complete. The urine is sometimes voided with great pain, or the urinary secretion is entirely suppressed for.a long time. The patient is unable to extend the right thigh fully. Very soon a swelling in the caecal region becomes distinctly perceptible, giving a faint sound on percussion, of various dimensions, and increasing with more or less rapidity in size. When the exudation has reached its climax, the gut is distinctly felt in the right side, like a hard, firm sausage. When the exudation is completed, the pains decrease considerably, sometimes disappear entirely, without, however, the constitutional condition of the patient improving in the least. The intense fever is now replaced by an extraordinary prostration and languor; the expression of the countenance is that of great suffer- ing, the pulse is not retarded. Death may take place with all the signs of an increasing loss of strength; or else the symptoms of perforation of the bowels and diffuse peritonitis may suddenly supervene, and cause a speedy dissolution. In favorable cases re- covery may take place very speedily, the exudation being rapidly absorbed. More frequently, however, reabsorption only takes place slowly. In such a case recovery is a slow process, the strength only returns very gradually, digestion is carried on irregularly. Even after the patient's health is apparently restored, the exuded mass remains perceptible for a long time. If, instead of being reabsorbed, the exudation of the cellular tis- sue is transformed into pus, the constitutional symptoms, of course, remain in full force, and the symptoms of a higher grade of puru- lent metamorphosis supervene besides. The swelling becomes more and more fluctuating; the skin grows red, and sooner or later the pus is discharged through the integuments. If the intestine remains intact, only a fistulous opening forms; if the intestine breaks, fecal matter is discharged through the fistula. Or else the pus finds an outlet into the gut, and quantities of pus and blood are discharged 442 Diseases of the Intestinal Canal. by the rectum. Or, finally, the pus may burrow downwards to- wards the thigh, in which case the abscess discharges in the groin. All these terminations are comparatively favorable, because the for- mation of pus results in adhesions which prevent the discharge of the pus into the abdominal cavity. Under all circumstances, how- ever, the healing of such abscesses proceeds very slowly, and leaves one or the other derangements of the gastric functions. This very violent form of typhlitis is not the most frequent. The disease generally arises more gradually, with symptoms that do not allow it to be recognized with any certainty. This generally hap- pens with typhlitis stercoralis. The arrest of the faeces in the caecum leads to inflammatory phenomena which, with the exception of a- most trifling sensitiveness, are scarcely recognizable by the senses. The evacuations are irregular, too scanty, there is a quantity of gas in the bowels, the patient does not feel well, although he is not alto- gether sick. Remissions take' place, during which the parts seem to be restored to their normal condition. Sooner or later another aggravation sets in, which exceeds the former attack in gravity; there is more fever, more languor. Soon after, the exudation in the intestine and the surrounding parts is distinctly felt. The consti- pation becomes more complete and persistent. Unless the patient recovers at this stage of the disease, the symptoms of the above- described acute attack, set in sooner or later. Extensive inflammatory processes in the caecum cannot take place without causing prominent disturbances of the constitutional equi- librium; this applies more particularly to ulcerative inflammation of the vermiform process. Many fatal cases of peritonitis that have arisen most unexpectedly, and have run a rapid course, are, after death, found to be the result of a perforation of the vermiform process. The terminations of typhlitis have already been enumerated in a previous chapter. If we include all kinds of possibilities, these terminations are very numerous. Beside the above-mentioned ter- minations, the following are particularly important: adhesions of the intestine; ulceration and chronic inflammation; chronic ex- hausting suppuration; inflammation of the adjoining bones. The disease seldom runs its course under two weeks; owing to the peculiar modifications of the exuded matter, the affection may continue for many months, before a complete cure takes place. The most favorable sign of recovery is a frequently occurring, fetid, fecal discharge, with decrease of the frequency of the pulse. Fre- Typhlitis, Perityphlitis. 443 quent evacuations, at the height of the disease, have no particular significance. Such evacuations generally consist only of mucus, or of mucus and blood, and evince the participation of the colon in the morbid process. Unless the discharges have been examined by the physician, the report of the patient alone may deceive him. The diagnosis is only difficult if the disease runs an almost latent course; if it is fully developed and exudation has set in, a mistake is impossible. An absolutely certain diagnosis can hardly be imagined, in view of the many possibilities that may occur during the course of the disease; as long as there are traces of the exudation still existing, as long as the bowels do not yet act with perfect regularity, and the bodily strength seems slow to return, we cannot be perfectly sure that the disease has been removed. There are comparatively few cases of typhlitis reported in our publications, although the disease is not by any means of rare occurrence. Some years ago Mercurius and liepar sulphuris were recommended for perityphlitis, in one of our periodicals. Since then we have treated several cases of this disease, and have always derived the best results from the exhibition of Mercurius. Accord- ing to our physiological provings, this remedy is only approxima- tively homceopathic to the disease, but the practical results justify its employment. As regards the use of Mercurius, we have to observe that it is only suitable as long as the exudative process continues, or as long as there is danger of ulterior disorganization, or where suppuration has actually set in. The intensity of the incipient symptoms need not prevent the use of this drug. As far as Hepar is concerned, we have never seen it do the least good. Where the absorption of the exuded fluid is retarded, and the dis- ease assumes the character of a lentescent fever, Bryonia is always the best remedy. When treating of peritonitis, this point will bo eliminated more fully. Bryonia is likewise appropriate at the com- mencement of typhlitis stercoralis, and is much relied on to re- store the regularity of the alvine evacuations. In the fortieth volume of the Allgem. Horn. Zeit. we have three cases of perityphlitis reported by Gauwerky, which he cured with high potencies of Rhus toxicodendron. On considering these cases more carefully, we find that the action of the drug on these occa- sions is highly questionable. Complete recovery, that is to say the complete disappearance of the exudation, required seven, eight and ten weeks. Under such circumstances we cannot suppose that the 444 Diseases of the Intestinal Canal. medicine accelerated the absorption, the more as the patients were young persons. Although the disease had assumed a lentescent type, yet it could not possibly have run such a long course, if the medicine had anything to do with abbreviating it. Of much more significance is Black's cure of two cases of typh- litis, by means of Lachesis (see British Journal, 1847). Here, too, we have to ask ourselves whether the previously-given Mercurius was not the true curative agent in these cases. This hypothesis is not weakened by the fact, that the disease continued to increase for a short time after Mercurius had been given, for we cannot suppose that it is within the power of any medicine to at once arrest an incipient exudation. The favorable action of a drug has to be measured by the whole course of the disease. If, as is gener- ally the case, we do not witness any pus after the exhibition of Mercurius, or no excessive exudation, and finally a rapid absorp- tion, all this is proof enough of the curative agency of the drug. Lachesis might lay claim to the cure of these cases, if it had been given alone, from the very commencement. For these reasons it is highly essential to sound observation, that, in morbid processes whose course is definite and demonstrable from beginning to end, the remedy should not be changed, unless such a change is rendered necessary by the supervention of extraordinary occurrences or changes; this method is more especially to be recommended in the use of Mercurius in typhlitis. We have laid down a similar rule when speaking of Aconite in enteritis, and we shall have other opportunities to allude to this circumstance. In evidently rec- ognized typhlitis, Aconite is no remedy, because it only corresponds to the fever of the first few days, not to the local process. Bella- donna is much more suitable, because it has a number of symptoms pointing to typhlitis. It is particularly adapted to inflammation confined to the intestinal mucous membrane, or where the serous coat of the intestine, not the cellular tissue, is involved. Veratrum should not be lost sight of in typhlitis, if the acute febrile pheno- mena are very soon replaced by threatening symptoms of paralysis of the intestine, if the pulse is exceedingly rapid and filiform, the skin of the extremities and the face is cool, or covered with a cold perspiration attended with anguish and prostration. Inasmuch as such symptoms scai cely ever occur at the very beginning of the disease, Veratrum will seldom be found indicated; for the subse- quently appearing and very similar symptoms require more partic- ularly Arsenicum and Lachesis. In typhlitis, Sulphur holds the Catarrhal Inflammation of the Rectum. 445 same rank as Bryonia. Whereas Bryonia has its use when the disease assumes the form of a lentescent fever, Sulphur is required after the characteristic fever has subsided and the exudation does not seem disposed to yield. It not unfrequently happens,that the disease conies under homoeopathic treatment at this period, after other means had been tried in vain for some time. Sulphur will scarcely ever fail to afford aid in such cases. If the disease should assume an abnormal course by the super- vention of diffuse peritonitis, we have to employ the remedies of which we shall make mention when speaking of this disease. If pus has become deposited in large quantities, medicinal action will prove fruitless until the pus has been discharged either internally or externally. Not till then, Silicea, Graphites, or Sulphur may be tried, in order to prevent the formation of incurable fistulous canals and osseous disorganizations. If possible, the opening of the ab- scess should not be left to nature, for the reason that the thick- ness of the soft parts through which the pus has to pass, is too great, and a further descension of the purulent matter is to be ap- prehended. Such results of a case of typhlitis that has been treated homoeopathically from the start, are unquestionably very rare, and generally come to us from the hands of Old-School physicians. If distinct traces of ulceration of the mucous lining are perceived, as is so often the case in the typhlitis of tuberculous individuals, the prognosis is extremely unfavorable, although we sometimes succeed in deferring the fatal result by the use of Phosphorus, lodium, Arsenicum. lodium, especially, has a surprising effect. Typhlitis stercoralis proper, always requires a long after-treat- ment and a careful supervision of the patients, since relapses are apt to set in unless the bowels are kept well regulated. Nuz vomica, Lycopodium, Sepia, are appropriate remedies; but they have to be continued for some time. The diet is the same as that recommended for enteritis, except that, in a case of typhlitis, the use of solid food has to be avoided for a much longer period of time; it is of great importance that not too much fecal matter should pass over the diseased surface. Applications of tepid water to the bowels have an excellent, although only palliative, effect. 4. Catarrhal Inflammation of the Rectum, Proctitis. [According to Kafka, this inflammation is either acute or chronic. Acute proctitis has no other anatomico-pathological phenomena than 446 Diseases of the Intestinal Canal. those which characterize inflammations of the mucous membranes generally. Its passage into ulceration or inflammation of the cel- lular tissue surrounding the rectum (peri-proctitis) is a very rare occurrence. Primarily acute proctitis is caused by a cold, by the action of ex- ternal cold upon the rectum, as when sitting on cold stones, on fresh grass, lying on the cold floor, or by the use of cold injections, cold sitz-baths, etc. It may likewise be occasioned by the action of external irritants upon the mucous membrane of the rectum, such as the too frequent use of irritating injections of soap-suds, vinegar, salt, etc., or by the introduction of plugs into the rectum for the purpose of facilitating a passage from the bowels; or by the action of worms, ascarides, foreign bodies, such as sharp-cornered plum- pits, the accumulation of indurated fecal masses, or by abuses of the rectum for vile purposes. Secondarily proctitis may accompany the ulcerous processes of the mucous membrane, such as tuberculosis, carcinoma, dysentery, typhus, syphilis, etc.; or inflammations of adjoining organs, cysti- tis, metritis, oophoritis, prostatitis. Catarrhal proctitis is recognized in the majority of cases by a violent tearing, stitching, throbbing or burning pain in the rectum, which is always accompanied by tenesmus. The patients experi- ence a sensation as if a foreign body were lodged in the rectum, which they endeavor to expel by hard pressing. While making this effort, the rectum either protrudes from the anus like a raw lump of flesh, that seems to be held tightly by the surrounding anus, or else the anal orifice is spasmodically contracted and at the same time drawn up, without any prolapsus of the rectum taking place. The pains spread from the region of the coccyx to the perinteum, to the sexual organs or the abdomen, and are often intolerable. They reach the acme of intensity during an alvine evacuation, more especially if the faeces are hard and dry, in which case these gener- ally appear tinged with blood. In case of diarrhoea, the stools cause a burning sensation and, when passing through the anus, an excruciating pain; they are likewise mixed with blood, and fre- quently excoriate the anus. On examination, the mucous membrane of the rectum looks dark- red, interstitially distended, hot and dry, the veins of the rectum are swollen. If the inflammation reaches a high degree of intensity, it is gen- Catarrhal Inflammation of the Rectum. 447 erally attended with disturbances in the urinary secretions, especi- ally with stranguria, dysuria, or even ischuria. Febrile symptoms only occur if the inflammation is intense ; in the lower grades of the inflammation, they are entirely absent. If the pain spreads to the abdomen, it is usually accompanied by vomiting and sometimes even by collapse. The disease commonly runs its course in two, three, or five days, amid a gradual abatement of the symptoms, and most generally terminates in recovery without passing into the chronic form. If symptoms of peritonitis are present, the disease may run a longer course; it may likewise become dangerous if the walls of the rectum should become perforated. Secondary proctitis terminates together with the disease occa- sioning it; if this should be dysentery or syphilis, the healing of the ulcers may result in stricture of the rectum. In general, the prognosis is favorable; it is only when complicated with peritonitis that the perforation, caused by the dissolution of the exudation, may endanger life. In treating an acute, primary proctitis, the existing causes have first to be discovered. If fever is present in catarrhal proctitis, occasioned by a cold, we first give Aconitum 3 ; this remedy usually causes a copious perspira- tion, after which all the symptoms diminish in intensity. If the fever is not very intense, the pain, however, very acute, the patient hardly able to bear it, and complains of a distressing tenesmus; if the protruding rectum is hot and constricted, if a throbbing is felt in it, if the anus is spasmodically contracted with- out any prolapsus of the rectum, and if strangury is present, we give Belladonna 3, in solution, every hour. If no improvement takes place in eight to twelve hours, we resort to Sulphate of Atro- pine 3, in the same form and dose. These remedies can be depended upon; they not only diminish the capillary hypersemia, but likewise the excessive sensibility of the rectum, and very soon initiate a dispersion of the inflammation. In case of diarrhoea, with violent pains before and during stool, discharges of mucus and blood which excoriate the anus, we give Merc, sol., 3d trit., every two or three hours. If the stools are hard, the evacuation is attended with great pain, and very often causes prolapsus of the rectum, or is accompanied by swelling of the veins of the rectum, we have derived benefit from the exhibition of Nux 3, or Sulphur 6. 448 Diseases of the Intestinal Canal. If tenesmus prevails, with spasmodic closing of the bladder (Ischuria), we recommend Hycscyamus 3. Secondary phenomena of the rectum, in the course of ulcerous processes, require, according as the symptoms may indicate, Arseni- cum 3 to 6, llepar sulphuris 3, Phosphorus 3, or Silicea 6. Proctitis, setting in in the course of adjoining inflammations, con- stitutes a painful complication, and generally yields to Belladonna or Atropine; these remedies at the same time act favorably upon metritis, cystitis, or oophoritis. Among external applications, we recommend the application of moist and tepid cloths, or moist and tepid poultices of flaxseed, to the anus; the distressing tenesmus is relieved by injections into the rectum of warm almond or olive oil, by means of a small syringe, or greasing the anus with Atropia ointment, in the proportion of one grain of Atropine to two or three drachms of fresh, unsalt but- ter. Warm sitz or vapor-baths relieve the pains in the rectum and the tenesmus. Excoriations of the anus are benefited by the appli- cation of linen rags soaked with oil, or greased with fresh, unsalt butter, or with sweet cream. A prolapsed rectum has to be replaced by manual interference; if the anus is too much constricted to admit of the operation, the Atropine ointment will have to be applied round the anus, after which the reposition of the rectum will very soon become feasible. If the stools are hard, and cannot be passed without much pain, we give Bryonia or Naz vomica, and resort to injections of oil, and a few glasses of loosening mi neral-water, (Congress or Rock- hill.) While the inflammation lasts, the diet must be restricted, and the patient must not be permitted to leave his bed. Chronic proctitis is characterized by interstitial puffing, and thickening of the lining membrane; livid color of this membrane; the presence of a mucous exudation on the surface of the lining membrane; thickening of the sub-mucous cellular tissue; polypous excrescences occasioned by the long continuance of the catarrh, and considerable secretion of mucus; erosions, and ulcerations of the mucous membrane; engorgement of the veins of the rectum, giving rise to frequent bleedings. Under certain circumstances the thick- ened cellular tissue surrounding the rectum, may become inflamed, (periproctitis.) Chronic proctitis is either a remnant of the acute form, especially if repeated relapses have taken place, or else it arises in consequence Catarrhal Inflammation of the Rectum. 449 of chronic obstructions of the portal system, that occur in diseases of the heart, lungs, pleura, liver, or of the vena porta itself, etc. Secondarily, chronic proctitis accompanies the various ulcerous processes of the rectum, mere particularly carcinoma and tuber- culosis. Chronic proctitis occurs more frequently than the acute form. The most constant symptom is the secretion of mucus from the rectum; if the mucus is secreted in small quantity, the fecal masses are generally lined with mucus; if the secretion of mucus is more copious, a muco-purulent substance is either exj elled from the rec- tum, after much urging, or else it continually passes away through the anus, which it keeps moist. The pains are inconsiderable, and are generally felt only during an evacuation. The patients complain of a sensation of pressure or tension, burning or tickling in the rectum. If the mucous membrane is thickened, the passage of the faeces is rendered difficult. The hem- orrhoidal veins are almost always engorged, and, in case of ulcera- tion taking place, bleed frequently. In chronic cases, accompanied by constipation and copious secretion of mucus, prolapsus ani is of frequent occurrence. This disease runs a slow course, sometimes for weeks or months, and sometimes, if the causes giving rise to the disease cannot be removed, continues until death. Cases remaining after frequent attacks of acute proctitis, or after improper treatment of such attacks, admit more easily of a cure. Chronic proctitis of long duration, frequently gives rise to ulcers of the rectum, with under- mined edges. Sometimes the cellular tissue around the rectum be- comes perforated and inflamed, in consequence of which, flstufe of the rectum may take place. The great relaxation of the rectum, consequent upon the copious secretion of mucus, or attended with habitual constipation and the passage of indurated faeces, may lead to permanent prolapsus of the rectum. In cases of chronic proctitis, remaining after frequent relapses, the prognosis is rather favorable. Proctitis occasioned by obstruc- tions of the vena porta, or of a secondary character, is difficult to cure and sometimes incurable. In treating chronic proctitis, we have to direct our attention to the quality and quantity of the mucus discharged from the anus, to the quality of the evacuations, to the sensations accom- panying them, to the condition of the veins of the rectum, and to the prolapsus, and ulcerations of the rectum, if such should be 450 Diseases of the Intestinal Canal. present. Nor should we lose sight of the possibility of periproc- titis setting in. Special inquiry should be instituted, whether polypi are present in the rectum; they may be both the sole cause, and likewise the con- sequence, of proctitis. On this account, we examine every patient, without regard to sex. Polypi of some size protrude at the anus, in the shape of dark-red or bluish, smooth, or fringed bodies. Some bleed more or less at every evacuation; physicians who neglect to institute a proper examination, are misled (by such an occurrence) into a belief that the bleeding is owing to hemorrhoids. Some do not bleed, but cause intense pain at every evacuation. On exam- ining the anus, sometimes no polypi are seen; but on requesting the patient to bear down, the polypi are observed, as described above. By introducing the finger into the rectum, we easily discover if the polypi are seated on pedicles, or whether they have a broad base. The polypi are either ligated, or they are twisted off, or removed by means of the recently introduced galvano-caustic methods. After the removal of the polypi, a perfect cure is generally obtained. In former years, we used to treat polypi with the high and low attenuations of Calc, carb., Phosph., Silic., and Thuya, but without the least result. If no polypi are present in the rectum, and copious quantities of mucus are secreted, we give Borax 3 to 6, two doses a day; at the same time we inject the rectum with this drug, in the proportion of ten grains to one ounce of distilled water. This remedy acts most favorably in cases of chronic proctitis remaining after frequent acute attacks. In secondary proctitis with venous hypernemia, we use Carbo vege- tabilis 6, Pulsatilla 3 to 6, Sulphur 6, [also Hamamelis from the tinc- ture up. II.] If the mucus is purulent and has a fetid odor, as when ulcers are present in the rectum, we give Ilcpar sulph. 3, or Sulphur 6, two to three doses a day. In such cases the symptoms may likewise indi- cate Thuya 6, especially if the mucus is sanguinolent; or Arseni- cm 6, or Carbo veg. 6, if the mucous discharge is attended with burning pains at the rectum; or Phosphorus 6, when there is tick- ling at the anus, or Nitri ac. 6, or Calcarea carb. 6, when there are pressing pains in the rectum. For fungoid growths and thickening of the mucous membrane, we recommend Phosphorus 6, and Natrum mur. 6; the last-named remedy especially if the stools are hard, and passed with difficulty. Cellulitis. 451 If the veins of the rectum are engorged and painful, we give Pulsatilla 6, Carbo veg. 6, or Sulphur 6, [also Hamamelis. II.] For hemorrhage from the veins of the rectum, we prescribe Phos- phorus 6, China 3, or Sulphur 6. [See also the remedies recom- mended for hemorrhoids. II.] Prolapsus of the rectum is strikingly relieved by Nux vom. 3, and Sulphur 6, [also by Mercurius 2d or 3d trit., and Ignatia 6. II.] ; if caused by relaxation of the mucous lining, we prescribe Calcarea carb. 6, or Lycopodium 6, and after replacing the rectum, we sup- port it by a compress, which should be held in place by a T-bandage. It is important that the bowels should be moved easily. This object is accomplished, in most cases, by using the above-mentioned remedies, by drinking a good deal of water, eating fruit, etc. The diet to be observed during the treatment of chronic proc- titis, should be nourishing without being heavy. Light meats and a great deal of water are most suitable. Heating food and bever- ages have to be carefully avoided. Chronic blennorrhoeas of the rectum, of long standing, are often benefited by cold sitz-baths, cold douches on the sacrum, the use of such mineral springs as Karlsbad, Marienbad, Kissingen, Homburg, sea-bathing and cold-water treatment. For anaemia we give Ferrum metallicum 1, two or three doses daily, we likewise prescribe country-air, a strengthening diet, and chalybeate baths. 5. Cellulitis, Inflammation of the Cellular Tissue of the Intestinal Canal. It occurs most frequently at the rectum, (periproctitis,) and at the caecum (perityphlitis.) Periproctitis represents an inflammation of the cellular tissue sur- rounding the rectum. Primarily it is caused by traumatic agencies, or by a cold, by continued sitting, or by some unknown causes. Secondarily it may be a sequal of chronic catarrhal proctitis, ulcer- ous processes in the rectum, or in adjoining organs, such as the pros- tate, bladder, uterus, etc. The patients experience pressing, or stitching pains, in the region of the rectum; sitting inconveniences them very much ; even walk- ing aggravates the pains, which sometimes reach a high degree of intensity. Gradually a swelling is seen in the neighborhood of the rectum, either near the perinseum or coccyx; or else no swelling is visible on the outside, but amid a gradual increase of the pains, a 452 Diseases of the Intestinal Canal. throbbing is felt in the rectum, accompanied by chills, which denote the formation of an abscess near the rectum. The abscess some- times remains undiscovered, even after the most careful examina- tion. Its locality might be ascertained by means of a digital explo- ration of the rectum, but this operation is so painful that the patients obstinately refuse to submit to it. The abscess encroaches upon the capacity of the rectum, and causes an obstinate constipa- tion, which is not unfrequently accompanied by dysuria. Sensitive patients have more or less fever, and are generally deprived of sleep. This inflammation runs a course of from eight days to a fortnight, if the abscess is visible externally ; it gradually fills, becomes softer, and discharges outwardly. If the abscess can neither be seen nor felt, it frequently discharges internally by perforating the rectum; fecal matter penetrates through this opening, accumulates outside of it, causes a new inflammation, and another opening in the neigh- borhood of the anus, giving rise to fistulas of the rectum. Abscesses, finding an outlet externally, generally heal perfectly; abscesses perforating the rectum often lead to extensive suppura- tion or ichorous disorganizations, which, for the most part, cause death by exhaustion, or with all the symptoms of pyaemia. Traumatic periproctitis is treated with Arnica 3, and cold appli- cations to the anus. Periproctitis caused by a cold, with pressing pains, requires Bel- lad. 3, Ignat. 3, Naz v. 3. For stitching pains we give Bryonia 3, and Phosph. 3. In either case we resort to cold or warm applications to the anus, according to the sensitiveness of the patient. If the inflammation is not too acute, we often succeed with these remedies in dispersing it, and preventing the formation of an ab- scess. Absorption of the remaining exudation is effected by Mer- curius 3, and Bryonia 3. As soon as a swelling becomes visible on the perimeum, or in the region of the coccyx, we cause warm flaxseed poultices to be ap- plied, in order to accelerate the suppurating process. At every visit the resistance of the swelling should be inquired into. If the abscess is sufficiently matured, a free incision should be made with a lancet, and a quantity of badly-smelling pus will be discharged, to the great relief of the patient. The abscess should be kept discharging, by inserting a plug of lint or a strip of linen into the opening, until all the pus is let out. A premature closing Cellulitis. 453 of the abscess may lead to a new attack of periproctitis and fistula of the rectum. If no swelling is visible, and the symptoms denote the existence of a deep-seated abscess close to the rectum, the physician has to examine the parts around the anus with great care, at every visit. As soon as he discovers a spot in the periphery of the anus, which is softer and more yielding than the other parts, a deep incision should be made, without loss of time, parallel to the longitudinal axis of the rectum. Perforation can only be prevented by thus se- curing a free outlet to the foul-smelling pus, which will be found mixed with blood. The subsequent treatment is the same as der scribed above. .> Perityphlitis is an inflammation of the cellular and connective tis- sue, which attache the caecum and the ascending colon to the iliac fascia. It is either caused primarily, by a cold, or by traumatic agencies; or is a consequence of typhlitis; or it occurs secondarily in the course of typhus, puerperal fever, pyaemia, etc. The most constant symptoms of traumatic or catarrhal perityph- litis, are: pain in the ileo-caecal region, increased by pressure, mo- tion, deep breathing; or swelling in this region, occasioned by the ra;id exudation; it is generally sharply defined, and very sensitive to pressure. If there is considerable meteorism, and the abdomen is very painful, it is sometimes difficult to find the swelling. Its pressure upon the caecum sometimes causes inveterate constipation; in bad cases symptoms of ileus may be occasioned; the pressure of the swelling upon adjoining nerves may give rise to severe pain, a sensation of formication, and even complete suspension of sensibility in the lower extremities ; pressure upon the veins may cause oedema, or symptoms denoting phlebitis; pressure upon the psoas or iliac muscle renders the motion of the right lower extremity painful. If this condition is accompanied by bilious vomiting, it generally denotes a co-existing peritonitis. If the bowel is entirely closed, fecal vomiting may take place. According as the inflammation is more or less intense, the fever is likewise more or less violent, the features are sunken, extremities cold; the formation of abscess sets in with chills. The superven- tion of peritonitis is attended with meteorism, singultus, ischuria, a small, filiform pulse, etc. The diarrhoea, which is present in some cases, may be attributed to a coexisting catarrh of the large intestines. Perityphlitis arising from typhlitis, has almost the same pheno- 454 Diseases of the Intestinal Canal. mena. In every case of typhlitis and inflammation of the vermi- form process, there is danger of perityphlitis, especially if obstinate constipation is present. In such cases the swelling is more deep- seated, and is not unfrequently covered by the caecum, which con- tains air, on which account the percussion-sound over the swelling is not unfrequently quite resonant. Secondary perityphlitis generally sets in with chills. Its course is so much more rapid, the more v olent the inflamma- tion, and the more extensive the coexisting peritonitis. In favora- ble cases the exudation is reabsorbed, and the inflammation is dis- persed ; this takes place more particularly in catarrhal and trau- matic perityphlitis. As the inflammation decreases, the swelling diminishes in size, the pains become less, and the patients recover their health and strength very rapidly. If the inflammation is not dispersed, the swelling gradually increases in size, a fluctuating ab- scess forms on the abdomen, or in the inguinal region, which, if it discharges outwardly, and the strength of the patient is good, may heal and terminate in recovery. If the patient's constitution is weak, and the suppuration profuse, or the pus changes to ichor, the patient may die of exhaustion. If perforation takes place into the ascending colon, or into the rectum, vagina, or uterus, the pus or ic ior is evacuated by the rec- tum or vagina, and the result may be favorable. If the pus is dis- charged into the peritoneal cavity, fatal peritonitis sets in very speedily. If in favorable cases the pus is either absorbed or evacuated, as stated before, adhesions or partial occlusions of the intestine may remain, occasioning obstinate constipation. Chronic suppurations or discharges of ichor always endanger life. The prognosis in perityphlitis is always dubious. Primary in- flammations are always less dangerous than secondary. An im- portant circumstance is the coexisting peritonitis. Puerperal and pyaemic perityphlitis are almost surely fatal. To moderate the inflammatory pain in primary perityphlitis, we give Belladonna 3, every quarter of an hour, half hour, or hour, without any regard to the presence or absence of fever or collapse. If Belladonna does not relieve, we give Atropine, and if signs of anti-peristaltic motion manifest themselves, we give Opium 1, or Morphia 1; after which the pains generally abate, and the signs of ileus disappear. If the swelling shows signs of decrease, we favor the process of Dysenteria. 455 absorption by giving Bryon. 3, or Merc. sol. 3 ; applying at the same time warm poultices to the swelling, or resorting to tepid baths, which means should not be omitted even during the period of inflammation. If the swelling increases in size, the abdominal integuments be- come tense and red, and the swelling shows a tendency to discharge on the outside, we apply poultices day and night, in order to facili- tate the suppurative process. As soon as the abscess is sufficiently matured, we make a free incision to prevent the pus from gravi- tating downwards. During this period we order a strengthening diet, and, if the dis- charge of pus is very profuse, we give China. 1, internally, every two hours. If the patient is anremic, we give Ferrwn 1, two or three doses a day. Peritonitis, caused by the discharge of pus into the peritoneal cavity, is fatal. H.] If we comprise under this general name the inflammatory pro- cesses of the colon and rectum, it is simply because we are anxious to do justice to the practical tendency of this work, even if we should have to pursue this course at the risk of doing violence to pathological systems. We comprehend in this class all those condi- tions that have the pathognomonic sign of dysentery, tenesmus, with deficient or very much diminished evacuation of fecal mat- ter ; hence the symptoms of colitis and proctitis will be found more or less completely in the following descriptions of diseases. If we had rigidly adhered to a principle of classification, it would have been necessary to treat of simple catarrhal dysentery in this place, and of epidemic dysentery in a subsequent part of this work, sim- ultaneously with typhus, cholera, etc. This would have compelled us to resort to many repetitions in the therapeutic section of the work, and would have rendered it difficult to contrast many points of diagnosis and treatment. 6. Dy senteri a. Dysentery. a. Catarrhal Dysentery. This form represents the simple catarrhal inflammation of the colon and.rectum. The etiology scarcely differs in any respect from the previously described affections of the bowels. It is worthy of note that dysentery inclines to supervene during other important local and general diseases ; and, although it is not, strictly speaking, a pernicious complication, and, as a general rule, is much less dan- 456 Diseases of the Intestinal Canal. gerous than an inflammation of the ileum, when occurring under similar circumstances, yet it deserves more particular attention on account of the pain it causes, and the weakness which the constant disturbance'of the patient's rest entails. The anatomical changes in this disease are only found completely developed in the rectum and at the lower extremity of the colon, more particularly in the region of the sigmoid flexure, and not at all, or only very slightly, towards the caecum; whereas the reverse is the case in ileo-colitis. The mucous membrane is red, interstitially distended, more or less infiltrated ; the follicles are slightly ulcerated, and ulcerated patches are found in the mucous membrane. A characteristic sign is, the disposition to plastic exudations upon the free surface of the mucous membrane, which often results in the formation of extensive pseudo- membranes. Symptoms, The disease sets in without any definite precursory symptoms, or suddenly with violent pinching, cutting, or cutting- pinching pains, radiating from the umbilical region downwards, and which are speedily succeeded by a violent urging to stool, with dis- charge of fecal, soft or watery masses. After the evacuation, the pains abate for a shorter or longer period, after which they return with renewed violence, and more particularly with increased urging, attended with tenesmus and severe pressing pain, during which a small quantity of white, and subsequently blood-stained, mucus is discharged, without any admixture of fecal matter in most cases. At the same time the patients experience an acute burning pain in the anus, and with every new discharge the tenesmus increases. In slighter cases the disease sometimes runs its course without any fever ; the more acute cases may be attended with violent fever ; the stomach is at times involved in the affection, at times not at all; there is loss of appetite, retching, nausea, vomiting, the tongue is usually quite clean. The duration of the disease usually depends upon its extent, which is pretty accurately measured by the extent of the pain. The slighter cases sometimes do not last more than a day, the severer cases last weeks, and then are disposed to pass into the chronic form. In the case of children the non-admixture of fecal matter in the stools is an exception to the rule; blood, pus, and scrapings of intestinal membrane, shreds of mucous membrane, and false membrane, are met with the more frequently, of a green, not homogeneous, color The dysentery of children assumes more easily a chronic form than in the case of adults, and almost always Dysenteria Epidemica. 457 leaves a peculiar disposition to relapses. The so-called teething-dys- entery is just such a catarrhal affection, and arises less frequently in consequence of the process of dentition than of other influences acting upon the little patient, especially an erroneous system of pre- paring and administering nourishment. In the case of children, even if there is no sign of fever, convulsive symptoms are apt to supervene, imparting a higher degree of importance to the other- wise not very important disease. A fatal termination of catarrhal dysentery, in a person of an otherwise good constitution, is a rare occurrence. Even where the disease sets in as a complication of other diseases, the danger inci- dent to its course is only of mediate importance. The treatment will be shown when we come to speak of dysentery proper. However trifling catarrhal dysentery may seem, dysentery proper is an important and dangerous disease, and so much more interest- ing to the homoeopathic practitioner, as the homoeopathic treatment of dysentery is infinitely superior to any other method of treatment. Nothing is better calculated to expose to view the advantages of a method of cure than the prevalence of some epidemic malady. The etiology of dysentery, although in a measure founded upon positive data, rests likewise upon hypotheses which it might be diffi- cult to demonstrate. The importance of this subject must be our excuse if we dwell upon this point more at length. Dysentery usually breaks out in an epidemic form; the few cases of sporadic dysentery that come to us for treatment, are either not dysentery, properly speaking, or else they are very rare occurrences. Dysentery is more particularly a disease of young persons and those of middle age, and very seldom attacks either the very young or very old. Epidemic dysentery almost always breaks out late in the summer, or in the beginning of fall, in very hot and dry seasons ; it seldom lasts until winter is somewhat advanced ; it seems to occur more frequently among the lower than the higher classes ; its spread is promoted by the living in crowded rooms; nothing shows this clearer than the devastations which dysentery causes in the ranks of armies. Neither city nor country people are spared; it even seems as though the latter were more fearfully visited by this plague. If a disposition to dysentery prevails, errors in diet and catarrhal exposures excite the attack; the statement, however, that b. Dysenteria Epidemica, Dysentery Proper. 458 Diseases of the Intestinal Canal. the use of fruit favors the breaking out of dysentery, is not yet proven. This assertion, at most, only applies to unripe fruit, or to such kinds as are apt to cause cholerine, diarrhoea, etc., such as the early cherries, plums, etc. There are, undoubtedly, individuals whose bowels are irritated by the use of any kind of fruit, and in whom it may cause an attack of dysentery. These detached and well established etiological data, cannot well be harmonized in one series, except by the supposition that there exists a peculiar virus, which has a special relation to the colon and rectum; for it is only in these parts that the phenomena of dysentery become localized. In this respect, dysentery is very near to Asiatic cholera, and likewise to other infectious epidemics. What the quality of the dysenteric virus is, has not yet been decided with any degree of certainty. That the virus is of a vege- table nature might be accepted as true, where dysentery spreads over extensive districts; but this theory does not apply where dys- entery attacks whole armies. A discussion of this point is not as useless as it might seem, since its proper solution is intimately con- nected with the prophylactic treatment of dysentery. This ques- tion may perhaps be better elucidated by subsequent epidemics. It is certain that the virus is engendered in the patient, and is trans- mitted by him like the poison of cholera. Contagion does not take place by contact, but the infection is propagated by water-closets, close-stools, etc. This theory, which is now received as explanatory of the spread of cholera, explains the fact, why the disease de- creases and disappears with the appearance of frost; the cold destroys the poison. This may be the reason also why dysentery sometimes continues as long as mid-winter, provided the warm weather lasts, and there is no frost. The circumstance that during an .epidemic all the inhabitants of one house, but not all the houses in the neighborhood, are attacked, and that epidemics spread more extensively, and more frequently in the country where the exhala- tions from excrementitious matter are more freely diffused through the air, speaks likewise in favor of the theory, that infection is communicated in the manner above described. Among armies in the field, the epidemic is propagated in a like manner, whereas the soldiers lying in barracks are protected much more efficaciously, and the cases of dysentery occurring among them are less numer- ous. Even if the views which we have here expressed, are not absolutely accepted as true, yet no reasonable physician will neglect to arrest the spread of the disease, by effecting the removal of the Dysenteria Epidemica. 459 various circumstances, which we have pointed out as exciting causes of the epidemic. Another important question regarding the etiology of dysentery is, whether an alteration in the functions of the liver does not constitute the chief exciting cause of the dis- ease. The origin of the epidemic, at a time when the action of the liver is known to be altered, and the affections of the liver which so often prevail, during and after epidemic dysentery, seem to confirm this opinion. Hence individuals in whom abnormal changes in the functions of the liver, have developed a disposition to be attacked with dysentery, are most likely to be assailed by this plague; this circumstance again shows why middle-aged persons should be most liable. The anatomical changes caused by dysentery, bear the greatest resemblance to the pathological process taking place in diphtheritis. An exudation forms upon the surface and within the tissue of the lining membrane, which shows an extraordinary disposition to purulent or gangrenous disorganization, and upon which all other phenomena depend. The resemblance of this process to that of diphtheritis is the more striking, if we take into consideration the etiology of the disease. The changes occur more particularly in the rectum, and sigmoid flexure, and become the more insigni- ficant as they approximate the ileum, which is but exceptionally involved in the pathological process. In the lighter grades of dys- entery, the mucous membrane exhibits here and there, narrow streaks of redness, the streaks extending transversely across the axis of the intestine, and mostly running parallel to one of the semilunar folds. The mucous membrane here is infiltrated, like- wise the subjacent cellular tissue, and the red places are lined with a soft, reddish-gray secretion, covered with bran-shaped pieces of epithelium, or else the epithelium is raised in the shape of a small vesicle. In the higher grades of the disease, the affected parts of the lining membrane are of larger size, more numerous, and more widely scattered. The mucous membrane is covered with gray or dingy-red membranous masses of exudation, of a gelatinous consist- ence ; they can only be pulled off together with the mucous mem- brane. The cellular tissue is considerably infiltrated, and usually so unequal, that the mucous membrane is raised like warts, in consequence. The intestine is dilated and filled with a blood-tinged fluid, containing no fecal matter but a good many epithelial and exudative shreds. The farther the wart-shaped elevations are extended, the more generally we meet with a purulent infiltration 460 Diseases of the Intestinal Canal. of the cellular tissue, by which the detaching of the infiltrated mucous membrane is facilitated. Ulcers now form, which are the more widely extended the more intense the attack had been, with shaggy, thickened, considerably undermined edges, and having a base of dingy-gray or blackish-colored cellular tissue; sometimes the infiltrated muscular coat forms the base of the ulcer. In the severest cases, the mucous membrane looks greenish-black, or as if carbonized; the purulent or ichorous infiltration is wide-spread; the cellular tissue is necrosed; the muscular coat is softened; the bowel is much dilated, and filled with a blackish, or brown-red purulent ichor. In the higher grades of the disease, the serous coat of the bowels, the peritoneum, and the omentum, are involved in the inflammatory process. We find an exuded fluid in the peritoneal cavity, which inclines to be transtormed into pus. The most frequent phenomenon in other organs are hepatic abscesses. Where the ulcers are not too extensive, they heal without much cicatrization. If the loss of mucous lining is considerable, contrac- ting cicatrices are the result, so that the bowel looks as if twisted around by cords, or presenting valve-shaped contractions. It is upon the duration of this process that the length of the period of convalescence depends. Symptoms. The breaking out of the disease is almost always preceded by precursory symptoms. The patient feels languid, pros- trate, and out of humor; the appetite is, more or less, wanting; there is oppression of the stomach, deranged digestion, and an in- creased accumulation of flatulence. These symptoms soon increase to nausea and desire to vomit, with coated tongue and foul taste; sleep is disturbed ; there is drawing in the extremities, sensitiveness to external cold, shiverings, and an accelerated pulse. These symp- toms show that the disease has invaded the organism. Above all, it is the diarrhoea which denotes the local sphere of the disease. Even if all the other precursory symptoms.are wanting, diarrhoea generally precedes the attack, in company with slight colicky pains, and without any further characteristic peculiarities. As these pains increase, the diarrhoeic discharges occur more frequently, but are, at the same time, more scanty; in the same proportion the tenes- mus, which precedes every discharge, begins to distress the patient. At times, after a few fecal evacuations, and at others after a some- what longer duration of the simple diarrhoea, fecal matter ceases to be excreted; this is the commencement of the real disease. The colicky pains, which are seldom wanting, increase in intensity, be- Dysenteria Epidemica. 461 come more continuous, and are attended with a painful urging to stool; a sensation as if the bowels would press out of the abdomen, or as though a heavy weight were suspended from the anus, or as if the sphincter ani would tear. When these pains reach their acme, there occurs a scanty discharge, attended with an intense burning at the anus. At first a remiss on of the distress take^ place after this discharge, but the more frequently it occurs, the more the tenesmus increases in violence, and the less it intermits after the evacuation has taken place. The evacuated substance, which, for some time, continues to show a little tinge, soon becomes a mere mucus, with a grayish admixture, or a more or less copious admixture of blood, (dysenteria rubra et alba, red and white dys- entery,) and of a peculiar insipid odor. In more violent cases, pure blood is evacuated. According as the disease is more or less in- tense, the discharges occur every hour, sometimes every few min- utes, so that the patient scarcely dares leave the chamber, however difficult it may be for him, owing to the continued violent and colicky pains, to sit up. The pains now become more tearing, cut- ting, radiating from the umbilicus downwards. The constitutional equilibrium is not much disturbed at the outset. In mild cases the fever is scarcely perceptible, but there are frequent chilly creepings. The pulse is but little accelerated, the temperature of the skin is not much increased. In proportion as the discharges increase in frequency, the pulse becomes correspondingly accelerated, hard and small, the skin hot and dry, the thirst distressing; the desire to vomit increases to real vomiting, although not regularly ; the appe- tite is entirely gone. The patient soon loses his strength, and feels unable to sit up. The affection may continue at this stage for a week, after which it may gradually terminate in recovery. If the local lesions are more considerable, the disease increases in intensity. The pulse grows frequent, small, and feeble, the thirst becomes ago- nizing, the temperature unequal, the extremities feel cool to the touch, the tongue can hardly be kept moist, the face has a cadav- erous expression, and the prostration is complete. Usually the abdomen is meteoristically distended and sensitive. The discharges follow each other more rapidly, and the tenesmus continues unin- terruptedly. The discharges, together with the blood, contain shreds of mucous membrane, and a number of membranous frag- ments. When the disease reaches this height, delirium is not an unusual occurrence. If the disease approaches a fatal termination, the discharges either become fetid, or else they cease entirely, or 462 Diseases of the Intestinal Canal. take prace involuntarily, as a sign that the bowel is paralyzed. It is always a bad symptom, if the discharges diminish in frequency without any corresponding improvement. Death supervenes amid symptoms of general prostration, meteorism, delirium, coma. The termination in recovery may be considered certain, if a general im- provement is accompanied by a decreasing frequency of the stools, and the colic abates, although the tenesmus still continues. As soon as the discharges evidence feces, and the fecal odor is restored, recovery may be considered under full headway. The pulse gener- ally continues somewhat more rapid, yet becomes fuller and stronger, and the febrile symptoms disappear. After a severe attack of dys- entery, recovery scarcely ever takes place very rapidly; which, as we said above, is owing- to the slowness with which the ulcerated surfaces heal; it may also be owing to the fact, that the condition of the digestive organs does not admit of a rapid reparation of the waste, by a copious supply of food. In armies, especially, the transition of acute into chronic dysen- tery is not a rare occurrence. The symptoms of chronic dysentery correspond with those of ulceration of the bowels, which indeed constitutes the basis of the chronic form. In such a case the fever disappears entirely, but the diarrhoea continues, consisting at one time of fecal masses, lined with pus and blood, and at other times of a sanguineo-purulent mucus, or changing about with obstinate constipation. At the same time the appetite does not return, and the patients continue to lose flesh. Death is apt to terminate such sufferings, though frequently not until they have lasted a long time. The severest forms of dysentery, the septic, putrid or typhoid form, are of very rare occurrence in our latitude; they are more frequently met with in hot climates. Such forms arise either be- cause the milder form assumes a malignant type, with all the signs of gangrenous destruction of the bowel, or else they break out at once with an extraordinary degree of intensity, characterized by the signs of a most acute typhus, and rapidly terminating in death. Strictly speaking, there is no transition into other affections ; the hepatic abscesses which do not occur ^infrequently, even among us, after a violent attack of dysentery, are most probably due to the absorption of pus into the vessels; or possibly to a disease of the liver, running its course simultaneously with dysentery. The prognosis, in the dysenteries of our own climate, is emphati- cally favorable under homoeopathic treatment. In the epidemic dysentery of 1846, where old-school physicians lost from ten to Dysenteria Epidemica. 463 twenty per centum of their patients, Dr. Elwert, of Hanover, did not lose one among nearly three hundred. This difference is too striking to be accounted for on any other ground than the inherent superiority of the homoeopathic treatment. We do not mean to assert, however, that every case of dysentery can recover under homoeopathic treatment. Treatment. According to our remarks on the etiological causes of dysentery, it is evident that there must be a prophylactic treat- ment of dysentery, and that it must result in great good. From what we have said on the subject, the single points of this prophy- lactic treatment can easily be inferred. In this place we desire to call attention to the absolute necessity of keeping the evacuations of dysenteric patients separate. It is, moreover, of the utmost im- portance to treat every diarrhoea that may occur during epidemic dysentery, with great care, and to arrest it as soon as possible, since it is an established fact that a diarrhoea produces an increased sen- sitiveness to the dysenteric virus. Among the remedies for dysentery, Mercurius occupies the first rank, and among the mercurial preparations it is the Corrosive Sub- limate. This remedy corresponds to the symptoms of ordinary dys- entery so perfectly, that it may safely be regarded as a specific remedy for the whole process. The leading phenomenon of dysen- (tery, the sanguineo-mucous evacuations without any fecal matter, attended with the most violent tenesmus and cutting colic, is a characteristic and constant symptom of poisoning with Corrosive Sublimate. As evidence that these effects of the Sublimate are not the result of a local action of the poison, we offer the following case of poisoning, from the Dublin Journal, February, 1856: A woman of twenty-five years, of lax constitution, was ordered injections of the Bichloride of Mercury, for ulcers of the vagina. About noon, she injected, by mistake, one third of a drachm in an ounce of water. Immediately after, she experienced violent, labor-like pains, followed by a copious secretion of thin mucus from the vagina. Shortly after, continual vomiting, a burning heat in the stomach, dry and hot tongue, with red edges, dryness in the fauces; after- wards frequent evacuations of a bloody mucus, with violent tenes- mus before and after; coldness of the extremities, spasmodic symp- toms in the fingers and toes. Pulse frequent and small. The tenes- mus continued three days. At the end of this period, symptoms of stomatitis made their appearance. This case is significant, since we rarely meet with a more specifically marked case of poisoning. 464 Diseases of the Intestinal Canal. These few features of the case contain the whole picture of dys- entery, even the preliminary symptoms. The fifty-one symptoms of Corrosive Sublimate, which Hahnemann mentions in his Mate- ria Medica, likewise contain all the essential phenomena of dysen- tery, among them one, which we did not mention in our previous description of the disease, and yet, is of tolerably frequent occur- rence; we mean ischuria accompanying the tenesmus. Here we evidently are in possession of a specific simillimum, and if anywhere, the homoeopathic law must find its verification in the application of this remedy. Indeed our literature offers abundant evidence of this fact; we can point to a number of cases, where Corrosive Sub- limate alone effected a cure in a very short period of time. The side-remarks with which various observers accompany their recom- mendation of this drug, are generally of very little consequence. Griesselich informs us, that it is particularly applicable where the local symptoms are very definite, with little fever, and an ab- sence of the acute distress, except the tenesmus; these statements contradict the action of the Sublimate in many respects. It is precisely the violently-cutting pains, proceeding from the umbili- cus downwards, that indicate Sublimate; the fever, although gen- erally not very violent in dysentery, is sufficiently well marked. All physicians, however, agree, that the lower attenuations of this remedy are preferable, and that it should not be given higher than* the sixth; they likewise agree, that the dose should be frequently repeated. The best plan is to give a dose of the remedy after every discharge: as the discharges diminish in frequency, the medicine will likewise have to be repeated less frequently. The effect of the remedy is perceived very soon, in most cases within thirty-six hours. Of course we cannot expect to perceive a striking improvement in twenty-four hours; nor would it be advisable to follow Griesselich's plan, and select another medicine, if no improvement takes place in that space of time. It is difficult to draw the line between Mercurius corrosivus and solubilis, as therapeutic agents in dysentery. The Sublimate almost always deserves a preference in epidemic dysentery; Mercurius sol. is preferable in the so-called white dysentery. In epidemic dysen- tery, the so-called white dysentery is of rare occurrence, and then only a very transitory phenomenon. On the contrary, catarrhal dysentery, is, in every respect, adapted to Mercurius sol., and it is only in exceptional cases that this remedy will prove unavailing. As long as the evacuations contain faeces, although in small quan- Dysenteria Epidemica. 465 tity, it is well to give the solubilis the preference, no matter -whether blood is discharged with the stools or not. On this account, this remedy is especially appropriate in the dysentery of children, espe- cially during the period of dentition. The triturations of solubilis are preferable, whereas the Sublimate acts better in solution. [The Mercurius vivus is preferred in this disease by many physi- cians. IL] To give Aconite at the commencement of dysentery, as Hartmann recommends, is not even justified by the violence of the fever; this kind of treatment only leads to a rather important loss of time. [This slur on Aconite will undoubtedly be objected to by thousands of our physicians. Although not a panacea, yet it deserves honor- able mention in this disease, especially when there is considerable loss of blood, and a burning distress in the anus, fever, thirst, foul tongue, headache, dizziness. The lower attenuations, from the first to the sixth, are to be preferred. II.] Next to Mercurius Belladonna is without doubt the most impor- tant remedy in dysentery, both the catarrhal and epidemic. As far as local symptoms are concerned, Belladonna is indicated by the violent urging to stool, with or without scanty discharge; violent pains in the distended abdomen, they are aggravated by pressure or else evidently of an inflammatory character ; liability of the rec- tum to protrude. Other prominent indications for Belladonna are: considerable urinary difficulties, even retention of urine; violent fever, also with delirium, severe gastric derangement, nausea, vomi- turition, vomiting. Belladonna is most frequently suitable for chil- dren; less so for adults. Colchicum is the main remedy in dysenteria alba proper, that is, the weaker forms of epidemic dysentery. The discharges are less frequent, but the tenesmus continues unabated; the colic is not severe, and restricted to the lower portion of the colon, it is a col- icky pain; catarrhal irritation of the stomach; tendency to bilious vomiting; not much fever, but great chilliness; urine saturated, dysuria. The catarrhal form of dysentery being exceedingly varied, a num- ber of other remedies might be recommended for this disease. Chamomilla, for instance, is a main remedy in the dysentery of teething children, if the local symptoms are accompanied by acute fever, restlessness, sleeplessness, constant cries, vomiting of bile, nightly exacerbations of the symptoms, or the symptoms only show themselves during night-time. Another remedy is Ipecacuanha^ 466 Diseases of the Intestinal Canal. when the tenesmus only sets in after the discharge, and there is fre- quent and distressing vomiting of bile, while the fever is not very considerable; Dulcamara and Pulsatilla, when the discharges con- sist of mere mucus; they mostly take place at night. Baryta, for the dysentery of children, when it threatens to become chronic, pro- vided there are no striking symptoms of ulceration of the intestines. Calcarea carbonica, is adapted to the same form of dysentery as Ba- ryta, likewise applicable to ulceration of the bowel, here it is even a chief remedy for children. We have already stated, that the above-mentioned remedies are sufficient in epidemic dysentery, unless it should pursue an entirely exceptional, abnormal course, or be complicated with various acces- sory symptoms. This statement likewise, only applies to cases that have been treated homceopathically, from the commencement. But we are also called upon to treat dysentery in its more advanced stages, Qr after the system has been saturated with powerful med- icines. For such abnormal forms of dysentery, the above-mentioned remedies are not sufficient, and one or more of the following list will have to be selected. Arsenicum album is never indicated at the commencement of dys- entery, only when evident signs of putrid decomposition become apparent, together with paralysis of the bowels and anus, in a slight degree. The evacuations have no longer a peculiarly insipid smell, but are fetid, of a blackish-brown color, mixed with numerous shreds of mucous membrane. The pains are uniformly severe, the fever is intense, attended with signs of rapid prostration. Of Rhus toxicodendron, Hartmann says: "It is particularly ap- plicable in protracted cases, where the violence of the symptoms has been diminished by the previous treatment, but where all the symptoms that characterized the attack from the commencement, are still present; it is prominently indicated by excessive prostra- tion, the blood is greatly deficient in plasticity, the organic activity threatens to become extinct; typhoid symptoms supervene." In other words, Rhus is suitable in typhoid dysentery, if septic phe- nomena threaten. Hence, Rhus is related to Arsenicum. A note- worthy symptom, is the circumstance that the evacuations appear at night; there are also involuntary discharges. Colocynthis is scarcely to be regarded as a remedy for dysentery proper, although it may be suitable to some extent, in the catarrhal form. It is variously recommended, but the reasons are not suffi- cient. The symptoms of Colocynth, bear no very striking resem- Dysenteria Epidemica. 467 blance to dysentery. Nor is Nux vomica, a medicine that deserves more particular attention than other remedies. On the other hand, it is of importance in lentescent conditions, such as sometimes re- main after dysentery. Aloes is not yet sufficiently proved, either theoretically or practically, to justify its use, in preference to so many other well tried remedies in this disease. Concerning Plumbum, Hartmann, uses the following language: " The dysenteries to which Plumbum is homoeopathic, are very severe, they constitute the so-called red dysentery, where nothing but blood is discharged; they are characterized by violent fever, severe, cutting pains in the stomach, and bowels, burning at the anus during the passage of the blood, and subsequent tenesmus." These statements do not correspond with the physiological action of lead. In the first place, violent fever-symptoms, are an exception in poisoning with lead; and then poisoning with lead acts slowly, like a lentescent fever. Nevertheless, Plumbum is an important remedy in this disease; nor is the constipation caused by lead, a counter- indication to its use. Constipation is an essential symptom of dys- entery, for the discharges do not contain any faeces. One case of poisoning, contains the following important symptoms: pain in the right hypochondrium, pressure at the stomach, empty eructations, nausea, aversion to food and drink, a sweetish-pappy taste; dry tongue with a thin whitish coating; frequent, dysenteric discharges resembling rice-water, these are often mixed with blood, with vio- lent tenesmus; cool skin; general prostration. Occasional parox- ysms of colicky pains. Afterwards the abdominal walls are drawn in,hard, the stools become involuntary, but the patient is conscious of them. This last symptom is of particular importance, since it points out the period when Plumbum should be preferred to any other remedy, namely: when the rectum and sphincter are para- lyzed. Septic, putrid phenomena, are unsuited to Lead; hence, it could not be administered in cases where the violence of the attack had caused gangrenous destruction of the parts, together with par- alysis. In such a case, beside Arsenicum, Secale cornutum would deserve our attention. According to Hartmann, Sulphur is indicated after the intensity of the characteristic symptoms of dysentery has been diminished by appropriate treatment up to a certain point, after which the improvement ceases, and the patient seems to grow worse again. Acidum sulphuricum may meet this new condition, unless the pres- ent symptoms should point to Sulphur. It is most efficacious in 468 Diseases of the Intestinal Canal. dysenteries with nocturnal exacerbations, with discharges of blood, mucus, and pus, fever, loss of appetite, colic, the patient wants to lie down; the colic often sets in with so much vehemence that it causes nausea, and such profuse perspiration, that the patient seems drenched with it. The fever seems to consist of flashes of dry heat, without much thirst. Next to Sulphur, we have Hepar sulphuris. This picture corresponds to chronic dysentery with ulceration of the intestines, at the period when colliquative phenomena set in. We have a few other important remedies adapted to this stage, namely: Acidum nitricum, China, Phosphorus, also Calcarea carbonica, The great diversity of symptoms characterizing ulceration of the bowels does not allow of a detailed description of the symptomatic indications for each of these drugs. Moreover, such a condition affords sufficient time to compare the proper remedies with great care. ' Regarding diet, the views are very much divided. It is question- able whether the deprivation-diet proposed by Hartmann, and most physicians, is necessary or advantageous to the patient. Slimy de- coctions are undoubtedly the best as a regular article of diet, but why the patient should have to drink boiled water, does not seem very clear. Small quantities of fresh water certainly cannot hurt any one, were he ever so sick; at any rate, this requires to be proven. Considering the arrest of digestive activity, it is, of course, absolutely necessary to avoid substances which, when digested, leave a considerable residue of fecal matter. As soon, however, as the patient can make up his mind to taste of it, let him partake of a little pure broth, or rather beef-tea ; for we should not forget that the dysenteric discharges carry off a good deal of albumen, and that It is principally this loss which promotes the rapid sinking of strength and the disposition to cedematous swellings. Even when convalescent, the patient should be very cautious in his diet, so that, in case ulcers should exist which cannot be recognized by any per- ceptible symptoms, the danger incident to such ulcerations should not be increased by avoidable aggravations. 7. Enteralgia, Colic. Colic is a morbid condition that does not admit of any precise definition. Nevertheless, modern pathologists have felt compelled to allow it a place in their pathological systems, although it does not rest upon any perceptible anatomical changes. We understand ■by the term colic, peculiar pains in the abdomen, occurring in par- Enteralgia, Colic. 469 oxysms, and attended with a feeling of illness, althongh not con- nected with any other ostensible disease of the intestinal canal. In spite of the scanty rays of light which have as yet been shed upon the true nature of this pathological process, a knowledge of its etiological causes is of great importance, and has considerable influ- ence upon the choice of the homoeopathic agent. In one respect, colic may be viewed as a purely neuralgic process, seated in the mesenteric plexus; as such, it is a thing of rare occurrence, and is seldom diagnosed with perfect certainty. In the next place, colic may be caused by the action of certain poisons, more particularly lead and copper, among whose effects upon the organism colic is a standing symptom. Finally, colic is almost always present in every disease of the bowels; of this kind of colic we only range in this category such colicky pains as do not hold a relation of effect and cause to any other special disease. This kind of colic is caused either by the contents of the bowels or the condition of the intes- tinal walls. With regard to the former, we have a colica flatulenta, stercoracea, verminosa, occasioned by an excessive development of gas, or an impeded motion of the gas through the intestinal canal, by an accumulation of fseces, worms, especially teenia. As regards the latter cause, we only have rheumatic colic, arising from a cold and affecting the muscular coat of the intestines in the same man- ner as rheumatism affects the muscles of other parts of the body The colic described as bilious does not belong here, since it evidently depends upon other morbid processes. A genuine hemorrhoidal colic is hypothetical rather than practical; what might be denom- inated as such, does not belong in this group. Regarding the causes of flatulent colic, we have to name the various deleterious agencies that produce acute and chronic catarrh of the stomach and bowels; rheumatic colic originates in suppression of the cutaneous secre- tions. Our best plan is to describe each kind of colic separately, and to. add the particular treatment to each description. Flatulent colic arises from the accumulation of large quantities: of gas in the intestines, or from the incarceration of smaller quan- tities within a definite locality. .The former condition is brought about by the use of flatulent food, or ot such things as are easily, decomposed and occasion the formation of gas; it may likewise be caused by violent emotions, in the case of sensitive persons, espe- cially hypochondriac and hysteric individuals. Among children who are principally fed on milk, and such as are brought up by 470 Diseases of the Intestinal Canal. hand, colic is of almost daily occurrence. An impeded movement of the gases may give rise to colic in such persons as are afflicted with habitual constipation ; this kind of colic has the same etiology as constipation. As regards symptoms, we transcribe Hartmann's Own statement: " The pain is as if the bowels were stretched apart, stitching, drawing, cutting, and is alleviated by compressing the abdomen. It is frequently shifting, with rumbling in the direction of the bowels, especially the colon, in which case the pain, moving all round the abdomen as it were, frequently involves the stomach, sometimes even the chest, where the impeded motion of the diaphragm causes dyspnoea. The abdomen is unequally distended in some parts, with- out hardness or great sensitiveness ; sometimes a tense, elastic, pain- ful swelling is felt somewhere, giving a tympanitic sound on percus- sion, and at one extremity of which, the hard, incarcerating fecal masses can be distinctly felt. In persons of spare habit, and if the bowel is unusually distended, it can be distinctly felt through the abdominal integuments, likewise its peristaltic motion. An emission of flatulence, upwards as well as downwards, affords more or less relief, which is likewise obtained by friction and pressing on the abdomen; if the attacks are very severe, this constitutes an excel- lent symptom, by which flatulent colic can be distinguished from enteritis. Sometimes the flatulence only reaches as far as the region of the left hip, where it causes an agonizingpain , after which it soon returns again with a noise. If the colic is very acute, it is some- times accompanied by ischuria, painful erections, coldness of the extremities; in such a case, the pulse is small, even intermittent. " One such attack does not last very long, but the attacks are apt to come on in a successive series until they sometimes become hab- itual." Treatment. To select the proper remedy, it is important to ascertain the origin of the colic. We, therefore, divide our reme- dies into two categories, those for excessive accumulation, and those for incarceration of gas. Belladonna. The bowels are only partially distended by gas, and their convolutions are distinctly felt through the abdominal integu- ments. The pain is pinching or pulling, a clutching as if with nails; is aggravated by an erect posture; ameliorated by bending double, by external pressure, and by lying down; There is retching, an- guish, congestions of the head. It deserves special consideration in the case of children, if the bowrels are more or less regular. Enteralgia, Colic. 471 Chamomilla is suitable in cases to which Belladonna is adapted, likewise principally in the case of children. The flatulence fills the abdominal cavity, moves about violently, and frequently gives rise to a sensation of ineffectual uro-ino- to stool. This kind of colic frequently precedes, for days, an attack of intestinal catarrh; the stools sometimes are passed more frequently from the commence- ment of the attack, without showing any marked changes of any kind. Cocculus, for constrictive, crampy and tearing pains, principally in the lower part of the abdomen, with partial distension, not relieved by emission of flatulence, with violent pressing down- wards, especially on the bladder; very frequently the stomach is full of gas, with frequent eructations. The attacks are easily ex- cited by eating, or they set in during the night. Cocculus is like- wise suitable, when there is great disposition to relapses. Nux vomica is, according to circumstances, appropriate in cither of these two varieties of flatulent colic. Hartmann recommends Nux, if the pains are deep-seated in the hypogastric region, and are accompanied by a sensation as if a cutting or sticking instru- ment were working on the bladder, the neck of the bladder, the commencement of the urethra, the perimeum, rectum and anus, as if cutting flatulence would press out at all these places; the pains are intolerable at every step, so that the patient has to bend double, whereas in rest, when sitting or lying, the pains disappear very rapidly. Where Nux vomica is indicated, the abdomen is never distended, is rather hard and drawn in, the pain is not keen, it is a distressing pressure; the bowels are constipated. Such attacks are not only met with singly as exceptional events, but likewise habitually, after a dietetic transgression, and without any apparent cause, more particularly among persons who, being of plethoric habit, lead a sedentary life. Lycopodium is a leading remedy where the bowels are obstinately constipated, and where the colic is caused by the stagnant fecal masses, and the attack has been of frequent occurrence. The pa- tients are afflicted to a great degree with habitual flatulence, which increases only at times to colicky paroxysms, more especially at the conclusion of the process of digestion, towards night, or early in the morning. Carbo vegetabilis should be mentioned in this place as a remedy for colic, where gas is engendered to excess, the emission of flat- ulence is difficult, and the stomach is involved in the whole morbid 472 Diseases of the Intestinal Canal. process. The distress is felt soon after eating, continues for some time, and only moderates if, after digestion is ended, the gas which is emitted in large quantities, can no more be replaced. For the colic of hysteric women, Hartmann recommends Ignatia amara^ and Asafoctida. Veratrum is frequently an appropriate remedy in such cases, likewise Cocculus. The attacks are always very obstinate and, owing to their capricious behaviour, it is a very difficult thing to obtain positive information concerning the effect a medicine has produced. For the colic of hypochondriacs we give, besides Nux vomica and Lycopodium, more especially Natrum muriaticum. Beside the remedies we have named, almost any capable of re- moving constipation, may be administered for the colic of hypochon- driacs, which is almost always an habitual condition of the system. [Dloscorea villosa, or the wild yam; a few drops of the tincture, every five or ten minutes, is an admirable remedy for this form of colic, likewise for bilious, neuralgic, and rheumatic colic. IL] Rheumatic colic is next to the form of colic, of which we have treated in the previous section, the most frequently occurring form of this disease. It is always the result of cold, occurs most fre- quently in-the hot season, and in the transition-period from sum- mer to fall. During this period it occurs so frequently, that it seems to act like an epidemic on a limited scale, even side by side with cholerine, and catarrhal dysentery. It is of very rare occur- rence in winter. This kind of colic generally breaks out all at once. In the morning, the patient is roused from sleep by a slight pinching pain in the umbilical region, with urging to stool, yet without diarrhoea; the pinching soon changes to real colic. This colic is seated round the umbilicus, whence it moves downwards, mostly to the left side. It sets in paroxysmally, every hour, half hour or more frequently; is a violent crampy, constrictive pain, attended with rumbling in the bowels, in the region where the pain is felt; this part is some- what sensitive to contact during the attack, whereas hard pressure affords relief. The violence of the pain often causes a cold perspira- tion to break out, and even syncope, may occur in consequence, or else the patients moan and hardly know how to keep quiet; the pain is somewhat relieved when the patients bend double, external warmth and an uniformly quiet recumbent posture, with warm covering, afford the most relief. The intermissions are almost Enteralgia, Colic. 473 entirely, or even quite free from pain. The alvine evacuations are either normal or retarded, or there are three to four papescent stools a day, which, however, afford no relief. The flatulence is not in- creased, but its passage through the bowels is exceedingly painful. The tongue is clean, the taste normal, the patient has some appetite, though not a great deal; yet the pain is excited whenever he eats a little more than usual. If the pain is severe, the patient may experience some nausea, but he does not vomit. There is no fever, but great chilliness. The attack is frequently accompanied by urinary difficulties. If left to itself, the affection runs a slow course; while the fre- quency of the attacks is gradually diminishing, the disorder drags along from two to three weeks, and every slight cold makes it worse again. The strength is not impaired, since the appetite continues, and the patient's sleep, although somewhat restless, is not mate- rially disturbed. It is only when the pain is very severe that a general feeling of weakness takes possession of the frame. In a few cases, the affection is connected with a more deeply penetrating intestinal catarrh, in which the colic continues after the catarrh has come to an end. The treatment of such a colic is very satisfactory. We possess a remedy against it which is almost always effective, whereas every other method of treatment seems without any avail. We mean Cotocynthis. It acts like a real specific in this disease. All the above-mentioned symptoms are contained in the pathogenesis of this drug, and we have here a fine illustration of the prompt and thorough manner in which a true specific simile cures. After giving this remedy the pains seldom continue longer than twenty-four hours, and at the end of this period are, at any rate, very much diminished. Without treatment the colic, if moderately violent, never abates or disappears, under four to six days. It is, however, necessary to give the medicine in a low attenuation, say the second, and to repeat the dose quite frequently, otherwise the certainty of a curative result is very much diminished. Except Colocynthis, we are not acquainted with a single remedy that acts as promptly and successfully as this one. The disease has such positive indications, without any side issues, that it seems use- less to multiply remedies. The only remedy that might possibly be of use, is Bryonia, but a mere glance at its pathogenesis shows that the symptoms of rheumatic colic are only very sparingly to be found in it. This disease is only rarely associated with acute intes- 474 Diseases of the Intestinal Canal. tinal catarrh; the colic, however, will always require our first care, on account of the severity of the pain. We first remove it by means of Colocynth, and afterwards proceed against the intestinal catarrh. Inasmuch as the colicky pains are very much increased by fre- quent and copious eating, especially by the ingestion of solid and flatulent food, it becomes a matter of course, that the patients should confine themselves to soups and slimy beverages. In severe cases they should lie down, in milder attacks they may enjoy a little open air. Embrocations of tepid water are not advisable; external warmth, if applied at all, should be applied dry. Neuralgic colic, which is the real colic, is, as we said above, a rare occurrence. If it does occur more frequently, it is then mis- taken for some other disease. How far endemic colic belongs to this category, has not yet been established , a priori, however, it does not seem that this colic is a purely neuralgic affection. The following case from our own practice may serve to illustrate the disease. The son of one of our merchants, eleven years of age, had been afflicted with a very painful abdominal affection, from his sixth year. The painfulness of the disease had been speedily relieved by homoeopathic treatment; a subsequent attack of paralysis had been cured by some other homoeopathic practitioner. For three years the boy enjoyed good health, until three months previous to our first examination of him, when the old affection, according to the state- ment of the parents, had set in again. This time the family phy- sician was unable to relieve the child; on the contrary, the distress increased continually. We found the following condition of things: The child had a slender frame, without being strikingly thin. He looked pale, with an expression of suffering in his face, and dark margins around the eyes. He complained of an exceedingly violent colic; it came in irregular paroxysms, independently of the time of day, meals, or other circumstances. It was located in the parts close to the umbilicus, sometimes radiating upwards, or downwards, in which latter case it was accompanied by an increased urging to urinate, with tenesmus of the bladder; it was a crampy, pinching pain, as though the bowels were clutched and twisted with nails. At first these paroxysms of pain had occurred at long intervals, latterly, however, the intermissions had been of short duration; the paroxysms lasted so long a time, that the pain seemed to be continuous. During the paroxysm the patient looked pale as a Enteralgia, Colic. 475 corpse, the skin was cold, with cold sweat on the forehead. He was very restless, moaned all the time, with his abdomen firmly compressed, nausea, occasional eructations, but no vomiting. The abdomen was contracted, hard, tense. The appetite only began to fail when the paroxysms became more frequent, the child being afraid of eating, lest the pains should grow worse; the bowels acted normady A careful examination revealed no abnormal condition in the abdomen. From November 21th to December 28th, the patient took succes- sively: Cuprum 6th trituration, Cocculus 3, Plumbum 6th tritura- tion, Colocynthis 2, without any marked signs of improvement being perceived. On the 29th of December he was given Plumbum 30, two pellets every third day. From this day the improvement con- tinued rapidly. After taking four doses the patient recovered, nor has any relapse taken place so far. It is now four years ago. This case corresponds perfectly with Romberg's description of neuralgia, and the treatment suggests a good many reflections. This is one of those cases where the same remedy had no effect in a low preparation, and when given in a high potency, effected a ppid cure. Was this owing to the neuralgic nature of the disease, or to other circumstances? This is difficult to decide,but the case shows that a remedy which is, in all respects, the true simile, should not be given up until it has been tried in its various potencies. Plum- bum and Cuprum, and in some violent cases, Arsenicum, are the only remedies from which we can expect curative results in this form of neuralgia^ Saturnine colic is the most constant symptom of lead-poisoning. It is most frequently met with among individuals whose daily busi- ness requires them to handle substances containing lead-we mean painters, miners, potters, tin-founders, type-founders, compositors ; or it may be caused by water running through leaden pipes, or by snuff packed away in lead, or by hair-dyes containing lead. How carefully we have to investigate, in cases resembling lead-colic, whether the disease is or is not caused by poisoning, is shown by Herapath, in the London Med. Gazette, 1850, where a whole village were attacked with lead-colic, by using water from a brook that flowed at some distance from lead works, and in eight hundred thousand parts of water contained one part of carbonate of lead. Beside the pains, the characteristic symptoms of lead-colic are: violent contraction of the abdominal muscles, retraction of the ab- 476 Diseases of the Intestinal Canal. domen, slow pulse, obstinate constipation. We transcribe Hart- mann's description of the disease. " The colicky pains are at first dull, intermittent; as the disease increases in violence, the pains become twisting, constrictive, boring; they concentrate in the pit of the stomach and umbilical region, whence they spread towards the chest, back, hips, into the upper and lower extremities. Finally, the paroxysms run into each other, the pain becomes continuous, and is often so agonizing, that the patients endeavor to moderate it by tossing about, writhing and twisting, crying and moaning; compressing the abdomen sometimes seems to moderate the pain. The abdominal muscles are sometimes contracted so rigidly that the abdomen is quite tense and hard, drawn in towards the spine, which can be felt through the abdomi- nal integuments. The bowels are obstinately constipated; some- times an evacuation is obtained, only with incredible effort, in a week or a fortnight, consisting of hard little balls resembling sheep- or goat-dung." Other symptoms are: loss of appetite, nausea, retching, vomiting of a^verdigris-like, or dark bitter substance; strangury or ischuria; retraction and contraction of the sphincter ani; the testes are spas- modically drawn up towards the abdominal ring; the breathing is anxious, oppressed, and even asthmatic, especially during the at- tacks of colic; the voice is hollow and without resonance, occa- sional singultus. Other symptoms of lead-disease, which are frequently observed in the course of lead-colic, are: tearing pains in the limbs, some- times alternating with the colic, especially at night; if these pains last any length of time, they result in weakness, trembling and par- alysis; lead-paralysis has this peculiarity, that the extensor muscles are paralyzed, and the flexor-muscles gain the ascendency, so that, where this phenomenon is particularly striking, the hands are drawn inwards, towards the forearm ; very often the pain in the limbs con- tinues at the same time. Other nervous paroxysms are: epileptic spasms, amaurosis, delirium. The patients emaciate very rapidly, the skin becomes dry, brittle, yellowish. Lead-colic lasts, at an average from a week to a fortnight. Under homoeopathic treatment the colic is very speedily cured, yet even under this treatment relapses are unavoidable, unless the cause of the disease is completely removed. After every relapse the lead- poisoning leaves permanent traces behind; the constipation becomes habitual; the patient retains a pale-yellow complexion, remains Enteralgia, Colic. 477 emaciated, feeble, becomes paralytic, dropsical. A termination in enteritis, or ileus, is of rare occurrence. Treatment. If there is a disease that can be regarded fixed, remaining always the same, and always reappearing under the same form, this disease is undoubtedly lead-colic. The above-described picture of the disease embodies two forms, acute and chronic. The latter is a sort of slow poisoning by lead that cannot be removed as speedily as an acute attack, for the reason that, when the disease is chronic, the poison indeed penetrates the organism more slowly, but at the same time more thoroughly, affecting every single organ, whereas in the acute form, the abdomen alone is invaded. In this disease Opium is undoubtedly a most valuable specific, acknowledged as such even by allopathic physicians, who prescribe it in connection with oil, in order to prevent the constipating effect of Opium. Ilomceopathic physicians explain the curative action of Opium in this disease, in a very different manner, for, it is upon its constipating action that the curative power of this drug in lead- colic depends. Hahnemann says: "Opium cures lead-colic homceo- pathically because the constipation produced by lead, yields to the Opium constipation." According to a vast number of observations, Opium is one of the most efficient remedies againt lead-colic; in prescribing Opium, there is no need of administering at the same time, Alum, purgatives, Ilyoscyamus, etc., in which allopathic phy- sicians indulge. In comparing the effects of Opium upon the healthy human body, with the poisonous effects of Lead, we discover a great similarity between these two orders of phenomena; and the cura- tive action of Opium in lead-colic is easily accounted for. The cures reported by Opium are not numerous, but sufficient to show, that a small dose of Opium is capable of curing the colic caused by lead. Platina is recommended in accordance with the observations of Franz, as even more efficient than Opium. So far, however, this recommendation has not been confirmed by practical experiments. Frank communicates a case, where a few doses of Platina effected some improvement, after which Nux vomica completed the cure. This remedy is variously recommended for lead-colic. For the sub- sequent paralytic conditions Hartmann praises Stramonium, for amaurosis, and deafness, Belladonna and Hyoscyamus, also, slight electric shocks. According to this author, Alumina likewise ren- ders essential service in the after-treatment of lead-colic. 478 Diseases of the Intestinal Canal. Regarding copper-colic, colica aeruginalis, we are as yet without any therapeutic observations; it may suffice if we transcribe Hart- mann's views concerning this matter. " This disease is comparatively of rare occurrence among workers in copper, for the cases of poisoning, which, because they were at- tended with colic, have been interpreted as cases of copper-colic, have not by any means, been satisfactorily demonstrated as such. The dis- ease commences with a decrease of strength and gradual emacia- tion, attended with depression of spirits and despondency. Next the bowels act irregularly, we have alternate diarrhoea, and constipa- tion ; after these symptoms have lasted for a time, the colic sets in quite suddenly. It is more distressing than lead-colic, the whole abdomen is involved in it. The pains intermit only during short periods, and resemble a severe enteritis; the abdomen is very sensi- tive to contact, and somewhat distended. At the same time the whole body participates in the affection. The face is pale, sunken, of a greenish-yellow color; the lips are livid, the gums have a slate- color. Paralytic symptoms in the extremities and in the tongue, are seldom wanting. An attack of this kind, which may not recur again until a year has elapsed, may last from four to eight weeks. The difference between lead and copper-colic depends principally upon the distension and painfulness, and the simultaneous involve- ment of the whole body, and also upon the alternate diarrhoea, and constipation, the former generally prevailing, and being associated with tenesmus." The treatment must first aim to moderate the phenomena border- ing on inflammation. For this purpose Belladonna is the best rem- edy, and if the sensitiveness is not excessive, Mercurius. Beside these remedies, we have next in order: Hepar sulphuris, Nux vomica, and Veratrum. Hartmann does not make mention of Arsen- icum, which, to judge by the symptoms, is certainly very suitable. The other species of colic, either are no affections of the intes- tinal canal, and derive their names from the peculiar character of the pain, like menstrual or uterine colic, hemorrhoidal colic, bilious colic, or else they belong in other sections of the work; for instance worm-colic, which will be treated of in the chapter on helmin- thiasis. [In these different forms of colic, Baehr omits the mention of Aconite. In flatulent and rheumatic colic, we have used this remedy with remarkable success. In neuralgic colic it has likewise rendered good service. We use the German tincture, five or six Stenosis of the Bowels, &c. 479 drops, in half a tumbler of water, a dessertspoonful every half hour until an improvement is obtained. We remind the reader of our previous remark on Dioscorea in colic. II.] 8. Stenosis of tlie Bowels, Occlusion, Obstruction of tbe Bowels. There are many causes which either contract the intestine, or render it impermeable to fecal matter. With a view of remedying this defect by therapeutic means, with a prospect of success, it is important that we should be well acquainted with the changes that take place in the bowel. Simple stenosis of the intestine is sometimes congenital, and, as such, incurable by internal therapeutic means. Acquired stenosis proceeds from the intestinal wall, which may be infiltrated with exuded matter; or it may be caused by the contracting cicatrices of healed ulcers; by the contraction of the intestinal walls in conse- quence of a continued emptiness of the bowels; and finally by fecal matter, or a foreign body remaining lodged in a certain local- ity of the intestinal canal. A second form of stenosis depends upon causes outside of the intestine; among these we number, a twisting of the intestine around its own axis, in consequence of being pulled on by the omentum, or by the inherent weight of the bowel; a sharp bend in the intestine, resulting from adhesions; and finally a contortion of the bowel, in consequence of recent adhesions with the peritoneum, with other organs, or with some other portion of bowel; these adhesions being remnants of more or less extensive inflammatory processes. One of the most important forms of occlusion, is that caused by incarceration of the intestine. It is either internal, caused by re- cently formed cords, or openings in the omentum, into which the intestine has forced itself, or else external, if a protruded portion of intestine has become detached from the rest of the bowels by strangulation. Finally, the bowels may become closed by the process of in- vagination, or volvulus. In this process, a piece of bowel slips into the bowel situated below it, in such a manner that the latter sur- rounds the former like a sheath. Since during this process the bowel is at the same time pulled upon by the omentum, the diminution of the diameter of the intestine becomes so much more consider- able. 480 Diseases of the Intestinal Canal. Of the various forms of stricture of the bowels, that caused by an inflammatory infiltration of the intestinal wall, or by incarcera- tion or invagination, may possibly become a subject for therapeutic experiments; hence it is important to obtain an exact knowledge of the kind of occlusion we have to deal with, in order not to injure the patient, and one's self, by futile efforts to effect a cure. In all the essential points, the symptoms of these different forms of stricture are pretty much the same; they only differ in degree. The occlusion caused by an infiltration of the intestinal wall, is only partial, so that the passage of the faeces is only impeded, not entirely prevented. That this difficulty is of great importance to the physician, is evident from the circumstance, that an obstinate and long-lasting constipation, is often caused by a stricture of the intestine, whether depending upon a bend, twist, or infiltration of the intestine. Hence, the want of success in attempting to combat such constipations by internal treatment; whereas if the constipa- tion sets in after an inflammatory affection of the bowels, there is some prospect of relieving it, by succeeding in removing the exist- ing exudation. The only characteristic sign of stenosis, is the size of the fieces, which is always very small if the stenosis is situated close above the rectum. If this is not the case, the diagnosis can only be based upon probabilities. Leading diagnostic points are: a partial distension of the abdomen at one place, which does not change; perhaps the possibility of discovering the fecal mass at this place by the touch; the peculiar form of the excreted fecal matter; the symptoms of intestinal catarrh, attended with consti- pation; and sometimes eructations, having the odor of fieces. The remedies that have to be tried for this disease, are of the class of those, that either stimulate the activity of the intestines, or exert a decided influence upon the resorption of exudations. In this last respect Sulphur is our choice, and if the accident is quite recent, Bryonia; in respect to the former, we prefer Nux vomica, and Bycopodium. If none of these remedies effect even a trace of improvement, it is certain that no cure is possible; and in such a case it is much better to check the disorder by a suitable diet, rather than by means of ineffectual medicines. The patients should use such food as will nourish them as much as possible, without giving rise to much 'fecal residue. Acute inflammations arising from the local irritation of incarcerated fecal matter, have to be watched and treated with special care. The symptoms of genuine stricture of the bowels by intussuscep- Stenosis of the Bowels, &c. 481 tion or incarceration, are the same at the beginning of the accident. Sometimes several days before more serious phenomena set in, the patients experience a slight, constantly increasing distension of the abdomen, complain of constipation and slight colicky pains. Sooner or later eructations, nausea, and finally vomiting supervene, and it is at this period that a physician is generally sent for. Sometimes these symptoms of stricture set in soon after incarceration has taken place, in which case the patients know at once and without the least doubt, where the somewhat sensitive spot is situated; very seldom, however, the pain is very considerable at the outset. If the above symptoms are associated with hernia, an error in diagnosis is not well possible; a mistake could only occur if the patient should deny the existence of hernia, which is often done by women. Hence a careful examination should be made, if our suspicion of the existence of hernia should be excited in the least. In a case of in- vagination, an examination will reveal the affected part, where the intestine feels harder or not entirely hard, and is somewhat sensi- tive to pressure. The whole picture of the disease becomes more distinctly marked, if the invagination is, at an early period, asso- ciated with a limited peritonitis; in consequence of which the pain becomes somewhat more acute. After the first vomiting, the symptoms rapidly increase in intensity, so much more so if, either with or without the physician'? consent, the patient takes a cathar- tic. After a cathartic the pains increase in intensity, and the vom- iting becomes much more frequent. At first remnants of food, mucus, and bile, are thrown up, very soon, however, the evacuations acquire the odor of fseces. They are often preceded by violent, crampy, or colicky pains, which continually increase as the disease lasts longer. The abdomen becomes more and. more distended. At an early period the face assumes the expression of great suffering, with pendulous features and a cadaverous complexion; the extrem- ities are cool, the pulse small and frequent. At times the patient is unable to partake of any nourishment, or only of liquid diet, any other kind of food is very soon thrown up, and with so much distress, that the patient declines partaking of anything in the shape of food. If the abdomen is very much distended, the protrud- ing and distended intestines are seen or felt. While the strength is constantly sinking, a condition of this kind may drag along for a fortnight, of which we had an instance some time ago, in the case of a man seventy-nine years old. With full consciousness death generally takes place amid infinite torture. The exhaustion is, of 482 Diseases of the Intestinal Canal. course, chiefly caused by the inability to partake of food, and, more- over, the excessive painfulness of the spasmodic attacks, which continually increases in proportion as the bowels become more distended. The symptoms change somewhat, if the invagination does not result in a complete incarceration of fecal matter. Some feces may pass through and be evacuated, so that we may be mistaken regard- ing the magnitude of the danger. This, however, is the case, only at the commencement of the trouble, since the opening is soon ren- dered impassable, either in consequence of the intestine being pulled on by the omentum, or a more advanced penetration of the intes- tine through the opening. Generally the gases alone have power to overcome the incarceration, so that the distension does not increase so rapidly, and all the phenomena develop themselves more slowly. On the contrary, the course of the disease is much more rapid, if a more or less extended peritonitis supervenes during the incarcera- tion. Under such circumstances, death generally takes place in a short space of time. We shall revert to this point hereafter. The terminations of occlusion of the intestines are not numerous; the most common of them is death. If inflammatory symptoms are wanting, the more complete is the incarceration, the sooner death takes place, though seldom before the eighth day. Invagina- tion may heal by sloughing of the intussuscepted portion, and ad- hesien of the ends of the intestine; generally, however, a more or less considerable degree of intestinal contraction remains behind. Incarceration may likewise terminate favorably, either by slough- ing of the intestine, and the consequent formation of an artificial anus, or by establishing a communication with some other portion of intestine. The prognosis is very unfavorable from the start, if no operative aid can be rendered as a dernier resort. It is the more unfavorable, the longer the occlusion has continued, in which case, the proba- bility of exudative adhesions having formed, is the greater. This likewise, applies to incarcerated hernia. Here, however, we have to add, that the strangulation of the vessels very soon causes gan- grene, which would render an operation useless. Where the stran- gulation had existed for several days, all aid by internal treatment will prove ineffectual, and we regard all opposite assertions as rest- ing upon a doubtful diagnosis. Treatment, We are just as certain that every non-homoeopath will smile at the proposition that hernia or invagination can be Stenosis of the Bowels, &c. 483 cured by internal treatment, as we are certain, that in a multitude1 of cases, the favorable action of internally administered remedies1 cannot be doubted. On this account, in every case of occlusion of the bowels, we are bound by the sacred obligations of our calling, to associate with appropriate surgical and mechanical means, the use of our own internal remedies, more particularly if the stricture is internal, and cannot be reached by external means. We shall not attempt to reply to the question, how, in such cases, internal treatment can be of any use, and refer, in the place of an answer, to the many practical cases, that abundantly testify to the success- ful employment of our remedial agents. Moreover, the process of the incarceration itself is a very obscure one. At the same time we should observe, that it is only at the beginning of an occlusion of the intestine, that internal remedies can be employed with success.' The remedies which have been employed, or rather recommended for incarceration or intussusception, are: Nux vomica, Opium, Vera- trum, Cocculus, Cuprum, Aconitum, Belladonna, Bryonia. Among these medicines Nux vomica holds the first rank, not only as to the number of cases treated successfully by this drug, but in regard to the positive certainty of success. In every case of occlusion, of whatever nature, this remedy should first be used, unless there are' evident signs of inflammation. These require either Belladonna or Aconite. The former deserves consideration, if the distension of the bowels progresses very rapidly; the latter if signs of general peri- tonitis are apparent. As far as we know, there are no cures with Opium published; its recommendation is based upon general prin- ciples; Hartmann likewise admits that he has no observations to offer with this agent. Nor have wTe any practical observations to' advance with Cocculus. The characteristic symptoms of Plumbum emphatically contradict the symptoms of incarceration. It is the constipation that seems to have singled out Lead as a remedy for ileus; whereas Lead causes a severe contraction of the abdomen, which becomes hard as a board: in incarceration, on the contrary, it is always very much distended. Veratrum and Arsenicum are indicated if a high degree of prostration, or rather inanition sets in. Veratrum is preferable if paralysis threatens to set in at an early period of the disease, attended with fainting fits, and cold perspiration; Arsenicum, if signs of gangrenous disorganization be- gin to show themselves. Both Cuprum and Bryonia are recom- mended for ileus. For fecal vomiting (ileus, miserere) without any signs of in vagi- 484 Diseases of the Intestinal Canal. nation, we have often given Colocynthis with the best result; vio- lent colicky pains were always the precursory symptoms of the act of vomiting. We would warn the reader against believing, that a cure by any of the above-mentioned remedies is reliable; on the contrary, it is very uncertain and of rare occurrence. But it is on this very ac- count, that, in an affection which is so inaccessible to internal treat- ment, those remedies should be tried, the more as the patient can- not possibly be injured by them, for no conscientious physician, at the same time that he uses internal treatment, will omit using all proper surgical appliances. In this respect we will add, that the taxis is often considerably facilitated, by placing the patient on his back, with his head low, and the pelvis raised very high; many ruptures which are otherwise hard to replace, sometimes re-enter the peritoneal cavity of themselves, by resorting to this posture; this rule likewise applies to incarcerated hernia. Applications of cold water or ice cannot be recommended, either in hernia or vol- vulus; in the case of the former, they will neither prevent nor di- minish the gangrenous sloughing caused by strangulation of the vessels; nor can they prevent or arrest peritonitis in a case of intus- susception. Copious cold injections, on the contrary, are said to have frequently produced excellent results; but they must be cold as ice, and given in rapid succession. We need scarcely add that in any form of occlusion of the bowels the use of food that may leave a considerable residue of fecal mat- ter, has to be avoided. [In number 13, vol. IX, of the United States Medical and Sur- gical Journal, a case of reduction of strangulated hernia by Doctor Bourillon is reported, where the operation that had been decided upon, was rendered unnecessary by the following preparation of Coffee: Take one hundred grammes of burnt and freshly ground coffee, and five cups of boiling water; make an infusion and strain; half a cupful every hour, taken cold, and a swallow at a time, not to provoke vomiting; such was the prescription. The next morning this hard and unyielding hernia had suddenly relaxed, after the sixth dose, and had returned to its place, with a gurgling sound. A truss was applied at once, and the hernia has not returned to this time. The following case has all the characteristics of volvulus, except that the stercoraceous vomiting had not yet made its appearance. Hemorrhoids, Piles. 485 It occurred in the practice of Doctor Jacob Reed, Jr., Grand Rapids, Michigan: "Called July 12th to see H. C., ten years of age-a well developed boy, who had passed nine days without having had a movement of the bowels. Found the little fellow suffering from the effects of a large dose of castor oil, which, with other purgatives, had been administered by the mother; no fever; tongue moderately coated; no nausea; tormina, tenesmus, frequent but ineffectual calls to stool; no tenderness over the abdomen, which was somewhat distended and dull upon percussion, except over the course of the colon, which was normally resonant. " Ordered rest, abstinence from all medicines; a large stimulating injection, which being immediately returned, was replaced by a soap supposi tory. "July 13th, eleventh day of retention; tormina and tenusmus increased, and extremely painful towitness; countenance troubled and fretful; fever, vomiting; abdomen tender upon pressure; tongue heavily coated. "Ordered warm fomentations to abdomen, with a full dose of opium per rectum; this administered at noon, gave the child two or three hours, quiet sleep, after which several copious liquid evacuations relieved the little fellow from his suffering. "No further treatment was called for." In a case of volvulus reported in the August number of the New England Medical Gazette, 1867, a cure was effected by giving Nux vomica, Opium and Arnica. We think the Arnica might have been omitted. H.] 9. Hemorrhoids, Piles. Hemorrhoids undoubtedly belong in the class of the most fre- quent and most obstinate ailments, and these two circumstances have imparted to them, from time immemorial, a peculiar impor- tance in the eyes of both physicians and lay-persons. Physicians of former schools, guided in their views of peculiar notions, have traced the fact of hemorrhoids to a peculiar disease, the hemor- rhoidal disease, a morbific entity, about as fabulous as Hahne- mann's psora, from which every possible disease has been, and still is derived by lay-persons. We admit that we do not believe in the existence of such a disease, nor do we require to believe in it, in order to obtain a rational understanding of its supposed phenomena. We look upon hemorrhoids as varicose enlargements of the veins of the rectum, depending upon a variety of causes, and symptomatic 486 Diseases of the Intestinal Canal. of some internal, frequently undefinable pathological process, which, as a consideration of its etiology will soon show us, may assume diversified manifestations. We deem it important to give more emphatic expression to this circumstance, because the hypothesis of an idiopathic disease must necessarily have an injurious effect upon the treatment to be pursued. EtiolotHj. Hemorrhoids are, almost without an exception, a dis- ease of middle-aged persons ; we meet them seldom or never before the age of pubescence; and, if they should exist at this early period, they gradually disappear again in a more advanced age. They occur most frequently among males, in the first place, because the reasons for their existence are more abundant and more deep-seated among men; and, in the second place, because an accumulation of blood in the veins of the rectum is, in a measure, prevented by ,the menstrual function. Spare individuals, without much adipose tissue, are more frequently attacked than well-fed persons; the temperament does not seem to have any influence in the matter. There is, doubtless, an hereditary disposition to hemorrhoids, but its influence must not be extended too far, for as bodily ailments are transmitted by birth, so, also, are bad habits of the vital process; this latter circumstance accounts for the so-called hereditary hem- orrhoids, just as readily and intelligibly as the gloomy mystery of an hereditary constitution. The varicose distension of the veins of the rectum takes place in the same manner as that of the veins of the thigh, or the less fre- quent distension of the veins of the arms or neck, in consequence of the impeded reflux of the blood. Whatever is capable of stop- ping this reflux, must be capable of giving rise to hemorrhoids. From this point of view, the liver and vena porta are some of the primary localities giving origin to hemorrhoids. If the circulation of the liver is disturbed, if the blood received by the vena porta is not carried onward with a corresponding rapidity, the veins lying back of this system become dilated. In a similar manner, but less immediately, disturbances in the pulmonary circulation give rise to hemorrhoids. Thus we find hemorrhoids coexisting with a high grade of emphysema and heart disease ; they impede the circulation in the lungs. In a more mechanical manner, varices of the rectum are caused by accumulations of fseces, the pressure of the gravid uterus, swellings in the pelvis. In some few cases none of these more general causes can be traced; the patients are robust individ- uals, of a healthy appearance, taking a great deal of exercise. In Hemorrhoids, Piles. 487 their case, it is not improbable that the disease may arise from a real abdominal plethora, since more nutriment, and consequently more blood, is carried to the vena porta than it can well control. The peculiar appearance of hemorrhoids in persons recovering from a severe disease, may be owing to various circumstances, all of which it is impossible to enumerate in this place. All those influences which give rise to the above-mentioned im- pediments in the circu'ation, may cause hemorrhoids. Among these we number a sedentary mode of living, accompanied by per- severing mental labor; a luxurious diet, and the use of quantities of farinaceous substances ; the habit of retaining the stool, to which females are particularly addicted from social reasons; the abuse of wine, beer, spirits, strong coffee, sharp condiments; the frequent use of violent drastics ; abuse of fat, or starch-containing substances, or such aliments as tend to produce an excess of gas in the bowels. In general, most of these deleterious influences that give rise to chronic catarrh of the stomach and bowels, belong in this category. Hemorrhoids are very frequent among persons who ride a great deal on horseback. It is not very clear why such an otherwise healthy exercise should cause such stagnations in the circulation, whether by arresting the reflux, or promoting the afflux of the blood. Symptoms. We have to distinguish with becoming care the hemorrhoidal symptoms proper, and those of the ailments that oc- casion the disorder. The appearance of the varices is almost always preceded, for a longer or shorter period, by a particular feeling of discomfort, or a constitutional condition responding to the ailments which occasion the hemorrhoids. In addition, we have the local symptoms in the rectum, such as tension, pressure, burning, espe- cially itching, also tenesmus. Persons who have not yet been trou- bled with varicose tumors, complain, moreover, of pains in the small of the back, which are sometimes very severe. The general health is almost always affected in a very specific manner; the patients are easily exhausted by work, are entirely out of humor, irritable, and disposed to feel vexed, not inclined to attend to any kind of work, complain of tightness and dulness of the head, diminished appetite, eructations, restless sleep, also urinary difficulties. The constitutional condition is not improved with the appearance of the hemorrhoidal tumors; on the other hand, an extraordinary im- provement is sometimes suddenly effected by a voluntary discharge of blood from the varicose vessels. This bleeding may take place 488 Diseases of the Intestinal Canal. in the very first days of the disease, and sometimes not till weeks have elapsed; it may be very slight, or else it may resemble a per- fect hemorrhage, and cause all the phenomena attending a profuse loss of blood. Where no blood is discharged, a copious secretion of mucus sometimes has the same good effect, only the improvement proceeds more slowly. The worst is, when no discharge of any kind takes place, in which case the disorder lasts so much longer. The degree of pain does not always correspond with the size of the swelling; small tumors sometimes are exceedingly painful, large tumors not at all. It is usually when sitting that the patient feels this pain most. After the blood is discharged, the tumor either disappears, or shrinks in size, and remains for some time in this diminished form, or else it continues unaltered. This is generally the case, if the affection has been of long standing. An attack of this kind lasts from a few days to several weeks. Its return is indefinite ; in some it seems to be typical, every month, three or six months; even years may elapse from one paroxysm to the next, until the disease is again provoked by some gross error in diet, or the resumption of some former mode of living in contra- vention of all natural laws. The influence of the seasons is some- times undeniable, since most attacks occur in the spring or fall of the year. The whole duration of the disease, from its inchoation to its final termination, extends over a long period; its spontaneous cure scarcely ever occurs before the fiftieth or sixtieth year, and even later. It is only under certain circumstances that the disease runs a shorter course. The hemorrhoids of convalescent patients are not usually very obstinate, and often disappear in a few months. If varices set in during pregnancy, they disappear again a few weeks after the birth of the child. According to the explanation we have given of hemorrhoids, a recession of these tumors, or a metastasis tc other organs, cannot, of course, be thought of. The phenomena that are supposed to have been observed in this respect, can easily be accounted for by the local affections occasioned by the hemorrhoids. Our remarks on the etiology of hemorrhoids show that the treat- ment should be conducted, in the first place, with a view of meeting the present attack, and in the second place, with the object of erad- icating the whole disease. We cannot possibly expatiate here upon all the details of such a radical cure; these particulars will be found contained in the various sections on affections of the liver, chronic intestinal catarrh, etc. However, we must not flatter ourselves that Hemorrhoids, Piles. 489 the hemorrhoids disappear in every case, together with their cause. We find it just as difficult to cure old hemorrhoids as we do to r move varicose veins on the legs ; whereas, as we stated before, the varices of pregnant women are easily cured after the birth of the infant. The prospect of a radical cure, in a great measure, depends upon the time the affection has lasted. Where the disease cannot be traced to any particular cause, it is, at any rate, advisable to regulate the patient's mode of life; regularity in going to stool, and moderate eating and drinking, should be insisted upon, in order to deprive the plethora, that may possibly exist, of all sustenance. The remedies that are at our disposal against this affection cannot well be separated into remedies for the present attack and those for the whole disease, hence we mention them indiscriminately in one series. Nux vomica is often capable of removing the whole disease, whether the hemorrhoids are fluent or blind. It is indicated, if the hemor- rhoids had been excited by the use of strong, heating beverages- wine, brandy, heating beer, and coffee; or by mental labor, deep studies, with a sedentary mode of life, continued compression of the abdomen; or by hard faeces, worms, especially ascarides, (in which case Valeriana, Mercurius, Ignatia, Marum verum, may sometimes be indicated ; and finally, by the pressure of an impregnated uterus, swelling of the abdominal organs, organic defects of the rectum, or of adjoining parts. If the patients complain of large-sized hemor- rhoidal tumors, with burning, stinging pains; if they experience a sensation as if the rectum were constricted, and the passage for the transmission of fteces were too narrow, accompanied by jerking, dull stitches in the small of the back and the ischiatic bones; if the least movement of the body causes a pain in the small of the back, as from a bruise, which causes the patients to exclaim, to walk and stand bent over; if after or between the evacuations pure blood is dis- charged, attended with urging to stool: Nux vomica is the remedy. (Hartmann.) To these statements we will add that what we have said regarding Nux when treating of intestinal catarrh, shows very satisfactorily where this remedy is capable of effecting a radical cure. It is equally adapted to hemorrhoids depending upon a gen- eral abdominal plethora, especially if the hemorrhoids cannot be made to bleed, and pain as if they were inflamed. Lycopodium is equally applicable to isolated attacks, as to the general disease; it is particularly indicated for hemorrhoidal tumors of long standing and large size. The pains are not so very severe, 490 Diseases of the Intestinal Canal. as the influence upon the general health is unfavorable. The lead- ing indications for this remedy are: a yellow-gray complexion, de- pression of spirits, lassitude and restlessness, which deprives the sufferer of sleep; obstinate constipation and excessive flatulence; considerable distension of the abdomen; discharge of a great deal of mucus with the faeces, liability of the rectum to protrude. Con- firmatory indications are: congestive symptoms in the thoracic or- gans; participation of the bladder in the hemorrhoidal disease, which is revealed by frequent urging to urinate, with discharge of urine rendered turbid by an admixture of mucus, or with streaks of dark blood floating in the liquid. This drug scarcely ever effects a radical cure, but palliates the pains. Belladonna affords powerful aid against single attacks, if the fol- lowing symptoms prevail: symptoms of general plethora, conges- tions of the head, violent pains in the back, febrile restlessness; and with reference to the locality of the pains: violent stitching and darting pains in the anus, sensitiveness of the tumors to contact; colicky pains previous to every evacuation; copious discharge of blood without any special relief. Retention of urine, and spasms of the rectum, afford additional indications for this drug. Bella- donna is likewise used externally by physicians of other Schools, and with excellent success. Aconite is recommended for the same symptoms as Belladonna, but the favorable results obtained with it, are not quite as numerous as those yielded by Belladonna. Arsenicum album is only appropriate as a means of cure, in single attacks; its good effects, at such times, are extraordinary, if the whole organism is deeply affected by the extreme violence of the attack. The pains in the anus are intensely burning or stinging, worse at night and during motion; the tumors or bunches are hot, dark-red, and painfully sensitive. The stools are accompanied by tenesmus and great increase of the pains, even to such an extent, that they cause the patients to faint; at the same time they lose their flesh and strength very rapidly. The pains in the rectum, are often associated with urinary difficulties, and violent burning pains in the back, and small of the back. There is much bleeding which, however, does not afford any relief. The blood is of a dark color. Carbo vegetabilis acts very similarly to Arsenic; the difference is mostly determined by the general phenomena. Hartmann recom- mends this remedy if there is violent rush of blood to the head, nose bleed, and a continual secretion of mucus from the anus, which stains the linen. For the last-mentioned symptom, Antimonium crudum may be compared. Hemorrhoids, Piles. 491 Sulphur is, with Kux vomica, the most distinguished remedy for the hemorrhoidal disease; it corresponds to all the phenomena of the attack, and to many of the general ailments that cause the dis- ease, more particularly to chronic catarrh of the intestines, and to affections of the liver. It is equally adapted to blind, fluent, and mucous hemorrhoids; it is indicated by a constant urging to stool, with either diarrhoeic discharges, or hard stool; violent pains in the protruding anus, as if inflamed; considerable pains in the back, and small of the back; painful urination with frequent urging; colicky pains in the bowels; hypochondriac depression of spirits; tendency to copious and exhausting perspiration; congestive dis- tress in the head, and chest. In such cases, if not occasioned, and kept up by local disorder of a malignant character, Sulphur, some- times aided by Nux vomica, will often effect a radical cure. Space is wanting to furnish a detailed enumeration of the symp- tomatic indications of the other remedies; we mention them, in connection with their more general spheres of therapeutic action. For copious bleeding, like hemorrhage, the chief remedy is Ar- senicum; next to it, we have Creosotum, Sabina, Acid am muriaticum, Millefolium. If the varices are inflamed and pus begins to form, we give Mer- curius; compare, moreover, Phosphorus and Hepir sulphuris. If women are afflicted with hemorrhoids, we may have to give, beside the remedies mentioned at the commencement of the chap- ter: Ignatia amara, Sepia, and Pulsatilla. If the bladder is involved, we give, next to Belladonna, Arsenicum, Sulphur, Lycopodium: Cantharides, Hepar sulphuris, G-raphites. The general symptoms may likewise point to Calcarea carbonica, Chamomilla, Acidum nitricum, Capsicum, Phosphori acidum. In view of the diversity of symptoms which characterize the hemorrhoidal disease, we could not well help recommending a large number of remedies for it; this multiplicity cannot possibly create the least confusion and uncertainty in the selection of a remedy, unless we lose sight of the circumstance, that the selection of the appropriate specific remedy in the case, is generally determined by the general phenomena, the local symptoms of most remedies re- sembling each other almost to a hair. The urgent wish of the patient to be relieved, as soon as possible, of his sufferings, in connection with the conviction, that internal treatment cannot possibly effect a radical cure in a short space of time, will, of course, make, it incumbent upon us not to ignore cer 492 Diseases of the Intestinal Canal. tain external applications that may have power to palliate the pa- tient's distress. Local depletions have scarcely ever had a favorable effect, and should be avoided, if for no other reasons, than that leech-bites are very apt to become inflamed. Moist applications, on the contrary, have an excellent effect. It is impossible to deter- mine a priori, whether cold or warm applications are preferable; this should be settled by a practical trial. It may, however, be taken for granted, that, when the rectum is dry, cold applications act better, and when a great deal of mucus is secreted, tepid, moist applications deserve the preference. Sitzbaths do not act as favor- ably, for the reason that their effect is more general, instead of being restricted to the affected locality. Ground flax-seed is the best material for warm moist poultices. If the stools are hard, dif- ficult and painful, tepid-water injections are very appropriate, and better than cold-water, only they must not be used too frequently in accordance with a mechanical routine. Ice-bladders alleviate the pain, but are apt to exert a bad effect generally, on which account they should be used carefully, and not too long at a time. [For fluent hemorrhoids, when the attack is characterized by profuse bleeding, with a burning distress at the anus, and general weakness, Aconite, first and second attenuation of the tincture of the root, will prove an admirable palliative. Among the new remedies lately introduced into homoeopathic practice by Dr. E. M. Hale, several have done good service in the treatment of piles. We call attention to the horse-chestnut, AEs. cuius Hippocastanum; the stone-root or Collinsonia Canadensis; the witch-hazel or Hamamelis Virginica; the golden seal or Hydrastis Canadensis. For particular indications, and clinical observations, we refer the reader to Hale's New Remedies, second edition; pub- lished by E. A. Lodge, Detroit, Mich. H.] 10. Helminthiasis, Worms. The number of intestinal worms that are found more or less fre- quently in the human bowels, is pretty large. A detailed enumera- tion of the different kinds of worms is, however, unimportant, and we, therefore, confine ourselves to naming only the oxyuris vermi- cularis, the ascaris lumbricoides and the trenia solium. The oxyuris vermicularis, or pin-worm, is the smallest of the three, is one-third or one-half of an inch long, of the thickness of an ordinary thread, and a distinctly perceptible swelling in the place of a head. Usually it is only found in the rectum, seldom Helminthiasis, Worms. 493 through the whole colon, and sometimes even in the vagina, into which it crawls from the anus. At times, only a few are seen to- gether; sometimes, however, they occur crowded together in large masses, most generally among children. The etiology will be dis- cussed afterwards. The phenomena occasioned by this worm, vary a great deal. One of the most common, is a violent, distressing itching of the anus, especially in the evening and at night, and disturbing sleep a great deal. Some children are driven almost frantic by this itching, and are tormented by an almost unaccountable nervousness in consequence of it. Among adults, this itching is scarcely ever so painful and severe. The irritation caused by the worms, some- times occasions a catarrhal affection of the mucous membrane of the rectum, or a spasmodic contraction of the sphincter, with a constant urging to stool, which is not less distressing than the itching. If a large number of them penetrate into the vagina, they cause severe itching, fluor alous, and the constant rubbing is apt to give rise to self-abuse. Beside these less important results, we sometimes meet without any otherwise assignable cause, with more important disturbances, principally of the central nervous system, sometimes resulting in indefinite spasmodic movements, and at other times in eclampsia, epilepsy, chorea, etc. We cannot prove that these affections are caused by worms, but this seems the more probable, as a removal of the worms is sometimes succeeded by an entire disappearance of the nervous disease. The treatment will be described in a subsequent chapter. Ascaris lumbricoides, the intestinal long worm, is the most com- mon of all. It is from six to twelve inches long, has a cylindrical body, tapering at both ends, of the size of a goose-quill. Its com- mon abode is the ileum and colon, the latter, however, less fre- quently; exceptionally the worm sometimes wanders into the stom- ach, the duodenum, the biliary duct; it has even been found in the larynx, and the peritoneal cavity. Very seldom only one worm is present in the intestine, generally there are several together, some- times as many as twenty or thirty, and even many more; in the case of a young man of twenty years, we have seen upwards of one hundred and seventy worms expelled in one week. The symptoms caused by the presence of these worms, vary greatly. In the majority of cases there are no very prominent symptoms present; it is only by accident that the presence of worms is generally discovered; the only symptom is perhaps an 494 Diseases of the Intestinal Canal. increased longing for rye-bread, and potatoes; and perhaps a less fresh and healthy complexion. More deep-seated and more general derangements, may be caused by a number of worms together, (in the above-mentioned case of the young man, the symptoms were of no account whatever,) or by the agglomeration of the worms into large balls, or by their entrance into some other organ; or else the bowels may be exceedingly irritable, in consequence of which a small number of worms may cause intestinal catarrh or enteritis, together with their consequences. Among these latter, we number the nervous phenomena caused by worms, which have already been mentioned in the paragraph on pin-worms. The ailments caused by lumbrici, often resemble greatly other more or less important processes, such as gastric fevers, typhus, dysentery, and likewise the above-mentioned nervous derange- ments ; it is of no small importance to ascertain their origin at an early period. Those nervous derangements manifest themselves by various phenomena, of more or less constant occurrence. The appetite becomes fitful, or the patient has a more or less exclusive or at any rate, decided hankering for farinaceous food; the nose and anus itch violently; the pupils are considerably dilated; the eyes are surrounded with dark margins; the patients are of a changeable and irritable mood; the fewer is irregular and of vari- able degrees of intensity; bowels act irregularly, at times consti- pated, at other times alternately constipated and loose, with fre- quent changes of this character. It sometimes happens, that the helminthic irritation occasions a real gastric fever, which does not always disappear immediately after the removal of the worms; large balls of these worms, may even cause the same functional or structural changes as hard masses of fecal matter. Properly speak- ing, it is only in children, that lumbrici cause nervous derange- ments, and it is well, when these derangements manifest them- selves, that the physician should direct his attention to the presence of worms. The tenia solium or tape-worm, is found in the northwestern parts of Europe, in the place of the tenia lata to be met with in other regions of country. It is twenty and more yards long, is smooth the best part of its length, and about a quarter to a third of an inch wide; towards the extremity representing the head, its shape is more rounded and thin, and the head itself is thin as a thread. The color is of a faintish white, with a yellowish tint. The worm consists of the very small head, which is sucked fast in Helminthiasis, Worms. 495 the intestinal mucous membrane, and to which a neck of the thin- ness of a thread, and half an inch in length is attached, from which neck, the single links of the worm afterwards proceed. At first these links are narrow, but rather short than broad, so'that the worm exhibits a series of closely-crowded transverse lines; the further removed from the head, the more the length of these links increases in proportion to their breadth, until the last links acquire a length of one inch and more. A more detailed description of the structure of these worms does not seem required in this place. The worm grows in length from the head outward, until the last full-grown links, become sooner or later detached, and are expelled with the stool.. The taenia has its principal abode in the ileum, and is only exceptionally met with in the colon. Generally there is only one taenia found in the same individual, although we are acquainted with one case where twenty-one worms were discharged by the same person. Such cases are, of course, very rare. As in the case of other worms, so are the disturbances caused by the taenia exceedingly various, both in kind and degree of inten- sity. It may be safely asserted, that in the majority of cases the taenia causes very little trouble, and that the patients do not become aware of its existence until a few links have been expelled with the stools, when a variety of ailments and distresses are forthwith traced to the taenia, which, in reality, are the work of the imagina- tion, rather than of the taenia. The mildest disturbances which the taenia occasions, are winding, twisting, colicky pains around and in the navel, not very intense, setting in paroxysmally, more partic- ularly after eating certain kinds of food, and in the morning when the stomach is yet empty. Generally these pains are associated with a little nausea, or even with a sensation of canine hunger, but these symptoms are so trifling that they are only complained of when the patient has become perfectly certain that a tsenia is growing in his bowels. Under circumstances, which it is difficult to analyze, more intense disturbances may show themselves, a disconnected enumer- ation of which we here subjoin: violent colicky pains in the bowels, or a creeping or crawling sensation as from a worm, around the um- bilicus, with increased secretion of saliva, nausea, even vomiting, especially after eating fermented food, herring, sharp condiments, sour fruit. Increased appetite, canine hunger, in spite of which the patient emaciates; itching of the nose and anus; sickly complex- ion; hypochondriac and irritable mood; irregular stool, alternately normal and diarrhceic; headache; disturbed sleep, vivid dreams; 496 Diseases of the Intestinal Canal. palpitation of the heart; changes in the sound of the voice. Fi- nally, the above-mentioned more striking affections of the general nervous system, which can be traced with more certainty to the presence of taenia. The author of this work had an attack of epi- lepsy at the age of eighteen, occasioned by the presence of taenia; after the expulsion of the worm the attack never returned. Never- theless, not every case of epilepsy complicated with taenia, must be regarded as a consequence of the taenia, and the physician should be guarded in hastily establishing a prognosis in accordance with this hypothesis; it is only in very recent cases of epilepsy, when the disease is not yet deeply rooted in the organism, that there is a fair probability of the epileptic paroxysms originating in the irri- tating action of the taenia. The presence of taenia can only be diagnosed with perfect cer- tainty, if the patient has actually passed links of the worm. Many lay-persons are too anxious to attribute their ailments, gastric de- rangements, such as heartburn, water-brash, etc., to the presence of taenia; especially if they experience a sensation as if a worm were crawling about in the stomach, or up the oesophagus; if, in such a case, no links are passed within a few weeks, it is pretty certain that there is no taenia. Most links are passed spontaneously at the time of the new moon. We know this from personal experience, for at such a time we have often passed dozens of links in one day; whereas, at other periods no links were seen for days. The dis- charge generally takes place a few hours previous to the desire for stool, and stops for a few hours after the evacuation. Etiology. We have preferred discussing the etiology of hel- minthiasis, after describing the symptoms of the different forms of worm-disease, because the former is very nearly connected with the therapeutical management. We cannot afford space or time to combat the views formerly entertained, regarding the formation of worms, and content our- selves with repeating what the most careful investigations have established as the truth in this respect; to which we propose to add a refutation of Hahnemann's own views. Regarding the formation of oxyuris vermicularis, commonly termed ascarides, no definite results have yet been arrived at. In the intestine, female worms are principally found, very seldom male ones, nor are eggs, or embryonic worm-formations met with; this seems to show that the larva of the worm must have been intro- duced, as such, into the intestine. It is certain, that this worm is Helminthiasis, Worms. 497 principally met with among children, and adults, who partake of a great deal of farinaceous diet. It makes no difference, whether the individual is of a robust or weakly frame. The fact that in many families every member of the household is afflicted with worms, is accounted for by the circumstance that all use the same kind of diet. The origin of lumbrici is likewise enveloped in a mysterious ob- scurity. Although of a very general occurrence, they are princi- pally found in children who eat a great deal of bread and farinaceous food, which imparts to them the peculiar habit of body to which the term scrofulous is generally applied. By this means the causal connection becomes, at all events, more intelligible and amenable to a philosophical analysis, than if the worms are regarded as the cause of such a condition. Female lumbrici likewise exist in larger num- ber in the intestine than male, although the number of male lum- brici exceeds that of the female oxyuris; every specimen seems to have progressed in its development; there is no embryonic stage, no deposition of eggs; here too, we seem compelled to adopt the theory, that the worm must have been introduced as such into the bowels. The adoption of an hypothesis of this kind becomes the more a necessity as we are perfectly acquainted with the manner in which the tape-worm is introduced and originated, and are somewhat jus- tified in reasoning from analogy, concerning the formation of other worms. Taenia arises from the cysticercus cellulosae, an animal parasite, which changes to a bladder of a larger size, to which a head, seated upon a neck, is attached. This head is provided with a crown of retractile hooks, and with four suckers. If the cysti- cercus reaches the interior of the intestine, it hooks on to the intes- tinal wall, throws off the tail-shaped bladder, and from the neck grow' out the above-described articulations. This proceeding has been demonstrated, by Kiichenmeister's investigations, as an unde- niable fact. The cysticercus is most frequently met with in the hog, and less frequently in cattle; it is killed by roasting, boiling, and thorough smoking; hence can only be introduced into the hu- man economy as an animated parasite, by the use of raw or badly smoked meat. This circumstance accounts for its rare occurrence in districts where little pork is eaten, or among the Jews; and the frequency of its occurrence in middle-aged individuals. Since the fashion has recently been introduced, of feeding children on raw meat, we have met with several instances of tape-worm, even among children scarcely fifteen months old. 498 Diseases of the Intestinal Canal. After what we have said, and according to all well-estahlished facts bearing upon this point, it seems to be undeniable, that not one of the various kinds of worms owes its existence to a peculiar pre-established disposition in the intestinal canal, but that they may develop themselves in every individual living under like external circumstances; hence that helminthiasis is not a disease suigeneris. At the same time, we must not omit to state that worms may cause derangements that may still continue after the removal of the para- sites, for the reason that their peculiar character, or their intensity, have made them independent diseases. Treatment. The question now is, how far these recently estab- lished facts, concerning the formation of worms, affect the treatment of this abnormal condition. Hahnemann asserts that the cure of helminthiasis consists in removing the morbid disposition in the intestine, which engenders and sustains the worms. This view cor- responded perfectly with Hahnemann's time, and we must not deem it an original idea of his, if he considered the removal of the worms as perfectly indifferent, and depended, for a complete cure of hel- minthiasis, upon the action of infinitesimal doses of the homoeo- pathic remedy. It is inconceivable, that there are homoeopathic physicians at the present time who still advocate Hahnemann's doctrines on this subject. Even if we admit that many morbid conditions, caused by worms, can be moderated, and even entirely removed, without the expulsion of the worms, this, certainly, does not mean that the helminthiasis is cured by such a result. It is not by any means true that an intestine which is morbidly affected by worms, must have been previously diseased, otherwise, the worms could have had no influence over it. Nor can it be alleged, in favor of Hahnemann's views, that morbid conditions of a very obstinate character sometimes remain after the removal of the entozoa; if an enteritis, caused by worms, has resulted in ulcera- tion of the intestines, it takes, of course, time to heal the ulcers. We need not extend these remarks farther, as homoeopathic practitioners generally no longer share Hahnemann's views on this point. If we mean to act as true physicians, we have to proceed in the treatment of helminthiasis as in that of any other pathologi- cal process; and have first to remove the cause, provided we are certain of having a correct knowledge of what it is, and where lo- cated. After having accomplished this object, we proceed to the further treatment of the remaining ailments. Hence, in the present case, our first aim should be to remove the definitely known cause, Helminthiasis, Worms. 499 or in other words to exterminate the entozoa. If, after having allowed the organism sufficient time to resume its normal condition, any derangements of the normal functions still remain, they will easily and permanently yield to the influence of suitable homoeo- pathic specifics. Of course the diet will have to be regulated in accordance with what we have stated in the etiological chapter; otherwise, the same deleterious causes might reproduce the same morbid results. Of all three kinds of worms, the expulsion of the oxyuris vermi- cularis, is, by all odds, the most difficult, because the least certain. This may be owing in a measure to the fact, that after the worms have once been expelled, a continuance of the former faulty mode of living soon causes a reproduction of the parasites. The mode of proceeding being very simple and harmless, it can, and may be easily repeated quite frequently. Internal remedies are inadequate, for t reason that the worm is lodged in the rectum, and does not easily come in contact with the poison. Remedies used internally may, moreover, cause hurtful accessory symptoms, which had better be avoided. Hence the proper method is to employ remedies exter nally, since they come immediately in contact with the entozoa. For this purpose we resort to injections, for which a variety of sub- stances may be used, from simple cold wmter to solutions of Corro- sive Sublimate, Sabadilla, Cina, Hepar sulphuris, etc. All these remedies have been employed with success; some, however, are too dangerous agents to be employed, without further thought, against such trifling inconveniences as worms. We have generally been able to proceed to our perfect satisfaction with simple garlic, or Allium sativum. A few drachms of fresh garlic are cut fine, boil- ing water is poured over it, and this infusion is used as an injection, as soon as it has sufficiently cooled. The worms which this injec- tion reaches, are certainly killed by it; hence it is well to use a large injection, in order to secure its ascension high up in the bowels. If worms should again show themselves, the injection must be repeated without loss of time. After the expulsion of the oxyuris, morbid symptoms will seldom remain visible; at any rate, they will soon disappear, such as the discharge of mucus from the anus. The remedies which homoeopaths use against the ailments caused by oxyuris, either have reference to single ailments, or to the removal of such changes in the intestinal canal as have hitherto been regarded as the causes of worms. These remedies are: Aconite, Cina, Ferrum, Mercurius, Cuprum; a second series are: Calcarea 500 Diseases of the Intestinal Canal. carbonica, Sulphur, Ferrum. After what has been said, we do not deem it necessary to enter into any further details concerning the use of these agents. The same diet has to be pursued as indicated in the subsequent paragraphs, where the management of lumbrici is treated of. [Weak injections of Fowler's solution, from fifteen to twenty drops to an ounce of water, or Carbolic acid in the same proportion, or stronger, will often destroy the worms ; the injection must not be thrown up high in the rectum. II.] The lumbricus, being lodged in the ileum, is not immediately ac- cessible to external remedies; hence can only be reached by inter- nal treatment. Cina seems to act as a true specific against this para- site, and, with proper management, no other medicine need be used. As regards the administration of the Semina cince, we find it par- ticularly inconvenient in the case of little children ; accessory medi- cinal symptoms are likewise frequently caused by their use. They Occur only feebly, and not very often after the use of Santonine, which is now almost universally used. Children mostly prefer it in the form of Troches Santonini, which generally contains one grain of the drug. From two to four troches, according to the age of the child, are given at night before bed-time, on two successive evenings. Care must be taken not to feed the children too much on farinaceous diet, on the day previous. The period between full and new moon is generally looked upon as the best time for the ad- ministration of the drug. Adequate experiments in an opposite direction have not yet been made; the method proposed commends itself from the circumstance, that at this time the worms are most frequently discharged spontaneously Cathartics are entirely un- necessary. If the troches are not to be had, the Santonine can just as easily be given with sugar of milk. Frequent doses should be administered, if the worms are numerous. The homoeopathic remedies against ailments caused by lumbrici, are the following: Cina, Nux vomica, Spigelia, Belladonna, Mer- curius, Calcarea, Pulsatilla, Antimonium crudum, and a few others less frequently used. It is difficult to say where each of these rem- edies should be given. According to Hartmann, Nux vomica is in- dicated in worm difficulties, if the abdomen is distended and sensi- tive, with a feeling of heat in the bowels; the stool is hard, there is a disposition to vomit, nervous irritability and aggravation of the symptoms early in the morning. For such symptoms, Nux should be given, whether worms are present or no.-Likewise China: nightly aggravation of the pains; after every meal the patient Helminthiasis, Worms. 501 complains of a painful colicky pressure under the umbilicus, with repletion of the abdomen, heartburn with accumulation of water in the mouth, oppression at the stomach and retching; extreme nerv- ous sensitiveness, with spasmodic muscular twitchings and trem- ulous weakness. Worms are certainly not required to indicate China for such a group of symptoms. Cina is an important remedy if the worm-symptoms are complicated with symptoms of cerebral derangement; it is here that the symptoms might easily lead us to the adoption of some other remedy. Where Cina or Santonine has already been employed in large quantities, neither will be found ade- quate when given in small doses; nevertheless, if the worms are not to be expelled immediately, a small dose may be found sufficient to remove the following more or less threatening symptoms: evening- chilliness, with small, rather hard, frequent pulse; not much sleep; tossing about in bed, crying out and starting during sleep; ill-humor, imbecile appearance, passing attacks of delirium, heaviness of the extremities; the face is at times pale and cold, at other times red and hot; dilatation of the pupils; constant rubbing at the tip of the nose; obstruction of the nose; slimy coating on the tongue; offensive eructations; vomiting; heat and distension of the ab- domen; colicky pains in the bowels; constipation, involuntary emis- sion of urine.-Beside the above-mentioned remedies, Zincum and Valeriana deserve especial attention if spasmodic symptoms are present. As a general rule worm-ailments should be treated as if no worms were present; hence it is unnecessary to single out any other remedies. In the case of lumbrici, as well as ascarides, the diet should strive to attain a twofold object; in the first place to prevent the produc- tion of new parasites, and in the second to protect the already en- feebled or diseased intestinal canal. Respecting the first } oint, fari- naceous food has to be partaken of as little as possible, and, if used, good sweet flour should be employed. Respecting the second point, the same precaution will have to be used, that has been recom- mended regarding the chronic intestinal catarrh of children. If Hartmann cautions against the use of milk, we cannot conceive of any possible reason for such advice. Milk is the best nourishment for the human organism, at any rate it never does any real injury. Much sugar or pastry should of course be avoided, were it only for the reason that even the best digestive powers are weakened by such abuse. In order to remove the ailments caused by the tsenia solium, the 502 Diseases of the Intestinal Canal. worm will in the first place have to be extirpated. The remedies that have been recommended for this purpose, not to mention the horse-cures that were formerly in vogue, are: Punica graiiatum., Poly- podium filix mas, Kousso, and Pottlera tinctoria, (Kameela.) Every one of these four remedies is reported to have effected radical cures; which of them is the best, has not yet been decided with certainty. If the superiority of any of them is measured by the trifling nature of the drug-symptoms it produces, Kousso undoubtedly carries off the palm. The powder of Kousso is best administered in the fol- lowing manner: From two and a half to three drachms are placed at night in a common tumbler, and cold water is poured upon it; care must be had to prevent any of the powder floating on the liquid. Early next morning this mass, after having been well stirred previously, is swallowed in two portions, leaving an interval of half an hour between. A preparatory treatment is not exactly required, except that no farinaceous food should be used for a day or two previous to the cure. To prevent nausea, a small cup of black cof- fee may be drank before taking the medicine, and if a disposition to vomit should be experienced nevertheless, a little lemon-juice may be swallowed. One and a half to four hours after taking the med- icine, the worm is expelled without the use of cathartics. We have found this proceeding efficacious in a number of cases treated by our- selves, only one case acted differently. The patient was a robust young woman. She had taken the medicine as directed, but twenty- four hours elapsed without any worm being passed. Without my advice she took several mild cathartics, but no worm came away with the diarrhoeic stools. Not till full eight days had elapsed, the worm was expelled in the shape of a hard ball wrapt in mucus and faeces. The bark of the Punica granatum is given in infusion, or in the shape of an extract; Filix mas is given in infusion or as an extract, also in tincture-form. If we do not at once expect the most complete success, namely the expulsion of the whole worm, head and all, Kousso is the best remedy. If the taenia should grow again, the cure can easily be repeated; for the expulsion of the worm does net leave the least medicinal symptoms. So far we are only ac- quainted with one case where the taenia grew again, after having been expelled by Kousso. A refutation of the rules laid down by Hahnemann, Hartmann, Hering and others, concerning the treatment of taenia, is deemed by us superfluous. At the time when these rules were published, the conditions which give origin to taenia, were absolutely un- Peritonitis, Inflammation of the Peritoneum. 503 known. If any ailments remain after the worm is expelled, we treat them without the least reference to the previous presence of the worm. Those who do not wish to be again molested by this parasite, have to abstain from the use of smoked or raw meat. C. DISEASES OF THE PERITONEUM. Tiiere are, strictly speaking, three kinds of idiopathic diseases of the peritoneum, namely: inflammation, puerperal peritonitis, and ascites. But inasmuch as, for many reasons, the second kind had better be treated of among the diseases of the female organs of generation, and ascites in the chapter on dropsy generally, all that remains for us to do here, is to treat of the first kind. Peritonitis, Inflammation of the Peritoneum. In Hartmann's Manual a description of true peritonitis is en- tirely omitted, although, the acute or phlegmonous enteritis corre- sponds tolerably well to peritonitis. An omission of this kind can only be accounted for upon the ground, that Hartmann supposed the peritoneum is always inflamed if the intestines are. As little, however, as pleurisy and pneumonia can be regarded as one, as little can enteritis and peritonitis be considered identical. Peritonitis ac- quires importance for the reason that the peritoneum is a serous membrane and, moreover, a serous membrane that is the most ex- tensive of its kind in the whole body. If we include the circumscribed forms of peritonitis, this inflam- mation is one of the most frequent we know of; as peritonitis diffusa it is, of course, of less frequent occurrence. If affects more particularly, middle-aged persons, and is very seldom met with among children, or among old people. The disease, for reasons which will be stated bye and bye, is more frequently met with among women than men. It is infinitely less frequent as an idio- pathic affection than as a secondary disease, probably because the peritoneum is well guarded by the thick abdominal integuments, against the action of external deleterious influences. In the main, the origin of the disease is traceable to the follow- ing causes. After all injuries which bring the peritoneal cavity in contact with atmospheric air, peritonitis may be expected in the majority 504 Diseases of the Peritoneum. of cases. Although the inflammation very often remains confined to the injured locality, yet it will almost certainly spread over a larger portion of the peritoneum, if blood, pus, or a certain quantity of atmospheric air enters the peritoneal cavity. This point deserves the utmost consideration in operations upon the abdominal cavity. The danger of inflammation is likewise greater, if the abdomen is very much distended before the operation, and collapses after it; hence, peritonitis is very apt to occur after the Csesarean operation, after tapping for ascites, and after operations during confinement. An intense cold will sometimes cause peritonitis among persons, who are otherwise perfectly healthy, Among women, a cold may be a matter of great importance. There is no question, that con- finement and the menses are very apt to cause peritonitis; espe- cially if a cold supervenes at such times. This observation is so common, even among lay-people, that women have become accus- tomed to be very careful at such times. The disappearance of the menses, or of the lochia, at the commencement of the inflamma- tion has given rise to the theory, that it is this suppression which causes the inflammation; it seems to us more simple, and more nat- ural, to reverse this relation of cause and effect. During confine- ment, the collapse of the distended abdomen exerts a powerful in- fluence ; hence, peritonitis is more apt to occur in the case of women, who have borne several children, than among primiparse. One of the most frequent causes of peritonitis are the inflamma- tory conditions of the organs, situated close to and within the peritoneal sac; the inflammation being communicated, either in consequence of its proximity to the serous covering, or else in con- sequence of the pus gradually penetrating to the peritonaeum. Thus the disease is met with as an accompaniment of gastritis, of affections of the bowels, ushered in with hypereemia, or inflammation; more particularly, in consequence of conditions which occasion an occlu- sion of the bowels, or in consequence of affections of the liver and spleen, metritis, inflammation of the psoas-muscle, abscesses on portions of the abdominal walls. All these causes, at times result in circumscribed, at others in diffuse inflammation. By far the most violent forms of peritonitis, and which run the most rapid course, occur if an organ becomes perforated, and its contents, or even the smallest portion thereof, escape into the peritoneal cavity. This occurs most frequently in the case of per- forating ulcer, ulcerations of the intestines, perforation of the ver- miform process, and gangrenous destruction consequent upon stric- ture of the intestine. Peritonitis, Inflammation of the Peritoneum. 505 Symptoms and course. These of course not only differ in degree, according as the inflammation is confined to small portions of the peritoneum, or, as diffuse peritonitis, invades the whole of the peritoneal expanse; even the diffuse form differs, according as it develops itself suddenly, or by degrees. Acute, diffuse peritonitis, either if caused by perforation, or when setting in as an idiopathic affection, almost always commences with a severe chill, attended with pain in the abdomen. This pain, which is the most characteristic symptom of the disease, is most intense from the very moment it is first felt. The pain is, as though a pointed knife were plunged through the abdomen, from above downwards, without the patient being always able to indicate the precise starting-point of it. Immediately after, a feeling of illness overtakes the patient, he feels unable to remain up, and he is satis- fied that a severe sickness is upon him. If peritonitis sets in, in consequence of the gradual spread of some other affection of the bowels, its own development is gradual; the existing local pains increase in intensity, and gradually spread over the whole abdomen, at times rapidly and at others more slowfly. In violent cases the invasion of the pain is not at once followed by violent fever; on the contrary, the patients die in a state bordering on syncope, with cold faces and cool extremities, and it is only the extremely hurried pulse that indicates the approach of a violent fever, which is scarcely ever more than twenty-four hours in coming. From its first beginning, the pain never abates one moment, except, that it sometimes seems more like a colicky pain; as the pain spreads the abdominal walls become so sensitive, that the patients cannot bear the least pressure, so that it is even a relief to them, if the blankets or sheets do not touch the abdomen. The least motion increases the intensity of the pains to such an extent, that the patients have to lie on their backs motionless, and dare not draw a deep breath, because the pain is aggravated by the pressure of the descending diaphragm; they even have to speak in a low whisper. The pains are at times tearing, at others stinging, lancinating, but most of the time fiercely burning, and with a soreness as from an open wound. Sometimes the disease sets in with violent vomiting, and diarrhoea, almost like cholerine; in such a case, the act of vomiting causes intense suffering. The general symptoms betray at first sight the existence of an intense disorder. At the first onset of the disease the face looks pale, with a peculiar expression of distress and anxiety, and with pendulous features; afterwards the face looks 506 Diseases of the Peritoneum. flushed, or else the paleness remains throughout the whole disease, in spite of the fever. The eyes are dull and unsteady. The breath- ing is hurried, is carried on with the ribs only, the speech is short, a mere whisper. The tongue is usually quite clean; there is a craving for cold water, yet only a small quantity can be drank at one time. Retching and vomiting, unless present at the first, are very apt to supervene; otherwise these phenomena and the diar- rhoea disappear as the disease increases in intensity; as a general rule, the peritonitis is attended with complete retention of stool the first eight days of its existence. The urine is always less; voiding it is often painful, or there is a constant urging, yet no urine is voided. The pulse is hurried, from one hundred and twenty to one hundred and sixty beats, and soon becomes small, hard and tense. The skin is dry and constricted, although profuse and ex- hausting sweats sometimes break out; the temperature varies from a burning heat to a disagreeable coolness. An examination of the abdomen is difficult on account of the pain, which is aggravated by the least attempt at percussion. Soon after the pains are felt, the abdomen becomes more and more distended, so that the distended bowels can be felt through the abdominal walls. The percussion- sound, which at first continues tympanitic, soon changes to a dull sound at the pendulous portions of the abdomen; but it is only in exceptional cases that the sound becomes perfectly empty, for the reason that the exudation is never sufficiently copious; in one very violent case, however, the dulness extended over the abdomen from one side to the other, as high up as the umbilicus. In the subse- quent stages of the disease, the boundaries of the exudation, if it acquires sufficient consistence, can be distinctly felt through the abdominal walls. At the commencement of the disease, the brain and the sensorium seem unassailed, except that the patient some- times complains of violent headache. The sleep is very much disturbed; if the patients sink momentarily into a sort of slumber, they at once become delirious. All such patients habitually lie on their backs, with the lower extremities slightly drawn up toward the abdomen. In the further course of the disease, the symptoms generally undergo the following changes: The distension of the abdomen in- creases more and more, although its painfulness to contact gener- ally decreases in proportion as the exudation becomes more copious; it even happens that the sensitiveness disappears entirely. This however, is a bad symptom, if at the same time the whole condition Peritonitis, Inflammation of the Peritoneum. 507 of the patient seems to change for the worse. The difficulty of breathing corresponds to the degree of meteoristic distension. The anguish increases, the lips become bluish. The pulse is a little slower than at the commencement of the fever, but its quality re- mains the same; it does not indicate any remission of the fever, whose intensity continues unabated. If the disease terminates fatally, the general sensorium is overwhelmingly brought under its influence, the patients grow apathetic, do not feel any pain; the pulse becomes imperceptible, the face has a sunken, cadaverous ap- pearance. Death may take place in thirty-six hours, and seems to be principally caused by paralysis of the bowels; the disease, how- ever, seldom terminates in such a short period of time; it generally continues until the seventh day. If death does not take place at this first onset of the disease, its further course depends upon the quantity of the exudation, and the changes it undergoes. In order to more clearly comprehend these processes, we will first give a description of the anatomical changes that take place in this disease. At the commencement of the attack the peritoneum appears slightly red, sometimes even ecchymosed. The redness is seldom general, on the contrary, it occurs in isolated spots, of greater or less extent. At the same time the surface soon acquires a faintish velvety appearance, without lustre, and soon becomes covered with a thin layer of exuded, mucus-like fluid. At this period we already begin to discover traces of exudation in the peritoneal cavity. The thin layers of exudation, which likewise loosely line the intestines, may remain the sole product of the inflammation; in such a case, adhesions easily take place between the bowels and the peritoneum, or between the bowels themselves, which either remain, or by the dragging action of the bowels are changed to ribbon or thread- shaped bridges, between the peritoneum and the abdominal viscera. The thicker these layers of exudation, the more copious the fluid exuded in the peritoneal cavity. This fluid contains a great deal of fibrin, is more or less turbid, mixed with flocks, even with fibrin- ous coagula, and generally contains pus-corpuscles in varied quanti- ties. Sometimes an excess of serum is poured out, in which case the fibrin is, of course, much less, and a copious admixture of albumen generally occurs ; in such a case the color is always darker, with a reddish or brown tint. The changes in the exuded fluid generally vary greatly. In favorable cases the fluid is first reabsorbed, and the solid parts 508 Diseases of the Peritoneum. remain for some time behind, before their gradual removal is effected; generally, however, isolated thickenings of the serous coat, or more or less considerable adhesions, remain as traces of the previous inflammation. Or a larger quantity of pus may form, in consequence of which a great deal more of the serum is reabsorbed, and more copious adhesions take place, spreading like sacculated foci over a large extent. Here, too, reabsorption is possible, leav- ing, however, considerable thickenings behind. Or an abscess may form which, when situated near the surface, and without too much resistance on the part of the abdominal walls, will break outwardly; whereas in the opposite case it finds an outlet into the interior of the intestine, or burrows downwards, following the course of the psoas-muscle, and causing further alterations in the lower extremity. The copious serous exudation, unless absorbed at a very early period, may lead to phenomena resembling those of ascites, and may obsti- nately persist for some time. If the peritoneum is only partially inflamed, the exudation in the peritoneal cavity is usually quite un- important, and the super-imposed layers of exudation have the greatest disposition to form adhesions which, however, do not pre- clude the local formation of pus. A malignant change is the meta- morphosis of the exudation into tubercular masses, which may easily occur in individuals of a tuberculous habit. In accordance with these anatomical changes, the disease assumes a different form as it progresses. If a most favorable metamor- phosis should occur, and the effused fluid should be reabsorbed without any further difficulty, the abdomen gradually becomes softer, the bowels are less distended, and begin to move, which is always looked upon as a very favorable symptom, and, above every- thing else, the respiration becomes less embarrassed. At the same time the pulse may remain accelerated for a long time, at any rate it is only exceptionally that it falls below 120 before convalescence is complete. The expression of the countenance likewise is a sure sign that a favorable change has taken place. Sometimes the im- provement sets in with a copious increase of the urinary secretion. Percussion and palpation soon reveal a considerable decrease of dul- ness, showing that the absorption of the fluid is going on, while the solidified exudation is, at the same time, more distinctly perceptible to the touch, and feels like a row of callous, unequal, bunchy indu- rations. Under certain circumstances the disease may remain sta- tionary at this point for wTeeks; the pulse remains hurried, the strength will not return, the appetite continues indifferent, and the Peritonitis, Inflammation of the Peritoneum. 509 exudation does not diminish. The patient is, moreover, tormented by frequent colicky pains. Not unfrequently sudden aggravations set in at this time, giving rise to the most serious apprehensions, and greatly prolonging the disease. From fear, the causes of such aggravation are sometimes kept concealed from the physician, especially if dietetic transgressions had been committed, or the patient had been very much excited by untoward occurrences. In a case of diffuse metro-peritonitis, which occurred in our own prac- tice, a dangerous aggravation was caused four times in succession, in consequence of which the disease was protracted for a period of sixteen weeks, which delay we were unable to account for, until the patient herself, having fully recovered from her disease, ex- plained the cause. All sorts of mortifying communications con- cerning her husband and sister had been whispered into her ear by a relative. This shows how delicately and carefully such patients should be treated, as long as the exudation is not entirely absorbed. It is remarkable how rapidly the absorption of apparently solidified masses is carried on in women whose constitutions are otherwise sound, at least up to the point when the exuded substance becomes imperceptible to the touch. A single week is sometimes sufficient for this purpose. From this time the patient begins to feel decidedly better; the appetite improves, the pulse almost becomes normal, the cutaneous functions are restored to their natural condition; only the colicky pains still continue to be experienced in the diseased locality, although the evacuations have resumed their natural course. For some time a considerable tendency to unimportant aggravations remains. On the contrary, if the exudation becomes purulent, the fever likewise abates at first, the pains become less, the meteorism and the consequent oppression of breathing and retention of stool de- crease, the dulness on percussion is less extensive, and the solidified exudation is felt more and more distinctly. But there is no increase of strength, on the contrary, the patients become evidently weaker, and look much worse. After a previous violent chill, the fever gradually returns, in paroxysms, to the original degree of intensity, the skin remaining mostly dry. It is only in the later stages of the disease that the fever assumes the full type of a hectic fever, and is accompanied by colliquative sweats. The exuded fluid forms dis- tinct sacs, imparting a striking irregularity to the abdominal walls; they are less hard, and have a doughy feel. In this way the pa- tient may linger along for many weeks; even if we succeed, which 510 Diseases of the Peritoneum. is seldom possible, in effecting absorption, it proceeds slowly, and is scarcely ever complete. Death may simply take place from ex- haustion, without the pus having been liberated. If an abscess should form, or the pus should penetrate into other organs, the question always will be what course the organism will pursue in trying to counterbalance this abnormal process. The relief suc- ceeding the discharge of the pus is either permanent and followed by an increase of strength, or else it is only momentary; and colli- quative phenomena set in rapidly, and with redoubled violence. Finally, the purulent discharge may give rise to another inflamma- tion and consequent death. Peritonitis, with prevalent tendency to decomposition, has its prototype in puerperal peritonitis, when treating of which, full in- formation will be communicated on this point. The transition to tubercles is marked by similar symptoms as the purulent metamorphosis, except that the fever is less violent. The disease runs its course with all the symptoms of phthisis, concerning the details of which the chapter on tuberculosis may be consulted. According to what we have stated, it is not always possible to determine the duration of the whole disease with anything like certainty at the commencement of the outbreak. If in a violent case, with extensive inflammation, the first week is happily passed without any unfavorable changes, the prospect of a good recovery is well founded. But if the reabsorption of the effused fluid is de- layed beyond the fourth week, the danger is great; nor is it dimin- ished by the longer duration of the disease. Under the form of a so-called chronic peritonitis, the disease may drag along for many months, and its consequences may remain visible throughout the patient's lifetime. The terminations of peritonitis differ according as the disease has been treated homceopathically or allopathically. We feel at liberty to give a more favorable prognosis in this disease, which is generally regarded as very fatal, than any other method of treatment is au- thorized to do. Our remedies not only prevent the exuded fluid from changing to pus, but they likewise promote absorption. The most unfavorable forms of peritonitis are those caused by perfora- tions, and likewise those that set in at once with typhoid symp- toms. For the same reason we meet under our treatment much less frequently with such consequences of inflammation as are caused by adhesions, breaks or bends of the bowels, dragging or strictures of the intestine, or as otherwise depend upon consider- Peritonitis, Inflammation of the Peritoneum. 511 able, callous thickenings of the peritoneum. The best criterion for a reliable prognosis is, after all, the pulse; as long as it is not nearly- restored to its normal condition, the danger is not passed, although the other indications may seem favorable. Treatment, Before we pass to the homoeopathic treatment of this disease, we will cast a glance at the manner in which it is treated by physicians of other Schools, in order to show the great superiority of the homoeopathic treatment over any other. With- out an exception the diagnosis of peritonitis is so certain, that it can hardly be said that the reported cure of a case of peritonitis was mistaken for that of some other disease. Peritonitis is one of those diseases which neither a so-called rational nor physiological physician fancies can be treated without blood-letting, and where the omission of bleeding is looked upon by a lay-person as down- right murder. It behooves us the more to fight against such a method with all our means, for venesection exerts undoubtedly a bad effect upon this disease. When speaking of apoplexy we took occasion to condemn the practice of blood-letting, but owing to the inability of establishing a reliable diagnosis, we had to build our argument upon an uncertain basis. The case is different with peri- tonitis, which is far more accessible to a rational comprehension. It is an inflammation which results in a very short time in copious exudation, more copious than takes place in any other inflamma- tion in the same space of time. Most probably this is mostly owing to the slight resistance of the bowels, and to the great extensibility of the abdominal walls; whereas the pleural cavity, although in other respects constructed very similarly to the peritoneal cavity, consists externally of the firm thoracic wall, and internally of the much less yielding pulmonary parenchyma. The copiousness of the peritoneal exudation accounts for many phenomena that are not otherwise peculiar to inflammations; we mean, for instance, that in many cases a tolerably high degree of anaemia sets in, which gives rise to the cold skin, the cadaverous paleness, the peculiar headache, the contracted smallness of the pulse, and the almost cyanotic ap- pearance of the patient. It is moreover certain that the abundance of serous exudation at the commencement of the disease is exceed- ingly threatening to life, or perhaps presents the only real danger at this stage, since it is the pressure exerted by this exudation that causes all the threatening symptoms. What can local or general depletions accomplish against this chief danger ? Is the serous ex- udation arrested by bleeding ? Certainly not; for the bleeding de- 512 Diseases of the Peritoneum. prives the blood of its plastic ingredients, hence it is the more dis- posed to form serous exudations. Moreover, the integrity of the whole volume of blood is rapidly restored by the absorption of scrum from every part of the organism, except from the morbidly altered parts of the peritoneum, and the really dangerous symptoms of general anaemia are rendered still more intense. Again, is the plastic exudation diminished or arrested ? Supposing this is so, yet in view of the present danger and the final termination, there is no advantage in bleeding. For the fluid that had been exuded in the first stage of the disease, before bleeding- was resorted to, remains where it is, only it is not increased; but the conditions under which the process of absorption can be carried on, are much more unfavor- able, and the chances of a purulent metamorphosis are greatly in- creased. Finally, we may ask the question, whether the influence of bleeding upon the general organism is such as to justify this pro- cess in spite of its disadvantages in other respects. What can here be said in favor of this proceeding in the presence of a disease which destroys life so rapidly by a premature exhaustion of the vital ener- gies ? Even if we were willing to admit the propriety of bleeding in a case of circumscribed peritonitis, yet in a case of this kind bleeding is unnecessary, since this form of peritonitis is very seldom suddenly dangerous. From these a priori reasons we deem every sanguineous depletion in peritonitis unjustifiable. In addition to this we have absolute evidence that peritonitis treated with bleeding, becomes more readily fatal at the onset, or that in the opposite case the convales- cence is very much retarded, and that the complete reabsorption of the exudation is a rare event; whereas the transformation into pus occurs quite frequently. Who, in the presence of such arguments to the contrary, can talk of rational proofs in favor of blood-let- ting? If we were disposed to invoke personalities, we could easily show that rational and physiological physicians do not insist much upon a rational demonstration in favor of bleeding, and that they simply take refuge, if need be, behind the old adage that it is so, and cannot be otherwise. Dire necessity is a very soft cushion to rest one's head upon. Other external applications will be discussed by and by, they do not constitute the most essential part of the treatment. To the internal remedies, on the contrary, we have to devote a few words. At present only two remedies are really in use, Opium and Calomel. The former is to restrict at the onset the activity of the intestines, and if no diarrhoea is present; the last- Peritonitis, Inflammation of the Peritoneum. 513 mentioned remedy, Calomel, is to excite stool. How absurd, how- ever, in a disease where the intestine is exquisitely paralyzed from the commencement of the attack, to give a medicine that dimin- ishes the functional activity of the bowels still more 1 Moreover, are not extensive and firm adhesions the more certain, the less they are disturbed and loosened by the movements of the bowels ? We are amazed at the assertion of a well-known pathologist and pro- fessor of clinical medicine, that in peritonitis Opium does not con- stipate the bowels, and that, on the contrary, it rather has a ten- dency to gently loosen them. Every homoeopath knows how to ac- count for this; why does not the pathologist likewise try to account for this phenomenon, which is certainly sufficiently striking ? The use of Calomel for the purpose of causing stool, is just as ab- surd as the use of Opium, the more as generally no stool follows. We shall afterwards find that the use of Mercury in this disease is justifiable, but not by any means as. a symptomatic remedy. Calo- mel and Opium, sanguineous depletions, cold or warm applications and injections, constitute the whole therapeutic apparatus, with which modern Medicine combats one of the most dangerous dis- eases ; hence nobody can wonder that peritonitis should have a mor- tality of seventy to seventy-five per cent., while the remaining twenty-five per cent, remain diseased the balance of their days, or at any rate retain the seeds of a variety of other ailments. Would it not be just as well, with just such a prospect before them, that Old-School physicians should pursue a strictly expectant treat- ment ? As we said above, Homoeopathy can boldly dispute the palm with any other method of cure, for the reason that it cures more cases of peritonitis, that its cures are throughout more complete, and that it effects a convalescence in a much shorter period of time. These results are obtained with the following remedies: Aconitum. When treating of enteritis, we gave it as our opinion, that Hartmann's recommendation of Aconite was not intended for enteritis, but for peritonitis, which is entirely omitted in his work, because he regards it as synonymous with enteritis; a view that it is difficult to comprehend, if we look at'the extreme difference of the tissues composing the intestine and the peritoneum. For many forms of peritonitis, Aconite is undoubtedly ihe most suitable and surest remedy, but not to the extent that Hartmann imagines. There is a vast difference between the two kinds of exudation, which we recognize very speedily. Aconite is the specific remedy, 514 Diseases of the Peritoneum. if the inflammation either spreads further from a circumscribed spot, or in cases where it sets in with more local symptoms, without the accompaniment of the general disturbances, which are some- times truly fearful, except perhaps the presence of an intense fever. It is in this manner, that inflammations with an excess of plastic exudation generally announce themselves; here meteorism never reaches the high degree it does in other forms of inflammation, and percussion usually yields a dull sound very indistinctly. We do not understand Hartmann's advice, to continue the Aconite until all the inflammatory symptoms have disappeared; for this would mean until the disease is cured; he meant probably febrile instead of inflammatory, but this likewise does not happen as he fancies. Observation has shown, that in inflammations Aconite is only use- ful until the exudation is completed. At this stage the pulse, in inflammations, for which Aconite is indicated, becomes somewhat slower and stronger, and the. pain abates in a marked manner, which is seldom the case before the fifth day of the disease. All physicians agree, that one of the lower attenuations should be given in repeated doses. Belladonna is suitable only at the commencement of peritonitis. It competes with Aconite, if the local symptoms are accompanied by severe congestions of the head and chest, with anguish, dyspnoea, restlessness, dark-red and bloated face; and continual and distres- sing vomiting of bile, which changes about with retching. The exudation is profuse, and the intestines are distended at an early stage of the disease, so that the single convolutions can be dis- tinctly felt through the abdominal integuments. Intestinal ca- tarrh, which may be present during the first days of the disease, is an additional recommendation for this drug, so is the develop- ment of this inflammation from enteritis. Belladonna is likewise an excellent remedy for the vomiting, which is apt to set in, in the subsequent stages of the disease; in this respect it is only surpassed by Arsenic in a few cases. The abatement of meteorism designates exactly the period when Belladonna is indicated. Veratrum album is related to Belladonna in some respects. If the disease sets in in the form of cholerine; more particularly, if the vomiting is copious and frequent, at the same time the patients look pale and sunken, and feel cool to the hand; the pulse is small at the onset, and the anguish, restlessness and thirst are exceed- ingly distressing, Veratrum is the appropriate remedy. As a general rule, the disease assumes this form in the first three days; Peritonitis, Inflammation of the Peritoneum. 515 afterwards other remedies have to he employed; although, if we judge of the homceopathicity of a remedy by mere symptoms, Veratrum should correspond to the disease throughout its whole course. Mercurius is less adapted to peritonitis than to enteritis. It seems to us a mistake to give Mercurius from the beginning; ex- cept in the entirely local inflammations. The tendency to suppura- tion is the best indication for this remedy. Hence, it is in the second and third week, that Mercurius must be given; and the more special indications are the above-mentioned phenomena, char- acterizing the process of purulent metamorphosis. It is the fre- quently exacerbating fever, with creeping chills, and copious per- spiration after the heat, which points to Mercury. In partial peri- tonitis, on the contrary; as soon as the inflammation is localized, Mercurius may be given at the onset. It is likewise appropriate if the purulent exudation seeks to penetrate to the outside and form an abscess. These four remedies are the only ones that need be given in the first stage of the disease. In the further course of the disease we may have to administer: Bryonia alba. Hartmann's assertion that peritonitis cannot be cured without Aconite, seems to us more applicable to Bryonia. It conies into play at the most decisive period in the development of the disease, namely: when we desire to remove the effused fluid as soon as possible. In saying this, we may be accused of generalizing too liberally, but we appeal to what we have said in the introduc- tion, namely: that these general statements are only intended as a guide to the Materia Medica, not as a means of superseding its use. In comparing the second stage of peritonitis with the pathogenesis of Bryonia, we shall find, that in the majority of cases this remedy is indicated by its physiological effects upon the healthy; it is al- most certain, that under the influence of Bryonia the exuded fluid is reabsorbed without causing any further derangements; hence, that no suppuration will take place. But the medicine should be used consistently; we cannot expect to obtain results in a day, that can only be obtained in from ten days to a fortnight. As a general rule, Bryonia is not indicated, if a copious diarrhoea is present; this, however, is a rare occurrence in the second stage, and, if it does occur, it is a bad omen. Sulphur is a second remedy we make use of in order to promote, or indeed, to excite the absorption of the exuded fluid. In cases 516 Diseases of the Peritoneum. where Bryonia leaves us in the lurch, or effects the absorption of the exudation only to a certain point, Sulphur is entirely appropri- ate. It acts even when the remaining portion of the exuded fluid had been left for months without any alteration. However, no hec- tic or colliquative symptoms must be present; the exuded substance should be lying in the abdominal cavity like a dead mass, and except the great weakness and the deficient reaction, no other ab- normal phenomena must be present. If symptoms of ulceration have appeared, Sulphur can only cause a loss of time. An appeal to the Materia Medica is less feasible in the case of Sulphur, than in that of any of the above-mentioned remedies; such remnants of intense inflammations often furnish but a small number of morbid phenomena, which are entirely insufficient for a correct selection of the drug in accordance with mere symptoms. Arsenicum album is very closely related to Veratrum album symp- tomatically ; in a present case, it is difficult to decide between the two remedies, especially at the commencement of the attack. In the further course of the disease, it is particularly the continued, violent, colicky pains, that point to Arsenicum; which is, likewise, sometimes indicated by the gradual development of the inflam- mation out of gastritis, the perforating ulcer, or ulceration of the bowels. Arsenic exerts, moreover, a striking influence, when the exuded fluid is copious and obstinately persistent, the abdomen, when percussed, simulating the phenomena of ascites. For all that we must not allow ourselves, by the peculiarities of the picture of the disease, more particularly by the extraordinary restlessness and anxiety, to be too readily induced to use Arsenic, as is so easily the case at the commencement of the disease. If Arsenic acts as a homoeopathic specific, the reaction must not be prostrated, on the contrary it must be vehement; hence the fever must be violent and continued. For the rest we refer the reader to our remarks on puerperal peritonitis, which will be found in the chapter of diseases of the female organs, and where the use of Arsenic will be discussed more fully. In the same chapter, more detailed statements will be found concerning the use of Rhus toxicodendron, of which, we here simply remark, that it is an excellent remedy in this disease, if it sets in all at once with all the fierceness and characteristics of typhus. It remains for us to mention several drugs, to which attention must be directed under certain circumstances. Opium is sometimes useful against the paralytic weakness of the intestinal canal, which Peritonitis, Inflammation of the Peritoneum. 517 often remains after the disappearance of the exudation; the intes- tine is unusually distended and the constipation is complete. Nux vomica is still more preferable under such circumstances, only the meteorism must not be too great. In general it is an excellent remedy in equalizing the remaining trifling irregularities in the digestive functions, especially the torpor of the bowels. China will only be found applicable in the subsequent course of peritonitis; it is the more suitable, the more the copious exudation, or other pre- viously existing conditions, have impressed upon the organism the appearances of anaemia. Phosphorus corresponds to conditions for which Mercurius, Arsenicum, or Rhus, had been given previously, and is to be exhibited when suppuration has set in, together with evident symptoms of colliquation, exhausting diarrhoea and hectic fever. Finally we recommend Colocynthis, which we gave in a case of diffuse peritonitis, with a mass of solidified exudation and uninterrupted colicky pain, with such success, that the disease took a favorable turn so suddenly, that in view of the length of time this pathological process had been going on, there could be no possible doubt that the medicine had produced the favorable chano-e. o The medicines we have indicated are most probably sufficient in every ease of peritonitis without any unusual complications. Single striking complications, such as may occur during convalescence, especially in the region of the liver, bladder or uterus, cannot be dwelt upon in extenso, since the diversity of their forms would not admit of a full description of their symptomatology. Complications of this kind always increase the difficulties of the treatment; this cannot be taught in a manual of Therapeutics, but the Materia Medica will have to be referred to for further information. Although we have every reason to depend upon the efficacy of our means of treatment, yet the disease is so dangerous, its first invasion fills the patient with so much anxiety, and it is so exces- sively painful, that we are anxious to find out and apply such remedial agents, as will afford a momentary relief from the pains; and will perhaps exert a curative influence upon the morbid process generally. We should resort to such palliative means with the more willingness, as thereby the attention of surrounding relatives is diverted from the patient. The chief palliatives are injections and fomentations. It is impossible to decide a priori whether cold, or moist, or dry and warm applications deserve a preference. At first, when the pains are very violent, the patient usually prefers 518 Diseases of the Peritoneum. cold applications, ice-cloths, or even a bladder filled with ice. There are, however, exceptions to this rule, more particularly the circum- stance that patients cannot bear the least weight on their bowels, on account of the extraordinary sensitiveness of these parts. Warm and moist fomentations are generally best applied on the fifth day, in some cases the patients prefer them at the very beginning of the disease; they are more especially useful, if the patients transpire very copiously. They should never be applied too hot, for too high a temperature is prejudicial. What had best be applied in a given case, will have to be decided by an actual trial, but such an experi- ment should be instituted with great care, lest obstinacy in waiting for a result should prove injurious. As a general rule, the fomen- tations that do not afford relief to the patient within a few hours, or are otherwise than pleasant to his feelings, are not adapted to his condition. As regards the wet sheet, which is praised by many, we have no experience of our own to offer. At first these wet clothes should be applied to the abdomen alone. In view of the great sensitiveness of the abdominal walls, it is doubtful whether such an application can be frequently repeated. Simple injections of water, whether cold or tepid, never have such a penetrating action, that their use should be insisted upon, in spite of the pain which they may inflict upon the patient. If used at the commence- ment of the disease, they will prove insufficient to remove the paral- ysis of the intestinal canal. During convalescence, on the contrary, injections of water often render excellent service. In scarcely any other disease, the diet deserves more careful atten- tion than in peritonitis. There is no necessity of enjoining special rest, since the pain which the patient suffers renders movement almost impossible. The case which we have related in a previous paragraph, shows, however, how important it is to keep all mental or emotional excitement away from the patient, since it will un- doubtedly exert an injurious influence. Moreover, the room should be kept at a uniform temperature of about fifty degrees F., the air should be kept fresh, and the patient should only be lightly covered. Feather beds should never be used as a covering. Very frequently all kinds of covering should be kept from the abdomen by some suitable contrivance, such as barrel-hoops. At the commencement of the disease, the patients are tormented by an agonizing thirst which can only be quenched by fresh water. Small lumps of ice in the mouth, likewise, render good service, and are particularly suit- able, if there is much retching and vomiting. Afterwards, if the Peritonitis, Inflammation of the Peritoneum. 519 appetite commences to return, such food should be used as will leave the smallest possible residue of fecal matter; the administra- tion of beef-broth should not be delayed too long, as exhaustion might prove fatal to the patient. Solid food should only be given gradually, and with the greatest care; the patients should be kept on a lean diet for some time, even though they should seem con- valescent. If exhaustion should set in suddenly, and at an early period, the use of small quantities of good wine will be attended with beneficial results. FIFTH SECTION. Diseases of the Liver, Spleen and Pancreas. A. DISEASES OF THE LIVER. In no other division of Pathology have such great revolutionary changes been effected by recent investigations, than in the doc- trine of diseases of the liver; but these changes do not date fur- ther back than some twenty or thirty years. Until then, the views concerning the functions and morbid changes of the liver were so confused and untenable, that the Pathology which had prevailed up to that time was really of no use; at least, no reliable system of Therapeutics could be built upon it. This circumstance is the more interesting, as the subject presents even now many obscure and un- certain points; and the material out of which we might build up a therapeutic edifice, based upon experience, is exceedingly scanty. It is in accordance with these views that the following chapters should be judged; it is not probable that all will be pleased with them. If, in making their reports, homoeopathic physicians would take the small trouble of presenting a diagnosis corresponding with the demands of pathology, the chapter of affections of the liver would become one of the most promising in the Therapeutics of our School, for the reason that we have a right to be proud of the bril- liant results we have achieved in this direction. In order to avoid continual repetitions, it is best to introduce the subject of affections of the liver, with a statement of the manner in which their physical examination has to be conducted, which will yield most important information in many cases. An objective examination is conducted by means of inspection, palpation and percussion. Inspection yields a distinct result only in cases of unusual en- iargement of the liver. In these cases the last ribs bulge more prominently, or the sharp edge of the right lobe of the liver becomes distinctly visible below them; else the left lobe is felt in the pit of 520 Diseases of the Liver. 521 the stomach as a swelling. These symptoms are most prominently marked in persons of a slender frame, the more so as the abdominal walls are drawn towards the vertebral column. Palpation likewise yields marked results only under certain cir- cumstances. If the liver has its normal size, the thoracic walls interfere very much with an examination by the hand; all that can be accomplished, is to satisfy one's self of the sensitiveness of the liver to external pressure. If the liver is enlarged, the lower sharp edge can often be distinctly felt; the left lobe can likewise be traced all around. We sometimes succeed in feeling biliary calculi through the abdominal walls, or swellings proceeding from the liver.' Some- times we are misled in our diagnosis by swellings in the abdominal cavity, hard excrements in the intestines, hypertrophy of the pan- creas, and an irritated stomach. To institute a proper examination, the patient has to lie down, with the head somewhat raised, but not too high, and the lower extremities drawn up; at the same time the respiration should be carried on quietly and uniformly; nor should the inspirations be too deep. Palpation is most successfully carried on during the act of expiration. Percussion is the best diagnostic aid, for the reason that it almost always yields some positive result. In its largest extent, the liver yields a perfectly dull sound, except that the upper edge is some- what higher,.on account of the organ encroaching, in a degree, upon the thoracic cavity ; and the lower sharp edge and the boundary of the left lobe, do not yield much dulness, on account of the subja- cent intestines. The upper margin of the liver extends from the lower extremity of the sternum along the lower border of the sixth rib as far as the side, where it reaches downwards below the eighth rib; whereas, close to the vertebral column it is bounded by the eleventh rib. Expiration and inspiration may drag it an inch higher up or lower down. The lower margin of the liver is pretty exactly described, anteriorly and laterally, by the lower edge of the last rib, beyond which it usually descends to a certain distance, without, however, a dull sound being yielded by the overreaching portion. Posteriorly the twelfth rib overreaches the liver. In the middle region, the left lobe of the liver overreaches somewhat the curve of the ribs, and generally extends as far as the mesian line of the abdomen. By these boundaries we are enabled to judge whether the liver is enlarged or not, and to what extent-a circum- stance of great weight in affections of this organ. Various circum- stances may render an exact delineation of the boundaries of the 522 Diseases of the Liver. liver impossible. Among these circumstances we number all dis- eases that cause such changes as will give rise to a dull percussion- sound along the boundaries of the liver: infiltration of the right lung, exudation in the right pleural cavity; in the middle region of the liver it is the accumulation of serum in the pericardium, especially if attended with a change in the position of the heart; along the lower edge, it is swellings in the abdominal cavity. Con- siderable exudations in the thoracic cavity may also push the liver downwards. During an examination by percussion, the respiration should be calm and uniform, and not too deep; and the patient should be in a horizontal posture, with easy extension of the body, so that the abdominal integuments are neither too much relaxed, nor too tightly stretched. For an analysis of the secretions, which is sometimes important, with a view of determining the presence and amount of bile, we refer to Chemical Manuals. Information of this kind is of little value, unless it is complete. 1. Hyperaemia of the IRiver. The structure of the liver, more particularly the arrangement of the vessels which conduct the blood to and from the liver, suggests a priori the probability that a sanguineous engorgement of this organ can not only easily take place, but is, indeed, of frequent oc- currence. However, we are not able to diagnose, with perfect cer- tainty, an hypersemia of the liver, unless it is so considerable that the volume of the liver is greatly increased. We can only conclude with some certainty, from the symptoms and other circumstances, that certain conditions, which will be discussed presently, must depend upon an increased quantity of blood, to be found at that time in the liver; and hence, that these conditions are the conse- quence of active sanguineous congestion. To give a minute account of the causes that occasion an accumulation of blood in the liver, by imped'ng the flow of blood from this organ, is not within the province of this book. We will simply state that hypersemia of the liver is more particularly occasioned by diseases of the heart, which interfere with the reception of the venous blood, and by pulmonary affections, with a considerably impaired faculty to respire freely. We will merely call to mind the circumstance, that tuberculous patients are frequently afflicted by liver complaint. The etiology of active hyperemia depends in the main upon the following circumstances: The various deleterious influences that Hyperaemia of the Liver. 523 give rise to obstinate constipation or hemorrhoids ; inordinate eat- ing, with disproportionate scantiness of waste, cause hyperaemia of the liver. Hence it is frequently met with among individuals who consume a great deal of nourishing food, and at the same time lead a very sedentary life, or who work too little in proportion to the quantity of food they eat, and in this way bring about a real ple- thora of the abdominal organs. Congestion of the liver is, more- over, frequently met with among women whose catamenia are not sufficiently copious, or even entirely suppressed, especially during the critical age. It is likewise undeniable that a disposition to this disease may be hereditary; we are acquainted with families in whom every adult member seems to have inherited liver complaint from the mother. Certain poisonous substances, which cause con- gestion of the liver in a majority of cases, are of great importance in this respect. In a subsequent part of this work, where we treat of intermittent fever, we shall likewise dwell upon the influence of malaria, and upon the action of China on the liver. Beside these influences, it is principally alcohol and Mercury that cause such congestive symptoms in the liver as are so frequently met with in practice. Nor can the influence of atmospheric and climatic condi- tions be denied. In the torrid zone, diseases of the liver are much more frequent than in the temperate zones. Northerners who have resided a long while in hot countries, are very apt to contract a striking disposition to derangements of the liver. Even with us affections of the liver are much more frequent in the hot summer and fall. They more particularly attack persons who use improper food, such as quantities of fat meat and the like, which cause de- rangements of the liver, not only in hot countries, but likewise among us during the heat of summer. Finally, it is certain that violent emotions increase the afflux of blood to the liver. If an at- tack of congestion of the liver has once existed, it always leaves a tendency to relapses, which sometimes become so seated in certain individuals, that the attacks return at almost definite intervals, more particularly in the months of May and September until No- vember, without apparently having been excited by any irregulari- ties in the mode of living, or by any deleterious influences what- soever. Symptoms. The phenomena of liver-hyperaemia not only differ in intensity, but likewise in extent and distinctness; this difference is best observed among patients who are frequently attacked with this disease, and with unequal degrees of violence. As prelimi- 524 Diseases of the Liver. nary symptoms, we may regard the disturbances caused by the above-mentioned deleterious influences in the intestinal canal, or in various other organs; and which differ a great deal on this account. An error in diet may cause catarrh of the stomach and bowels; mental excitement may cause slight headache and loss of appetite; alcohol may occasion gastric derangements, etc. Otherwise the pre- liminary symptoms are of no importance, because they never point to the disease with absolute certainty. The first real symptom of disease, is a sensation of tension and fulness in the region of the liver, and a not very painful, but disagreeable pressure in that re- gion. This is generally accompanied by a peculiar disturbance of the mental equilibrium; the patients feel languid and weary, they are restless; the thought of not being able to succeed in their busi- ness, drives them about from place to place; they look on the dark side of every thing, are irritable and out of humor; their sleep is disturbed. According as the hypersemia is more or less consider- able, the local symptoms likewise vary in intensity, but really acute pains are rarely felt, nor is the sensitiveness to pressure very great, yet tight clothing is not agreeable. The appetite is not very much impaired, the bowels may act regularly, but are generally consti- pated ; the urine becomes dark at an early stage of the disorder, and deposits a sediment. Occasionally the patient vomits. The secre- tion of bile is not always uniformly affected, the stools sometimes containing more, and at other times less bile; the patient looks somewhat jaundiced, but never to a great extent. Febrile symp- toms are only present when the attacks are severe. It is only in the more marked forms of this disease that percussion reveals an enlargement of the liver, and then only very prominently in case the attacks return very often; in such a case the eye alone is suffi- cient to recognize the more marked convexity of the liver. An attack lasts from a few days to several weeks. It generally terminates in recovery, unless the patient, who never feels sick enough to keep his bed, commits gross mistakes. The trouble either decreases gradually, or else it disappears all at once and is replaced by a perfect feeling of health. If the disorder returns fre- quently, it never leaves again entirely. In such a case it looks more like a chronic disease with occasional exacerbations. In the course of time the liver becomes enlarged, more particularly during an exacerbation of the symptoms. The constitutional condition of the patient remains permanently disturbed in various ways, he complains of derangements of the stomach, constipation, and want Hyperaemia of the Liver. 525 of clearness of the head; he becomes fitful, irritable, and his com- plexion remains sallow. Off and on he vomits bile, and has at the same time violent attacks of headache. From such apparently trifling symptoms, a more formidable disorganization will some- times result. In isolated attacks the prognosis is always favorable, provided the cause which provoked the attack, is not allowed to act perma- nently. In chronic cases of this kind, the prospect of a cure is more uncertain. All we can do, in manv cases, is to effect a e'en- eral improvement, and a less frequent return of the paroxysms. Women passing through the critical age, often recover spontane- ously, in proportion as the organism gets the upper hand of the disturbances caused by the stoppage of the menstrual functions. The affections of the liver caused by Alcohol and Mercury, will be treated of more fully in subsequent parts of this work. Nor is this the place for such forms of hypersemia, as are apt to supervene during catarrh of the stomach, or to result in an attack of bilious colic, bilious gastric fever and the like. The affection of the liver being symptomatic in such cases, such complications will be dis- cussed in connection with the main diseases Treatment, From what we have said it is evident that the treatment should be conducted with reference to the exciting cause, and the special attack, as well as with reference to the chronic form of the whole disease. Our remarks on the etiological causes of the disease will suggest the proper mode of meeting the indicatio caus- alis; in selecting a remedy, homoeopathic practitioners may like- wise keep this object in view ; the diet will likewise have to be regulated accordingly. For a single attack the most frequently homoeopathic remedy is Nux vomica. This medicine has, as it were, a more specific relation to the liver than to the stomach. The phenomena caused by Nux in the region of the liver, designate every degree of hyperremia, even to fully-developed inflammation. Pressure and tension, stitches during motion and contact, sensitiveness of the region of the li- ver to contact, swelling of the liver, and jaundiced complexion: all these symptoms point to Nux as an important remedy for diseases of the liver. In addition to this we have the phenomena in other organs, especially in the digestive organs, (which need here not be mentioned more in detail, and the peculiarities of the mental and emotive sphere; together with the exciting cause. Nux vomica is particularly suitable if, the symptoms corresponding, the complexion 526 Diseases of the Liver. has a bright hue, with a slightly yellowish tint; however, we do not mean to suggest that this alone constitutes a sufficient indica- tion for Nux. This remedy is likewise indicated in chronic hyper- semia, where, however, it is not sufficient and will have to be asso- ciated with other remedies. The liver-symptoms of Ignatia amara are almost the same as those of Nux ; they differ more particularly in their accessory symptoms. Ignatia is particularly suitable for women, whereas Nux is more adapted to the female organism. The genuine nervous constitution is its proper sphere of action, together with the mental disturbances to which such patients are liable, and the ailments caused more especially by grief, fright or chagrin. If the menses are profuse, irregular, and always attended with violent pains and congestions, Ignatia is indicated so much more specifically. This remedy is like- wise adapted to the chronic form. Chamomilla is one of the best remedies if the attacks have not yet occurred very frequently, and consequently if the liver has still pre- served its normal condition, and the attack was brought on by a fit of anger or chagrin. The region of the liver is not exactly painful, but the patient experiences a distressing dull pressure in that region, which is not aggravated by either motion or contact. On the con- trary, the patient complains of colicky pains in the umbilical regie n and in the stomach, attended with bilious vomiting, dyspnoea, anx- iety, and the complexion has an icteric hue. There are always symp- soms of catarrhal irritation of the intestine. Bryonia alba is only appropriate to a few obscure cases where the patient experiences a painful pressure in the region of the liver, with sensitiveness to pressure in that region; but the symptoms are otherwise indistinct, and the affection seems more like an attack of excessive debility. Belladonna is indicated in cases of hyperaemia bordering very closely on inflammation, from which it is at first distinguished with difficulty, more particularly if the patients are plethoric individuals. The region of the liver is painful and very sensitive to pressure; there is considerable headache with flushed face and feverish pulse; the stomach is likewise affected, and there is frequent vomiting of a watery mucus mixed with bile. The patient complains of intense thirst. Mercurius is next to Belladonna in similarity of action; it is more adapted to hepatitis than to simple hyperaemia. For further details we refer to the chapter on hepatitis. Hyperasmia of the Liver. 527 Beside Nux and Ignatia, we have to employ several other rem- edies in the chronic form of the disease, provided a cure is at all possible. Sulphur holds the first rank. We shall have to dwell upon its relation to the liver more fully and frequently in subse- quent chapters; hence we shall content ourselves with a brief allu- sion to these points in the present instance. It is suitable in hyper- trophy of the liver; the organ is sensitive to contact; there is little icterus, nor is less bile passed with the stool; the circulation in the intestinal canal seems impeded, and symptoms of catarrh of the stomach are not wanting. An occasional attack of distressing itch- ing of the skin, which, without any visible change in this organ, is present in affections of the liver generally, and more especially in hypenemia, is a characteristic indication for Sulphur. Next to Sul- phur, Sepia is the most prominent remedy. It is more particularly suitable for women in the critical years ; the menses appear irregu- larly, sometimes remain suspended for months, and are attended with more or less violent uterine difficulties. The local pains in the region of the liver are not considerable, generally amounting to a continued crampy pressure, with occasional fugitive stitches, espe- cially about the catamenial period, without any marked swelling of the liver or icterus, although the complexion is somewhat jaundiced. Sepia, too, corresponds to the cutaneous symptoms of individuals afflicted with liver-complaint, more especially if the local symptoms are very prominent, and are attended with violent itching. Beside the digestive symptoms which always furnish very marked indica- tions for Sepia, we have to call attention to the sudden and violent, but not long continuing congestions to the heart, chest and head, revealed more especially by rapid changes of color in the face. Few drugs are in such characteristic rapport with the liver as China. We know that the continued use of China, as well as Quinine, in intermittent fevers, is usually succeeded by a consider- able swelling of the liver, which cannot well be looked upon as anything else than a fully developed hypersemia. This circum- stance alone is sufficient to direct our attention to China in affec- tions of the liver. The local symptoms are not sufficiently char- acteristic to establish a distinction between the action of China and that of other medicines; they are a sensation of pressure or stitches, with sensitiveness in the region of the liver, to external pressure, attended with bloat in this region. Hence, the selection of China will have principally to be determined by the multitu- dinous symptoms which it causes in the same organs. The chief 528 Diseases of the Liver. symptoms among them are: A pale, grayish-yellow, icteric color of the skin; sickly appearance; aggravations at night or after a meal; sensitiveness to external cold; origin of the disease in conse- quence of other slow morbid conditions, or after losses of blood, or abuse of Mercury; a general debility out of all proportion to the other symptoms. Beside these three remedies we have to direct particular attention to Lycopodium and Staphysagria. For other remedies we refer to the chapter on chronic hepatitis. During a first attack, the diet and mode of life are of not so much consequence, since the patients feel badly enough to eat and drink cautiously, and generally to behave with a great deal of discretion. Knowing, however, how easily patients may relapse and contract chronic hyperaemia and enlargement of the liver, it behooves us to give them full instructions regarding their beha- vior during the paroxysm. Our remarks on the etiological causes of the disease are sufficient to show what ought to be avoided; we must, add that coffee and tea should likewise be avoided, as well as the habit of sleeping or sitting in a stooping posture after a meal. In the spring, and more especially in the fall, patients should be doubly careful, live moderately and with great regularity, and avoid beer. The copious use of fruit in any form, drinking a great deal of water, sour milk, or butter-milk, are much to be com- mended. The favorite bonny-clabber, however, should be used with a great deal of discretion, since an otherwise perfectly sound stom- ach is easily spoiled by it. In judging of the effect of bonny-clabber upon the process of nutrition, we should not be guided by the re- sults obtained at spa's or hygienic establishments; the radical changes in the whole mode of living which prevails in these places is much more decisive than the use of clabber. [In chronic hy- persemia hepatis, Garduus marianus in infusion will be found an excellent remedy. H.] 3. Hepatitis, Inflammation of the IRiver. In consequence of numerous repetitions, we should have to extend the therapeutic portion of this section too far, if we were to treat the different forms of hepatitis separately. Hence we prefer adopt- ing the general classification into acute and chronic, which com- prises all the more important differences. The acute form comprises not only the inflammation of the parenchyma, but likewise, that of the capsules of the liver, and the vena porta. Hepatitis Acuta. 529 a. Hepatitis Acuta, Acute Inflammation of the Inver. Inflammation of the parenchyma of the liver is of rare occur rence in our temperate zone, whereas it is frequently met with in some of the tropical countries, and diminishes in frequency in pro- portion as we approximate to the poles. It cannot be denied that Northerners who emigrate South are taken sick more frequent ly than natives; this may be owing to an altogether unnatural mode of living. But even there, it is only exceptionally that the disease occurs as a purely primary malady, but it is generally a consequence of septic or ulcerative processes, especially dysentery which, with us, is very seldom succeeded by abscesses of the liver. Moreover an inflammation of the vena porta may extend to the liver. Injuries of the brain constitute a peculiar, hitherto unac- countable, cause of hepatitis. It may likewise be caused by mech- anical injuries, contusions, wounds, etc., and by biliary calculi. The anatomical changes caused by hepatitis in the beginning of the disease, are very difficult to demonstrate, since other derange- ments may produce similar effects. Parenchymatous hepatitis never affects more than a portion of the liver; generally it has only one focus, seldom several; the right lobe of the liver is, by far, the most frequent locality of the inflammation. A post-mortem examina- tion, generally only reveals the termination of the inflammation in the cadaver; we find an abscess which often creates large caverns, seldom a number of small foci. The seat of the inflammation is more or less close to the surface; in the latter case the abscess may open externally, and either discharge into the abdominal cavity, or break through the integuments. Since, before the abscess breaks, its surface usually forms adhesions with the neighbouring parts, a discharge into a free cavity is of rare occurrence. At the same time the whole organ is more or less swollen, at times, only the dis- eased lobe of the liver, at times both. Symptoms, The phenomena of suppurative hepatitis differ in degree, extent, and distinctness. The local symptoms are sometimes so few in number, or so obscure, that a sure diagnosis is scarcely possible, and becomes peculiarly difficult if the inflammation is a complication of other affections, by which it is more or less com- pletely obscured. This may readily happen during the course of malignant dysenteries, where the liver may swell up and become painful, even if no inflammation is present. Hence, in many secon- dary cases of hepatitis, we only meet with a portion of the symp- 530 Diseases of the Liver. toms; to be subsequently indicated as the symptoms of a distinctly recognizable, idiopathic hepatitis. Generally, it is very difficult to define the commencement of the inflammation with anything like certainty; it scarcely ever sets in with a chill, which almost always ushers in other important inflammations. The region of the liver becomes painful, sensitive to pressure, and frequently bulges very visibly The pain is more or less violent, seldom lancing or burn- ing; more frequently it is a dull pressure. The faint dulness of the percussion-sound extends over a larger surface, sometimes the edge of the liver can be plainly felt under the short ribs. Icteric symptoms are seldom marked, sometimes they are entirely absent. The intestinal canal is generally very much involved in the morbid process; the stomach rejects all food, the appetite is gone, and the patient is troubled with loathing, retching and vomiting. The bowels are generally costive; the discharges are light-colored, or of an ash-gray or clay color, corresponding with the degree of icteric color of the skin. The liver being very painful, breathing, cough- ing and sneezing are of course correspondingly aggravated and painful, even to a high degree of dyspnoea and other phenomena simulating pleuritis. The fever at first is not very violent, and has marked remissions, the pulse is not much hurried. All these symp- toms change as soon as the abscess commences to form. Now the fever becomes continuous and is only interrupted by violent chills; soon it assumes a peculiar adynamic character, and finally, changes to a well-marked hectic fever ; or else the whole path ological process looks very much like lentescent typhus. At first, the local pains increase in intensity, but after the abscess is fully formed, they abate somewhat; icterus now is almost always present. The stomach is very much affected, the patients are tormented by a distressing retching. The pain in the right shoulder, and the numbness of the right arm are, if not characteristic, at least somewhat pathogno- monic signs of the disease Sometimes the whole of the right side is painful. At this stage, the brain is very much involved, violent circumscribed headache, sopor and delirium setting in. In addi- tion to all these symptoms, the patient now rapidly emaciates, and, after the disease has lasted a short time, death may set in by ex- haustion., Usually, however, the disease drags along more slowly, and without the abscess passing beyond the boundaries of the liver, life is destroyed by ulceration of this organ, attended with hectic phenomena. If the abscess discharges, the course of the disease will depend upon the accompanying circumstances. If the abscess Perihepatitis, Capsular Hepatitis. 531 discharges outwardly, we notice a prominent, generally a fluctua- ting spot, which breaks after a while, and permits the pus to escaped Under favorable circumstances, the opening afterwards closes and heals, or else the suppuration continues and hectic fever sets in. A discharge inwardly, whether into the cavity of the chest, the intes- tine, the peritoneal cavity or elsewhere, is generally fatal; although at first the patients feel somewhat relieved. A capsular insulation of the abscess is a rare occurence in this disease. The whole duration of the disease varies from a few weeks to several months, the duration of the abscess is, of course, not in- cluded in this period The prognosis depends upon the various circumstances mentioned in the symptomatology of the disease. In the majority of cases the diagnosis presents a good many difficulties, because the local symptoms are not very characteristic, and may just as well indicate a severe hypersemia, as other affec- tions of the liver. A rigid diagnosis can only be established if an abscess can be demonstrated, or the disease runs an acute and char- acteristic course; otherwise a reported cure of hepatitis should be received cum grano salis-, not because it is difficult to cure this dis- ease, but that it is of rare occurrence, and it is difficult to show that it was a case of hepatitis. The treatment will be described at the end of this chapter, to- gether with both the other forms. b. Perihepatitis^ Inflammation of the Capsules of the Liver, Capsular Hepatitis. This form of hepatitis admits of a decided division into acute and chronic; the chronic form will be treated of in the next chapter. Perihepatitis owes its origin, most commonly, to all the circum- stances which we have pointed out as causes of hypersemia; one form of this inflammation, which will be more fully treated of in the chapter on chronic hepatitis, is more particularly due to the habitual abuse of alcohol. That it may be caused by mechanical injury may be regarded as possible, but is not a very frequent occurrence. Symptoms, Unless a preliminary stage, consisting of the symp- toms of hypersemia, precedes, the disease generally sets in with the sudden chill that is peculiar to the access of every severe disease, and which is at once followed by more or less violent local pains. At times these pains are a simple pressure, a painful sensation of fulness in the region of the liver, with tension across the whole 532 Diseases of the Liver. epigastric region, and a slight increase of sensitiveness to external pressure; or else, which is more frequently the case, they are acute, lancinating, burning pains, darting into the abdomen; the region of the liver is sensitive to the least pressure, and the pain is aggra- vated by the least motion. The liver is more or less swollen, and corresponding icteric symptoms generally appear. The fever is at times slight, at other times intense and continuous. The symptoms in other organs generally correspond to the intensity and extent of the disease; the stomach is always involved, and, as in the former, so may retching and vomiting be present in this form. The breath- ing is very often greatly impeded on account of the pain, the move- ments of the diaphragm, in consequence, being very much inter- fered with. The course is either that of a circumscribed peritonitis, (in eight days to a fortnight health being gradually restored,) or else the inflammation spreads, acting like a diffuse peritonitis; or finally the disease terminates in the chronic form. It is only if the second lesult should happen, that there is danger of a fatal termination; otherwise the disease is one of the less threatening kinds, although very painful. The diagnosis meets with a good many difficulties; the distinctive signs between simple hypersemia and hepatitis may be entirely missing, and in the next place parenchymatous and peri- hepatitis may seem entirely alike at the beginning. From hy- persemia, perihepatitis is best distinguished by the fever; parenchy- matous and perihepatitis are distinguished from each other by the circumstance, that, in the last-mentioned form the swelling is less, the painfulness is spread over a larger surface and is more intense, and the icterus is less marked. The treatment will be indicated in the next chapter. c. Pylephlebitis, Inflammation of the Vena Porta. We subjoin this form in this place, because the vena porta exerts a deep influence on the condition of the liver, and its inflammation is very commonly the cause of a suppurative inflammation of this viscus. The causes of the inflammation of the vena porta are either deleterious influences that affect it directly, or inflammations of adjoining parts; or inflammation of the rectum and colon. The first kind, which is the really primary form of the disease, is by far the least frequent. A progression of acute forms of hepatitis, especially of perihepatitis, is a common occurrence. Among the Pylephlebitis, Inflammation of the Vena Porta. 533 inflammatory processes it is more particularly dysentery which leads to pylephlebitis, in consequence of the gangrenous destruction of the mucous lining. Symptoms. Since a post-mortem examination frequently re- veals evident signs of pylephlebitis in the obliterations of single ramifications of the main trunk, without any corresponding mor- bid symptoms having been observed during the lifetime of the patient, we must suppose, that such inflammatory processes can run their course without any prominent symptoms. If the inflam- mation is more violent and more diffuse, we first notice a violent, generally burning pain in the region of the liver, which is very soon succeeded by a considerable swelling of this organ, with wide- spread sensitiveness. At the onset, the fever is not as intense as during hepatitis; however, the functions of the stomach and intes- tinal canal are very much disturbed. The inflammation usually advances rapidly towards suppuration, subsequent to which a change takes place in the character of the fever, which is now fre- quently interrupted by chilly creepings. Generally the inflamma- tory process now invades the parenchyma of the liver, where it commonly excites an intense suppurative hepatitis. Pylephlebitis has, moreover, a few, more or less, pathognomonic symptoms. At the head of the list we have the icterus, which is scarcely ever as much marked in any abnormal condition of the liver, as in this in- flammation. Next, we almost always have a considerable swelling of the spleen, and the vessels of the abdomen reveal the symptoms of a high degree of plethora, that may easily lead to hemorrhage from the bowels, and serous exudations in the peritoneal cavity The terminations of pylephlebitis are either in recovery, which is, however, seldom complete, or in adhesions or suppuration. Adhe- sions are only of importance, if they involve a large number of ramifications or the main trunk of the vein. In such a case we notice all the signs of an impeded portal circulation: hemorrhoids, swelling of the spleen, hemorrhages from the stomach and bowels, violent intestinal catarrhs, dropsical symptoms, which in the long run attain to an extraordinary development, and the icterus which remains unchanged. In suppuration the signs of an absces- in the liver become most prominent, although a metastatic pneumonia may arise, having a fatal termination. Death seldom takes place after a short period of time, generally not till a few weeks have elapsed; with symptoms of a high degree of exhaustion, and complete emaciation. Where pylephlebitis constitutes a mere com- 534 Diseases of the Liver. plication of some other acute inflammation, it is almost always sure to end fatally. Treatment. If we comprise these three forms in one series, it is because in practice we are very apt to content ourselves with the general diagnosis of an inflammatory condition; and we do not take the trouble to distinguish the different kinds, which are, however, of great importance, so far as the first and second forms are con- cerned, since they respectively require different remedies. It is like- wise of importance to know whether hepatitis emanates from a phlebitis or not; for phlebitis certainly requires to be treated with other medicines, and may possibly be removed before a complication with hepatitis renders it a fatal disease. In order to give the reader an opportunity of making himself acquainted with the remedies that are adapted to the various cases, which may leave us in doubt as to which form of inflammation they belong, we here give the leading symptomatic indication for each remedy separately. Aconitum is recommended by Hartmann very earnestly at the commencement of hepatitis. But we have already stated that the parenchymatous form seldom sets in with intense fever and other phenomena of acute inflammation; in this form Aconite will not often be found appropriate. It is different with perihepatitis, for which Aconite is probably the best remedy, at least at the onset. Be this as it may, Aconite is not selected in such cases in accord- ance with the fever-symptoms, a form of homceopathicity which is very much objected to at the present time, but strictly in accord- ance with its physiological symptoms; among which the character- istic symptoms of hepatitis, even the two first forms, are to be found. As a characteristic symptom we have the short and pain- ful cough, which is more particularly apt to set in when the upper surface of the liver is inflamed. Belladonna has been found better adapted to this disease than Aconite; this at least is the opinion of most of our physicians. Perihepatitis is more particularly its proper sphere of action, if the following symptoms prevail: stitching pains, rather superficial, like pleurisy-pains, aggravated by pressure, inspiration, coughing or ly- ing on the affected side; they spread as far as the neck and shoul- der. At the same time we have dry cough, oppression of breath- ing, hiccough, congestions of the head, with obscuration of sight, and sensation of fainting; fulness and tension across the pit of the stomach; violent thirst, sleepless tossing about, sometimes with in- ability to collect one's senses; nausea, retching, distressing vomit- Pylephlebitis, Inflammation of the Vena Porta. 535 ting, and continued fever, attended with a high increase of tempera- ture. When the local pains abate, which they generally do as soon as the exudation terminates, we must no longer expect any partic- ular good effects from Belladonna. Bryonia alba is generally appropriate as a sequel to Belladonna, even in parenchymatous hepatitis, provided it does not set in with too much violence, but, as is generally the case, resembles a light typhus. The icteric symptoms are not very prominent with 1 ryo- nia; the fever is continuous, although not very violent, the pain is burning, although not very intense. Mercurius solubilis is the most important remedy in the worst form of parenchymatous hepatitis. The region of the liver is very sen- sitive to contact, and is especially painful when the patient draws breath, coughs, etc.; the pain in the liver is a painful pressure or a burning, stinging pain; the liver is enlarged; there is consider- able icterus. These local symptoms, however, are much less to be depended upon than the general ones. Mercury should be given when suppuration is about to set in. This period is more definitely indicated by a burning fever, changing about with violent chills. It is, moreover, indicated by striking nocturnal exacerbations, great restlessness, an agonizing thirst, with desire for very cold drinks, and marked jaundice. Phosphorus is, without doubt, one of the more important remedies in inflammatory affections of the liver, with well-marked icteric symptoms, which it excites very rapidly in connection with inflam- matory symptoms. If we consider these effects side by side with its general action upon the organism, we infer that Phosphorus is more especially indicated in those violent forms of hepatitis accom- panied by deeply pervading typhoid symptoms, and rapid prostra- tion of strength. It is the only remedy which we can employ in pylephlebitis with any prospect of success; phlebitis is an appro- priate sphere of action for Phosphorus; likewise pysemic pheno- mena in ulcerations of the intestinal canal, with metastasis to the lungs. The remedies which we have named so far, are only beneficially applicable during the acute form of the disease; but we know that convalescence, or even a fatal termination, is sometimes slow; in such a case the disease takes upon itself changes that have to be met by a different class of remedies. Nux vomica will be found of especial benefit after the fever is re- moved, the liver continues painful and bloated, the skin is still jaun- 536 Diseases of the Liver. diced, the strength is still down and the digestive functions very much disturbed. The acute stage seldom exhibits symptoms that point to Nux as a true simile. China is very similar in its action to Nux vomica; this remedy has already been referred to in speak- ing of hyperemia of the liver, and will be mentioned more fully in the next chapter. The acute form of the inflammation is not the proper sphere of action for China; it is more appropriate in com- bating the residuary consequences of the disease, such as enlarge- ment of the liver, and the accompanying digestive derangements. Sulphur, one of the most efficient remedies in diseases of the liver, is essentially adapted to chronic inflammatory conditions, and may likewise be required in a case of abscess whose dispersion Mercury was unable to accomplish, or which had discharged on the outside, forming a fistulous opening. If, in such a case, the general symp- toms point to China, Sulphur nevertheless is required for the local symptoms. Phosphorus likewise is important in the phthisis hepa- tica proper; Arsenic also deserves honorable mention. Owing to the incurable nature of such a condition of the parts, we can hardly expect to obtain curative results from any of these remedies. Lyco- podium, Sepia, Silicea likewise come into play; for more special in- dications we refer to the next chapter. It is difficult to regulate the diet in these forms of liver-disease. If the patients are very sick, if they are troubled with a disposition to vomit, there is no difficulty in controlling their desire to eat, for they cannot eat anything. But if the stomach is not much af- fected, or if the appetite begins to return, the greatest precaution is necessary. The aversion to meat and fat which these patients experience, is an important sign of Nature, that this kind of food should either be avoided, or else should be given very cautiously. This circumstance is very unfavorable to convalescence; and the desire to do away with the emaciation and obviate the great pros- tration of strength, may lead one to hurt the patient in the vain hope of benefiting him. Wine never does any good in the whole course of the inflammation. If the patient desires anything re- freshing for his burning thirst, water and mild vegetable acids, either in the shape of syrups or jellies, are most suitable for this purpose. Hepatitis Chronica. 537 3. Hepatitis Chronica, Chronic Inflammatory Affections of the Eiver. Under this heading we comprehend divers conditions of the liver which can all be traced more or less directly to inflammation, among which we class the yellow atrophy of the liver, since it does not seem desirable to devote a special chapter to such an obscure dis- ease. In the succeeding paragraphs we therefore group the fol- lowing diseases side by side: fatty liver, hypertro hy of the liver, waxy or amyloid liver, granular liver, cirrhosis of the liver, nutmeg- liver, and acute yellow atrophy of the liver. If fault should be found for bringing so many different conditions together in one chapter, we will meet the objection by referring the reader to the therapeutic chapter. The etiology of chronic hepatitis is, in many respects, the same as that of hypenemia, where particulars may be found. The main causes of these abnormal conditions are: sedentary mode of life, espe- cially when associated with a large supply of food; a disproportio- nate amount of nourishing, fat-making food, hot climate, excessive heat even in our own temperate zone; abuse of Cinchona, Mercury, Alcohol; miasmatic influences; intermittent fevers, syphilis, exces- sive emotional excitements, continued deep grief, etc. In this class of exciting causes likewise belong all kinds of diseases which im- pede the circulation in the liver, especially diseases of the heart and lungs, with greatly diminished capacity of breathing. Such chronic affections of the liver are very apt to supervene in individuals af- flicted with so-called dyscrasias. As was said before, acute forms of liver-disease are very apt to change to one of these chronic forms. It is a very difficult matter to trace the above-mentioned forms of disease to special causes referring exclusively to one particular form, since the same deleterious influences may cause any one of these ab- normal conditions; nevertheless, certain influences are almost al- ways succeeded by the same forms. Cirrhosis, for instance, is prin- cipally met with in persons addicted to the use of alcohol, whereas the peculiar nodular form of the liver, (syphiloma,) is chiefly met with among syphilitic subjects. Fatty liver is not only found in those who eat much fat, or are disposed to excessive formation of fat, but likewise, (and this has hitherto remained unaccounted for,) in persons who are afflicted with rapidly wasting diseases, especially tuberculosis. Waxy liver is only met with among individuals who 538 Diseases of the Liver. are afflicted with constitutional diseases, such as rickets, scrofulosis, syphilis, and hy drargyrosis. As regards age, children remain entirely free from chronic liver- disease, except syphilitic affections; old people likewise are rarely attacked with liver-disease. It is particularly middle-aged persons who are afflicted with such disorders. Some forms of it attack principally men, cirrhosis, for instance, which is easily accounted for; but as a general rule, women are, under similar circumstances, more liable to the disease than men. As we stated when treating of hypenemia, some forms of liver-disease are hereditary, although, even in such cases, the disease does not appear until the age of pubescence, whereas not a trace of the disease had been visible before. The various morbid conditions of the liver differ so greatly, with reference to their anatomical changes and symptomatic manifesta- tions, that we shall have to consider each of them separately. The so-called hypertrophy of the liver, by which we understand an increase of substance of this organ without any apparent exudation, results most probably from repeated attacks of hyperaemia. The shape of the liver is not particularly altered, but upon the whole is larger than the normal size, and the parenchyma is generally much firmer, darker, and contains more blood. Or the liver, with an unequal increase of substance, exhibits unequal patches upon the cut surface, the veins of the liver having become enlarged, and looking like isolated spots in the rest of the organ (nutmeg- liver.) In consequence of the pressure of the blood, this form may afterwards result in a shrinking of the liver-cells, and formation of areolar tissue, so that the tissue of the liver may assume an appear- ance like that of cirrhosis. In simple hypertrophy of the liver the symptoms are generally unimportant, and not persistent, but occurring in paroxysms. The commencement of the disease almost always escapes observation, until our attention is excited by local pains, pressure in the region of the liver, enlargement of this viscus, with a slight transient attack of icterus. These symptoms are attended with derange- ments of the digestive system. The appetite may remain good, but the food does not seem to digest well; after a meal the patients feel lazy, are troubled with eructations or heartburn, and pressure at the stomach. The bowels are costive, the patients are tormented with piles; often fitful and desponding, or irritable. When taken at the onset, the disease is always curable, although only after a Hepatitis Chronica. 539 long lapse of time; but a cure is no longer possible, if a nutmeg- liver has become atrophied. Cirrhosis of the liver (granular liver) consists in an excessive for- mation of adventitious areolar tissue, in consequence of which the substance of the liver becomes atrophied. At first the size of the liver remains unchanged, very rarely it is slightly enlarged; in the subsequent course of the disease it is more or less diminished in size. The shape of the liver changes in consequence of the greater or less shrinking of the margins of the liver, until they finally acquire a membranous consistence of great firmness and density, without any parenchyma; the right lobe becomes more and more globular, and the left is almost entirely atrophied. The capsular covering is thickened, firm, and seems drawn in here and there, which gives a knobby, unequal, granular appearance to the surface. The tissue has a firmer consistence, sometimes as firm as cartilage. When cut, the parenchyma is lighter colored, and of a coriaceous firmness. Here, too, the granulations appear, first of a yellow color, and after- wards showing a grayish tint, embedded in a tenacious, whitish fibrous tissue, which sometimes takes the place of large portions of the parenchyma. The symptoms of incipient cirrhosis are identical with those of perihepatitis, but are not often very intense, and resemble rather the symptoms of simple hyperemia. Hence, it is very seldom that they become an object of medical treatment, because the disease mostly affects drunkards, who will not consult a physician for trifling ailments. When the affection is at its height, most of the phenomena are easily accounted for by the compression and oblit- eration of the ramifications of the portal vein, in consequence of which the circulation through the hepatic vessels is very much im- peded. Local symptoms, properly speaking, only exist at the com- mencement of the disease, whereas, as the disease progresses, all painfulness disappears. The dull sound over the left lobe dimin- ishes more and more, and very soon disappears entirely. The icteric symptoms are never entirely absent, but on the other hand never exist to a high degree, and are limited to a dirty-gray color of the skin and face, a light-yellow color of the sclerotica, and frequently a more or less yellow color of the urine. The phenomena of ob- structed circulation in the digestive organs are quite marked. The gastro-intestinal catarrh exists to a high degree; however, there is no increased excretion of faeces, but the bowels are constipated, and a copious quantity of tenacious mucus is discharged. The faeces 540 Diseases of the Liver. are either of a light-yellow, or more commonly of a clay, grayish- white color. Hemorrhoids are scarcely ever absent, and the en- gorgement of the veins of the intestines or rectum, in the long run almost always lead to hemorrhage from these vessels. The appetite being almost entirely gone, nutrition is rapidly and thoroughly prostrated. The urine is always secreted in smaller quantity, and is generally charged with uric-acid sediments. In addition to this, the equally impeded flow of the splenetic blood almost always causes an increased enlargement of the spleen. These symptoms are asso- ciated with a more or less rapidly progressing exudation of serum into the peritoneal cavity. The ascites, unless arrested by death, always increases to a high degree, nor does its increase depend upon an increased or decreased secretion of urine. This is characteristic of this form of ascites. The duration of the disease is always pro- tracted. If death takes place prematurely in a few months, it is generally caused by secondary complications; otherwise, the dis- ease may last for years before the patients succumb, with all the signs of a fully developed marasmus. When the disease has reached its acme, the prognosis is decidedly unfavorable, since it is impossible to remove the newly-formed con- nective tissue, and to secure a corresponding restoration of the liver-cells. It is even questionable whether the disease can be ar- rested in its incipiency. It is only for the sake of completeness, that we mention the syphilitic form of hepatitis. In its essential features it greatly re- sembles cirrhosis. In syphiloma, likewise, we have the formation of an excess of connective tissue, which causes the hepatic paren- chyma to shrivel, except that, in this disease, it forms deeper fur- rows, which impart to the liver a lobular appearance, and not, as in cirrhosis, fine granulations. This disease is only a partial mani- festation of constitutional syphilis, nor is it characterized by striking symptoms, and its treatment is, in all respects, identical with that of general syphilis. Fatty liver is one of the most common abnormal conditions of the liver; its advent sometimes is so insidious, that the boun- dary between a sound and abnormal condition of the liver can scarcely be defined; a copious infiltration of fat may even be asso- ciated with a feeling of health. Fatty liver may likewise arise in consequence of a peculiar metamorphosis of inflammatory exuda- tions into fat; in such a case, the shape and general condition of the liver depend upon the primary disease. Hepatitis Chronica. 541 In a tolerably high grade of fatty liver this organ is always en- larged ; it is flattened out, less bulging, its edges are changed, their normal sharpness being superseded by a more or less striking round- ness. The enlargement may be considerable. The color is lighter, a yellowish red or entirely yellow, with irregular red patches. The consistence is much less, sometimes like dough, so that the pressure of the Anger remains. On cutting through the liver, the knife is seen lined with a coating- of fat. The symptoms corresponding to this form of the disease, vary greatly, at least in intensity. How far a copious accumulation of fat agrees with every appearance of health, is shown by the fatten- ing of animals, which likewise teaches the important lesson, that the conditions under which the process of fattening is carried on, may develop diseases of the most malignant kind. With men the case is not different. If individuals, having little mental and phy- sical exercise, with a large supply of nutritious food, grow large and acquire very fat livers, they may feel perfectly well, with the exception of a little awkwardness and heaviness ; but if they should be attacked with some acute disease, they run infinitely more risk. In other persons, enlargement of the liver causes a pressure in the right side, dyspnoea, but no pain. Peculiar symptoms often arise if the left lobe is enlarged and presses upon the stomach. This may easily give rise to the idea of some malignant disease, for the reason that a distressing vomiting almost always occurs, attended even with violent pains. With fatty liver, the skin is said to contain a great deal more fat than usual, and to consequently acquire a glis- tening appearance. Icterus is never present. Percussion, and sometimes palpation, are the surest diagnostic means, for this form of enlargement may possibly exist without any pain, and at the same time be attended with a perfect feeling of health. Fatty liver, such as is often met with in the colliquative stage of tuberculosis, is a bad omen. Probably, in consequence of secondary hypenemia, it is associated with increased painfulness, so that the pains in the liver become a chief source of distress to patients thus afflicted. Waxy or amyloid liver greatly resembles the former variety in its physical symptoms. The liver is considerably enlarged, its edges are rounded and thickened, and its consistence is firmer instead of being softer, as in fatty liver. The substance of the liver is infil- trated at times with a dense, lardaceous mass throughout its whole extent, while at other times only in parts; this mass causes the 542 Diseases of the Liver. parenchyma of the liver to shrivel up. The color is grayish; on the cut surface it glistens like lard, and is uniformly mottled red. The symptoms of this disorder are less certain, for the reason that amyloid liver is always a partial manifestation of some consti- tutional disease. Icterus is generally absent, nor do the patients experience much pain. An almost unavoidable consequence is the exudation of serum into the peritoneal cavity. Altogether, its re- semblance to cirrhosis is not trifling, except that the symptoms of a considerably impeded hepatic circulation are either wanting, or only present in a slight degree. The disorder is of long duration, since it only progresses very slowly. The diagnosis of fatty liver is some- what facilitated by the circumstance, that the disease attacks indi viduals afflicted with some dycrasia, and likewise by an analysis of the secondary phenomena arising from the primary disorganiza- tion ; from cirrhosis it is most easily distinguished by the great enlargement of the organ. Acute yellow atrophy is a morbid condition of the liver that has not yet been satisfactorily explained and accounted for; in many respects it resembles softening of the brain. The morbid process consists in decomposition of the substance of the liver, and con- siderable diminution of its volume. This may have shrivelled up to one half the normal size of the liver. At the same time the organ is flattened out, flabby and unelastic, and its surface wrinkled. The color is a bright-yellow, almost without any admixture of red. At times the disease sets in suddenly and acutely, at others very gradually. In the latter case various digestive disturbances are observed, such as are characteristic of catarrhal affections of the stomach and bowels, accompanied by slight icteric symptoms. These, however, scarcely ever continue very long. The actual dis- ease sets in with pains in the region of the liver, which is like- wise very sensitive to pressure, and with a rapidly increasing and finally very intense jaundice. Very soon percussion reveals a dimi- nution of the natural dulness of sound until in some cases it dis- appears entirely. Corresponding to the diminution of the size of the liver, the spleen generally increases in size. At an early period, the local symptoms become associated with those of sympathetic cerebral irritation, such as violent headache, restlessness, irritable mood, which are soon followed by delirium and muscular twitches. The fever is very fierce, the temperature very high, pulse frequent, sometimes slow, always small and soft. The appetite is entirely gone; at first there is both retention of stool and urine. These Hepatitis Chronica. 543 phenomena of severe irritation are very soon followed by total col- lapse. The patients become comatose, and the pulse grows smaller and more frequent. Stool and urine are discharged involuntarily, the tongue becomes dry and cracked, colliquative sweats break out, petechise appear, hemorrhages from the intestinal canal set in, and death soon after supervenes. From the first appearance of the cere- bral symptoms a fatal termination is reached very rapidly, mostly in a week. The diagnosis of this disease is not uncertain, except if an ex- amination of the region of the liver is neglected; in such a case it may be confounded with typhus the more easily, the longer the pre- liminary stage continues. If the normal dulness of sound disap- pears, the diagnosis becomes pretty well assured; for in no other disease does this disappearance of the normal dulness take place as rapidly. Some regard this disease as absolutely fatal, others only condi- tionally so. Both parties are right to a certain extent. The for- mer diagnose acute yellow atrophy only if the last stage, which runs a very rapid course, has already set in; the other party refer to the disease as recognized in its first beginnings. At all events, no method of treatment can boast of having performed many cures of this disease. It should be observed that no icterus, though scarcely perceptible at first and apparently harmless, should be neglected, because we cannot know what mischief may be hidden behind it. By this means many an acute attack may be avoided, although we may not be able to show how this is accomplished. Treatment. From what we have said when describing each single form of the disease, it is evident what result we may expect to accomplish by treatment. Whereas, simple hypertrophy, fatty and amyloid liver, may admit of a more or less complete cure, a cure of acute yellow atrophy is of questionable possibility, and fully-developed cirrhosis defies every attempt at a cure. This knowl- edge is important because it will induce us to search for remedies in all curable forms of liver-disease, and to confine ourselves to pal- liative treatment in incurable cases. We are thereby induced to heed such affections of the liver as arise very gradually, even the most trifling irregularities of the hepatic functions, since even cirr- hosis, if taken at the onset, may be arrested and the incipient dis- organization removed by a process of retrograde metamorphosis. The medicines which will be recommended for these different forms of liver-disease, can only be presented more or less hypotheti- 544 Diseases of the Liver. cally, since in the cases of liver-disease reported in our publications, the diagnosis is anything but certain. Nor do our physiological provings present the necessary clearness in their relations to disea- ses of the liver, so that secondary or accessory circumstances will have to guide us in the selection of our remedies. Nux vomica, of which mention has been made when treating of acute affections of the liver, is likewise indispensable in chronic liver-disease. Slight derangements, or such as are not attended with riiaterial changes, are easily removed by Nux; in more deep- seated diseases it can only act as a palliative, the completion of the cure being left to other medicines. This medicine is best suited to individuals affected 'with abdominal plethora, using a deal of fat and wine, taking very little physical or mental exercise, or working too hard mentally and being of a sanguine temperament. To gen- uine inveterate drunkards, Nux vomica is of comparatively little use. Simple hypertrophy and fatty liver are more particularly favorably acted upon by Nux; in the former it is more especially suit- able if it arose from repeated attacks of hypersemia, and the liver is subject to paroxysms of painful sensitiveness. It is appropriate in fatty liver, if this disorder exists without any simultaneous ex- cess of general obesity. It is more especially in the enlargements caused by abuse of Cinchona, that Nux is endowed with a specific power to control. Among the special indications, the phenomena of the stomach and intestinal canal are particularly noteworthy. The distress is excited or aggravated by eating, the bowels are dis- posed to be constipated; but the constipation is not obstinate, nor are the faeces colorless. Nux is seldom sufficient to effect a cure; in inveterate cases, never. In the more malignant forms of the liver-disease, Nux may at most have a good effect in the beginning, when they do not differ much from the non-malignant forms; after- wards, when the obstructions of the portal circulation become more prominent, even a palliative effect can no longer be expected. Of all the medicines at our command, Sulphur is most frequently applicable in chronic affections of the liver; for the reason that, even when regarded from the most diverse points of view, it is still adapted to the most diversified forms. In non-malignant diseases, where Nux is a suitable but insufficient remedy, it is Sulphur which completes the action of Nux vomica, and effects a cure. In liver- complaint caused by abuse of Cinchona or Mercury, especially the latter, Sulphur is indispensable, as likewise for the residuary conse- quences of acute inflammatory affections, especially for hypertrophy Hepatitis Chronica. 545 of the liver. Until now nothing definite can be said respecting the action of Sulphur in cirrhosis. However, since we know that this disorganization is caused by an exudation into the parenchyma of the liver, and that, reasoning from analogy, Sulphur must exert an influence upon it, this alone may be sufficient to induce a trial of this remedy. In amyloid liver this remedy promises better suc- cess, in the first place for the above-mentioned reason, and in the second place on account of its action upon inveterate dyscrasic processes of every kind, especially rickets and bydrargyrosis. We must be spared the trouble of enumerating single symptoms; the effects of Sulphur are too numerous; but we have to point out two circumstances that contra-indicate the exhibition of Sulphur. The stools must not be colorless, as is so often the case in the higher grades of this disease, nor must there be much jaundice, two cir- cumstances that are generally closely connected. Much cannot be expected from Sulphur if ascites or intestinal hemorrhage is present, or if the strength of the patient is entirely consumed; for, in order to have its effect, Sulphur must be assisted in its action by the strength required for the reactive endeavors of the organism. The violent itching in diseases of the liver, and the exanthemata which are so often present during these diseases, are good indica- tions for Sulphur. China has been alluded to very fully when treating of hyperaemia of the liver, where the reader will find more detailed information. A few additional remarks are needed here. Among the symptoms of China there are many indications of icterus, but the bile-pigment is not absent in the excretions. Where China is to act homoeo- pathically, the secretion of bile must not have been entirely sus- pended. When treating waxy liver we may often be reminded of China, because this kind of liver is only met with in cachectic sub- jects; a radical cure must not, however, be expected of this drug. In rarer cases, where the affection of the liver is attended with ex- hausting diarrhoea, or when there is profuse bleeding from the stomach or bowels, or the'spleen is much enlarged, China will do efficient service. From the well-known effects of large doses of Cinchona, it is apparent that this drug must have a specific cura- tive action in enlargement of the liver arising from the influence of malaria and being often of considerable size. Sometimes it re- lieves the liver-pains experienced by tuberculous patients; in such cases the stomach always is deeply involved in the distress can ed by the condition of the liver. 546 Diseases of the Liver. Sepia. We have repeatedly stated in former paragraphs that this remedy is specially adapted to females with a bright com- plexion, disposed to sudden changes of color and having dark- brown margins around the eyes. Such individuals are always very sensitive, irritable, disposed to congestions, having a fine, trans- parent skin, and being frequently troubled with hepatic spots, they are undoubtedly inclined to diseases of the liver. It is more partic- ularly non-malignant tumors of the liver that come within the curative range of Sepia, if they are accompanied by icterus, and the passage of bile into the intestinal canal is very much dimin- ished, the region of the liver is occasionally painful. A feeling of languor much greater than the looks would lead one to suppose, aversion to meat, distress at the stomach, irregular menses: these symptoms point to Sepia. Among the symptoms of Sepia we have likewise the peculiar itching of individuals suffering with liver- complaint, and also the congestions in various parts of the body. The mental and moral symptoms of Sepia are likewise somewhat characteristic: hypochondriac mood, loss of spirits, looking on the dark side of things, occasional paroxysms of irritability, disposi- tion to feel vexed and to show an irascible temper. Lycopodium occupies a high rank among the remedies for diseases of the liver, not only by virtue of its physiological symptoms, but likewise on account of the practical results that we expect to ac- complish by it. If our literature contains but few cases of cure of diseases of the liver with Lycopodium, it is because Lycopodium is only suited to the most severe among them and is scarcely ever alone sufficient to effect a cure. Lycopodium is particularly adapted to the treatment of cirrhosis, and to such affections generally as are characterized by considerable obstruction of the portal circula- tion. In speaking of the prognosis of this disease we have shown that our hopes of curing such a disorder are very slim, hence we must not expect too much of Lycopodium. Among the single symptoms those referring to the feelings, and the symptoms of chronic gastro-intestinal catarrh are particularly prominent; of course a variety of pains are experienced in the region of the liver, but they are very imperfectly defined in the pathogenesis. Lyco- podium has no icteric symptoms properly speaking; indeed they are mostly absent in this disease, but it has in their place a peculiar sallowness of the complexion. Besides well-marked hemorrhoidal ailments, Lycopodium has likewise vomiting of blood, exudation of serum into the peritoneal cavity, and rapid emaciation. Hepatitis Chronica. 547 Digitalis purpurea has been variously tried in liver-complaint; it is not only suitable in slight attacks of icterus, which generally pass off again spontaneously in a very short time, but it is likewise spe- cially adapted to some of the worst forms of liver-disease. In all such cases, however, icteric symptoms have to be strikingly present. We desire to direct special attention to the many points of corre- spondential relation between acute yellow atrophy and the effects of Digitalis. The marked cerebral symptoms consisting of severe irritation, which is speedily followed by complete depression; the peculiar character of the pulse, varying between extreme frequency and remarkable slowness; the retention of urine; the painfulness of the region of the liver attended with rapidly increasing icterus; the agonizing anguish of the patient, and, finally, the preliminary symptoms while the disease is slowly and gradually preparing for an outbreak, are all to be found in the pathogenesis of Digitalis; and there is scarcely a drug that has such a rapid prostration of strength without any corresponding colliquative phenomena as Di- gitalis. Among the remedies that could possibly be used, Digitalis is undoubtedly the nearest. [Some years ago we were called to see an old man of seventy-two years, who was employed in one of the machine shops of this city; an exceedingly sober person who never used a drop of liquor of any kind. This man had up to this time enjoyed a fair share of good health, and had never given much employment to physicians; nor had he taken much medicine of any kind. After having felt more or less indisposed for a few days, he took to his bed, and we were sent for. We found him slightly delirious, jaundiced, tongue not much coated, skin dry and constricted, pulse about hundred. The old man failed from hour to hour, and died in a few days. A post- mortem revealed nutmeg-liver. The parenchyma of the liver was exceedingly rotten throughout its whole extent. The year follow- ing, his son, who was a man of about forty years, and had always enjoyed good health, except that he was unable to undergo much fatigue, was taken down with the following symptoms: Saffron- color of the skin from the top of the head to the soles of the feet; even the tongue and fauces had this appearance; the urine had a blackish-yellow appearance and deposited a similarly-colored sedi- ment. Bowels loose, the discharges having the same dark-yellow color. Pulse exceedingly intermittent and irregular, feeble and slow. It was a case of what the people in our part of the country designate as black jaundice. Remembering the condition of his 548 Diseases of the Liver. father's liver, we had a right to infer that in this case the liver must be badly diseased; yet there was no tenderness in the region of the liver, nor could we discover any change either in the size or shape of the liver by percussion or palpation. We gave this man Digi- talis, small doses at first, which had no effect whatever, and after- wards large doses of ten to fifteen drops in half a tumbler of water in the course of the day. No other medicine was given, and the patient was able to attend to business after having been confined to his room three weeks. There was no trace of jaundice left. The year following this man was taken sick again; he was slightly icteric, but there was no intermission of the pulse; no sen- sitiveness in the region of the liver, except the left lobe, which was somewhat swollen and painful. The bowels where tumefied; stools very scanty and light-colored; urine dark, depositing a great deal of bilious sediment, and having a foul smell. The patient's spirits were very much depressed; tongue looked foul; he complained of headache and excessive prostration; he soon became very much emaciated. We treated him with Arsenic and Nux. Fowler's so- lution was often used, in the proportion of ten drops to a tumbler of water, in the course of a day. The man was confined to his room about five weeks. He made a perfect recovery, grew fat and strong and has worked hard ever since. II.] Phosphorus has a remarkable similarity to Digitalis in relation to acute yellow atrophy. When speaking of hepatitis, we have di- rected attention to the constant action of Phosphorus upon the liver, which is uncommonly intense even in the first days, and is attended with acute pains in the region of the liver. We are in possession of abundant material showing the anatomical changes which Phos- phorus occasions in the liver. According to these results it is not any of the ordinary acute inflammations which Phosphorus causes. The most common changes are a copious infiltration of fat, which may, however, have existed anteriorly to the poisoning; at any rate this point is by no means removed beyond the sphere of doubt. In two cases where death took place after the seventh day, a large por- tion of the liver showed great resemblance to the liver in a state of acute yellow atrophy, especially so far as the Liver-cells are con- cerned, and where the gall-bladder, instead of bile, contained a pale- yellow, slimy, ropy fluid. According to these changes, with which the general symptoms correspond, Phosphorus may be fairly tried in acute yellow atrophy. The frequent occurrence of fatty liver would likewise seem to suggest the employment of Phosphorus in Hepatitis Chronica. 549 tjiis disease. Here the accumulation of fat cannot be accounted for in the same manner as in tuberculosis; however, although it takes place very rapidly, yet a condition of this kind furnishes an addi- tional important indication for the use of Phosphorus in this disease. There are but few symptoms in the pathogenesis of lodium, that point clearly and unmistakably to affections of the liver; at all events they are insufficient to warrant a recommendation of lod- ium in diseases of the liver. The praises that have been bestowed upon lodium in hypertrophy of the liver, amyloid liver, mercurial affections of the liver, are entirely based upon the well-known gen- eral indications. There may be a great deal of truth in them, but they are more or less vague and hypothetical, and the use of the remedy is purely empirical.. Hartmann has the following more par- ticular indications: " In jaundice, not in simple icterus as the fol- lowing symptoms show, lodium is indicated if the skin is of a dirty- yellow color, there is a high degree of emaciation, irritable and de- sponding mood, yellow or almost brown, dark complexion, thick coating on the tongue, a good deal of thirst, nausea, clay-colored stools changing about with constipation, dark, yellowish-green, smarting urine, etc.; it is suitable after Mercury has been used to excess. This agent has a large sphere of action, for it comprehends even jaundice with structural changes in the liver, dyscratic condi- tions, hectic fever, etc." This last recommendation is undoubtedly intended for the last-mentioned pathological process. [The July number, 1868, of the American Journal of the Medical Sciences, contains an interesting article by John Homans, M. D., of Boston, Mass., on acute atrophy of the liver, with remarks upon the similarity between this disease and the effects of poisoning by Phosphorus. His remarks are illustrated by a number of cases. In concluding his article the writer offers the following observations: " Much has been written on the physiological action of Phosphorus during the last six or seven years. All writers, so far as I have ex- amined their statements, agree that Phosphorus, taken internally, produces a fatty degeneration of the secreting portion of the kidney and liver; in many instances the heart and lungs were in a state of fatty degeneration and even the brain also. Lewin (see Sydenham Soc. Year-book, 1863) made experiments on rabbits and frogs, and found fatty liver in six out of eight rabbits which had lived eight days after the administration of Phosphorus. " Numerous papers on poisoning by Phosphorus are to be found in the foreign, and especially in the German Journals for the past 550 Diseases of the Liver. year, which fully confirm the modern views of the similarity of tlje symptoms with those of acute atrophy of the liver, and of the rapi- dity with which fatty degeneration of almost all parts of the body occurs in these cases," (Sydenham Soc. Year-book, 1863.) "This subject is considered and accounts of cases may be found in the Union Medicale, in the Archives Generales, in Virchow's Ar- chives, in Canstatt, in Schmidt's Jahrbuch, in Wagner's Archives, in the Medico-Chirurgical Transactions for 1867, in the Vienna Medical Journals, and other Periodicals. From what I can learn, it seems to me that the action of Phosphorus on the liver is second- ary to a change in the constitution of the blood, and that fatty de- generation of the liver is not necessarily the cause of death, because sometimes a fatal result follows poisoning by Phosphorus, and the liver is found to be neither atrophied nor fatty." After giving the symptoms in eight cases of poisoning by Phos- phorus in the human subject, the Doctor remarks: " The similarity in the symptoms of the two affections, (acute atrophy of the liver and poisoning by Phosphorus,) is, I should judge, rather more marked than in the post-mortem appearances. In both there may be vomiting, either of an hemorrhagic character or not; there may be pain at the epigastrium, restlessness and irritability, rigors, jaun- dice, tympanitis, retention of urine, delirium, somnolence, convul- sions, and coma. After death there may be found, in both, extra- vasations of blood in various tissues and organs, blood liquid and dark-colored, bloody fluid in alimentary canal, fatty degeneration of the liver and kidneys, and ascites, (generally slight.) But, so far as my observations or reading of descriptions have extended, the gross appearances of the liver are very unlike. It is not so limp, and shrunken, and atrophied, nor has it the peculiar rhubarb-like color, (in many parts,) in cases of poisoning by Phosphorus, that it has in acute atrophy." II.] Conium maculatum. Rentsch has communicated an interesting cure by this drug in the "Allg. Hom. Zeitung." It is not very cer- tain which of the above-described affections of the liver was cured by Rentsch, but the liver was very much enlarged and the consti- tutional disturbance was very great; as it is only met with in severe diseases of this viscus. There are but few cases of liver-complaint reported in our Journals, that have been cured with Conium. This medicine is evidently not used a great deal, nevertheless, but few medicines can show more distinct and striking liver-symptoms than Conium. Hepatitis Chronica. 551 Calcarea carbonica is, like Conium, scarcely ever recommended for affections of the liver without being associated with some other medicine. Considering, however, what an influence this medicine exerts upon the most deep-seated gastric derangements, especially when the secretion of bile is either diminished or entirely suspended, Calcarea must certainly appear one of the most important remedies in liver-complaint. It is particularly adapted to such complaints in the case of women and children. The local symptoms are numer- ous. but not very distinct; the constitutional symptoms are very significant. Calcarea likewise exerts an influence upon liver-com- plaint in the case of tuberculous and chlorotic patients. Waxy liver seems to come more particularly within the range of Calcarea, the more as this disorder only occurs among cachectic individuals. Silicea is closely related to Calcarea carb., it is particularly suit- able in the case of cachectic persons, especially if the affection of the liver is associated with diseases of the bones. Tire attending intestinal catarrh should not be accompanied by an increase of fecal evacuations. Neither our practical observations nor the physiolog- ical provings inform us very precisely in what particular class of liver-disease this remedy will prove most serviceable; at all events, in the liver-complaint of tuberculous individuals Silicea will prove very useful. In addition to these statements we will mention a symptom that seems to be met with exclusively in diseases of the liver, although it does not exactly state how the liver is diseased; we allude to a peculiar, almost sudden change in the finger-nails, they lose their transparency, assume a yellowish hue, crack longi- tudinally, increase considerably in thickness, and, in a few months, become quite ill-shapen. This change is a sure evidence of some existing liver-disease, and points to a small number of remedies, all of which exert a powerful influence upon the liver: Silicea, Sulphur, Antiwionium crudam, and Graphites, [also Mercurius virus. II.] In many cases this one symptom contributes a great deal towards estab- lishing the diagnosis upon a firm basis; it maybe further remarked that this symptom is oidy observed in diseases of the liver that are not of a malignant character. Nitri acidum is another medicine having a decided action upon the liver, although we are as yet unable to state in what special form of liver-disease it is indicated. The well marked icterus, the urine full of bile, the colorless stools, and the painful sensitiveness of the region of the liver, show conclusively in what manner the liver is affected. Existing hemorrhoids and chronic intestinal catarrh de- 552 Diseases of the Liver. fine still more clearly the specific adaptation of Nitri aeidum to the existing case, for they show that no bile enters the bowels from the gall-bladder, and that the ramifications of the portal vein are com- pressed or even obliterated. Hence it is in cirrhosis, syphiloma and atrophied nutmeg liver, that Nitri aeidum may prove useful. The antidotal power of this remedy against the mercurial disease is well known, and we need scarcely state that the diseases of the liver caused by Mercury find their remedy in Nitric acid. Carbo vejetabilis is not only to be considered in its special relation to the liver, but likewise in its general relation to the organism. The reactive energies of the organism are entirely prostrate. Viewed from this point, Carbo vegetabilis will not be suitable in the less important diseases of the liver, nor generally at the commence- ment of the more important ones, but not until the circulation begins to be very much impeded, the patient shows signs of emacia- tion, and th<?serous exudation into the peritoneal cavity has com- menced. In addition to these symptoms we always have a high degree of gastro-intestinal catarrh, the hemorrhoidal vessels are very much engorged, vomiting of blood sets in. Hence, cirrhosis seems to constitute the proper sphere of action for Carbo veg., especially if the disease occurs among drunkards. Moreover, Carbo is fre- quently indicated in the chronic atfections evidently resulting from continued losses of animal fluids, such as metrorrhagia and excessive lactation. Arsenicum album acts pretty much in the same way as the former remedy; the symptoms resemble each other greatly, in most re- spects, except that Arsenicum is not appropriate when the reactive powers of the system are entirely prostrate. Waxy liver evidently depending upon dyscrasia, is favorably acted upon by Arsenicum. We have already shown that in certain stages of liver-disease only a palliative result can be obtained; this is more particularly the case when remedies like Arsenic and Carbo veg. are required. A great deal is done if the urinary secretion is increased, and the gen- eral dropsical symptoms are diminished, which will likewise lessen the patient's anxiety. We should commit a sin of omission should we here close the list of our remedies for liver-complaint. There are other medicines, the special indications for which it is beyond the sphere of this work to state, that may likewise be required by certain specific symptoms; they are Graphites, Hepar sulphuris calcareum, Antimonium crudum, Kali carbonicum, Lachesis, Chelidonium majus, Mercurius, Natrum muriaticum, Ferrum, Magnesia muriatica. Regarding these drugs Hepatitis Chronica. 553 we are greatly in need of more extensive practical observations; their local symptoms are only obscurely hinted at in our provings, and the utmost care will be required, in order to establish their homoeopathicity upon an accurate knowledge of the symptoms. Although a frequent change of medicines is not advisable in dis- eases of the liver, yet we should not, on this account, overlook intercurrent morbid conditions, since a good share of success fre- quently depends upon their speedy removal, especially if the ab- dominal viscera are concerned in this exceptional treatment. The frequent congestions of the liver deserve particular consideration. This is not the place to dwell upon the effect of certain mineral waters, since we are not as yet in possession of provings, instituted with reference to their homoeopathicity to certain diseases. How- ever, we know that certain desperate cases of disease of the liver have either been cured, or materially improved by the Karlsbad, Marienbad, etc., and this should induce us, in doubtful cases, not to postpone the use of such remedial agents beyond a certain limit of time. It not unfrequently happens that an affection of the liver, which seems beyond the reach of our remedies, is improved by the Karlsbad, or some other mineral water, and that then our medicines act with much better effect. In every form of chronic hepatitis the diet is a subject of the ut- most importance. If the disease is curable, a sound diet will pro- mote the cure; if it is incurable, it will help to preserve the organ- ism as long as possible. The above-mentioned etiological influences sufficiently show what and where certain restrictions are required. Dietetic rules cannot be laid down too rigidly; a single error in diet may entail pernicious consequences. Fat food, especially boiled or fried fat, is to be forbidden, likewise coffee, tea, spirits, and sharp condiments. On the contrary, the use of any kind of fruit should be encouraged; carbonated water may be used as a beverage. Wine and beer have to be used cautiously and moderately, except if the patient is very weak. The condition of the digestive tract will have to be considered with so much more care, as it is opposed to every undue attempt to'preserve the vital strength. Where sed- entary habits or a luxurious mode of living has caused the disease, vigorous and continued exercise is indispensable, so far at least as the existing strength will permit. In conclusion, we will mention a palliative means that is often resorted to too soon-we mean tapping. It is difficult to lay down a rule in this respect; nevertheless, it is always well to delay the 554 Diseases of the Liver. operation as long as the fluid is confined to the peritoneal cavity It generally accumulates again with great rapidity, and the patient is thus deprived of his last remnant of strength; on this account alone, if on no other, such extreme means ought only to be resorted to very sparingly. In general dropsy, tapping acts much more favorably, and the effect is much more lasting. After tapping it is proper to compress the abdomen, for the purpose of preventing the extension of the abdominal walls ; such a compression is best effected by suitably arranged corsets, not by means of a bandage, which is easily pushed out of its proper position. 4. Icterus, Aurigo, Jaundice. We apply this name to the deposition of bile-pigment in the skin and eye; in some of the preceding chapters we have had frequent opportunities to call attention to this characteristic phenomenon. The essential process in jaundice is a retention of bile in the liver and gall-bladder, and consequent transition into the blood. Hence, this affection is not an independent disease, but one that occurs in connection with other morbid changes, and we should not here de- vote a special chapter to it, if it were not in most cases beyond our power to recognize the causal or primary disease, so that the mor- bid process generally seems to us purely idiopathic. In part, the causes of jaundice have been stated in the preceding chapter on the various diseases of the liver. We have shown that all the morbid processes implying a compression of the biliary ducts, result in icterus. In these cases jaundice is simply a symptom of some other disease. More directly, and apparently more idiopathi- cally, the disease may likewise be caused by deleterious influences acting directly upon the gall-bladder and excretory ducts of the bile. In this respect, the disease may be caused by biliary calculi remaining for a longer or shorter period in the excretory duct, an occurrence that is undoubtedly much more frequent than is gener- ally supposed, since it may be perfectly painless, and only in the smaller number of eases causes such distress as is generally attrib- uted to the passage of biliary calculi. The excretory ducts of the bile may be compressed by adventitious formations, cicatrices, or ab- scesses, without being themselves diseased; or else their diameter is lessened, in consequence of a morbid affection of their mucous mem- brane. This last-mentioned circumstance causes catarrhal icterus, very rarely as an idiopathic disease, but in consequence of the ca- tarrhal process spreading from the duodenum to the gall-bladder. Icterus, Aurigo, Jaundice, 555 Whether icterus can be the consequence of spasm of the excretory ducts, is questionable. Without any demonstrable changes in the liver, jaundice may occur during the course of various severe dis- eases, such as pneumonia, typhus, intermittent fever, affections of the spleen. Jaundice occurring after violent emotions, and some- times very rapidly, is a very curious occurrence, defying every phy- siological explanation. Next to these more directly acting causes, which it is sometimes very difficult to explain, we have to consider other more indirectly acting ones, which are of importance so far as the selection of proper remedies is concerned. Under this head we have to enu- merate all the etiological influences mentioned previously in connec- tion with acute catarrh of the stomach and bowels, likewise the various causes of diseases of the liver, to which chapter we refer the reader. We may observe that various circumstances, which usually or very readily cause intestinal catarrh, may likewise directly lead to icterus; among these causes we note, more particu- larly, immoderate eating and pregnancy. A special disposition to jaundice seems to be more frequent than it really is; it is often not only difficult but impossible to make out specific changes in the liver; and thus it is that an affection of this viscus which is the real cause of the jaundice, seems to have nothing to do with it. As regards age and sex, neither seems to show any particular predisposition for jaundice. Infancy manifests a tendency to icterus, which seems even to constitute a part of the normal physiological life of new-born infants, and it is sometimes very difficult to decide whether the icteric process remains within the boundaries of this normal development. Most new-born chil- dren have a jaundiced appearance in the second or third week; however, this is not real jaundice, for the yellow tint of the eyes is absent. Hence icterus neonatorum can only be talked of, if the eye shows the characteristic yellow tint; the yellow color of the skin arises from the copious quantity of the blood accumulated in the dermis of new-born infants, on which account the bright redness which usually succeeds the yellow color, soon changes to the nor- mal white color. These remarks show that, as a rule, icterus is symptomatic of some other disease, and that it is only in rare instances that icterus is an idiopathic process. Symptoms. It is very seldom that the disease sets in without precursory symptoms; but they are trifling and the patient is only 556 Diseases of the Liver. reminded of them after the yellow color has made its appearance. In the attacks of primary as well as secondary jaundice the patients feel faint, sick, out of humor, their appetite is less and they complain of bitter taste and pains in the limbs. In the secondary forms of jaundice all these symptoms or only single ones of them are added to those already existing. The characteristic color of the skin may set in suddenly or only gradually. Generally the bile-pigment is first seen in the urine, the faeces lose their color more and more, after which the conjunctiva and finally the skin become icteric. There are cases where the skin remains free from the yellow tint, although the conjunctiva and urine show a marked yellow color. The color changes between a bright yellow and a dark-brown, some- times assumes a reddish, and more frequently a greenish tint; the urine especially inclines to assume this color. The skin is generally tinged unequally. In intense cases the mucous membrane of the mouth is likewise distinctly tinged. As the disease continues the color becomes more intense, although it may remain unchanged for weeks. The color of the urine does not always keep even pace with the color of the skin; the urine sometimes exhibiting an intensely yellow tinge whereas the skin remains colorless; or show- ing only a slightly yellow appearance, while the skin looks bronze- colored. The presence of bile-pigment is shown by Nitric Acid containing a small quantity of nitrous oxide. Fill a glass tube full of urine and allow the acid to trickle down the side of the tube; very soon layers of different colors, green, bluish, violet and red, will be seen in the fluid, after which the yellow color of the urine reappears. The perspiration likewise sometimes contains so much bile-pigment that it stains the linen yellow. The more the bile is prevented from mixing up with the faeces, the less color they will exhibit, until they finally look like common loam, and, in the highest degree of the disease, like clay. The nature of the stools is an important aid in determining how far the bile is retained out of the bowels and what are the patient's prospects of being cured. The color of the stools is indeed the only safe criterion of an im- provement, since even days after the bile has resumed its flow, the skin and conjunctiva may retain their yellow color. The excre- ments are always remarkably devoid of cohesion and dry; diarrhoea is a rare occurrence. Those characteristic symptoms of jaundice are attended with various derangements of the general organism, of course inde- pendently of the causal disease. It is only in rare cases that, after Icterus, Aurigo, Jaundice. 557 the breaking out of the icterus, the general organism does not suf- fer; the patients feel well, have a good appetite, and are at most a little less vigorous and enduring than before, their sleep is likewise more restless; in such a case, although the color of the skin may be intensely yellow, the secretion of bile is not entirely suspended, and the stool is still somewhat tinged, though less than usual. The digestion is apt to suffer from the beginning. The tongue is thickly coated, the taste disgustingly bitter, the appetite is gone, at least there is no desire for animal food, the nausea seldom increases to actual vomiting. The stool is very fetid and of the above-men- tioned character, attended with copious flatulence which distends the abdomen. The pulse acts very strangely, it is generally less frequent than the normal pulse, seldom more so. This decrease in the frequency of the pulse must be an effect of the bile, for it like- wise sets in if the jaundice is a complication of febrile diseases; frequency of the pulse, under such circumstances, is always om- inous of unfavorable results. The loss of strength is usually pro- portionate to the intensity of the icterus and there generally super- venes an exceedingly irritable, desponding state of mind which looks on the dark side of everything and which the patients can- not possibly get rid of. Sleep is generally restless, disturbed by dreams; the skin is very dry. The distressing itching, to which allusion has been made in former paragraphs, is seldom absent. That this itching is not caused by a contact of the reabsorbed bile with the cutaneous nerves, is proven by the fact that it is met with in affections of the liver without any jaundice. The duration of such light attacks varies; if we calculate the duration by the period when the bile commences to reappear in the al vine evacua- tions, it may be only a few days; but more commonly it extends to several weeks. The yellow color of the skin sometimes does not disappear until weeks after the patients have recovered their nat- ural feeling of health. But it is not always that jaundice runs such a mild course; some- times it breaks out as a malignant disease, or assumes a malignant character while running its course. The pulse, in such a case, be- comes more hurried, and the temperature rises with occasional attacks of intercurrent chills; the nervous system likewise suffers, as is seen by the violent headache which attacks the patient at the commencement of the disease and by the subsequent delirium. The patient loses his strength very soon, and emaciates very rap- idly. There is a striking disposition to petechial effusions. Such 558 Diseases of the Liver. a malignant change may take place very suddenly, but may like- wise set in very gradually under the form of a lentescent or hectic fever. When at its acme this malignant form may only last a few hours, but it may likewise drag along for months. It is one of the most fatal diseases. The icterus neonatorum is not essentially distinct from that of full-grown persons. We have said that the mildest forms of this disorder do not seem to be a deviation from the normal condition of the organism, and that the icteric nature of the disease itself is problematical. As in the case of adults, so in that of infants do the real retentions of bile either present the symptoms of a malig- nant disease, or else are without any noticeable symptomatic mani- festations. Malignant symptoms, however, are more readily noticed in infants, because they are always more easily affected by hurtful influences and assimilation is so suddenly and radically interfered with. This last-mentioned result generally depends upon the diar- rhoea, which is always present during the icterus of children in its worst form. In addition to this we have the symptoms of a deeply- pervading gastro-intestinal catarrh, tendency to convulsions, and, in the highest grades of the disease, symptoms of putrid decomposition. Ordinary simple forms of jaundice mostly terminate favorably; the malignant forms are decidedly rare. New-born infants, of course, run the greatest danger. In adults, the appearance of a rapid pulse and diarrhoea, is a bad sign and renders the prognosis exceedingly doubtful. Whether jaundice can terminate fatally, unless it is symptomatic of some other severe disease, is questionable. Treatment, From what we have said, it is evidently impor- tant to the successful treatment of jaundice that we should be ac- quainted with the internal changes upon which it depends. While we have no means of removing the pressure caused by abscesses, adventitious formations, cicatrices, etc, from the biliary ducts; or of removing the obstacles occasioned by the presence of a biliary calculus; and while our aid, in malignant diseases of the liver, seems of questionable utility, we are in possession of a number of excellent remedies against the benign forms of jaundice. Only we must not stop to judge of the result of our remedial agents by the color of the skin and conjunctiva, for this might deceive us; but we should be guided by the color of the stools, where a favorable change in the secretion of bile is first made manifest, and, after that, by the urine, which shows more definitely than any other se- cretion, whether, and how much, bile is still reabsorbed. If, in Icterus, Aurigo, Jaundice. 559 giving the indications for the different remedies, we seem to indulge in too many generalities, the reader will please remember that for the primary causal affections of jaundice, he is referred to the chap- ters where these are treated of. According to Hartmann, the following medicines contain in their pathogeneses the symptoms of jaundice: Aconitum, Arsenicum, Bryonia, Calcarea carbonica, Cantharides, Carbo vegetabilis, China, Conium, Cuprum., Digitalis, Podium, ALercurius, Acidum nitricum, Nux vomica, Plumbum, Pulsatilla, Ranunculus, Rhus toxicodendron, Secale cornutum, Sulphur, Acidum sulphuricum. We might tran- scribe the whole passage if it contained more characteristic indica- tions for each special remedy, but will endeavor to give the more essential parts. For all that, Hartmann has left out some impor- tant remedies, such as Phosphorus; and so far as the practical ne- cessities of the physician are concerned, the list is too large, for some of the medicines are only of use in the more severe affections of the liver, not in simple jaundice. When treating of the etiology of jaundice, we showed that this disease is often caused in consequence of a catarrhal irritation of the mucous membrane of the stomach and duodenum, spreading to the mucous lining of the excretory ducts of the bile. Since this need not necessarily be an acute catarrh, but may result just as well from a chronic form of this disease, many of the remedies that have been recommended for chronic gastro-intestinal catarrh, will likewise come into play in the treatment of jaundice. The first among these is Mercurius. It is not only appropriate in jaundice with fever, but equally so in jaundice without. It is, however, more particularly adapted to the former. The secretion of bile should not be entirely suspended, or else the stools should be liquid. The stomach shows the symptoms of acute catarrh: loss of appetite, perverse desires, eructati< ns, loathing, vomiting, increase of the gastric symptoms after every meal, and thickly coated tongue; in addition we have painfulness of the region of the liver. The skin has a moderate yellow tinge, not very deeply marked. In the icterus neonatorum and of children generally, the remedy is particularly useful. Among the chronic forms, Mercurius is eminently suitable in jaundice caused by abuse of Cinchona. Nux vomica has a still more extensive sphere of action than the former drug. It is likewise principally adapted to the treatment of catarrhal jaundice with fever. The liver has all the symptoms 560 Diseases of the Liver. characteristic of hypersemia, moreover, spasmodic symptoms, as occur in colic from the presence of biliary calculi. The secretion of bile is almost entirely suspended. The bowels are torpid, the patient is troubled with swellings of the hemorrhoidal vessels. The stomach symptoms are similar to those of Mercurius, but they may likewise occur when the stomach is empty. The disease is chiefly caused by a sedentary mode of life, a large supply of iood, abuse of fat, wine, coffee, spirits. The chronic forms of jaundice to which Nux corresponds, can easily be inferred from our remarks on the subject of gastro-intestinal catarrh; we may add, that no remedy has effected better and more numerous curative results than Nux. Bryonia alba is particularly appropriate in jaundice with fevei, where its choice is more particularly determined by the peculiar symptoms of the gastric range: thick whitish coating of the tongue; nausea, retching and vomiting, which is excited both by eating and drinking; obstinate constipation. The complexion is pale and. sickly, whereas Nux has a bright color of the face, together with the yellowish tint. The secretion of bile is not entirely suspended, the evacuations remain slightly colored. Bryonia is specifically indicated by extreme languor, or rather by a general feeling of illness. Aconitum has been recommended and used in jaundice, but it seems to us very improperly in what we call simple jaundice. It is undoubtedly adapted to jaundice depending upon an hyperremic enlargement of the liver, or upon capsular hepatitis, but not in painless or catarrhal jaundice. According to our provings Aco- nite has no colorless stools, hence is not appropriate in jaundice of the highest grade. Belladonna has among its symptoms the two most essential char- acteristics of jaundice, yellow color of the conjunctiva and com- pletely colorless stools. We have shown before, its intimate rela- tion to the liver. In our Periodicals, we indeed find some cases of chronic jaundice reported cured with Belladonna; we imagine, however, that it will prove much more efficient in the acute forms with fever, both if the jaundice is caused by an acute catarrh, and likewise in the more malignant forms of the disease. The peculiar pulse, first slow and afterwards very rapid, and the intense head- ache, which easily becomes associated with violent delirium, are two circumstances that we do not find in any other remedy, with more marked and definite distinctness, than in Belladonna; these render this remedy one of great importance in malignant jaundice. Icterus, Aurigo, Jaundice. 561 We here subjoin the remedies that compete with Belladonna in the more malignant forms of this disease: Digitalis purpurea is superior to Belladonna, on account of its re- markable action upon the pulse. What distinguishes Belladonna from Digitalis is, that with the former the face is injected and Hushed, whereas Digitalis is indicated by paleness of the counte- nance. For the rest we refer the reader to our remarks on Digita- lis, in the article on chronic hepatitis. The objection that Digitalis manifests its action upon the liver subsequently to that upon the heart, whereas in jaundice the liver is primarily affected, is easily met by the suggestion that it is not by any means shown what causes the slow pulse in jaundice, and hence which organ is first acted upon by Digitalis. A good deal in this respect depends upon the individuality of the patient, and for the present we shall have to content ourselves with the peculiar and exceedingly character- istic totality and connection of the symptoms. Phosphorus has likewise been alluded to in the article on chronic hepatitis. It is strange that Hartmann should have omitted this remedy among those that cause symptoms of jaundice; and that even Sorge, in his treatise on Phosphorus, does not seem to think much of the relations of this drug to the liver. We are guided by several cases of poisoning, which evidently have not come under Sorge's knowledge, and which have induced us to speak favorably of Phosphorus in acute atrophy of the liver.* We cannot dwell upon this subject more fully in this place, on account of its special character, only it seems to us that Sorge restricts the sphere of Phosphorus in diseases of the liver too much, when he says: " In chronic catarrh of the stomach this case authorizes the employment of Phosphorus as a homoeopathic remedy, if bile-pigment is at the same time found in the urine in consequence of a sympathetic affec- tion of the biliary ductsand when he afterwards points to Phos- phorus in fatty liver in connection with uraemic and slight icteric phenomena. It is our opinion that at the present time we are not as yet acquainted with a better homoeopathic remedy for the tolerably obscure connection between pneumonia and jaundice than Phos- phorus ; likewise for the connection of jaundice with symptoms of a highly developed affection of the brain. At all events the cura- tive sphere of Phosphorus, in this respect, has to be verified by clinical observations, and all we can do is to point out the great similarity between the disease and the action of the drug. * See remarks in brackets, page 549. H. 562 Diseases of the Liver. Sepia has been repeatedly found useful in the case of patients, especially females, who look as if they were afflicted with liver- complaint, or who are inclined to affections of the liver; their com- plexion is of a bright rather than pale color, with brown-yellow color of the eyelids. Besides other symptoms showing the homceo- pathicity of this drug to jaundice, we find among its pathogenesis the leading symptom, namely, the absence of color in the alvine evacuations. The general character of Sepia shows that it is not so well adapted to the acute as to the chronic form of jaundice, with frequently recurring paroxysms. Sulphur, the importance of which has been already pointed out, is likewise suitable only in chronic cases, and then only if material changes exist in the structure of the liver. Chamomilla is recommended more frequently than it deserves. It is particularly indicated in the icterus neonatorum, which, how- ever, may likewise pass off without any treatment, generally in a short time, and favorably. China, one of our chief remedies in hepatic diseases, is likewise suitable in the chronic, but not in the febrile form of icterus. China is particularly indicated by the condition of the stomach. Aversion to food, especially meat; perverse appetite; nausea, with canine hunger; distention of the abdomen after every meal; oppression of the stomach ; eructations; bitter or bitter-sour taste ; vomiting of mucus; a sallow and sickly complexion ; dryness and roughness of the skin ; languor and weariness ; constipation, alternating with diarrhoea; clay or loam-colored faeces, constitute the main indica- tions. China renders good service if the liver-complaint was caused by Mercury or malaria, and likewise in the threatening form of icterus, caused by excessive loss of animal fluids, blood, etc. Fe- males passing through the critical period, are frequently attacked with symptoms of icterus, without any great changes in the liver having taken place. There is no necessity of dwelling any further upon the special indications of other remedies in jaundice. This is the more un- necessary, as chronic jaundice is simply a symptom of the various forms of liver-complaint that have been described in previous chap- ters. We here subjoin some of the more important medicines that have not been mentioned before. In febrile jaundice: Pulsatilla, Rhus toxicodendron, Veratrum album, also Conium and Cuprum, the last-mentioned agent under the same circumstances as Belladonna, Digitalis purpurea, Phosphorus, if the blood is poisoned by the bile. Icterus, Aurigo, Jaundice. 563 In chronic jaundice: Arsenicum, Aurum, Acidum nitricum, or sul- phuricum, Carbo Vegetabilis, Calcarea, lodium,-Acidum nitricum and lodium are of particular use in jaundice caused by Mercury. According to Hartmann, lodium is more especially indicated in the deeply-penetrating icterus of dyscrasic individuals. We deem it advisable to transcribe Hartmann's arrangement of the remedies for icterus, in accordance with the exciting causes of the disease; he says, Part I, page 466: If the jaundice is caused by vexation, anger, mortified feelings, we use: Aconitum, Bryonia, Chamomilla, China, Ignatia, Nux vomica, Natrum muriaticum, Sul- phur. If caused by a cold, sudden change of temperature: Dul- camara, Nux vomica, Chamomilla ; if caused by overloading the stomach and indulging in improper diet: Pulsatilla, Antimonium, Bryonia, Carbo vegetabilis, Chamomilla, Natrum, Nux vomica; if caused by abuse of chamomile: Ignatia, Nux vomica, Pulsatilla, China, by abuse of Mercury: China, Hepar sulphuris, Sulphur, Acidum nitricum, Asafoetida, lodium, Arsenicum', by abuse of Cin- chona: Pulsatilla, Arsenicum, Mercurius, Ipecacuanha. The jaun- dice caused bv the pressure of the impregnated uterus upon the liver, is probably most promptly relieved and removed by Nux vomica, Ipecac, and Natrum muriaticum. The dyspeptic phenomena which sometimes remain after an attack of jaundice, such as loss of appetite, aversion to food, nausea, oppression at the stomach after eating, obstinate constipation and the like, most commonly yield to Bryonia. The diet of icteric patients should be regulated with the same care as if some important disease of the liver had to be removed, the more as in jaundice running a long course, we cannot be sure whether some important defect in the condition of the liver ought not to be suspected. Marked symptoms of gastro-intestinal catarrh should not be overlooked. Avoiding fat food, spirits and fermented articles of diet, is of great importance ; the use of ripe fruit, in any shape and mode of preparation, is much to be recommended. [To the list of remedies indicated in the preceding paragraphs we will add the following: Gelseminum or the yellow jessamine; it causes creamy, papescent stools, and seems to exert a depressing influence upon the secretion of bile. Hydrastis or the golden seal, has cured several inveterate cases of jaundice; it was given in large doses of the mother-tincture. We refer the reader to Hale's New Remedies, second edition, page 576. Podophyllum peltatum, or mandrake, has cured jaundice; it may be given in the second or 564 Diseases of the Liver. third trituration, or even higher. We have found it excellent i:i moderate attacks of jaundice without fever. Sanguinaria or the common blood-root, is likewise frequently used in jaundice by eclectic physicians. In homcepathic practice our experience with this remedy is not yet very extensive. II.] The tendency inherent in the bile to form firm concretions, is quite considerable; hence biliari calculi are a common occurrence. The causes of such concretions are very obscure; they occur in in- dividuals of the most varied constitutions, and pursuing the most diversified occupations, diet and habits of life. Their formation seems to be most promoted by a copious supply of animal food, and by the use of lime-water. As a rule, such calculi are not met with until after the thirtieth year; they occur more frequently among females, and their formation is promoted by every circumstance that causes an arrest of the flow of bile. Biliary calculi are chiefly found in the gall-bladder; here they are met with in large numbers, seldom as solitary concretions. In the latter case their form is oval or rounded; where several concre- tions are present they assume an angular form with more or less curved surfaces, in consequence of the sides being rubbed off, and of the pressure and counter-pressure they exert upon each other. They mostly consist of a nucleus, round which a lighter-colored layer of lime has been deposited, which is again surrounded by an envelope composed principally of cholesterine and bile-pigment. Their color is at times light, at others white, yellow, dark-brown, dark-gray or black. They are not very firm; in their recent state they are friable and can easily be crushed. Bilious concretions may be without any danger to the individual affected with them; they may be expelled without any pain; on the other hand they may acquire importance from the pains which they cause and from the lesions to which they give rise. In this respect, the size of the concretions is of much less importance than their shape and the internal condition of the gall-bladder; biliary calculi of the largest size sometimes cause the least distress. Hence the symptoms caused by these concretions vary a great deal according to their shape and intensity of pain. In slight cases a short-lasting spasmodic pain corresponding to the region of the gall-bladder, accompanies the expulsion of the calculi into the bowels. In other cases the pain is continuous but not violent 5. Cholelithiasis, Biliari Calculi. Cholelithiasis, Biliari Calculi. 565 sometimes it is paroxysmal. It is only in the smallest number of cases that the calculi cause regular attacks of colic. This colic com- monly sets in all at once, the patient feeling otherwise perfectly well; it is attended with a more or less violent pain in the region of the gall-bladder. Generally this pain increases very rapidly in intensity; it is an intolerably burning, boring pain, and, while in- creasing in intensity, radiates over the chest and abdomen to vary- ing distances. At the same time the region of the liver becomes exceedingly painful to pressure, it is apt to bloat, and, in conse- quence of the contraction of the abdominal muscles, the abdomen becomes hard as a board. The pain is generally so distressing and acute, and the patients find it so difficult to breathe, that they toss about in the greatest agony. The general constitutional condition is likewise affected by the pain according to the sensitiveness of the patient and the duration of the pain. Although there is no fever, yet the pulse soon becomes small, filiform, almost uncount- able, disappears even entirely, although the heart is in tumultuous motion; the skin becomes correspondingly cool and is covered with a cold perspiration, the complexion is cadaverous. The pain is most commonly associated with distressing vomiting and retching which terminates in a painful hiccuping. The nervous system participates in the violent racking of the frame; the patient is attacked by violent chills or local cramps, especially of the gastroc- nemii muscles, or else by violent convulsions at times tonic, at others clonic, which are apt to terminate in syncope. Such par- oxysms sometimes last a few hours, at others a day and longer. The pains usually all cease as soon as the calculus enters the intes- tine ; sometimes they disappear gradually or have complete remis- sions according to the condition of the excretory ducts of the gall- bladder, or to the peculiar shape of the calculus which at times adheres and at others moves on again. After the pain ceases, all the incidental ailments generally disappear very rapidly, and noth- ing remains but languor and weariness. About this time icterus makes its appearance in different degrees of intensity. The appear- ance of icterus depends upon the length of time that the excretory ducts of the bile remain obstructed. If the obstruction only con- tinues a short time, the icterus may not break out at all; on the contrary, if the obstruction lasts long, the jaundice may already set in during the pains. As regards frequency the attacks vary, but the same individual is scarcely ever attacked once, only; be- cause, as we stated before, solitary concretions cause pain only ex- 566 Diseases of the Liver. ceptionally, whereas a multitude of smaller concretions that have become sharply angular by rubbing against each other, penetrate more easily into the excretory duct and cause a more acute irri- tation. The terminations of colic from the presence of biliari calculi, or rather the consequences of cholelithiasis, vary a great deal. Death scarcely ever takes place in consequence of an attack of such colic. If the calculus remains incarcerated for a long time, and fills at the same time the whole space of the excretory duct, we obtain a pic- ture of a fully developed icterus with the various symptoms pre- viously described. If the incarceration is not removed, suppura- tive hepatitis, inflammation of the gall-bladder and its excretory ducts may be the consequence. In the last-mentioned case the patients succumb to peritonitis arising from perforation of the gall- bladder, or, if the gall-bladder should have become adherent to the surrounding parts, the patients fall away gradually until death ends their sufferings. The diagnosis of biliari calculi is generally very easy and sure. The scat of the pain, the sudden beginning and the equally sudden cessation of the pain, and above all the discharge of bilious con- cretions with the feeces, establish the diagnosis. If the concretions are soft, they may not appear in the faeces, for the former may break up and scatter during their passage through the intestines. If the colic is not violent, it is difficult to recognize its true char- acter, especially if the symptoms of the stomach are not very prom- inent and the attack runs a slow course. The swelling and pain- fulness of the region of the liver may remind one of hepatitis, or else the symptoms may be those of acute hypereemia of the liver* The spasmodic symptoms do not generally follow immediately after the commencement of an attack, so that it is scarcely possible to confound it with eclampsia, epilepsy, etc. The treatment involves an abbreviation and mitigation of the attacks of colic, and a prevention of all further mischief from it; at the same time we must try to prevent the return or reproduc- tion of new concretions by proper treatment. In treating this form of colic, every independent observer must deem it highly improbable that medicine can act upon these biliary concretions, the examples of cure with which all such objections are met, do not remove the suspicion whether the biliary calculi might not have passed through the duct with equal rapidity with out any medicine being administered for that purpose. But if the Cholelithiasis, Biliari Calculi. 567 interests and feelings of the patient and his relatives impose upon us the duty of trying the effect of proper medicines, on the other hand we should not be in too great a hurry to attribute our success to the action of the medicine and, in accordance with former favor- able observations, to establish a prognosis that might fail us to our detriment. With these restrictions and reservations we here trans- cribe Hartmann's remarks concerning this form of colic, observing at the same time that, in our own practice at least, we have never yet obtained any degree of evident success by adopting the treat- ment he proposes. " One of the leading remedies in this disease is Chamomilla, in frequently repeated, not too powerful, doses. It is appropriate, for the consequences of suppressed mortification of the feelings during a meal, in persons of a choleric temperament, but will prove in- effectual if the exciting cause continues to act afresh all the time. Chamomilla is indicated by the following symptoms: painful pres- sure in the pit of the stomach, in the stomach and hypochondria, especially after eating, with regurgitation of the ingesta, followed by bitter or bilious vomiting, with restless, desperate tossing about and violent headache as if the head would burst." ''Under similar circumstances, only with greater intensity of the symptoms, after suffering an internal, gnawing humiliation or some unworthy treatment, Colocynthis ranks above Chamomilla in colic from biliary calculi. These causes will always invite the physician's attention to this drug, more especially if bilious vomiting and a painful pressure in the region of the stomach are present. " Both these remedies failed us in. several cases where I fancied I had chosen the right remedy, until the yellow color of the skin led me to Digitalis. It acted with remarkable promptness when the aching and heavy pain in the stomach was accompanied by exces- sive and violent green vomiting, a rapid and sudden prostration of strength and frequent attacks of syncope. The stools generally had a whitish color, had to be brought away by injections, and the urine had a dark color. In this fearful disease I have likewise employed Laurocerasus, China, Veratrum, Cuprum with more or less success in accordance with the most prominent symptoms. It is a difficult matter in this terrible agony, where the patient is un- able to give the least explanation of his sufferings, and the physi- cian has to be guided altogether by his own surmises, to hit every time upon the right remedy. Nux vomica and Nux moschata have likewise done some good, the former if the spasm was centred in 568 Diseases of the Liver. the stomach, and had been preceded for some days by retching and eructations. Injections of oil always afforded some relief, even if no fecal matter came away; the intermissions, at least, seemed to last longer after such injections; likewise after frictions with warm oil in the hypochondria. "No remedy,however, has seemed to act with more lasting bene- fit than Arsenic, even in the most violent cases, when the patients lay without consciousness, with the pallor of death in their coun- tenances and covered with the sweat of anguish, in a state of per- fect apathy; when the syncope never ceased, and was only inter- rupted by occasional fruitless efforts to vomit. After a single dose the vital reaction seemed to be restored in five minutes, and went on until the disease was entirely subdued. At a later period, when- ever the disease set in with unceasing cardialgia and colicky pains of the most violent kind, with horrid burning in the affected parts, frequent vomiting, excessive weakness, constipation and a visible reflection of the distress in the countenance, I gave Arsenic from first to last." Let every reader pass his own criticism on the preceding state- ments and draw his own conclusions relative to the errors they contain. If we take symptomatic similarities for our guide, Ar- senic is undoubtedly the best remedy, the more as it generally exerts a wonderfully soothing influence upon the irritated nervous system; it seems to us as though no other medicine could dispute the rank with Arsenic. Beside this remedy, Veratrum and Cocculus are excellent in this disease; likewise Belladonna although less fre- quently. Of more decisive value than Hartmann's injections of oil, are the moist and warm fomentations in the region of the liver, which will likewise attract the attention of the horrified and im- patient relatives. They may be applied as warm as possible. Where the parts are not too painful, gentle kneading with the fist has a decidedly soothing effect. Against a tendency to the formation of biliary calculi, a careful diet is the most effective remedy, and Nux vomica and Sulphur are admirable supports. If the biliary calculi are numerous, which can be inferred with tolerable certainty from the angular shape of those that are passed, the truly sovereign remedy is the water of Carlsbad, the waters of Marienbad and Kissingen being less effi- cient. We cannot accede to Hartmann's opinion, who advises us to use the artificially prepared water, if the natural waters cannot be had. Whether a fruit-cure, especially the grape-cure, will prove Carcinoma Hepatis. 569 efficient, has not yet been clearly ascertained; at all events veg- etable acids are the best means to properly regulate the functions of the liver. Whether Turpentine alone is sufficient, has not yet been satisfactorily shown. It is a chief ingredient of Durand's celebrated remedy for this trouble, and probably the only efficient one. Generally the same diet should be adopted that has been recommended in affections of the liver; it cannot be regulated with sufficient care. The deposition of carcinomatous growths in the liver is one of the most common accompaniments of what is generally designated as the carcinomatous diathesis. Where the carcinoma is restricted to the liver, the causes of the disease are quite obscure, and it is so much more difficult to trace them to their first beginning as their development is gradual and had commenced long before the time when the patient first complained of his trouble and the physician was able to establish a certain diagnosis. Carcinoma of the liver is most commonly a consequence of surgical operations on carcino- matous degenerations in other parts of the body, in consequence of which the cancerous virus was excited into action throughout the body. For these reasons carcinoma of the liver constitutes one of the most frequent forms of the carcinomatous disease. The most common kind of cancer of the liver is the fungus me- dullaris, which generally has several foci, and seldom appears as a solitary fungus, but, as an infiltrating substance, may likewise per- meate a large portion of the liver. The single tubercles vary from the size of a pin's head to that of a fist, and beyond; they gener- ally exhibit a whitish tint, and, only when very soft, their color is red or even black in consequence of hemorrhagic effusions. They are most commonly located near the surface, beyond which they grow in the form of semi-globular elevations, which generally pre- sent an umbilical depression. They may be changed to ichor, or degenerate into fat or form capsular cysts. The symptoms caused by carcinoma of the liver, differ in inten- sity according to the size and locality of the degeneration, so that the disease sometimes remains without any symptoms. Usually the disease commences with the vague symptoms of hypersemia or of fatty liver, with pressure and a feeling of fulness in the right hypochondrium. As the cancerous tubercles near the surface, par- tial peritonitis usually sets in, with occasionally more or less consider- 6. Carcinoma Ilcpatis, Cancer of the Ci ver. 570 Diseases of the Liver. able painfulness, which is, of course, less than in acute hepatitis, but as a rule exceeds that of any other affection of the liver and, on that account, is an important diagnostic sign. If the carcinoma is deep-seated, the pain may be entirely absent. An important item in the diagnosis of carcinoma of the liver is the rapid enlargement of this organ even to an enormous size, and the consequent bulging of the margin of the ribs. The carcinomatous protuberances upon the surface of the liver can generally be felt. The immediate conse- quences of carcinoma are, a suspension of the biliary secretion and obstructions in the portal circulation. Icterus may be entirely ab- sent; but if biliary ducts are compressed by carcinomatous tuber- cles, a more or less marked icterus develops itself, the stool retain- ing its color; it is only when the excretory ducts of the bile are compressed, that the icteric tint becomes excessive, in which case the icterus constitutes a valuable diagnostic sign. If the carcinoma is seated on the portal vein and compresses it, serum very soon accumulates in the peritoneal cavity, the quantity of which is pro- portionate to the degree of the compression and the size of the corn- pressed branches, even as we stated in a former chapter when treat- ing of the pathological processes accompanying chronic hepatitis. The constitutional symptoms vary a great deal. Sometimes the stomach and intestinal canal are much disturbed by the affection of the liver, and sometimes they remain perfectly free from all traces of trouble. This circumstance cannot always be accounted for by the influence of the carcinoma upon the secretion of bile. On the other hand the nature of the affection shows itself at an early stage, by the changes it produces in the general condition of the patient, who becomes a prey to the peculiar depression of spirits engendered by the carcinomatous cachexia, emaciates and falls away without any apparent cause for these changes; for the appetite may remain normal, nor are the excretions increased. Indirect consequences are: the spread of the carcinoma to neighboring organs, carcino- matous degenerations in the peritoneal cavity, diffuse acute or chronic peritonitis, ichorous dissolution and discharge outwardly. As a rule, Carcinoma of the liver is an incurable affection which must prove fatal sooner or later. The duration varies from a few months to a number of years, and depends upon the rapidity with which the cancer grows. Carcinomata that break out after opera- tions, are generally more speedily fatal, than such as are restricted to the liver. A treatment pursued with a view of curing the disease, has very Carcinoma Hepatis. 571 small chances of success. Reported cures should be received with a great deal of distrust. Our duty, therefore, seems to be to pur- sue a palliative course by endeavoring to remove single prominent symptoms, without troubling ourselves about the general disease. No remarkable success can even be expected by this treatment. It is not possible to point out the medicines that may have to be used for such a purpose. If we desire to act upon the liver, the medi- cines that will answer our purpose in this direction, together with the necessary therapeutic instructions, may be found mentioned in chapters 3d and 4th. For other disturbances we refer the reader to the respective chapters where they are treated of. It is strange that no mention is made of this not unfrequent disease in Hart- mann's work, as though he considered all treatment futile. We have already stated that our Periodicals do not contain a single reliable cure of carcinoma of the liver. The water of Karlsbad is said to have effected a few cures. The use of this remedy should not be delayed too long, nor the chances of a cure be lessened by an ob- stinate adherence to other remedial agents. We have dwelt upon carcinoma of the liver somewhat exten- sively, because the diagnosis and prognosis of the disease are of great importance. The following points are essential to a correct diag- nosis. Extraordinary enlargement of the liver with bulging of the margin of the ribs; unequal, knobby feeling of the surface of the liver; paroxysms of great painfulness; a high grade of icterus with swelling of the liver; marasmus which cannot be accounted for from any other causes, and is accompanied by derangements of the liver; carcinomatous symptoms in other organs; carcinomatous de- generations that had been operated on previously. [Some years ago we treated a lady for headache; for years past she had been subject to the most agonizing attacks of a stupefying headache; during the attack her generally sallow complexion changed to a dark-browr hue. For the last few years the attacks of the headache had beer fiercer and more frequent. Nothing relieved her but a dose of Aloes, which opened her bowels which were habitually costive. A post-mortem examination revealed extensive cancerous degener- ations in the liver and spleen, that had remained utterly unknown and unsuspected for years. During the last six weeks of her life the carcinomatous degeneration invaded the mammae and the inguinal glands. There was no enlargement or painfulness of the liver or spleen. II.] We have made no mention of the echinococcus, another aftec- 572 Diseases of the Spleen. tion of the liver; this parasite is of very rare occurrence in our climate, nor are we acquainted with any remedy by means of which this disease could be cured, hence a treatise on the diagnosis of this disease would be valueless in a therapeutic point of view. B. DISEASES OF THE SPLEEN. The pathological conditions of the spleen belong to the most ob_ score and least known points of Pathology. This is mostly owing to the circumstance that it is only during the last twenty years that more careful investigations concerning the functions of this organ have been instituted, which, on account of inherent difficulties and a liability to deception, have not yet yielded any very brilliant re- sults, and have more especially shed very little light on the func- tional disturbances to which the spleen is liable. We know most undoubtedly that in leucaemia the spleen is generally very much dis- eased ; but whether the disease is the cause or consequence of the leucaemia, is not yet decided; for the circumstance that the spleen is one of the great organs of sanguification, does not justify the hy- pothesis that leucaemia originates in the spleen as an abnormal phy- siological process; we have not as yet got that far in our knowl- edge. However, although we are not yet able to draw many con- clusions from the still mysterious functions of the spleen, the ana- tomical structure of this organ suggests an explanation for many of its morbid conditions. The tissue of the spleen is softer than that of any other glandular body, and contains a number of cavi- ties that seem to be formed by the veins. This circumstance alone enables it to receive a quantity of blood into its interior. In addi- tion to this, however, the capsule of the spleen is very flabby, and only capable of slight resistance to the pressure of the blood from within. The tissue of the spleen, moreover, possesses only a slight degree of elasticity, so that, if engorged with blood, it returns to its former condition only with great difficulty. After receiving the larger veins of the stomach and other less important ones, the veins of the spleen pour their contents into the vena portarum. The spleen is only held loosely in its place by folds of the peritoneum. These anatomical data account for the frequent participation of the spleen in diseases of the abdominal viscera, for the influence of affections of the spleen upon the stomach, and the proportionate scarcity of a separate disease of the spleen. Hence we see diseases Splenitis, Inflammation of the Spleen. 573 of the liver that impede the flow of blood from the vena portarum, or, in general, all diseases that interfere with the reflux of the blood from the abdominal cavity, such as emphysema of the lungs and diseases of the right heart, accompanied by considerable enlarge- ment of the spleen. The loose attachments of the spleen explain to us how this enlarged viscus may sometimes leave its normal posi- tion by gravitating downwards. Again the connection of the veins of the stomach with the vena lienalis explains how obstructions in the circulation of the blood in the spleen can easily result in vomit- ing of blood. The changes which the spleen undergoes in acute infectious dis- eases, are so far, however, inexplicable. Enlargement of the spleen is principally seen in typhus and intermittent fever; in the former it is said to determine the character of the disease, which is not so. Leaving out intermittent fever, where a well defined anomalous change in the blood cannot well be proven, splenetic tumors are principally caused by such morbid conditions as result in a striking alteration of the composition of the blood. Beside these morbid changes in the spleen where the enlargement of this viscus appears like an isolated symptom, without having the character of an idiopathic disease, we meet with splenetic tumors that do not seem to originate in any specific or known cause, but probably because the patients do not know how to account for them. These tumors are exactly like hypertrophy that had arisen from continued sanguineous engorgement, and which, after the removal of the primary disturbance, remained behind as an idiopathic dis- ease. For instance, in malarious districts they are often met with in individuals who never had fever and ague. From these statements it is evident that there is no special thera- peutics for hypertrophied conditions of the spleen, any more than it is possible to present them as some special form of disease. If, however, we should be called upon to treat an hypertrophy of the last-named kind, the chief remedies would be: China, Arsenicum, and Natrum muriaiicum, less frequently Lycopodium. A fully developed splenitis is a very rare disease, the lower grades of this disease are undoubtedly more frequent, although not easily recognized with positive certainty on account of the vague- ness of the symptoms. The causes of this disease are very indefinite. Injuries, running, Splenitis, Inflammation of the Spleen 574 Diseases of the Spleen. excessive bodily exertions, a cold, suppression of normal or habitual losses of blood, spread of the inflammation of adjoining organs, are mentioned as such causes, but with very doubtful propriety. The inflammation is either seated in the capsule or substance of the spleen; the former is the more frequent of the two, in which case the splenitis is a sort of circumscribed peritonitis which does not affect the organ itself. An inflammation of the substance of the spleen almost always affects only a part of the organ, and very commonly terminates in the formation of an abscess. We tran- scribe Hartmann's statement of the symptoms, with this remark, however, that his definition of a splenitis will seldom be found ap- plicable to the fully developed disease. "Violent, stitching, boring, tensive, throbbing pains in the left hypochondrium, region of the spleen, spreading to the shoulder, clavicle, nipple, or else to the stomach, back, and downwards to the kidneys; they interfere with the act of respiration, constrict the epigastrium, are aggravated by pressure on the left hypochondrium, by motion and deep breathing, coughing, sneezing, etc., and make it either difficult or impossible for the patient to lie on the left side. This painfulness continues unabated; sometimes the temperature in the region of the spleen is sensibly higher, and, if the lower and anterior portion of the spleen is affected, it is felt anteriorly in the region of the ninth and tenth rib like a hard, round, not very mov- able body which is exceedingly painful to pressure. The following accompanying symptoms are frequently present: Oppression of breathing, anxiety, cough, dyspeptic symptoms, vomiting, burning in the region of the stomach, frequently a bitter or sour taste with burning- eructations, retching-, vomiting-which affords no relief, hie- cough. Most every attack of splenitis is attended with vomiting of blood, almost at the beginning of it; at first the blood is usually mixed with bile and mucus; it looks like serum, except that it has the blackish color of venous blood. Afterwards the blood that is vomited, is thicker, blacker and thrown up in larger quantity. Ob- scuration of sight, vertigo, disposition to faint, are frequently pres- ent, especially in the erect position. The fever is a synocha, the thirst distressing, pulse changing, at the left radius it is often sus- pended, intermittent; the urine is burning-hot, dark-brown, less fre- quently of a dirty, saffron-color. The fever is of the remittent type, sometimes even quartan or tertian." The disease runs its course in from a week to a fortnight, after which sweat, critical urine, phlyctaenee around the mouth, and occa- Splenitis, Inflammation of the Spleen. 575 sional attacks of moderate epistaxis set in, and the inflammation and swelling are dispersed. Induration and permanent enlargement of the spleen may remain as consequences of the inflammation. Death rarely ensues; it is brought about by softening or suppura- tion of the parenchyma. A slight degree of inflammation of the capsule is not a very rare occurrence. The violent stitches which are suddenly felt in the region of the spleen after a violent effort, such as running immedi- ately after a copious meal, and which stop one's breath and are dis- tinguished from ordinary splenetic stitches by continuing unabated for one or more weeks, are undoubtedly manifestations of this cap- sular inflammation. The general health is not much disturbed, and there are no symptoms present that might lead one to infer the ex- istence of functional disturbances of the spleen. Such a condition can scarcely be regarded as a simple hyperaemia. In order to obtain a correct diagnosis of organic alterations of the spleen, it is important that the situation of the organ should be carefully determined, and that the direction which the en'argement generally takes should be exactly known. The normal spleen yields a dull sound on percussion, from the free border of the eleventh rib upwards and backwards, within a space of two inches to two inches and a half. As a rule the spleen enlarges first anteriorly, hence the dulness is more sensibly perceived towards the margin of the false ribs, beyond which it is scarcely ever felt to a great'extent. It is only when the enlargement is considerable that the dulness is felt beyond the eleventh rib; and in such a case the spleen can be dis- tinctly felt. In particular cases the dulness is felt along the whole of the left half of the abdomen, down to the iliac bone. The homoeopathic treatment of splenitis has not yet been firmly established by practical experience, Hartmann's statements in this respect are speculative and require to be verified by clinical observa- tions. We here transcribe his remarks concerning the treatment of splenitis, because they contain the names of all the leading remedies in this disease. " In idiopathic splenitis the fever is generally more acute than in splenitis complicated with other diseases; a few doses of Aconite will always improve the case. If this remedy only moderates the fever without removing any of the main symptoms, it would be foolish to persist in the use of the drug with a view of obtaining a result of this kind by sheer force as it were. Under such circum- stances a remedy in homoeopathic rapport with the symptoms should 576 Diseases of the Spleen. be given. We have such a remedy in Nux vomica, more particu- larly if the sensation of an internal swelling; the stitching pain which is aggravated by contact and motion; the spasmodic pain in the left hypochondrium, with qualmishness, especially in the pit of the stomach; the aversion to food and the fainting fits; the vomit- ing of blood or the mere gulping up of a dark blood from the stom- ach are attended with other gastric derangements, dyspeptic condi- tions, constipation, etc., and previous derangements, the constitution and temperament of the patient likewise point to Nux. "Arnica is an excellent remedy in this inflammation, if the blood, which is vomited up, is coagulated, the color is between bright- and dark-red, and the respiration is interfered with by a continued aching, stitching pain in the left hypochondrium. "Next to this remedy we have Cantharides, not, however, unless the kidney of the same side is inflamed and there is a continual retching with discharge of a small quantity of blood, a stitching pressure and feeling of fulness in the left hypochondrium as far as the dorsal vertebrae, with tossing about as if in a desperate agony. "Belladonna is undoubtedly an efficient remedy in splenitis; sanguineous congestions constitute the proper sphere of action for Belladonna, and congestion of the spleen is the forerunner of inflam- mation of this organ. Although the symptoms of splenitis are very obscure, yet even if the inflammatory symptoms, as we see them, should lead us to suspect an inflammation of some of the adjoining organs, Belladonna would still be indicated by its homceopathicity to the latter. Chamomilla, likewise, deserves being mentioned, for a tensive and burning pain in the left hypochondrium is character- istic of this drug, likewise a pressure in the pit of the stomach, frequent hiccuping. " Although China is of very little use in really inflammatory dis- eases, yet I am satisfied that, after the fever has been moderated by a few doses of Aconite, it will prove of eminent service, if the vital strength has become depressed by the frequent vomiting of blood, and the pinching pressure, which is experienced at the com- mencement of the disease, is changed to sharp, cutting stitches, with swelling and hardness of the spleen. Nor is it out of place, if frequent diarrhoeic stools set in, with discharge of a dark, coagu- lated blood, although Arsenic may deserve the preference under such circumstances, especially if the patient complains of a violent burning pain in the spleen with swelling of this organ, in connec- tion with an uninterrupted anxiety and throbbing in the pit of the Splenitis, Inflammation of the Spleen. 577 stomach which is distinctly felt by the finger; likewise if the spleen is swollen and painful and the patient is prevented by the tearing stitches from lying on that side. The accompanying fever is charac- terized by a dry, burning heat, with great thirst, restlessness, prae- cordial anguish, sallow complexion, dry and cracked lips, white coating of the tongue, bitter taste in the mouth, nausea, aversion to food, etc." "Bryonia is homoeopathic in the absence of diarrhoea and vomit- ing of blood; the stitching pains in the region of the spleen are attended with constipation. In my opinion, Bryonia and Pulsatilla are most frequently indicated in inflammation of the capsula of the spleen, if the stitching and aching pain is very much aggravated by every motion, and a swelling is distinctly perceptible in the pain- ful region." " Homoeopathic physicians, myself included, have found the cura- tive power of the above-mentioned medicines in splenitis confirmed by experience; however, they are not the only remedies in this dis- ease, but, to judge by the symptoms, the following may likewise prove efficacious: Laurocerasus, Mezereum, Drosera, Stannum, Plum- bum, Spigelia, Lycopodium, Carbo vegetabilis, and others." To these statements we take the liberty of adding a few remarks. Hartmann's predilection for Aconite has undoubtedly induced him to assign to this agent a high place among the remedies for splenitis, although he admits that the homoeopathicity of Aconite to this dis- ease is not very striking. Belladonna seems the more appropriate even at the onset, especially if the stomach is very much afl'ected, which is almost always the case. Among Hartmann's last series, Mezereum is the only remedy that may prove useful, the balance are not at all appropriate in such an acute disease, at any rate they have no very strikingly characteristic symptom. On the other hand Stannum, Plumbum, Carbo veg., and more particularly Lyco- podium, may be tried, if the inflammation persists and finally passes into the chronic form in the shape of a splenetic tumor. Beside the above-mentioned remedies we have: Berberis, Bromuyn, Agnus cas- tus, and Mercurius; the last-mentioned remedy more, from general reasons based upon analogy, than by virtue of physiologico-homce- opathic similarities. In the chronic form, Podium and Sulphur are likewise indicated. It is desirable, on account of the scanty mate- rial, that every case of splenitis, treated homoeopath ically, should be published. This is the only method of obtaining satisfactory evidence regarding the reliability of the above-mentioned drugs as homoeopathic remedies for this disease. C. DISEASES OF THE PANCREAS. In our opinion the pancreas is much less accessible than the spleen, and the knowledge we possess of its morbid alterations is as yet so imperfect and uncertain that it is impossible to infer the nature of these alterations from the phenomena on the living; we can at most decide that the pancreas is diseased. We have com- municated a case in the Zeit. fur Hom. Klinik, 1857, which, as far as we know, is the only clinical case of this disease that has as yet been recorded in our Journals, and corresponds to the picture of what our modern pathologists have designated as sub-acute inflam- mation of the pancreas. We here subjoin a brief recapitulation of the symptoms. Appetite slight, but occasionally a sensation of hunger; tongue thinly coated, taste bad but not particularly definable; directly under the stomach, above the navel, extending from the mesian line to the left, and at a corresponding spot of the back, insuffer- able pains that cannot be described, exacerbating in the evening or during the early part of the night. The painful region is some- what sensitive to hard pressure, but no swelling can be discovered. Five or six hours after eating solid food, vomiting sets in, which is sometimes sudden and violent, never preceded by nausea, and mit- igating the local pain; a slimy fluid resembling serum is vomited up, containing food if any had been partaken of shortly before, not otherwise. In addition: headache, languor, anxiety and despond- ing mood, restless sleep, scarcely any fever, expression of suffering; marked emaciation with occasional diarrhoea. There was, how- ever, no icterus which is always present to some extent in pan- creatitis. Nux vomica, Cuprum, Podium, Veratrum album, Arsenicum were given in vain. Mercurius and Sulphur might perhaps have been tried. After the Sulphate of Atropine a most decided improvement set in. Belladonna might perhaps have acted just as well; at any rate we should try it in a similar case. The above-mentioned symp- toms might likewise suggest Digitalis purpurea which is their homoeopathic simile. Phosphorus has the chief symptom, the vom- iting. It is of importance to fix the diagnosis in this affection. It has peculiar difficulties, especially if the vomiting is not sufficiently characteristic. The disease is readily confounded with an affection 578 Diseases of the Pancreas. 579 of the stomach, especially with chronic catarrh of this organ. But if we keep an eye on the fact that actual stomach-symptoms are absent; that the vomiting, in case it should occur in an attack of catarrh of the stomach in such a manner and at such a time, must always depend upon considerable changes of the pylorus having no symptomatic manifestations; that the pain is felt in a different locality from what it is in catarrh of the stomach; that the course of the disease is subacute, not chronic; that finally the stool is characterized by peculiarities that are not present either in catarrh of the stomach or bowels; it would seem as though the diagnosis could not be very difficult. Pancreatic affections attended with a decrease of the secretion of saliva, are beyond the reach of our present means of diagnosis. It has frequently happened that an emaciation that could not be accounted for by any morbid action taking place in other organs, has been traced to structural alterations of the pancreas. Consider- ing what a powerful influence the saliva has upon the digestion, we can easily understand that a defective quality or a deficient se- cretion of the pancreatic juice must give rise in a superior degree to the symptoms which are caused by a deficiency of saliva. SIXTH SECTION. Diseases of the Uropoietic System. A. DISEASES OF THE KIDNEYS. It is not very long since the diseases of the kidneys have become a special subject of the attention of physicians. Whatever im- portant part the renal secretions have played in the practice of medicine from its earliest beginning, the changes in the urine were attributed more to general than to local causes. It is only since the beginning of the present century that the united efforts of chemistry and pathological anatomy have effected an essential prog- ress in the diagnosis of the morbid conditions of the kidneys, to which Bright's discovery has furnished the most important incen- tive. These improvements dating only as far back as the last twenty years, it becomes self-evident that Hahnemann, in spite of his excellent knowledge of chemistry, knew but little of the urine and its changes. Hence the great deficiency, in our Materia Me- dica, of useful objective symptoms of the urinary organs, which subsequent provers have in vain or but imperfectly tried to remedy. That the importance of objective symptoms, especially in the do- main of renal affections, should not be undervalued, must be clear to any one who, in view of our modern means of diagnosis, under- takes to treat such morbid conditions in accordance with our homoeopathic provings; for in no disease are we more easily mis- led by the general symptoms than in affections of the kidneys. It is probably on this account that such affections occupy but a small space in the literature of our school, and we wish to have it under- stood that the therapeutic portion of this section contains a great deal that is hypothetical and unproven. In order to render further repetitions unnecessary, we will here discuss more fully certain points referring to the diagnosis of renal diseases. 580 Diseases of the Kidneys. 581 The situation of the kidneys on both sides, and close to the vertebral column, where they are surrounded by a thick layer of fat and loose cellular tissue, and covered externally by a heavy layer of muscular tissue, renders it impossible and always uncertain in most cases, to obtain a knowledge of their condition by palpation and percussion, the more so as percussion must necessarily lead to deceptive results on account of the peculiar situation of the intestine, and palpation cannot be conducted with certainty on ac- count of the movable position of the kidneys. For an apprecia- tion of local sensations of pain it is sufficient to know that the kidneys are situated on both sides of and near the upper lumbar vertebrae, from the lower edge of the eleventh or the upper edge of the twelfth rib as far as near the upper rim of the os ilium. An analysis of the urine remains the only sure means of diagno- sis. It cannot be expected that we should furnish here a detailed statement of the different points referring to this subject; this would take up a very considerable space. In his Vierteljahrsschrift, Clotar Muller has collated the most important items of urinary analysis; for special data we refer the reader to this article and content ourselves in this place with communicating the most neces- sary facts. The chemical composition of the urine is of little or no signifi- cance in diseases of the kidneys; the deviations from the normal quantity of uric acid, salts, etc., scarcely ever points to a primary, idiopathic affection of the kidneys, and is of importance only with a view of arriving at a correct diagnostic appreciation of various other morbid conditions, but more particularly of constitutional dis- eases. We infer the existence of renal diseases from an abnormal quantity of the urine, from deviations from the specific weight of the urine, and from the substances mixed up with this fluid. The quantity of normal urine cannot well be defined. It depends upon the supply of food, upon the quantity of the liquids drank, upon muscular and mental action,.upon the activity of the skin, upon the condition of the atmosphere, and upon individual and not further demonstrable peculiarities. How difficult it is to determine these different influences correctly, is only clear to those who have persistently measured the quantity of their urine. In spite of large quantities of liquids having been drank, the urinary secretion may be comparatively small, if the cutaneous exhalations are very copi- ous, or a good deal of salt food has been used. Beer, especially hop- beer causes a profuse flow of urine in most persons; in exceptional 582 Diseases of the Kidneys. cases, the quantity of urine is lessened. Coffee and tea retard the secretion of urine, yet the quantity voided, is increased; wine, on the contrary, diminishes the secretion of urine in almost every one. That more urine is voided in winter than in summer, is easily ac- counted for by the increase of perspiration in the summer season; but the weather being apparently unchanged, perceptible changes may take place in the quantity of urine, depending upon differences in atmospheric pressure, and the amount of electric tension. Con- tinued bodily exertion diminishes, continued mental exertion in- creases the urinary secretion; after great commotions of the mind or feelings we likewise often have a large increase of urine. We mention these points in order to show how important it is to inves- tigate and observe all these circumstances before jumping at the conclusion that the urine is morbidly increased. In addition to these normal variations in the quantity of the urinary fluid we have others belonging more or less in the domain of disease, and being of great importance to the physician. We have shown how the normal cutaneous activity affects the urine; this influence is still more strikingly observed in many disturbances of the cutaneous functions. In extensive burns the renal function is much interfered with; likewise in consequence of sudden colds, inflammations of the skin and the epispastic action of vesicatories, not so much in conse- quence of their specific stimulating effect. Finally the urine is much less in all febrile conditions, and likewise in some affections without fever, especially heart-disease; here the quantity of urine is always more or less sensibly diminished. The question now is when the quantity of the urine justifies the conclusion that w'e have an affection of the kidneys to deal with. The normal quantity of urine, when a moderate quantity of liquid is taken, varies from 24 to 40 ounces per day, or from 800 to 1,200 cubic centimeters. This quantity is about equal to the volume of one and a half ordinary wine-bottles. A continued increase or decrease of this quantity justifies the suspicion that the kidneys are diseased, unless some -very acute febrile affection should be present, in which case an extremely small quantity of urine is sometimes secreted. For ordinary purposes, and with a view of securing an approximate determination of the quantity of urine, a bottle and a half full of water may be poured into the chamber, and the quantity of urine voided in twenty-four hours, may be measured accordingly; if we desire a more exact measurement, a glass-cylinder provided with a centimeter-scale is absolutely required. Diseases of the Kidneys. 583 The specific gravity of the urine is subject to the same variations as the quantity. In the normal condition it is so much higher ini proportion as the quantity of urine voided in the course of a day is less; this is inferred from the circumstance that the excretion of solid substances in the course of twenty-four hours remains about the same; the specific gravity being determined by the quantity of. the solids, it becomes self-evident that this gravity is increased or diminished according as there is more or less water in the urine; The normal specific gravity is between 1,010 and 1,032, also 1,034, the latter figure being very questionable. The less the specific gravity when the quantity of urine is very much diminished; or the higher when the quantity is very much increased, the more we are justified in suspecting the existence of renal disease; in doubt- ful cases the use of the areometer becomes indispensable. Even if the results obtained by means of this instrument are not extremely accurate, yet they are sufficiently so for all practical purposes, and the facility with which the instrument can be used, commends it to our favorable consideration. The urine is mixed up with a great many substances. Independ- ently of those that are rarely found in it, it sometimes contains blood, coloring matter, pus, mucus, gravel, coagula, albumen and sugar. The admixture of blood is generally recognized by the red, or even brown-red, blackish color, sometimes with a bluish tint. If there is but little blood, it cannot well be confounded with bile-pig- ment. The presence of blood-corpuscles as revealed by the micro- scope, places the presence of blood beyond all'doubt. Sometimes these are absent,' although the urine may be intensely colored like blood; this occurs only in diseases with a typhoid composition of the blood. If bloody coagula are present, an error of diagnosis can- not possibly be committed. From which of the urinary organs the blood is derived, will be shown when we come to treat of renal hemorrhage. The diagnostic value of the coloring matter of the urine is not yet firmly settled. We have already alluded to the hsematine in the urine; the presence of albumen and sugar in the urine is likewise often revealed by a peculiar color of this fluid, the presence of al- bumen by a feeble bluish-green tint, and that of sugar by a yellow- ish-green. This, however, is of trifling value, for even without this peculiar color, the symptoms will demand a careful examination of the urine. 584 Diseases of the Kidneys. Pus and mucus form almost the same appearances; they can only be distinguished by the microscope. Such a microscopic examina- tion is important because pus points rather to a disease of the kid- neys, mucus to some abnormal condition of the bladder. We must not overlook the fact that even in the normal condition of the sys- tem mucus is often secreted with the urine. In the clear urine mucus floats as a transparent cloud at some distance from the bot- tom of the vessel. Gravel is scarcely ever found in the urine, except when the kid- neys are diseased. We do not mean to say that the structural changes of the kidneys must be considerable, for the formation of gravel generally results from defective nutrition. However, it is also met with in individuals who lead a very uniform and simple life; under such circumstances it is most probably the result of some abnormal change in the kidneys. Of the larger concretions, such as renal calculi, we shall speak hereafter. Coagula, either in the shape of granular conglomerations, or as cylindrical formations, constitute one of the most important admix- tures of the urine. Their presence can only be determined by the microscope. We shall recur to these foreign elements in the urine when we come to treat of Bright's disease. Albumen is not only found in the urine in Bright's disease, but likewise in smaller quantity in physiologically normal conditions, such as pregnancy. Its presence is of importance only when there is an excessive quantity of it, small quantities being of no moment. A large quantity of albumen in the urine always indicates an in- tense disease of the kidneys. Albumen can be tested for in two different ways. After having first satisfied ourselves that the urine has an acid reaction, we fill a test-tube half full of this fluid. If there is no acid reaction, we first add a little acetic acid, until a feeble degree of acid reaction is obtained. After heating the urine over the flame of a spirit-lamp, the fluid, as soon as the boiling point is nearly reached, shows a cloud at its surface, which gradu- ally spreads towards the bottom of the vessel, and is caused by the coagulation of the albumen. Its density increases in proportion as the urine contains more albumen. If there is but a small quantity of albumen, the cloud becomes visible only after the urine has been allowed to settle and cool, and the coagulated particles have col- lected at the bottom of the tube. If there is much albumen, the coagulation generally takes place in larger flocks. Inasmuch as the Phosphates, by boiling, yield a precipitate resembling albumen, the Diseases of the Kidneys. 585 urine has either to be further tested with nitric acid, or a little dilute muriatic acid should be added to the boiled liquid, in which case albumen will remain und.ssolved, whereas the cloudiness caused by the presence of Phosphates is soon dispersed. The second test consists in dropping into a like quantity of urine, as before stated, drops of nitric acid. A precipitate of coagulated albumen will likewise be thrown down. It is always advisable to ivsort to both these tests. Sugar in the urine is not a symptom of some specific, idiopathic disease of the kidneys, but of an intensely penetrating constitutional affection. Since we have classed diabetes amona* the diseases of the o kidneys, it is proper that the means by which sugar can be detected in the urine, should be explained in this place. If, independent of general morbid phenomena, the urine is excreted in excessive quanti- ties, having a somewhat dim or cloudy appearance, with a very slight, greenish-yellow tint, and a specific gravity, which never falls below the highest figure above mentioned, or even exceeds it, we may almost certainly conclude that the urine contains sugar. The chemical methods of testing for sugar are too complicated for the practical physician, and can only be employed with great loss of time. Since all he cares to know is, whether sugar is present in the urine, whose increase or decrease is indicated with more or less positiveness by the rise and fall of the specific gravity, we propose the following methods of testing for sugar as the most practicable. We will indicate several methods, in order to enable the physician to verify the results of his experiments by applying a variety of tests, for not one of them singly can be depended upon with abso- lute certainty. This is easily accounted for by the differences in the composition of the urine. 1. Dissolve in the urine to be examined, a small quantity of ex- tract of ox-gall, add gradually concentrated sulphuric acid, and stir carefully with a little glass rod. If a purple-red color ensues, the liquid contains sugar. 2. Equal parts of urine and lime-water are made to boil in a test- tube ; if no color is seen, there is no sugar; on the contrary, if the mixture shows more or less color, it contains sugar. 3. In a test-tube, mix equal parts of urine and a solution of the Carbonate of Soda (consisting of one part of crystallized Carbonate of Soda and three parts of distilled water;) add to this mixture a pinch of the Nitrate of Bismuth, and heat the whole until it begins to boil. If, after boiling, the snow-white salt of Bismuth shows 586 Diseases of the Kidneys. the least blackness or gray color, the presence of sugar is indicated with positive certainty; no other constituent of the urine is capable of chano'ino' the salt of Bismuth to a sub-oxide, or even to metallic Bismuth. Pure rock sugar does not induce a reaction of this kind, but glucose does. 4. Dissolve a drachm of the Bichromate of Potash in two ounces of distilled water, add two drachms of concentrated sulphuric acid; let the mixture settle, and pour the clear fluid cautiously off the sediment. Heat equal parts of this liquid and diabetic urine, until they boil, if sugar is present, even one half per cent, of it will yield a characteristic blue-green color, whereas a whitish precipitate indi- cates the presence of albumen. Reaction sets in even without the urine being heated, except, that it takes more time, whereas boiling excites the reaction at once. The blue-green color becomes more or less striking, according as there is more or less sugar, so that, with a little practice, the increase or decrease of sugar can be deter- mined by this method. If there is no sugar in the urine, a dirty brownish-red color ensues, at most with a very feeble greenish tint, which, however, does not indicate the presence of sugar. The pres- ence of albumen, bile-pigment, or bile-acids does not prevent the reaction. With these four tests, all of which are simple, and can be applied without any outlay for instruments or reagents, the presence of sugar can be detected in every case, which is the main point in practice. We deem it unnecessary to dwell here more fully upon general pathological or therapeutical data concerning the kidneys, the more as we shall refer to this subject as far as may be necessary, in the following chapters. In opposition to other inflammatory affections of the kidneys of which mention will be made hereafter, we apply the name of neph- ritis, or nephritis vera, or insterstitial inflammation of the kidneys, to an inflammation of the tissue connecting the tubuli uriniferi. The etiology is in many respects very obscure. The disease oc- curs chiefly among middle-aged persons, and befalls men more fre- quently than women. Proximate causes of the disease are: Contu- sions of the region of the kidneys, sharp or adhering renal calculi, violent colds, employment of various drugs, such as oil of turpen- tine, cantharides, nitre, also savin, whether used internally or ex- ternally ; sometimes violent, extensive burns. Secondarily the disease 1. Nephritis, Inflammation of the Kidneys. Nephritis, Inflammation of the Kidneys. 587 is often caused by suppurative inflammations in other organs, affec- tions of the brain and spinal marrow, heart-disease, etc. Insterstitial nephritis usually sets in, like other acute inflammatory diseases, with a violent chill, which is almost immediately succeeded by the local pains. After they have reached the acme of their in- tensity, they extend over the whole region of the kidneys, on both sides; they are continuous, of different degrees of acuteness, cannot easily be described according to their nature, they are considerably aggravated by pressure upon the renal region, likewise by violent contractions of the diaphragm, or by motion generally, also by lying on the affected side and by the warmth of the bed. They are scarcely ever restricted to the kidneys; on the contrary, following the course of the ureters they radiate into the bladder, testicles, and, in the case of females into the round ligaments and thighs. Sometimes the testicles are found drawn up spasmodically towards the abdominal ring. With the appearance of these pains the urin- ary secretion diminishes in proportion as the inflammation involves a larger portion of the kidneys, so that the secretion of urine may be entirely suspended. At first the urine is only saturated, some- times tinged like blood; but it may likewise preserve its normal color, if one kidney is sound and the other does not secrete any urine at all. The general constitutional equilibrium is very much dis- turbed. The fever is very violent, the pulse hurried and soon be- comes small and contracted, the skin is hot and dry, the thirst agonizing. The patients feel sick to the core. Vomiting is a fre- quent occurrence without the stomach appearing much deranged, for the tongue may be quite clean. At first the bowels are quite constipated, the appetite is gone. The further course of the disease varies in accordance with the peculiar anatomical changes in the kidneys, on which account we here subjoin a description of them. The inflammation very seldom invades the whole extent of the kidney, generally only a part of it; sometimes it is confined to single foci. At the beginning of this morbid process the kidney is enlarged, intensely red, its parenchyma is permeated by a thickish, bloody fluid, through which the internal structure of the kidney is but indistinctly perceived. Very soon the infiltration becomes dis- colored, somewhat yellowish, then grayish or of a brownish-gray color, after which isolated yellow points are seen in it which denote the commencement of suppuration. These points increase in size, either forming detached foci of suppuration, of different sizes and usually of a cuneiform shape, or else they run together into one 588 Diseases of the Kidneys. largo cavernous abscess which may even fill the whole of the kid- ney. Side by side with the purulent deposits a number of small, or else a few detached more considerable hemorrhagic effusions, may often be seen. The suppuration may heal by forming cicatrized tissue; or else the pus may become encysted, and, its solid constitu- ents being absorbed, may become inspissated; or it may find an outlet into the pelvis of the kidney, or into adjoining organs. In less frequent cases the inflammatory infiltration acts as in cirrhosis of the liver, giving rise to an excess of interstitial cicatrized tissue which results in atrophy of the kidney. The atrophied kidney shows many depressions on the surface, which is covered with gran- ulations and has a pale appearance. A larger abscess may like- wise result in atrophy of the renal parenchyma, although less ex- tensive than when the suppuration of the cortical substance is more diffuse. The further course of nephritis corresponds with the changes that have been indicated. Recovery may take place after the first onset of the disease, without any suppuration having taken place, or by arresting it, the completeness of the recovery being shown most conclusively by the urine resuming its normal quality. On the con- trary, if suppuration sets in, the local pain decreases, becomes duller and more like a painful pressure; the fever, however, increases, frequent chills or shiverings are experienced by the patient, the tongue becomes coated, the stomach is still more disturbed, pus is found in the urine at an early stage of the disease and there is fre- quently an admixture of blood. The patient becomes anxious, restless, the pulse is more frequent and smaller. The subsequent phenomena depend upon how far the urinary secretion is suspended. If only one kidney is diseased, or only a small portion of both, there is no material diminution of the quantity of urine secreted; an ab- scess forms, with the usual phenomena characterizing the suppura- tive process, the abscess either discharging and recovery taking place, or else renal phthisis setting in, with all the symptoms of marasmus gradually supervening. This last mentioned result may drag along for months, the urine containing pus all the time. Characteristic features of renal phthisis are, a great tendency to malignant affections of the skin, dermatitis, decubitus. If the uri- nary secretion is considerably impeded by an infiltration of the kid- neys, symptoms make their appearance which denote the superven- tion of uraemia. They set in most suddenly when the excretion of urine had been completely suspended from the beginning, and the Nephritis, Inflammation of the Kidneys. 589 patients die in a few days, with all the symptoms of an intense cerebral typhus. They may likewise set in gradually, so that the disease, by slow degrees, assumes a typhoid character. The patients sink into a state of sopor, are attacked with a more or less violent delirium, convulsions, and finally die comatose. This uraemic in- toxication may likewise supervene, if the disease runs a very chronic course, so that it is almost impossible to recognize it as such, because the morbid renal symptoms are not very important, at any rate very indistinct. The diagnosis of nephritis cannot always be made with perfect certainty, because the symptoms are sometimes very trifling, and, moreover, very little characteristic. The difference between neph- ritis and Bright's disease will be pointed out in a subsequent chap- ter. The distinction between typhus and nephritis is often difficult, unless the attack has been watched from the commencement. It is, to some extent, pathognomonic of a high degree of nephritis, that the urine is excreted in an extremely small quantity, and always contains pus-corpuscles. In nephritis the bowels are almost always obstinately constipated; if the disease terminates in phthisis, the constipation changes to diarrhoea. The prognosis is unfavorable only if the symptoms of uraemia become more and more manifest, until they reach the highest de- gree of intensity. In other respects the disease becomes the more threatening, the more protracted a course it runs, until it finally terminates in phthisis. If the pus has an outlet through the ure- ters, the renal abscess is of not so much importance; but from the moment it seeks another outlet, there is great, although no imme- diate danger. We here subjoin a few remarks on the inflammation of the pel- vis-pyelitis-the treatment of which is in many respects like that of nephritis. Pyelitis easily arises from the same causes as nephritis, more particularly from the presence of urinary concretions; or it may result from the spread of other inflammatory processes, accom- panied by violent general catarrhal inflammatory phenomena. The symptoms likewise resemble each other very closely, except that the disease does not set in so suddenly and with as much in- tensity; the symptoms of gastric derangement are less regularly present, and the painfulness is not so great, especially at the com- mencement of the attack. The urine becomes turbid and purulent at an early stage of the disease, and is usually tinged with blood. 590 Diseases of the Kidneys. The excretion of urine takes place very frequently and is very pain- ful. Uraemia occurs rarely as the disease progresses, which becomes immediately threatening only if an existing concretion cannot be removed and speedy ulceration is the consequence. On the other hand the affection is exceedingly disposed to become chronic, and, in that case, becomes dangerous by the constant loss of pus. While voiding the urine it is uniformly turbid, of a greenish, bright-yellow or whitish color; after settling, the super-natant liquid is clear, and a loose, white sediment is formed, being sharply separated from the liquid and consisting of pus and mucus. Since these substances likewise coagulate, their nature cannot be inferred exclusively from applying the tests for albumen, but they have to be examined mi- croscopically. Chronic pyelitis is a very obstinate, and, when highly developed, a very dangerous affection, although years may some- times elapse until a fatal termination is reached. We omit mentioning an inflammation of the capsule of the kid- ney because, if existing separately and alone, it is difficult to diagnose, even if abscesses have formed that discharge their con- tents into the adjoining organs, for their origin cannot be traced to the kidney with any positive certainty. Treatment. Among the remedies for nephritis we have to select those whose external as well as internal use results in this disease; they are principally: Cantharides, Terebinthina, Sabina, Nitrum, whose specific action upon the kidneys has been satisfac- torily and abundantly revealed to us by the ignorance of lay-people as well as by the shortsightedness and boldness of physicians. They are mostly appropriate only as long as the disease retains its acute character, not in its chronic form. Cantharides. From Schroff's experiments with this drug we transcribe the following poisoning with Cantharidin because it con- tains a full and striking image of nephritis. For particulars we refer to the "Zeitschrift der Gesellschaft der yErzte in Wien," 1855, Nd. VIL and VIII. At half-past four in the afternoon 0.01 gramme of Cantharidin was swallowed, without any admixture. Soon after, an increased feeling of warmth on the tongue, where a number of hyperaemic spots became visible; increased secretion of saliva. Next, a burn- ing in the stomach, eructations, nausea and oppression on the chest; tongue and lips extremely sensitive; deglutition, even of liquids, is impossible. The pulse falls from 62 to 56. In the eve- ning, copious, papescent stool; the urine is voided without any diffi- Nephritis, Inflammation of the Kidneys. 591 culty. After the lapse of eight hours marked blisters break out on the tongue and gums. Between midnight and four o'clock in the morning the chill gradually gives way to an increase of warmth, the pulse increasing to 90. At the same time involuntary, but painless discharges of urine, which become more and more frequent, and finally painful, until they take place every two or three minutes, attended w.th such a violent spasm, that stool becomes impossible. The urine now is mixed with blood. At four in the morning, stool with tenesmus. From this time a drawing, stitching pain in the region of the kidneys, aggravated by external pressure. Violent vomiting in the morning, after tasting a little water, ag-ain in three hours, with expulsion, first of greenish, afterwards reddish, and finally chocolate-colored substances. The stool likewise contains blood. At one o'clock at noon, twenty-one hours after taking the drug, flushed face, hot skin, pulse 80; in the mouth the effects of the local action of t.ie drug are visible; violent pains in the stom- ach, bowels, and kidneys; constant urging to urinate, burning of the urine in the urethra, the mouth of which is red and swollen. The urine is voided in tolerable quantity, but averages less than usual, deposits a copious, loose, slimy sediment, and shows here and there a reddish tinge. Under the microscope degenerated blood- corpuscles and normal pus-globules are seen, a quantity of epithelium and fibrinous cylinders. The reaction is feebly alkaline. Upon the addition of concentrated nitric acid, a dense cloud is thrown down. The pains in the kidneys lasted until the fifth day, whereas a fort- night after some traces of poisoning still remained visible. To this picture of nephritis, which can scarcely be drawn with more completeness and accuracy, we will add a few data from other detached observations. In Schroff's case, the evident action of Cantharidin did not become visible until after some time. Usually it sets in after six or twelve hours. In a case related by Jaffe, it began three hours after the poison had been administered, with the most marked intensity. According to Bouillaud, vesicatories, if applied to scarified surfaces, act with a high degree of intensity; albuminuria is always present in such cases. After Cantharidin a post-mortem shows inflammation of the kidneys more or less fully developed and extended, but it is never stated in what parts of the kidneys the inflammatory process is principally located. The rapid appearance of pus-globules in the urine seems to imply the existence of pyelitis. In the next chapter we shall revert to this subject more fully. The symptoms of a moderate degree of ursemic intoxi- cation are noticed in some cases of poisoning with Cantharidin. 592 Diseases of the Kidneys. Those statements show that, if anywhere, it is in the treatment of nephritis with Cantharides that the law of similarity must prove true. Hartmann considers Cantharides as one of the chief remedies for nephritis, and gives the following indications for its use : "Stitching, lancinating, and tearing pains in the renal and lumbar region, aggravated by the least motion, even until they seem intol- erable, and sometimes arresting the breathing by the suddenness of their appearance; painful urination, which is sometimes even im- possible, or discharge of the urine drop by drop; it is mixed with blood, and the emission is attended with the most agonizing, burn- ing pains, in which case it is very likely that both kidneys are inflamed. The accompanying fever is usually very acute, the pulse frequent, full and rather hard, thirst great, cheeks hot and flushed; loss of appetite, constipation; the sleep is disturbed by the violent pains and the urging to urinate, which is generally more frequently experienced during the night; or the patient sleeps only by snatches, and feels much worse in the morning." These symptoms embody not only an inflammation of the kid- neys, but likewise of the other urinary organs. The inflammation superinduced by Cantharidin always runs a rapid course, is not in- clined to become chronic, nor is there a trace of suppuration. Hence, the remedy is especially applicable in the first stage of nephritis. Regarding Terebinthina we refer the reader to our remarks on the subject of Bright's disease. Sabina, if we may judge from its pathogenesis, is not particularly appropriate in nephritis; at any rate, the pathogenetic effects of this drug in the urinary sphere, are not sufficiently precise. My attention was directed to Sabina by a tolerably violent nephritis, which it excited in a female who had swallowed a large dose of it for the purpose of producing a miscarriage, which attempt, how- ever, did not succeed. The nephritis caused by this drug is not a consequence, but independent of the abortus. Nitrum causes a nephritis that generally assumes a chronic form, with evident signs of pus in the urine. This effect, if caused by poisonous doses, is at first covered up by the extreme depression of the whole organism, and does not become manifest until at a later period. At that time the urine looks pale and turbid, or has a bloody tinge, depositing a thick, sharply delineated, white sedi- ment which, when shaken, floats upwards in the shape of large flocks. The renal region is very painful, the emission of the urine more or less impeded. Nephritis, Inflammation of the Kidneys. 593 Copaiva, Cubebs and Mezereum likewise cause inflammatory symp- toms in the urinary organs. We have no adequate provings of either of these drugs. Nevertheless, they deserve our most atten- tive consideration. We now have reached the better known and more frequently used drugs, namely: • Aconitum, which corresponds to nephritis, not only on account of the fever, but likewise in its special action upon the urinary organs. The secretion of urine is much less, takes place more frequently and with more difficulty, and is painful; in a case of poisoning the kid- neys are found strongly engorged with blood. These local symp- toms, in connection with the more gener.d ones of a case of Acouite- poisoning, justify the selection of Aconite, especially in the first stage of the disease. Next to Cantharides, Belladonna is undoubtedly the main remedy in nephritis. Hartmann recommends it if the pains in the kidneys are stinging-burning, extend towards the bladder, come in parox- ysms, like colicky pains ; at the same time cardialgia, a fiery urine which is passed in small quantities, anxiety, restlessness, constipa- tion. Pus is likewise found in the urine. The local inflammatory symptoms, in connection with those of the brain,'show that Bella- donna corresponds fully with incipient uraemia, or even when at- tended with violent delirium, the more as complete retention of urine is one of the effects of Belladonna ; hence, it is in a very acute attack of nephritis where symptoms of uraemia appear already in the first few days of the disease, that Belladonna is indicated. Mercurius does not yield to Belladonna in importance as a remedy for nephritis. If we recommend Mercurius as adapted to the in- cipient stage of suppuration, we do not base our recommendation upon a few isolated inflammatory symptoms in the pathogenesis of Mercury, but upon the special symptomatic homoeopathicity of this drug to the disease. This homoeopathicity is proven by the pathoge- nesis of the drug. We have diminished secretion of urine, with increased urging:; urine saturated, dark-brown, mixed with blood, cloudy, with a white sediment that looks like flour, or a white sedi- ment which, when stirred, looks like clouds of flocks and shreds. These phenomena alone are sufficient to justify the selection of Mer- cury the more since the ailments that generally co-exist with Mer- cury, can be found in the pathogenesis of this drug, more especially the peculiar fever and the gastric derangements. Mercurius like- wise corresponds to the course of ursemia; it has power to cause a 594 Diseases of the Kidneys. condition simulating typhus, with powerful convulsions. The dis- tinction between Belladonna and Mercurius, beside the special data, rests in the circumstance that the Belladonna-convulsions break out speedily, when the poison first begins to act; the Mercurius-convul- sions, on the contrary, not till the poison has acted for some time, which shows that Mercurius is more appropriate where, after the inflammation has lasted for some time, symptoms of suppuration and subsequently those of uraemia gradually become manifest. If the question is asked : What mercurial preparation is most homoeo- pathic to nephritis? we answer Mercurius corrosivus. A severe poisoning with Calomel or metallic Mercury sometimes is without any symptoms of nephritis ; in a poisoning with sublimate, they are almost as characteristic as dysentery. Among my pharmaco- dynamic records there are three cases of poisoning with Corrosive Sublimate, with the following post-mortem symptoms: The kid- neys are enlarged, dark-red on the cut surface^ the pyramids and the cortical substance can scarcely be distinguished one from the other. (The urinary secretion had been almost entirely suppressed.) Three days after the poison had been swallowed, no more urine was secreted. The left kidney was of looser texture than normally; it contained a small abscess filled with pus; the bladder completely empty, and exceedingly contracted. Here we have the anatomical picture of nephritis from the first bloody exudation to the forma- tion of an abscess. At the time when the kidney containing this abscess was dissected, (the report of the case is to be found in the Edinburgh Med. and Surg. Journal, 1811, vol. VIL, page 150,) the anatomy of the kidney was still imperfectly known, and hence a detailed description of the post-mortem symptoms is wanting. But the data are sufficient to show that Corrosive Sublimate oc- cupies the first rank among the Mercurial preparations as a remedy for nephritis. Hepar sulphuris is likewise a remedy for nephritis, although Hart- mann is wrong in placing it side by side with Belladonna. Hepar has no retention of urine, nor any symptoms of incipient nephritis, but it seems appropriate in nephritis threatening to become chronic. The renal region is painful, the paroxysms of stitching pains radiate to the bladder and thigh, they are not violent; the urine is pale, turbid, even when being voided, depositing a white, flocculent sedi- ment. The blood, if there is any, is discharged with the last drops of urine; it most likely indicates a disease of the bladder, not of the kidney. The fever denotes suppuration, a violent chill alter- Nephritis, Inflammation of the Kidneys. 595 nating with burning heat. These symptoms likewise show that 11 epar is not indicated at the beginning of suppuration, but after the suppurative process is completed. Nux vomica seems to us little suitable in nephritis; however, we will transcribe Hartmann's statements on the subject: "If a sup- pression of habitual hemorrhages or abuse of spirits is the cause of the nephritis, which, in such a case, results from abdominal conges- tion, Nux will be found the best remedy, if distention of the abdo- men, pressure, heat, burning in the region of the kidneys and loins are present. Experience has shown, moreover, that Nux is likewise adapted to other nephritic difficulties, whose symptoms are strik- ingly similar to the primary effects of Nux, even to kidney-diseases caused by renal calculi or by suppressed hemorrhoids." Colocynthis is likewise mentioned by Hartmann as a renal remedy, but whether correctly or not, is still an open question. The charac- teristic symptomFoul-smelling urine, which, after settling, soon becomes thick like jelly or coagulated albumen is so isolated that too much importance should not be attached to it. Colocynthis might, perhaps, be appropriate in inflammatory renal affections caused by calculi, a*' 1, according to the above-mentioned symptom, in violent catarrh of die bladder. Phosphorus is undoubtedly of much more importance in affections of the kidneys, than in the use that has thus far been made of it, and Sorge's treatise would lead one to suppose. Phosphorus being more homoeopathic to Bright's disease than to any other affec- tion of the kidneys, we shall postpone our remarks on Phosphorus until the next chapter. Cannabis is recommended by Hartmann in the following words: " Too little attention has been paid to Cannabis generally, and to nephritis in particular. Cannabis will always prove useful for a drawing, ulcerative pain from the region of the kidneys down to the groin, accompanied by an anxious sensation and nausea." Among a large number of cases of poisoning by Cannabis, the records of which are in our possession, there is no action on the kidneys denoting inflammation of this viscus, perceptible. The re- tention of urine is evidently a consequence of the narcotic action of the drug. The Indian hemp, hashish, may perhaps differ from our own native Cannabis in this, that it acts more intensely upon the urinary organs, for we find the following symptoms recorded in our Materia Medica: Ulcerative pain in the region of the kidneys, with or without contact; this pain spreads down into the thighs; 596 Diseases of the Kidneys. frequent urination, but diminished quantity of urine; retention of urine; urine bloody, turbid, as if mixed with pus and whitish shreds. According to these symptoms, Cannabis should not be overlooked in nephritis. Pulsatilla is said to be excellent if nephritis is caused by suppres- sion of the menses. It seems, however, as if Pulsatilla acted less specifically upon the kidneys than upon the bladder, and did not cause inflammation, but simply a catarrh of the bladder. In prac- tice it cannot be placed in the front rank of renal remedies. Beside the above-mentioned remedies we have for acute neph- ritis: Cocculus, Veratrwn, Clematis^ and Rhus toxicodendron. For the chronic form of nephritis, a more detailed list of remedies will be found in the next chapter. The reader will there also find a few other remedies of particular importance in uraemia, Phus tox. being one of the most efficient. In nephritis the diet is a subject of considerable interest. Above all things we must take care to avoid articles of diet that might impart too many solid constituents to the urine. Although most patients would feel a natural disinclination to solid food, yet it is well that the physician should emphatically protest against its use. In few diseases is a strict deprivation cure more necessary than in nephritis. At the same time our object is attained in a different way, by ordering the patient to drink much fresh water, even car- bonated water; the use of stewed fruit is both refreshing and ad- vantageous to the patient. Under certain circumstances, tepid drinks may agree better with the patient, at any rate, they need not be objected to; a mixture of water and acidulated juice of some fruit, especially apples, is more particularly to be commended. 2. Morbus Briglitii, Bright's Disease of the Kidneys. Under this heading we class the different conditions described as nephritis parenchymatosa, crouposa, desquamativa, and as cir- rhosis of the kidneys, in so far as they all have the characteristic signs of Bright's disease: inflammatory exudation into the tubuli uriniferi with their various terminations and sequelae. The etiology of this disease cannot be traced with any positive certainty. Although, as a rule, it sets in as a secondary affection, yet the question may fairly be asked whether it does not sometimes break out as a primary disease. Bright's disease chiefly befalls persons of middle age, less fre- quently children, and still less old people. Males seem more dis- Morbus Brightii. 597 posed to contract this disease, probably because they use such noxious substances as predispose to it, more frequently than women, Feeble individuals are more frequently attacked than vigorous persons. Damp and cold weather is considered one of the most frequent causes of this disease, which is supposed to account for its frequent occurrence in the countries of the Northwest of Europe, especially England, Holland, and the coast of the North Sea. Even if we admit, however, that colds, which are so common in these countries, may give rise to renal diseases, in consequence of a sup- pression of the cutaneous exhalations, on the other hand we must not forget that the abuse of alcoholic beverages, which is such a prevalent vice in these countries, likewise is a main cause of the nephritis, which is so frequently met with among their inhabitants. But it is not only alcohol, but likewise the above-mentioned drugs and poisons that cause both nephritis and Bright's disease. Among general febrile diseases, it is particularly after cholera and scarla7 tina that parenchymatous nephritis occurs, although it may like7 wise develop itself after other acute affections, but rather except tionally. Among chronic diseases, it is dyscrasias, such as rachitis; arthritis, and scrofulosis, which are often accompanied by this dis- ease. We are no more able to account for the connection between these dyscrasias and Bright's disease, than we are for the frequent occurrence of Bright's disease during extensive suppurations of, bones, altho :gh we may know that the quality of the urine, during such conditions of the system, undergoes considerable changes. , Symptoms and course, Since a knowledge of the anatomi- cal changes are of great importance to an accurate comprehension of the symptoms of the disease, we first furnish a short description of these changes. They may naturally be classified in three stages. In the first stage the kidney is enlarged to double its size and weight, its surface is smooth but injected, and unequally reddened , the albuginea can easily be detached; it is opaque, and beneath it small extravasations are frequently observed. On section the cortical substance is chiefly found altered. It is considerably thicker, of a dark-red or brown-red color, with isolated bright-red points, sometimes completely mottled, friable, and soaked with a turbid and viscid fluid, which can be squeezed out, and under the microscope reveals cylindrical casts of the size of the tubuli urini- feri, partially covered with epithelium and blood-cells. The other parts of the kidney are likewise more or less vividly injected. In the second stage the volume of the kidney is still larger, the sur- 598 Diseases of the Kidneys. face mostly continues smooth, or is covered with single granular tions, no longer injected red, but the color passing more and more into a gray or yellowish tint; it is unequal, and sometimes looks as if sprinkled. The albuginea can still easily be detached. On sec- tion the cortical substance looks still larger than during- the first Stage; its color is no longer dark, but of a reddish-gray, and finally of a yellowish-gray or clear yellow. The cut surface has a greasy 'ustre. Under the microscope the tubuli uriniferi of the cortical substance appear considerably enlarged, filled with exudation, which already shows partial traces of fatty degeneration, and with co- pious epithelium ; the granulations on the surface are found to be dilated tubuli uriniferi. The third stage includes the retrograde metamorphosis of the exudation. In consequence of this process, the volume and weight of the kidney decrease again more and more, until they finally shrink, sometimes quite considerably below the normal figure. The surface appears uneven, knobby, covered with detached granulations, and traversed by depressions or fur- rows ; the albuginea adheres very firmly. On cutting through the kidney, the tissue is found to be denser and more tenacious, and the cut surface is strikingly dry. The cortical substance now is seen to be the real focus of the disease. It gradually shrinks away, sometimes to such an extent that it seems like a narrow border round the cut surface. Its color is a mixture of gray, red and yel- low, sometimes striated. The rest of the kidney is but little altered in appearance and size, or some parts may still appear injected. These changes are seldom witnessed in both kidneys; it is even a rare occurrence that the whole of only one kidney is invaded by this morbid process; very commonly the symptoms of two stages are found side by side in the same kidney. A division of Bright's disease into acute and chronic, is a very difficult task. What can at most be asserted is, that the disease only passes through the first stage, or goes on its course further into the other stages. It is only the characteristic nephritis during scarlatina, very seldom during the course of other exanthematic fevers, to which the name of Bright's disease can properly be ap- plied, for the reason that in most cases it passes only through the first stage. The cause of it, in our opinion at least, is not so much a difference in the etiological influences, as the age of the patients. Nephritis after scarlatina is scarcely ever met with, except in chil- dren or young persons, in whom the reactive efforts of the organ- ism differ greatly, especially in regard to the kidneys, from those Morbus Brightii. 599 of middle-aged persons. This difference is likewise clearly mani- fested by the symptoms, as the following description sufficiently shows. The acute form of Bright's disease, after scarlatina, generally sets in with distinct febrile phenomena, sometimes with pain in the renal region, and almost always associated with vomiting at an early perio. 1, a circumstance that deserves to be considered with great care in convalescents from scarlet fever. Only in rare cases the disease develops itself without the above-mentioned symptoms, in a more insidious manner, or is covered up by the other morbid phenomena accompanying the exanthem. From the onset, the quantity of the urine is considerably lessened, but a day seldom passes that some urine is not voided. The urine has a very dark color, red or brown like beer, makes a very consistent foam, and, after settling, deposits a dark sediment, in which the microscope discovers numerous blood-cells, a quantity of epithelium and fibrin- ous easts. The previously mentioned tests for albumen yield copious coagula. The excretion of the urine is interrupted; there is a good deal of urging, with scanty discharge. These symptoms of disturbance of the renal functions are very soon succeeded by an oedematous swelling over the whole body, which is first strikingly seen in the face, and attains a high degree of intensity. During this stage, the fever is generally not very violent, the patients may even feel tolerably well, and have some appetite. The thirst is always great, they desire cold drinks; the skin is entirely inactive, cool, feels dry, and has a pale, sickly color. The bowels are gener- ally confined; the presence of diarrhoea is not a favorable symp- tom. If the disease has a favorable termination, which may take several weeks, the urine is again secreted in larger quantity, the morbid products in the urine decrease, the skin resumes its func- tional activity, and without any special signs of disordered func- tions, the disease soon yields to perfect recovery. Not unfrequently, however, such patients succumb to inflammations of other organs, or, which is less frequently the case, the second and third stage of the disease may appear. The supervention of uraemia is of rare oc- currence, and, if a prominent cedema after scarlatina is accompanied by cerebral symptoms, meningitis may be suspected. If the dis- ease runs a rapid and favorable course, there is no great loss of strength, and the patients generally recover very rapidly. Where Bright's disease is not a sequela of acute diseases, it has an entirely different beginning. Under such circumstances, the 600 Diseases of the Kidneys. first stage may indeed pass away very rapidly with the more or less marked symptoms of typhus, which, however, is generally asso- ciated with convulsions, and where the accompanying cedema of the face generally shows the true character of the disease. If both kidneys are affected, and the urinary excretion is entirely sus- pended, an acute dropsy may suddenly cause death. But almost always the disease commences without any preliminary symptoms, without chilliness or heat, and without local pains, at any rate those pains are not very prominent. Thus it happens that the pa- tients are unable to indicate the beginning of their trouble. Insen- sibly they begin to complain, their strength diminishes, they feel that some illness is about to overtake them, the appetite is less, symptoms of stomach-catarrh become manifest, the intestines may likewise be similarly affected. The urine is voided as usual, seldom less, rather more, and should the disease set in with much severity, the urine shows the above-mentioned darker color, and diminishes in quantity. Usually it is feebly turbid, even while being voided, of a pale color, of a bluish-green tint, foams very strongly, and the foam lasts a great while. Only at the commencement of the dis- ease, blood is found mixed up with it. The test for albumen show decisive results. The microscope reveals numerous fibrinous casts, at first accompanied by blood-cells and epithelium, afterwards cov- ered with fat globules and granules. The specific gravity is always much less, even down to 1005 ; this is owing to the great decrease of urea, and of the urates and other salts. Under these circum- stances, an anaemic appearance and other signs of impoverished blood soon set in, which point to the existence of some important constitutional malady, without its locality being indicated with positive certainty, and the ominous significance of which can only be determined by a careful investigation of the urine. Much less rapidly than with the acute form, sometimes even at a remarkably late period, but rarely before the termination of a few weeks, a symptom makes its appearance, together with the dropsical phe- nomena, which renders any error in diagnosis almost impossible. Here, too, one of the first symptoms is oedema of the skin, which has the peculiarity to be more prominent in one place or the other, and at times to disappear entirely. It is always most marked in the face and on the lower extremities. While the oedema of the skin is constantly increasing, water finally accumulates in the cavi- ties, and the patient succumbs to the injury which the increasing pressure of the water inflicts upon the most important organs. Morbus Brightii. 601 This, however, is not the only manner in which the disease car ter- minate. It is a peculiarity of Bright's disease to easily develop malignant affections in other organs, such as inflammations of the thoracic viscera and of the peritonaeum, the dangerous nature of which is increased by the renal affection, and which generally ter- minate fatally. It seems as if the increase of danger resulted from the altered relations of waste and supply, or, perhaps, from the extreme anaemia. The very frequent pulmonary and intestinal catarrhs are likewise threatening prognostics; they are principally characterized by the secretion of chiefly serous substances that seem to act as a substitute for the disturbed renal and cutaneous functions, but take down the patient's strength at a rapid rate. The most obscure diseases, although their presence has been demon- strated in a number of cases, are the diseases of the heart which are so frequently met with in albuminuria. Beside the products of former pericarditis or endocarditis, we mostly meet with hypertro- phy of the left ventricle. The connection of these diseases cannot always be definitely shown, for the reason that we have not always an opportunity of watching the patients from the commencement of the disease. Although the heart affection seems, in most cases, to be of a secondary character, yet in many cases it must evidently have been the primary disease and the first cause of the renal dis- order. Nor is the action of nephritis upon the eyes cleared up; all we know is, that the renal disease is very frequently associated with a more or less complete amaurosis, which the most careful ex- amination of the eyes is not always able to trace definitely to san- guineous extravasations or disorganizations of the retina. Uraemia does not usually supervene during this disease, or, at any rate, not to a very great extent; this may, however, be owing to the prema- ture supervention of death .by dropsy, or in consequence of some malignant inflammation. In the more acute cases the disease hastens, with uniform rapid- ity, onward towards a fatal termination. If the disease runs a more chronic course, its intensity varies; remissions that almost seem intermissions, and of various duration, are observed, during which the strength of the patient not only increases, but the albu- men disappears from the urine down to a scarcely perceptible trace. Accordingly, the disease at times lasts months, and at others years; there are no positive landmarks by which the duration of the dis- ease can be determined a priori even approximatively. The prog- nosis is always very doubtful; in cases of long standing it is abso- 602 Diseases of the Kidneys. lately unfavorable. A complete cure is most easily effected in recent cases that do not run a too rapid course. An actually exist- ing cirrhosis of the kidneys cannot be removed; at any rate, such a thing is improbable. The danger is essentially increased, if there is a tendency to inflammation of other viscera, or by the presence of heart-disease. If the disease had been caused by external cir- cumstances, a damp climate or dwelling, or frequent colds, the re- moval of these causes may be of great importance. Treatment. Our literature has very few cures, or even mere reports of cases of Bright's disease. Some of them have even to be regarded as doubtful. Nor are there any more cases of albuminu- ria to be met with in our periodicals. The cause of this is undoubt- edly that in Hahnemann's time albuminuria was not yet thought of. After Hahnemann something has been accomplished in the domain of the diseases of urinary organs and their treatment; but not enough to enable us to oppose an exact pathogenesis to the pa- thological group. When treating of other affections, we have often taken the opportunity of calling attention to this inconvenience, which is scarcely ever more acutely felt than in renal diseases, for the reason that the characteristic symptoms have to be left unno- ticed, and the other symptoms are either so unimportant, or have so little reference to the real focus of the disease, that they are absolutely insufficient to guide us in selecting the true remedy. These remarks are particularly applicable to the last stage of Bright's disease, 'which is at the same time the worst, because it holds out so little hope of recovery. On this account we cannot help admitting that the therapeutic chapter of this disease is not yet based upon experience, and this has induced us to indicate a more than usual number of remedies that may be found suitable for it. Terebinthina. In the All. Hom. Zeit., vol. LI., we read the follow- ing concise but interesting case of poisoning: "A healthy man who had never been suffering with any special disease of the kid- neys, took for taenia one and a half ounces of spirits of turpen- tine, with an equal quantity of castor oil; soon after he was at- tacked with dulness of the head, vomiting, and diarrhoea. In eight hours he experienced frequent urging to urinate, with scanty dis- charge of a burning urine containing bloody coagula. During the night he urinated fourteen to fifteen times, and the whole of the following day the urging continued, but with less pain. The urine, which was copiously mixed with blood and albumen, showed under Morbus Brightii. 603 the microscope cylindrical casts, inflammation-cells, crystals of the oxalate of lime, but no epithelium. At the end of seventeen days, the blood and albumen gradually disappeared, and the urine re- sumed its normal quality. This case is instructive. It plainly shows a tolerably acute attack of Bright's disease, except that no epithelial debris were found in the urine, although, with such symp- toms, it is difficult to understand why renal epithelium should not necessarily have been detached. It seems as though, in this par- ticular, the examination of the urine must have been defective. Corresponding with the above-mentioned symptoms, we And in the Materia Medica: violent pains in the kidneys, extending down- wards along the course of the ureters; painful, greatly diminished excretion of a bloody urine, which afterwards becomes more co- pious, turbid and slimy, and of a whitish color. In addition to these symptoms we have anasarca and general prostration. These symptoms fully justify the use of Turpentine in Bright's disease, but only in the first, and perhaps in the second stage, not in the third. The peculiarity of this medicine, in causing an erythema similar to the scarlet eruption, affords an important indication for the use of this drug in post-scarlatinal nephritis. As yet our re- ports of cures with Turpentine are very scanty. Cantharides. To what we have said in the preceding chapter, to which we refer the reader, we add a few items belonging in the same group. We have given, in a previous chapter, the pathologi- cal evidences upon which the diagnosis of an acute attack of Bright's disease can be predicated with positive certainty. Clemens has likewise seen a long-lasting, violent albuminuria result from Cantharides. Although this remedy seems, properly speaking, only suitable in the first stage of the disease, yet the previously-quoted observation will undoubtedly induce us to try Cantharides, even if no trace of inflammatory symptoms are present. At this stage, however, all similarity between the natural and the drug disease will most likely have disappeared. Phosphorus. Sorge, in his well-known essay on Phosphorus, dis- patches this drug in its relation to the kidney, with a very few words. He gives this abstract: "The urine contained several times a number of epithelial scales, pus, and mucus-corpuscles, albumen in six cases, in two cases exudation-casts, and in one case blood- corpuscles. Hence Phosphorus may prove a remedy against Bright's disease, although there is as yet no cure of this disease recorded in our works." He then mentions a cure which, however, is only that 604 Diseases of the Kidneys. of a post-scarlatinal croupous nephritis. We have to extend these notes still further, and begin with furnishing a few detached toxi- cological data. Nitsche (Wiener Wochenblatt, 1857) found in a man who had always enjoyed good health, and who had perished four days after having swallowed the Phosphorus: kidneys disor- ganized as in Bright's disease, the cortical substance not very gran- ular, the corpora and rete Malpighii considerably injected, the tubuli uriniferi tilled with exudation-casts. In addition an incipient pneu- monia. While the patient was still alive, the urine had shown albumen and exudation-casts, but a higher specific gravity, an in- crease of the Sulphates and Phosphates, and a diminution of the Chlorides. In several rapidly fatal cases, a somewhat advanced pneumonia was found associated with considerable hyper semi a of the kidneys. After poisoning with Phosphorus, the skin is almost always pale and anaemic; mention is often made of a waxy color of the skin, or of its having a yellowish tint. By contrasting with these toxical symptoms, which were obtained by means of large, rapidly destroying doses of the poison, the pathogenetic symptoms of Phosphorus, as contained in the Materia Medica, we shall find that Phosphorus is not only homoeopathic to the first stage of Bright's disease, but likewise to post-scarlatinal nephritis, and to the whole course of the disease. It is to Phosphorus that we more particularly resort, in cases of Bright's disease depending upon sup- purations of bones, or associated with pneumonia or malignant pul- monary catarrh. Phosphorus is likewise adapted to Bright's dis- ease, complicated with amaurosis. A copious, watery diarrhoea is one of the most constant effects of Phosphorus. Arsenicum album is frequently recommended as a remedy for Bright's disease, but whether correctly so, should be carefully as- certained. Among a number of acute and chronic cases of poison- ing with Arsenic, we have only met with one case that had hyper- semia of the kidneys, but no other sign of degeneration. This is no accident. If Arsenic had a specific effect upon the kidneys, symp- toms of the arsenical disease, both of a subjective and objective character, would be met with in every case of slow poisoning by Arsenic, which is, however, not the case. The kidney-symptoms contained in the Materia Medica, are indeed calculated, upon a first cursory review, to excite our attention; but, when examined more closely, they appear much more like manifestations of the general effect of Arsenic than of the local action. In the same manner marked urinary difficulties are witnessed in severe constitutional Morbus Brightii. 605 diseases, without the kidneys being affected. No more than in the first stage, is Arsenic adapted to the second stage of Bright's dis- ease. We have stated above that this disease causes a slow sinking of the vital energies, without any striking local symptoms, but with the well-defined character of ansemia. But we are unable to con- ceive what great similarity exists between this stage of Bright's disease, and the effects of Arsenic. Hence, we think that we should commit a mistake, were we to prescribe Arsenic for the dropsy which supervenes during Bright's disease. This remedy will be found the more useful if the heart is involved in the disease, for instance in carditis. Di jitalis purpurea is undoubtedly an important remedy in Bright's disease, although there is, as yet, no case of poisoning on record where albumen has been found in the urine. Diodtalis does not cause a renal affection like parenchymatous nephritis; on the con- trary, the similarity between the third stage and the effects of Digitalis is very great, more particularly as regards the general con- stitutional symptoms. It would carry us too far were we to go into particulars regarding this point, on which account we refer to our essay on Digitalis, and call attention to the fact, that Christison has given Digitalin in two cases of Bright's disease, in doses of one seventy-fifth of a grain, two or three times a day, with the most decided advantage. But even if we would admit that the uncom plicated form of Bright's disease does not belong to the therapeutic domain of Digitalis, yet this remedy is undoubtedly of the utmost importance, if the renal affection is combined with heart-disease. A peculiar indication for Digitalis are the apparently rheumatic pains which are not unfrequently met with in nephritis ; and, more- over, the characteristic pulmonary catarrh, with profuse serous ex- pectoration. Colchicum autumnale exerts a very constant and decided action upon the kidneys. Unfortunately the post-mortem examinations, made in the cases of poisoning with which we have become ac- quainted, on account of their rapidly fatal end, showed no other significant changes of ti-sue, than a marked hyperjemia of the kid- neys. The urinary secretions and excretions, on the contrary, show a number of characteristic changes, among which the extraordinary inaction of the skin is very prominent. This last-mentioned cir- cumstance leads us to propose Colchicum as a remedy for the post- scarlatinal Bright's disease. This remedy is not appropriate in the chronic form of the disease. 606 Diseases of the Kidneys. Colocynthis acts very similarly to Colchicum, as far as the local symptoms are concerned, and deserves a place among the remedies for post-scarlatinal Bright's disease. The pathogenetic differences between the two remedies are restricted to the general symptoms. Nitri acidum has no very definite symptoms pointing to Bright's disease, but deserves careful attention. Its selection depends upon a few general points of importance, such as albuminuria resulting from suppurations of bones, abuse of Mercury, and dyscrasias. It is curious how greatly this drug is praised by other physicians in this disease. Secale cornutum is recommended by Trinks for scarlatinal dropsy, lie relates several undeniable cures. Corresponding symptoms.are: Diminished urine; turbid, bloody urine, depositing a copious sedi- ment, or else watery, colorless urine, which is turbid even while being voided. Accordingly, Secale cornutum corresponds to the last stage of Bright's disease, the more as the rest of the symptoms will likewise be found to correspond, more particularly the cedema- tous swellings. Helleborus niger is recommended as a remedy for scarlatinal dropsy, although no special cases are reported. [Not long ago we cured a case of scarlatinal dropsy with this remedy. The patient was a consumptive boy of seven years. There was a highly devel- oped general anasarca, and the sexual organs were fearfully swollen. We put the boy on five drops of the tincture in half a tumbler of water, for about a fortnight; the patient recovered without any further untoward symptoms. II.] Symptomatically, however, this remedy does not correspond to Bright's disease, and will most likely prove of small value in this malady. Lycopodium is sufficiently known as one of the most efficient renal remedies, but we are not yet acquainted with the exact nature of its action. No attempt has, as yet, been made to clear up this point. Among the urinary symptoms we have: Increased secre- tion of a whitish-turbid, foaming urine, which is easily decomposed. These are important symptoms. In addition we have : great weak- ness, an anaemic appearance, symptoms of heart-disease, excessive tendency to pulmonary catarrhs, great depression of spirits, etc. These symptoms might justify the use of Lycopodium in the third stage of Bright's disease. Sulphur. We have already stated that it is difficult to pick out the characteristic, or rather the constant symptoms of Sulphur in the pathogenesis of this drug. This remark likewise applies to its Morbus Brightii. 607 urinary symptoms. All we know is, that Sulphur causes impor- tant changes in the urinary range, and that many of the symptoms point to Bright's disease, more particularly the cloudiness of the colorless urine while being voided,, with rapid decomposition. Other considerations, in the absence' of definite symptoms, direct our attention to Sulphur. Parenchymatous nephritis results in copious exudation, upon the speedy removal of which everything depends. Tn most inflammations Sulphur is unquestionably an ex- cellent remedy to promote absorption, even if the symptoms do not indicate it. How much more good may we expect from it, if its physiological effects seem to correspond with the case before us. Moreover, in most dyscrasic affections, Sulphur is indispensable, and we know that dyscrasic individuals arc easily attacked by Bright's disease. To Calcarea carbonica the same remarks apply as to Sulphur. The local symptoms are very distinct, more so than with most other remedies, and the other symptoms frequently correspond. Its rela- tion to scrofulosis and to suppuration^ of bones, is very specific. In general, Calcarea carb, is suitable for impoverished individuals whose constitutions have been impaired by perverse modes of living. To the above-mentioned remedies we add the following more or less important ones, in order to enlarge the means of treating a dis- ease which, therapeutically speaking, has as yet been very poorly provided for: Pulsatilla, Bryonia, Thuja, Mezereum, Sabadilla, Creasotam, Ferrum, Conium maculatum, China. Beside these medicinal agents we have to mention another one which, under certain circumstances, is more powerful than either of the foregoing-it is water. In any form of Bright's disease, the skin is very inactive; we know, moreover, 'that an interruption of the cutaneous functions is very apt to result in nephritis. Hence, the self-evident conclusion, that a restoration of the normal activity of the skin must favor, or perhaps of itself cause, a restoration of the normal functions of the kidneys. Water is, at all events, the safest and mildest means to accomplish this purpose, provided a correct use is made of it. Its use is most evident in scarlatinal dropsy. If, as soon as the first symptoms of nephritis, or even of anasarca show themselves, the patient is wrapped in a wet sheet, the danger of these morbid processes is much lessened ; at any rate, our own experience has shown us that the skin, and hence the kidneys, recover their activity in from six to eight days at the latest. To 608 Diseases of the Kidneys. accomplish this purpose the patients were wrapped up for about five hours every day, and after that rubbed dry. A hurtful influence was never perceived after such a pack. Many may perhaps be frightened away from this use of cold water by the antiquated dread of using this liquid in acute exanthemata. Let such persons inquire of hydropaths what results they obtain by employing cold water even from the beginning. Cold water has not only curative, but likewise prophylactic virtues. We, at least, have become satis- fied of the great probability that patients who are washed all over when the period of desquamation is setting in, and after the wash- ing are well rubbed down, are not attacked with dropsy. Regard- ing the use of water in chronic parenchymatous nephritis proper, opinions are very much divided. Tepid baths are generally recom- mended. But their usefulness is very questionable, because they do not incite an independent activity of the skin. Under such circum- stances the vapor bath would be preferable, although we place the cold wet pack ahead of the latter. The result may never be as favorable as in scarlet-fever, probably for the reason that the cold water is not immediately resorted to as soon as the scarlatina breaks out; but even at a later stage a successful palliation may be hoped for with certainty. Drinking quantities of cold water may be of more questionable utility. Many persons are benefited by this proceeding as much as others are injured by it. This has to be determined by careful experiments. In this disease the diet is an object of much importance. That spirits, condiments, all articles of diet that have a powerful action upon the kidneys, or coffee and tea, celery, parsley, onions, etc., have to be rigorously avoided, is a matter of course. It is equally clear that etiological influences, as far as they can be ascertained, have to be adequately"met. Positive means have likewise to be employed. The anremic appearance of the patients shows of itself that they require an abundant quantity of invigorating, animal food, were it only to replace the loss of albumen. Too much can- not be done in this respect, provided the stomach of the patient is not made sick by excessive quantities. The cautious use of good wine, and still more of good beer, containing but a small quantity of hops, can only be useful, more particularly in the case of persons who have been addicted to the use of spirits. Of course this can only apply to chronic nephritis, not to the really inflammatory stage. Milk is an important article of diet. It is only in excep- tional cases that it does not agree with patients' stomachs; as a Hemorrhage in the Kidneys. 609 rule it will prove the best, it being the mildest and most perfect nourishment, and its use cannot be insisted upon with sufficient force. Good fruit in any shape, more especially such as contains a good deal of sugar, like grapes, may likewise be used by the patient without fear. This is not the place to dwell upon the effect of various mineral waters. They are scarcely ever ordered at the beginning, when they might, perhaps, afford help. In the last stage it is not likely that they will do more good than any other method of treatment. If the disease has to be treated during its acute course, the diet, is of course the same as that of acute nephritis. [Grauvogl pro- fesses to have cured acute attacks of Bright's disease with teaspoon- ful doses of Cochineal. We call the reader's attention to an inter- esting article on Bright's disease, in the 13th volume of the British Journal of Homoeopathy, by Doc tor Joseph Kidd. Helonin is effica- cious in this disease. H.] 3. Hemorrhage in the Kidneys. The blood may be discharged into the tissue of the kidneys, as well as into the tubuli uriniferi, or into the pelvis of the kidney. In the former case ecchymoses or small extravasations or real apo- plectic foci arise, the beginning of which it is, however, difficult to diagnose, and hence cannot become a subject for therapeutic meas- ures. It is only when the blood finds an outlet outwardly, that we can, to some extent, infer from what organ the hemorrhage comes. The blood-mixed urine may proceed from any part of the urinary organs. We shall presently show what means are at our command to determine the origin of the hemorrhage. The causes of the affection are, principally renal concretions, which wound the mucous membranes with their sharp corners; moreover, contusions of the renal region, excessive muscular exer- tions, prominent hypenemia of the kidneys, medicines that have an irritating effect upon the kidneys, likewise various articles of diet, such as asparagus, celery, garlic, and suppression of physiological or habitual hemorrhages; these are known as the causes of hyper- femia of the kidneys. Hemorrhage of the kidneys is, moreover, an accompanying symptom of inflammatory affections of the kidneys, and of diseases that terminate in, or are characterized by dissolu- tion of the blood, such as typhus, scurvy, and malignant growths in the kidneys. The symptoms which accompany the renal hemorrhage, depend, in all cases where the hemorrhage is symptomatic of some othei 610 Diseases of the Kidneys. disease, upon the symptoms of this disease; it is only where the hemorrhage is very considerable that it may become the cause of morbid phenomena peculiar to it. But even if the hemorrhage exists as an apparently or really idiopathic disease, the accompany- ing ailments may be very unimportant. This depends mostly upon the circumstance, whether the blood coagulates in the kidney or in the ureter. If this is the case, the impediment to the excretion of .he urine causes pains in the renal region, being at times a dull pressure or a tearing distress, and at others increasing to violent colicky paroxysms, without their enabling us to determine the amount of resistance which the coagulated blood opposes to the urine. On this account subjective symptoms of this kind have but little value, and serve at most to render the diagnosis in such cases more secure, whereas the objective symptoms alone would leave us in the dark. The accumulation of a quantity of bloody coagula in the bladder sometimes causes so much distress in the interior of this organ, that we feel tempted to locate the seat of the trouble in this region. The retention of the urine is really the important fact in the case. Sometimes it has a pale-red color, at times a brown and even a black color; after settling, a scanty dark-brown, amorphous sediment, or a bloody clot, is deposited at the bottom of the vessel. In renal hemorrhage the blood is always more or less decomposed and discolored ; this circumstance can be made available with some certainty, as a distinctive sign that the blood does not come from the bladder. The coagula coming away with the urine have a vermiform shape, so fashioned by the ureter. A microscopic exami- nation is of special importance. If the blood had been discharged into the uriniferous tubules, we see cylindrical casts, covered with blood-cells; this phenomenon alone is sufficient to diagnose renal hemorrhage. If the hemorrhage proceeds from the pelvis of the kidney, the cylinders are of course absent, and only the blood-cells are principally altered. Chemical analysis results in a scanty yield of albumen from the blood, but may likewise show, in dubious cases, whether the color of the urine arises from the presence of blood or from some other admixture, and is of particular import- ance if no blood-corpuscles are excreted with the urine. Heller's test for hsematin is simple, and can be conducted without loss of time. To the heated urine we add a mixture of caustic potash, and then heat it again. A sediment is thrown down which, when the light shines upon it, has a dingy, reddish-yellow color; but, when the light shines through it, has a bright, blood-red appearance. Hemorrhage in the Kidneys. 611 The course of renal hemorrhage depends, in the first place, upon the primary causative affection, and secondly upon circumstances which it is not in our power to determine a priori. Sometimes the disorder is confined to a few discharges of blood, and sometimes it lasts for weeks without an interruption. Even if the hemorrhage is considerable, there is particular danger only in exceptional cases; except the consequences of a loss of blood, which are never very marked, the accident leaves no serious disturbance behind. Tnis applies, however, only to idiopathic hemorrhage, whereas sympto- matic hemorrhages may, of course, cause a great deal of exhaustion. Treatment, We should not hesitate to transcribe Hartmann's whole passage concerning the treatment of renal hemorrhage, if he did not generalize too much, whereas it certainly is not the same thing whether the blood comes from the kidney or bladder. More- over, since a distinction between these two kinds of hemorrhage cannot always be made, we refer the reader to the chapter on hem- orrhage from the bladder, where the remedies that are not men- tioned here, will be found indicated. In every hemorrhage from the urinary organs, we have to exam- ine with great care whether there is an inflammatory or some other prominent morbid condition present. If the hemorrhage is the main symptom, the following remedies will have to be resorted to: Terebinthina. It is only exceptionally that this drug has a dis- charge of pure blood with the urine; the blood is most usually in- timately mixed with the urine, which has a dirty brown-red or even blackish color. If this symptom of itself denotes hemorrhage from the kidneys, this fact derives additional confirmation from the circumstance, that Terebinthina generally acts upon the kidneys rather than upon the bladder. Hartmann recommends it more par- ticularly, if the bloody urine is accompanied by violent burning and drawing pains in the kidneys, spasmodic urging and pressing in the region of the bladder, which, when in a sitting posture, moves up- ward towards both kidneys, and disappears on motion; moreover, previous to urination, during rest, the patient complains of tenes- mus and cutting in the bladder, alternating with a similar sensation in the umbilical region. Terebinthina is likewise an excellent remedy if the hemorrhage is the result of a peculiar composition of the blood, which sometimes exists without any considerable consti- tutional symptoms in scurvy; for instance, among mariners who return home after a long voyage, or among people who live in damp and close dwellings. 612 Diseases of the Kidneys. Arnica is recommended by many physicians, and likewise by Hart- mann, for renal hemorrhage caused by mechanical injuries, such as concussion, etc., but such recommendations are not based so much upon the physiological action of the drug, as upon the well-known general indication, that Arnica is a remedy for mechanical injuries. Nux vomica is likewise a remedy for renal hemorrhage, not simply a means, as Hartmann teaches, for subduing vascular irritation. The bloody urine of Nux evidently depends upon other causes than a simple bleeding. Cantharides. We transcribe all the essential parts of Hartmann's own statements: " This remedy is one of the chief remedies for renal hemorrhage, especially if no evident cause can be assigned to it; among its primary effects we have not only the bloody urine, but likewise the pains accompanying its discharge. The most com- mon pain which a bloody urine occasions along the course of the urethra, and which this remedy relieves with perfect certainty, is a burning pain, which is the more keenly felt the less blood is passed at one discharge, either with or without urine; hence, the pain is felt most acutely when the blood is discharged drop by drop. Some- times this difficulty of urinating depends upon an obstruction of the orifice of the urethra in the bladder by coagulated blood, some- times upon a spasmodic contraction of the sphincters; in the former case bloody shreds or blackish clots of coagulated blood are passed with every drop of urine, as long as any coagulated blood remains in the bladder, after which pure, clear blood is discharged. In the latter case relief is afforded by vapors of hot milk or water ascend- ing to the region of the bladder and sexual organs. In either case, when there are violent cutting, pressing, and spasmodic pains in the region of the bladder extending along the ureters to the kidneys, Cantharides will be employed with advantage, and afford the de- sired relief. Cantharides are not only indicated if the blood in the urine proceeds from the bladder, but likewise if it originates in an affection of the kidneys or ureters, and is attended with burning, stinging, drawing, keen pains in the lumbar and renal region." That which in the preceding paragraph refers to hemorrhage from the bladder, has been left by us purposely united to other parts re- ferring to the kidneys, otherwise the meaning of this passage would have been obscured. With reference to renal hemorrhage, how- ever, we will add a few remarks. Cantharides never cause a co- pious discharge of blood from the kidneys ; this discharge is always associated with marked symptoms of severe hypersemia, or even in- Hemorrhage in the Kidneys. 613 cipient inflammation. This distinguishes Cantharides, most promi- nently, from Terebinthina. If the blood from the kidneys is filled with exudation-casts, as above described, Cantharides are indicated above any other remedy, likewise if the hemorrhage is caused by renal calculi. At all events they are more efficient in hemorrhage from the bladder than from the kidneys. If the hemorrhage is caused by the abuse of Cantharides, the best antidote is Camphora, together with the copious use of tepid water. Ipecacuanha is an important remedy, if the hemorrhage is very copious, and phenomena of anaemia make their appearance, such as paleness, faint feeling, cold skin, nausea; such cases are rare. Millefolium. The pathogenesis of this drug is not sufficiently accu- rate to enable us to use it in accordance with homoeopathic indica- tions. Used empirically, it has shown great excellence as a specific remedy in haematuria, with painfulness of the kidneys, from which the blood evidently proceeded. The same may be said of Uva ursi. Hartmann says of this drug: "In a case where no other remedy seemed disposed to do any good, and where the discharge of blood was attended with loss of mucus, painful urging previous to urination and constipation, I have em- ployed this remedy with remarkable success." It was given in the form of a decoction. Secale cornutum has not been known or used much as a remedy for urinary affections, and can only be recommended for bloody urine if the blood-disks are entirely, or nearly absent in the urine, which may be regarded as a sign of a peculiar dissolution of the blood. For this reason Secale cornutum may prove useful in cer- tain very severe febrile conditions, if the bloody urine occurs as a complicating symptom. Phosphorus is indicated under the same circumstances as the pre- vious remedy, but is likewise adapted to chronic hematuria, if the discharge of urine is very painful and the urinary excretion much less. If the trouble is caused by sexual excesses, onanism, Phosphorus is, next to Aux vomica and China, a leading remedy. Arsenicum album is an efficient remedy, both in the acute and chronic form of renal hemorrhage. The local symptoms will scarcely ever be sufficient to determine the selection of Arsenic; the general symptoms should indicate and sanction its employment. It is chiefly indicated by the following symptoms: The emission of urine is very painful, the urine is much less in quantity, there is strangury, wide-spread burning pains in the urinary organs, para- 614 Diseases of the Kidneys. lytic phenomena in the bladder, rapid decomposition of the urine in the vessel, deficiency of bloody coagula, the urine being, however, of a very dark color. Lycopodium will have to be selected in accordance with the general symptoms, rather than the local, the latter being but vaguely defined. It is only adapted to the chronic form when ex- isting in decrepit individuals, in connection with chronic catarrhal affections of the lining membrane of the urinary organs. Colchicum autumnale deserves especial consideration, if the disease is caused by a cold or by getting wet, with scalding urine. Cannabis, Capsicum, Pulsatilla, Squilla, Zincum, are mentioned here for the sake of completeness ; we shall recur to these remedies when we come to speak of hemorrhage from the bladder. [Aconite should not be forgotten as a remedy for renal hemorrhage ; we have effected cures of this disease with Aconite, without calling in the aid of any other drug. It is indicated by swelling and soreness of the renal region, heat, throbbing. IL] Regarding the diet, we refer the reader to what we have said on this subject in the chapter on nephritis. Excessive care may, per- haps, not always be necessary; but in haematuria it is better to do a little too much than not enough. The abuse of liquids should be forbidden; they can only be allowed if bloody coagula prevent the urinary excretion; liquids exert an increasing pressure upon them. That external means, such as cold, dry, or moist warmth, foot or sitz-baths, act favorably, cannot well be proven, nor should they be recommended. 4. Renal Calculi, Gravel. The formation of urinary concretions in the kidneys is a common occurrence, but frequently remains unnoticed, because no abnormal symptoms are caused by them. In most cases, the causes of this affection are obscure, or very indefinite. Although the concretions of uric acid are generally met with in plethoric individuals who mostly live on animal food, yet they likewise occur in weakly per- sons, who use a very spare diet. Without doubt, the mode ol living is the cause of the concretions; although a peculiar dispo- sition must likewise exist, which is as yet unknown to us. The urinary concretions in the kidneys generally consist of Urates, less frequently of Phosphates, or the salts of lime. Their size varies; at times they form a fine sandy deposit, gravel; at other times larger bodies, whose shapes vary according to their Renal Calculi, Gravel. 615 locality and tbeir place of origin; they may even be large enough to fill the pelvis of the kidney. Their surface is, at times smooth, at others rough; the number of calculi contained in one kidney is very indefinite; sometimes their sides, where they had been in con- tact with other calculi, form regular facets. The symptoms caused by renal calculi, are very important to the physician, because they frequently attain a great height, and have the appearance of great danger, as though life itself were imperilled by them. Gravel may exist without any morbid symptoms; in other cases, the passage, and perhaps the formation of gravel are attended with marked derangements of the functions of the stomach, the main feature of which, generally, is an excess of acidity. We have pointed out this connection when speaking of chronic catarrh of the stomach. Even larger calculi may exist and be passed with- out any pain. This depends upon the size of the calculus, its smoothness, roughness, or the angularity of its form, upon the width of the ureters, upon the sensitiveness of the urinary passages to the foreign body, whether and what severe disturbances the passage of the calculus occasions. These symptoms together, are generally designated by the name of renal colic. It should be observed, how- ever, that other obstacles to the excretion of urine, such as the presence of bloody coagula in renal hemorrhage, may cause renal colic, except that such colic is usually less persistent, violent, and distressing; for the reason that the obstruction is not fixed, and does not irritate or wound the mucous membrane. Renal colic generally breaks out suddenly, after a severe effort or concussion; its gradual development from indefinite pains in the renal region, whence they spread to adjoining parts, is of less fre- quent occurrence; the former generally takes place if the pains announce the entrance of a renal calculus into the ureter ; the latter, if the pain is occasioned by a gradual irritation of the renal pelvis, or by a change in the position of the concretion. The pains gener- ally are very violent, are felt in the region of the affected kidney, whence they spread to the bladder and the thigh, and, when ex- cessive, generally affect the whole side. The patients suffer a great deal, are tortured by an agonizing anxiety, and have no rest in any position or place. Their face is at times pale as death, at others bright-red; the body is cool, the pulse small and frequent. If the parts are very sensitive, convulsive symptoms are apt to set in. The passage of urine is impeded and painful, sometimes the stran- gury is complete. The pains sometimes continue gradually to 616 Diseases of the Kidneys. increase, until the abdomen shrinks from the least touch, or else they remain unchanged, or they remit at intervals until they finally cease entirely, and the patient again enjoys perfect health. In such cases the concretions usually pass off, soon after, with the urine. Very often heematuria takes place after the passage of the calculus. If the calculus has not passed, the pain may continue and nephritis result in consequence. The passage through the ureter, which, after the intense pain has somewhat abated, the patient is able to watch and point out as the calculus progresses, lasts from a few hours to several days. The diagnosis of renal colic is not always very easy; at the com- mencement the affection is often confounded with peritonitis, car- dialgia, enteralgia ; a misapprehension that is amply justified by the apparently threatening symptoms. The most common character- istic indications of the disease are: the fixed starting-point of the pain, together with the urinary difficulties. The prognosis is un- favorable only, if the concretions remain in the kidney and cause a dangerous irritation in this viscus. An arrest of the calculus in the ureter is a rare exception. Treatment. The main object of the treatment must be to pre- vent the renewal of the concretion, which is most essentially accom- plished by attending to the diet. How to prevent the renewal of the calculi, composed of the salts of lime or of Phosphates, seems to remain a mystery for the present; whereas a good deal can be accomplished so far as the urates are concerned. If the individual is affected with catarrh of the stomach or excessive acidity, this should be corrected; the patients must content themselves with a moderate and lean diet, partake sparingly of animal food, and entirely avoid all fat; on the other hand they may eat vegetables and a great deal of fruit, drink quantities of water, and discard the use of spirits entirely. By such means we have it, at any rate, in our power to acquire an influence over the disease. An attack of renal colic itself is most likely beyond the reach of strictly medical treatment, whatever may be asserted to the contrary by many practitioners. The calculus has to pass through the ureter, and no medicine can hasten this passage. Moreover it is impossible to judge of the effect of any medicine, because we cannot decide a priori how soon a calculus will pass if no medicines are employed. A young woman, one of our own patients, passed two small calculi in about sixteen hours, and a third, an inch in length, in four days, in spite of the remedies that were employed to facilitate the passage. Diabetes Mellitus, Melituria, Glycosuria. 617 Nux vomica and Colocynthis, perhaps also, Cantharides, are most likely to exert an influence. Of more importance are external applications, more especially a tepid or warm bath, perhaps also, the cold sitz or foot-bath, and drinking copious quantities of water, in order to increase the pressure of the urine upon the calculus. Renal colic is one of those diseases, where even the strictest homoeo- path will sometimes feel called upon to prescribe a large dose of Morphine ; but the dose should be large enough to exert its narcotic action, in spite of the intense pain. Narcotizing inhalations of Chloroform are perhaps preferable to Morphine, although neither always secure relief from this great distress. [Doctor Becher of Muehlhausen, employs with great success, for renal calculus and gravel, the Citrated Borate of Magnesia, which has a slightly acid taste, and with sugar resembles lemonade powder, and which can very easily be taken. Two cases are reported in the 24th volume of the British Journal of Homceopathy. Dose: As much as will stand on the point of a knife, every two hours, or less frequently, if the case will permit. Very soon after the commence- ment of the administration of the drug, the pain diminishes, and the calculi are passed without pain. The Borate can be obtained from the apothecary, Doctor Kayser, at Muehlhausen. IL] If we locate this morbid process among the diseases of the kidneys, we do not mean to be understood as though we regarded diabetes as a renal disease. In so far, however, as the main symptom of this affection proceeds from the kidneys; in so far as the urine is the most important diagnostic sign in this disease, we have deemed it proper, because of the opportunity of explaining the necessary examination of the urine, to offer our remarks on this disease in this chapter, instead of giving it its proper place among the constitutional diseases. The problematical character of the whole process, its comparatively rare occurrence, and our comparative ignorance of a suitable treatment of this disease, will be accepted as our excuse, if we content ourselves with briefly mentioning the main data. If a case should occur in a physician's practice, he will have an abund- ance of time to consult special works on the subject. The etiology of diabetes is enveloped in complete obscurity; all data referring to it are purely hypothetical, and rest upon the patient's endeavor to trace his disease to some cause, in order to meet the questions addressed to him by the physician. The true 5. Diabetes Mellitus, Melituria, Glycosuria. 618 Diseases of the Kidneys. cause is the more inaccessible to observation as the disorder com- monly sets in gradually, and is not communicated to the physician until, by its long continuance, it has become an inveterate malady. It is important for us to know that sugar is said to have been dis- covered in the urine, after poisoning by lead or copper. Nor does age shed light on the subject; although most cases of this disease occur between the ages of twenty-five and fifty years, yet children and old people are likewise known to have been attacked with it. It is an established fact, that the disease prevails chiefly among males, and that it occurs much less frequently in the torrid than in the temperate zone. In diabetes, pathological anatomy leaves us completely in the lurch: not one structural change has either been discovered in the kidneys or liver as a constant phenomenon; a very general post- mortem appearance in this disease, is a rather high grade of pulmo- nary tuberculosis. The symptoms of this disease cannot well be ranged together in a coherent series, but have to be considered one by one. The main symptom is the excretion of sugar by the urine, saliva, and perspiration. In the introduction to this section, we have mentioned the methods how sugar can be detected in the urine. Although this fluid looks very pale, yet it has a high specific gravity, which varies between 1020 and 1050, and may even rise to a higher figure; this is the more remarkable, as an extraordi- nary quantity of urine is usually discharged. A specific gravity of 1037 to 1039 indicates, almost certainly, the presence of sugar in the urine, for we are as yet unacquainted with any disease where the specific gravity of the urine rises so high. The color of the urine generally is of a dim straw-color, with a greenish tint; the dimness is considerable only in case other renal affections are present. On voiding the urine, it makes a foam, which generally lasts for some time. The percentage of sugar in the urine varies at different times of the day and at different periods, between two and twelve per cent, and above. For some hours after a meal, the quan- tity of sugar in the urine is larger; hence, if we desire to obtain results of reliable and undisputed validity, the urine will have to be tested for sugar for a period of at least twenty-four hours. It is a known fact that sugar is derived from the starch contained in the food, although this is not the only source of sugar, for it does not entirely disappear, even if we restrict the diet to animal food exclusively. This observation is of particular importance in regu- lating the diet of diabetic patients. Diabetes Mellitus, Melituria, Glycosuria. 619 The second main symptom is, an unusual increase of the urinary secretion, which is almost always present, and, when the disease is at its height, is never absent. In the course of a day, the patient voids ten times and upwards the normal quantity of urine, corres- ponding to the quantity of liquid that had been drank in the same space of time. The assertion that the quantity of urine voided in twenty-four hours exceeds the quantity of liquid drank in this space of time, has been shown by recent investigations to be, most likely, fallacious. The quantity of urine is not always in definite propor- tion to the quantity of sugar in the urine. This may increase, whereas the urine decreases in quantity, and vice versa. At all events, the largest quantity of urine is voided after a meal. The third and never-failing main symptom is the ravenous hun- ger, which it is impossible to account for. Many patients consume incredible quantities of food without experiencing any derangements of the stomach. We have known a diabetic patient who consumed every day from seven to ten pounds of meat, without, however, eating anything else. From these three main phenomena proceed a series of others, with more or less regularity and distinctness. The skin is almost always extremely dry and inactive, so that the patients do not perspire, even in the greatest summer heat. Since this condition of things will naturally occasion a suppression of habitual perspiration, of the feet for instance, this suppression has often been regarded as the cause of diabetes, whereas the reverse is the fact. The great dryness of the skin renders it very sensitive to cold, and creates a remarkable tendency to catarrhal irritations. The thirst is proportionate to the quantity of urine, hence is sometimes perfectly agonizing. It is particularly intense after a meal, and in the night. It is scarcely credible what immense quan- tities of water a diabetic patient is capable of swallowing in the course of a day; the thirst is quenched only for a short time, even if the patient drinks ever so much water. The buccal cavity is very seldom remarkably dry; the tongue is mostly clean, the taste sweetish, the breath has a nauseous odor; the teeth readily turn black, and become carious, and the gums look ulcerated and spongy, as in scurvy. The stomach is seldom affected; acid eructations are very fre juent; the patient has a particular longing for farinaceous food; the alvine discharges are always very dry; the bowels are costive. Almost always, a decrease or complete loss of sexual power takes place at an early period of the 620 Diseases of the Kidneys. disease; the lens very frequently becomes dim, and the hair falls out. If the disease lasts any time, the cerebral energy decreases even unto complete imbecility, a tendency to furuncles and decubi- tus becomes manifest, and pulmonary tuberculosis very often closes the scene. A striking symptom is the extraordinary emaciation, which continues to increase, in spite of eating, and is particularly striking in the face, whose bony framework is distinctly seen, even if the patients still seem very vigorous. With such symptoms the disease runs a slow course, unless the patient's constitution was previously tainted with disease. This disease scarcely ever terminates fatally under a year, unless other inflammatory or gangrenous affections, to which the patients in- cline, suddenly cause a fatal termination. With careful nursing and proper diet the patients may last for years, and even be capable of doing some work; hence it is, that in the lower walks of life diabetes terminates fatally much more rapidly than in the higher. Generally the disease has longer or shorter remissions, or even in- termissions of some length, which arc frequently regarded as a cure without being so. Diabetes generally terminates fatally, either with the symptoms of hectic fever, or in consequence of intervening complications of a malignant character. Only a few permanent and complete cures are recorded. Reports of diabetic cases are incomplete and unre- liable, for the reason that, owing to the peculiar course of the dis- ease the same physician scarcely ever attends the same patient from the commencement to the end of his trouble. Treatment. What we have said in previous paragraphs shows that the treatment of diabetes is almost hopeless; indeed, we must confess that even under homoeopathic treatment patients have not been materially benefited. Before giving a list of the remedies usually employed in this disease, it may be proper to cast a glance at the usual method of treating it. It is literally true, that there is scarcely a medicine that has not been used and recommended in diabetes. The remissions, which are very apt to take place in this disease, have most probably been regarded as an effect of the medicine. It is an admitted fact, how- ever, that so far we are not acquainted with any medicine or group of medicines that have evinced reliable curative powers in diabetes. Most prominent are the Carbonates of Potash, Creasotum, and Quinine; a cure by the last-mentioned drug is reported in the "Deutsche Klinik" of last year, the Quinine being used in very Diabetes Mellitus, Melituria, Glycosuria. 621 large and continued doses of the drug. The most frequent and most reliable curative effects have so far been obtained from the waters of Karlsbad and Vichy; both have effected radical cures, which have been reported in the journals. Great stress has recently been laid on the diet. It is a fact that the exclusive use of animal diet diminishes the quantity of sugar in the urine to an extraordinary degree, but yet some sugar remains. Such a diet, however, cannot be carried out, even with the most iron will, not even if small quantities of farinaceous food are per- mitted. Moreover, the result of such a severe regimen does not compensate for the great sacrifice ; a cure is never obtained by such means, even the apparent improvement loses its importance, for the leason that the diminished quantity of sugar in the urine is owing to the circumstance that fewer substances are introduced into the organism capable of being eliminated as sugar. We do not mean to be understood as though a rigorous diet were entirely useless, for it is undeniable that under a strict animal diet the patients last longer; what we contend for is, that the diet need not be so severe. Many physicians bear testimony that their diabetic patients did very well with a moderate farinaceous and a copious invigorating meat diet; whereas other physicians will admit that but few of their patients were able to live through such a rigorous meat diet, and preferred abandoning it, together with their physician. Those delude themselves who fancy that they have obtained great results by causing a diminution of the sugar by artificial means. An im- provement only exists if, with the same quantity of food, the amount of sugar grows less, and hence the tendency of the organism to this abnormal elimination of sugar has been diminished. We subjoin a few rules for a proper diet. We have already stated that any kind of animal food may be permitted, hence the question is: What kind of vegetable diet may be allowed? This should be regulated by positive instructions, so as to prevent the patient from giving himself up to his ravenous appetite. He may be allowed a certain quantity of bread, that need not be too scanty; he may likewise indulge now and then in the moderate use of potatoes or a certain quantity of rice. These three articles of diet are sufficient, and everything else should be forbidden. Vegetables containing the least quantity of sugar are best adapted to our purpose, such as cabbage, asparagus, spinage, beans, salad of different kinds. Fruit may be allowed, if the stomach can bear it; strawberries and peaches are the best kinds. The excessive thirst of the patients 622 Diseases of the Kidneys. likewise requires to be attended to with great care. Bouehardat has set up the proposition, that the metamorphosis of starch into sugar requires a considerable quantity of water, hence that the de- gree of thirst is proportionate to the quantity of sugar produced. It would seem, therefore, that the intense thirst is a natural desire of the organism, and that there can be no danger in appeasing it. But, inasmuch as the patients may be tempted to drink too much, it is well to regulate the quantity of the liquids they drink, as nearly as possible, by fixed rules. The best beverage is fresh water, although the patients like to have their usual allowance of coffee and tea. In view of their copious meat diet, the moderate use of good claret with their food is likewise to be commended. Coming to the treatment of diabetes by strictly homoeopathic remedies, we confess that we are as yet unacquainted with any specifics against this disease. So far we are not aware that the provings of any of our drugs have yielded sugar in the urine. It is from the presence of sugar in the urine that most of the other symptoms of the disease arise; hence, this symptom is the most important and of indispensable necessity to establish a relation of similarity. It is evident that the absence of this symptom renders the reliable selection of a drug impossible, and that of any drug exceedingly difficult. We cannot, therefore, wonder that our liter- ature should not have a single cure of diabetes to boast of. Having no corresponding remedy to oppose to the main symptom, we have to be guided in the selection of a drug by the accessory symptoms, although but few of them are contained in the patho- genesis of our drugs. The remedies that have so far been recom- mended for diabetes, are: Argentum, m£tallicum, Arsenicum, Plum- bum, Sulphur, Cuprum. Argentum is recommended even by Hahnemann as a suitable remedy for diabetes, and Rueckert reports in his " Klinischen Er- fahrungen," a cure of diabetes by means of Argentum, where, how- ever, the main business, an analysis of the urine, had been neglected. We do not see in what way Argentum is homoeopathic to diabetes, since the characteristic symptoms are wanting. In many respects Arsenicum may be regarded as a simile; it has the sudden, exten- sive emaciation, the sinking of strength, the disposition to gan- grenous inflammations of the skin, an increase of the urinary secre- tion together with an agonizing thirst. But the excessive hunger and the unquenchable thirst are wanting; for the Arsenic-thirst only admits of small quantities of liquids being drank very fre- Diabetes Mellitus, Melituria, Glycosuria. 623 quently. Hence, these symptoms do not point to Arsenic as a strictly homoeopathic remedy ; indeed, we do not possess any reports of cures effected with this drug. [Granvogl, in his Homoeopathy, Vol. II, page 175, relates a cure of diabetes mellitus with Arsenic. The patient was reduced to a skeleton, his mouth excessively dry, thirst agonizing; he fancied that somebody standing by performed every occupation for him, ate, washed, in short did everything for him; he was forty-eight years old, and very dissipated; he was cured in three months. II.] Cuprum has more homoeopathic similarity th^n Arsenic. Cuprum is more especially indicated i>y the following symptoms: Slowly- progressing, extreme emaciation, symptoms of tubercular suppura- tion in the lungs, violent cerebral depression, increased hunger, sweetish taste in the mouth, increased secretion of urine, especially at night, dry and scanty stool, decrease of sexual excitement. Plumbum has all these symptoms in a more marked degree, and, what is more important, much more constantly. We know that the emaciation caused by Plumbum gradually reaches an extraordi- nary degree, that the symptoms of suppuration in the lungs are very common, that a genuine hectic fever sets in, and that impotence is a very common result of lead-poisoning. The constipation is very obstinate; the urine, although generally less, is sometimes very much increased; the hunger is very great, the taste almost always sweetish, alternating with sour. The disposition to catarrhal ulcera- tion of the mouth, and to malignant inflammations of the skin, is likewise present, and we admit with Kurtz, that our Materia Medica does not contain a single drug whose symptoms are so strikingly similar to diabetes as Plumbum. Practical results, how- ever, are altogether wanting. Sulphur, too, has some of the more prominent symptoms of diabetes among its symptoms, such as; the great emaciation, the sweetish taste, the constipation, the increased flow of urine, etc. In our practice we have made a per- sistent use of the drug in two cases without witnessing the least result from its employment. We must add, however, that we gave the thirtieth potency; of course, lower potencies, as may easily be imagined, had a better effect. To these remedies we must add, China, Creasetum, and Lachesis. In a previous paragraph, we have alluded to a cure of diabetes with large doses of Quinine, but large or small doses, Quinine achieved the cure. The similarity of the effects of Cinchona to the symp- toms of diabetes is not very striking; it does not affect the special 624 Diseases of the Kidneys. symptoms, but is rather of a general nature. A cure by Creaso- tum is related in the Prussian Vereinszeitung, of 1855. The sugar at once diminished in quantity quite considerably, but the general condition of the patient grew worse, (probably in consequence of taking too large doses,) after which an improvement was effected by China, subsequently to which, a return to the Creasotum was fol- lowed by a complete disappearance of the sugar, and at the same time by a general amelioration of the constitutional symptoms. In comparing the symptoms of Creasotum, more especially the urinary symptoms, to those, of Diabetes, we shall find that this cure can be accounted for by the law of Homoeopathic similarity. The urine is excreted in larger quantity, is colorless, turbid, has an offensive odor; the bowels are constipated and the faeces very dry ; impotence. Lachesis has many symptoms that seem to refer to this disease, but it is well known that the value of these symptoms is very unsteady and uncertain. According to P. Frank, the bite of the dipsas causes diabetes, and the connection of serpent-poisons with affec- tions resembling diabetes has frequently been noticed. One of our colleagues was acquainted with a man, sixty years of age, in whom the excessive use of salt developed every symptom of diabetes, which disappeared as soon as he stopped this pernicious habit. About four years ago, a French physician made the discovery that daily doses of 1.5 centigrammes of the Muriate of Uranium caused sugar to appear in the urine. If we had had a fair opportunity for instituting provings, we should have done so at once, but we found it inconvenient to carry out such a purpose. However, we had a chance to experiment with the drug on two diabetic patients, a boy of thirteen years, and a farmer aged forty years. Unfor- tunately, on account of the distance at which these patients resided from our office, and their own want of perseverance, we were unable to make many or perfect observations. Both pursued their accustomed mode of living; nevertheless in the case of the Loy, the specific gravity fell from 1042 to 1030, and in the case of the man, from 1039 to 1031 ; the thirst, hunger, and the quantity of the urine likewise diminishe.l very greatly. Doctor Weber made two similar observations on two patients, both of whom died of typhoid, probably uraemic symptoms. After taking Uranium, second trituration, the specific gravity always decreased. These results would be trifling, if they did not concern a disease against which our means of treatment have so far proved inefficient; the drug, undoubtedly, deserves to be subjected to further trials. Cystitis. 625 In conclusion, we repeat, that the use of the waters of Karlsbad and Vichy has constantly shown such favorable results in diabetes, that it is a physician's duty to send every patient, whose circum- stances will admit of it, to those springs. These spa's being only visited during the fine season, time enough remains during the winter, to try other remedial agents in such cases. B. DISEASES OF THE BLADDER. 1. Cystitis, Inflammation of the Bladder. Cystitis, in most cases, involves the mucous lining of the blad- der, and as such is designated cystitis catarrhalis; or it is accom- panied by diphtheritic exudation, cystitis crouposa, or else it may be located in the connective tissue enveloping the bladder, in which case the name of peri-cystitis is applied to it. The two last-men- tioned forms being very rare, and the necessity of diagnosing them being of rare occurrence, we here only speak of cystitis catarrhalis, both acute and chronic. The most frequent causes of cystitis are irritations affecting the mucous lining of the bladder directly; they are either mechanical: catheterism, injections into the bladder, stone, or medicinal: acrid diuretics, Cantharides, Copaiva, Cubebs, or even the decomposing urine itself. In other cases the disease may occur as a complica- tion ; inflammatory disturbances of adjoining organs may spread to the bladder, or the cystitis may simply be symptomatic of some acute general affection. In rare cases only a cold alone will be suf- ficient to cause an inflammation of the bladder. The symptoms of acute cystitis vary. The local symptoms may amount to no more than a slight feeling of pressure in the region of the bladder, and are scarcely ever as intense as Hartmann describes them. Amid more or less febrile motions, the patient always expe- riences at first a pain when urinating. When the attack first sets in, a larger quantity of urine is voided with a painful urging; soon, however, the urine is voided only in drops, and amid the most ago- nizing pains, as though burning embers were passing through the urethra. This symptom is most strikingly witnessed in the most acute form of cystitis after the use of new beer; it is characteristic of this inflammation. Very soon the difficulty of urinating becomes associated with a constant pain in the region of the bladder; it is 40 626 Diseases of the Bladder. a cutting or stitching pain, and is aggravated by motion, urging to stool, coughing, sneezing, pressure from without; it spreads up- wards and downwards to the penis, perinaeum, and thigh. At the outset of the disease the urine is clear; after a while it becomes slightly tinged with blood, and, in the further course of the disease, mixed with flocks of mucus and pus-corpuscles, turbid, inclined to decomposition. The general health is not always disturbed corres- pondingly to the abnormal sensations proceeding from the bladder ; at the commencement of the disease the general health is not much impaired, and it is only at a later period that restlessness, chills, loss of appetite, and even vomiting set in. The disease very frequently runs such a rapid course, that an improvement and even complete recovery may take place in a few days. If the disease increases in intensity, the tenesmus of the bladder may increase to complete retention, the bladder becomes extremely distended, and threatening symptoms of prostration set in, which may end in death. Usually, however, the disease, unless recovery takes place, assumes a lentescent character, and becomes chronic. In the chronic form the pains decrease considerably, only the constant urging remains. The mucus is secreted in considerable quantity, and along with it pus, so that the urine has a marked white-yellow appearance, sometimes like milk, and deposits a very tenacious mucous sediment. The tendency to decomposition is very great, the reaction decidedly alkaline, less frequently neutral. How- ever, the urine is decomposed only, if it remains for a long time in the bladder. Unless peculiar circumstances hasten the loss of strength, it generally takes place very slowly, and the disease may continue for years before death takes place from exhaustion. Com- plete recovery is a rare event. Among the sequelae, we distinguish ulceration of the mucous membrane, hypertrophy of the walls of the bladder, paralysis of the detrusor muscle; it is particularly the two first-named sequelae that hasten the fatal termination of the disorder, by causing hectic fever and a real phthisis of the bladder. What we have said shows that the prognosis is quite uncertain. Even if we usually succeed in overcoming an acute catarrh of the bladder, yet ailments sometimes remain for a long time after the slightest attacks, to which the careless or improper conduct of the patient may impart a high degree of gravity. Chronic catarrh of the. bladder is always a dangerous disorder, whenever a great deal of mucus and pus is secreted. Cystitis. 627 Treatment. The most important remedy against the acute form are Cantharides. In a previous paragraph we have called at- tention to the constant and characteristic effect of Cantharides upon the kidneys, and we will here observe that the relation of this medi- cine to the bladder is much more definite and profound. In order to avoid unnecessary repetitions, we refer the reader to what we have said on the subject of Cantharides when treating of nephritis; here we simply describe the symptoms that specially refer to cysti- tis, and which characterize every case of poisoning by Cantharides, whereas the symptoms of nephritis are of less frequent occurrence. Spasmodic, distressing pains in the perinseum and along the urethra, spreading into the testicles, that seem to be drawn up, as if by force; burning, almost insufferable pains in the bladder, spasmodic pains in the thighs; cutting pain through the abdomen; burning pains in the glans; the excretion of urine is more or less obstructed, dribbling of the urine drop by drop, during which it seems like molten lead, the pains are very much increased, and the tenesmus is frightful. The urine is at first clear, afterwards saturated, tur- bid, tinged with blood, and sometimes drops of pure blood are passed. Great tendency to painful erections; excessive restless- ness, with marked fever. These symptoms embody a perfect image of acute cystitis, and we may include the profuse secretion of mucus taking place in a case of chronic poisoning, likewise an image of the further course of cystitis. It cannot be denied that this effect of Cantharides seldom lasts beyond the fifth day, and hence, in long lasting cases of cystitis, we had better look about for other medicines. This remedy deserves especial consideration if the cys- titis arises from nephritis, or else caused this latter disease, and likewise in cystitis caused by gonorrhoea. In the chronic form Cantharides are scarcely ever appropriate. There is good reason why the medicine should not be given in too large a dose ; we have frequently seen instantaneous aggravations take place after the third trituration. Aconitum is scarcely ever indicated in cystitis; the intense fever only accompanies very violent inflammations, to which the symp- toms of Aconite do not by any means correspond. [We think that Baehr undervalues altogether the usefulness of Aconite in this dis- ease. In rheumatic cystitis Aconite is not only invaluable, but the true specific remedy, superior to Cantharides. II.] Cannabis. The bladder symptoms of this drug so nearly resemble those of Cantharides, that it is very difficult to distinguish them 628 Diseases of the Bladder. from each other. At most the action of Cannabis is less intense. Ef the particular remedy is not clearly indicated by the accessory phenomena, it may be well, as Kreussler advises, to give Cannabis, if Cantharides have afforded no relief within twenty-four hours. Colocynthis. The characteristic differences between this drug and Cantharides are more marked. We have tenesmus of the bladder, but less intense, and the pains at urinating are felt over the whole abdomen. The main difference resides in the quality of the urine, which is quite dim, even while being voided, and deposits a tena- cious, ropy sediment. Hence, Colocynthis is not adapted to cysti- tis at the commencement of the disease, but during the period when the pains begin to abate, and mucus begins to be discharged, which scarcely ever takes place before the fifth day. In the chronic form Colocynthis is likewise indicated, provided the disease had not been of too long standing, and no important anatomical changes had taken place. Mercurius solubilis is very nearly related to the former drug; it has likewise a profuse secretion of mucus at urinating, together with the other diagnostic symptoms. The difference between this and other remedies, will easily be determined from a comparison be- tween their accessory symptoms; violent fever with chilly creep- ings, and great sensitiveness in the region of the bladder, are characteristic indications for Mercurius; gonorrhoeal cystitis like- wise requires Mercurius. If the urine contains pus, Mercurius is preferable to Colocynthis under all circumstances. The remedies that have been named so far, will be found suffi- cient in all eases of acute cystitis. In addition the following may be considered: Hepar sulphuris, Nur vomica, Pulsatilla, Belladonna, Mezereum. In chronic catarrh of the bladder, the following reme- dies may have to be used: Acidum phosphoricum for the so-called milky urine, or in other words urine with excessive secretion of mucus, so that the mucus coagulates even in the bladder; the urine is rapidly decomposed, even before being voided. Arsenicum album may have to be used in cystitis running a rapid course with threatening symptoms, more particularly, however, in chronic cystitis, when the extraordinary ischuria gives rise to violent distention of the bladder, and threatens to paralyze this organ, and symptoms of ulceration are evidently present. The strength of the patient sinks rapidly, amid febrile motions; the urine is dim, mixed with pus rather than mucus, de- composing very rapidly, and occasionally, but not always, mixed Hematuria. 629 with blood. Lycopodium may be required in old cases; the patients' constitutions are worn out, blood is discharged occasionally, as in the so-called hemorrhoids of the bladder. The pains are trifling, but there is a constant distressing urging, although but little urine in the bladder. Causticum; the detrusor urinse is paralyzed, in consequence of the long-lasting retention of urine, so that in spite of the large quantity of urine in the bladder, very little urine is emitted, or only by fits and starts. Carbo vegetabilis is likewise adapted to vesical catarrh attended with paralytic symptoms. Beside these medicines, the following deserve attention: Graph- ites, Sulphur, Alumina, Conium maeulatum, Sepia, Aurum, Senega, Capsicum, Sarsaparilla. [In chronic catarrh of the bladder, origi- nating in gonorrhoea, Copaivee balsamum may be the best remedy. Some time ago we cured a case of this kind with Copaiva and Cin- chona, giving fifteen drops of the Copaiva three times a day. The patient was a middle-aged man, and had consulted some of the first physicians in New York. He had been afflicted with the dis- ease for several years, which had been caused by improper treat- ment of gonorrhoea with injections. The discharge had been sup- pressed, and left him with chronic catarrh of the bladder. This came on in paroxysms, with distressing urging every few minutes; at each urination he only passed a few drops of urine and a quan- tity of purulent mucus. The patient improved very rapidly, indeed immediately after taking the Copaiva, and has remained free from all trouble for the last few years. H.] The diet has to be regulated with great care. In acute as well as chronic cases, such a diet should be observed as will keep the urine as free from solids as possible, although this is not an easy task to accomplish, because the patients have to use substantial nourishment in order to sustain their strength. In acute cases the patient should eat as little animal food as possible, and should avoid all kinds of spices, coffee, tea, wfine, spirits; the use of copious quantities of water should, how'ever, be insisted on. Carbonated water has an unmistakably beneficial effect. 3. Hematuria, Bloody Urine. Bloody urine not depending upon the above-described renal hem- orrhage, but proceeding from the bladder, originates most com- monly in injuries of the mucous membrane of the bladder by foreign bodies, or by concretions. Moreover, hematuria and malignant growths in the bladder may arise from cystitis and its consequences, 630 Diseases of the Bladder. ulcerations and dilatation of the vessels. It is seldom the case that hemorrhage from the bladder occurs without any evidently mate- rial cause. As in the kidneys, so in the bladder, certain poisons may cause hemorrhage, though in the latter less frequently than in the former. Excepting the symptoms of the causal affection, the symptoms of hematuria are generally trifling, determined, for the most part, by the coagula that form very readily and interfere with the easy flow of urine. Hence, we have urging, tenesmus, spasm of the bladder, burning or cutting pains, and very frequently a perfect absence of pain. The symptoms are always restricted to the blad- der, and do not involve the kidneys in any way. As a rule the blood is not intimately mixed with the urine, is not decomposed, and, if the hemorrhage is at all considerable, the blood coagulates in such quantity that the catheter is often required in order to effect a passage for the urine. The flow of blood from the bladder very easily exceeds the quantity flowing from the kidneys, and hence superinduces more readily the phenomena entailed by loss of blood. On the other hand, an hemorrhage from the bladder usually has a shorter duration than hemorrhage from the kidneys, and scarcely ever lasts uninterruptedly for weeks. Of itself it is scarcely ever an accident of any great importance. Treatment. The remedies recommended for renal hemorrhage are likewise appropriate in hematuria; we, therefore, refer to the former, and add the following particulars in this place. Cantharides may only be found suitable in hematuria accompanied by violent symptoms of irritation; they are not adapted to hemor- rhage without much pain. Particulars may be found in the chap- ter on renal hemorrhage; likewise regarding Terebinthina, which we are seldom called upon to use in this affection. Arnica is the best remedy if the bleeding is occasioned by the catheter, by an operation or by concretions. Ipecacuanha is indicated in copious hemorrhage, with coldness of the skin, nausea, vomiting, fainting, retention of urine on account of the bloody coagula, dark color of the lost blood. Cannabis in the same cases as Cantharides, and likewise if the blood is lost from the urethra. For the so-called hemorrhoids of the bladder, which usually occur in consequence of, or attended with chronic catarrh of the bladder, and where the loss of blood occurs periodically, but sometimes in large quantity, the chief remedies are: Lycopodium, Arsenicum, Sulphur. If pure blood is discharged, especially immediately after urinating, Meze- Enuresis Nocturna. 631 reum is required. If the hemorrhage is caused by irritating drugs, especially by Cantharides, ^amphora is the remedy. There are many other remedies that have bloody urine among their symp- toms, but we have not deemed it necessary to enumerate them in this place. [We have often cured hematuria with Aconite root, first attenuation, especially in the case of bilious individuals, with sallow complexion, a wiry frame, and bilious-nervous temperament. We can recommend the Canada flea-bane, or the Erifferon cana- dense, and Hamamelis virgin iana, or witch -hazel, as far superior to many of the above-mentioned remedies. Small doses, however, will not answer. Trillium'pendulum, or the beth-root, is highly recom- mended by some physicians; we have no experience of our own to offer. H.] 3. Enuresis Nocturna, Wetiisig the Bed. This inconvenience would be of little consequence, except for the crying abuses to which the endeavor to remove it has led. Phy- sicians as well as parents have supposed that this weakness could be done away with by purely educational means, which were, more- over suggested by the most insane views regarding its causes. Lat- terly, physicians have improved their methods of meeting this accident; lay-persons, however, are still true to their absurd preju- dices in this respect. Wetting the bed is an accident to which children are liable; it seldom lasts beyond the age of pubescence, still less beyond the age of twenty years. Healthy individuals scarcely ever wet their beds more than once. This trouble generally dates from the earliest in- fancy, and rarely makes its appearance at a later period. Various causes have been assigned for it, and corresponding methods of treatment devised for its cure, however with varied results. Lazi- ness may give rise to it in many cases, but more frequently it is the fear of getting up in the dark. A common cause of the trouble is, that children sleep too soundly to be roused from their sleep by the irritating action of the urine upon the bladder. Yet the bladder need not be weak or paralyzed; if so, the accident may take place even during a light sleep. The children generally say that they dreamed of wetting the bed, showing that the irritation was not sufficiently powerful to wake them. The quality of the urine may causQ a passing attack of enuresis ; we see this in children who are liable to catarrhal attacks, and, under such circumstances, imme- diately void a saturated urine. The irritation caused by pin-worms may likewise induce enuresis. 632 Diseases of the Bladder. Corporal punishment should never be resorted to as a means of curing this weakness, which is rather made worse by it than other- wise ; older children are made so nervous by this treatment, that they sometimes remain wide awake half the night. On the con- trary, their sense of honor and will should be appealed to. It is of no use to keep the ordinary beverage from them in the evening; this may cover up the weakness for a time, which returns again as soon as a little more liquid is again partaken of. Nor is it of any more use to frequently rouse children from their sleep at night. If no abnormal conditions forbid, the best plan is to gradually ac- custom the bladder to hold larger quantities of liquid. Children should be accustomed during the day to retain the urine as long as may seem proper, and not to yield to the least desire to urinate, as is their usual custom. This system, if carried out consistently and vigorously, is often alone sufficient, in otherwise normal cases, to effect a cure, of course not in a few days. By measuring the quan- tity of urine at every discharge, we can determine a priori the time when the enuresis will cease. The more the quantity increases the nearer we are to a cure. This method has the advantage of being readily adopted by the children, provided they are promised a speedy delivery from their trouble. The r ader may infer from what we have said, that we do not entertain a very high opinion of the efficacy of internal remedies in this disease, except when enuresis is a purely secondary affection, in which case w'e resort to the remedies for catarrh of the bladder, helminthiasis, etc. But inasmuch as no torturing effi cts need be apprehended from the remedies proposed by homoeopathic practice for this disease, like those inflicted by one of the leaders of the Physiological School, whose means of cure recommended for it are truly startling and even frightful, we here name the remedies that may be given with more or less good effect: Belladonna, Pulsatilla, Cina, Causticuni, Sepia, Sulphur. One of our oldest practitioners recommends the last-named medicine in the thirtieth potency, and at lono- intervals; but we confess that we have never derived the least benefit from it, unless the above-proposed precautionary meas- ures were at the same time adopted. [The Nitrate or Muriate of Uranium may have a very good effect. II.] This spasm is a symptom in many affections of the urinary organs, and, as such, is not referred to in this place. There is no doubt 4. Cystospasmus, Spasm of the Bladder. Cystospasmus. 633 that it may likewise represent a pure neurosis of the bladder, although its occurrence as such is comparatively rare. The disease may break out at any age, but is most frequent in middle-aged individuals of the male sex. All persons with weak and irritable nerves are predisposed to this affection, hence it is most frequently met with among hypochondriac and hysteric individuals. Hence, a sudden emotion, an outburst of passion, great depression of strength, violent exertions during sexual intercourse, onanism, may be proximate causes of the disease. Whether a simple spasm of the bladder may be caused by a cold, is questionable. A spasm of the bladder commonly sets in quite suddenly, the patient being otherwise in the enjoyment of good health, as a violent, constric- tive pain, proceeding from the neck of the bladder, and extending along the dorsum of the penis towards the glans, attended with partial or complete erection, sometimes radiating to the groin, testes, thighs, and very often, at the same time, along the perinseum towards the anus, accompanied by a pain resembling tenesmus. If the spasm affects the detrusor muscle alone, the least accumulation of urine excites a violent desire to void it, so that the patients are sometimes unable to prevent the flow of urine ; if the sphincter is affected, the urine is either voided drop by drop or cannot be voided at all; if the detrusor and sphincter are affected at the same time, we have the most violent urging to urinate, attended with a more or less complete inability to void the urine; this last-mentioned case is most apt to cause nervous phenomena of a different kind, such as anguish, restlessness, trembling, convulsions, violent tenesmus. An attack of spasm may last from one or more minutes to half an hour. After the pains begin to abate, the urine sometimes passes off in a full stream, clearer' and paler than usual. The return of the paroxysm is not governed by any rule, since the spasm some- times only takes place once, sometimes a number of times, even on the same day. Treatment, Hartmann's therapeutic recommendations not only refer to the mere spasm, but likewise to a spasm sympto- matic of other morbid complications. Our previous remarks con- cerning Cantharides, Cannabis, Terebinthina, etc., show that these remedies may cure the latter kind of spasm. We want to know the remedies that will cure spasm of the bladder when occurring as a pure neurosis. We have very few practical indications to guide us in the selection of a lemedy, most probably because cystospas- mus is a very rare affection. We may take it for granted, however, 634 Diseases of the Bladder. that such remedies will prove most effectual as are capable of ex- citing genuine spasms in other organs and systems. Nux vomica ranks first among such remedies. It not only meets all the bladder- symptoms, but likewise the consequences of sexual excesses, onan- ism, etc.; likewise hypochondria and other conditions that have been referred to among the etiological causes. A second important remedy is Ilyoscyamus, well known to veterinary surgeons as a good remedy for the spasmodic urinary difficulties of horses; clinical observations of this kind on the human species are as yet very scanty. Belladonna and Cocculus likewise deserve mention. Although we place these remedies in the front rank, yet we are willing to admit that the other remedies, which we have indicated for acute catarrh of the bladder, may likewise prove useful, more especially Colocyn- this, and likewise Colchicum, Pulsatilla, Sarsaparilla. Hartmann recommends the last-mentioned remedy as particularly efficacious for spasms of the bladder caused by stone in the bladder. [Spasm of the bladder, caused by a cold, yields speedily and permanently to Aconite, first attenuation of the tincture of the root, or to a few drops of the German tincture in half a tumbler of water. IL] The peculiar character of this disease suggests the propriety of trying to relieve the patient by external applications. Water is most adapted to this purpose. As a rule, warm sitz-baths or warm fomentations to the region of the bladder afford the most relief; it is only now and then that very cold water, or a cold-water injec- tion may be preferable. The patient may likewise be advised, as soon as the spasm commences, to drink large quantities of water, either cold or warm. In thirty minutes the water will have entered the bladder. The use of water is especially desirable, if the attack was caused by acrid, medicines or beer. 5. Cystoplegia, Paralysis of the Bladder. Although this form of paralysis has been alluded to in the first section of this work, yet we deem a few additional remarks on the subject indispensable, for the reason that paralysis of the bladder sometimes occurs as an idiopathic disease, independent of affections of the spine or brain, and becomes a source of great distress to those who are afflicted with it. The causes of this affection, beside those that originate in the central organs of the nervous system, are of three kinds, namely: advanced age or premature marasmus, excessive distention of the bladder, and sexual excesses, particularly onanism. The symptoms Cystospasmus. 635 vary, according as the sphincter or the detrusor muscle is paralyzed. In the former case, and if the paralysis is complete, the urine flows off involuntarily, as soon as the bladder is somewhat distended, whereas, if the paralysis is incomplete, in a case of so-called paral- ytic weakness, the patients are indeed able to retain the urine for a short, but never for any great length of time. This last-named condition is met with quite frequently, and many persons are afflicted with this weakness without consulting a physician on the subject. If the detrusor is paralyzed, the bladder acquires an undue distention before it overcomes the normal resistance of the sphincter, and only a portion of the contents is voided, always with the co- operation of the abdominal muscles. If both muscles of the blad- der are paralyzed at the same time, it becomes excessively and permanently distended, and only the smallest portion of the urine is voided voluntarily. We shall here speak only of the two forms of paralysis that origi. nate in excessive distention of the bladder and in sexual excesses, onanism, etc.; for paralysis of the bladder, which befalls old people, is not amenable to systematic treatment. In the former cases, the patients are generally younger persons. The first form of paralysis from excessive distention, is caused by an undue retention of urine, which young girls are particularly apt to indulge in, a paralysis similar to that which may attack the rectum from an analogous cause. In such a case, the physician may interfere, not only with prophylactic, but likewise with curative means. The prophy- lactic treatment consists in advising mothers to warn their children against indulging in such unreasonable prudery, and to explain to them the consequences of such foolish conduct. The curative treat- ment consists in prescribing Ignatia, Rhus tox., Ruta graveolens, or Baryta carbonica, the precise indications for which we omit, for the reason, that each case will have to be treated in accordance with its own special symptoms. Paralysis of the bladder, arising from abuse of the sexual organs, is generally only a semi-paralysis, a more or less marked weakness. Of course, a successful treatment implies a mode of life in accordance with sound hygiene and morality. The remedies are: Nux vomica, Ignatia, Phosphorus, China, Causticum. In both these forms of paralysis, cold water is an important means of cure; it may be used as a cold sitz-bath, or wet sheet, or as an injection. Paralysis of the bladder, consequent upon severe labor, has to be treated in the same manner; it generally disappears of itself, but may likewise remain as a permanent weakness.