fc^SS NLM000858539 / J .1 HUGHES' COMPEND OF PRACTICE. PHYSICIANS' EDITION. 4 TO PHYSICIANS. The several essential qualities which a good Visiting List should possess are, compactness, convenience of arrangement, and strength to resist the unusual hard wear it receives. These qualities are all com- bined in Lindsay & Blakiston's Physicians' Visiting List, which has now been published for nearly forty years, and no better evidence of the practical worth of this book can be offered than the uniform increase in popularity it has enjoyed with each successive issue. One of its chief features is its size; it measures 6}i x 3^ inches, and the smallest size weighs but 3% ounces and is only 3/% of an inch thick. The large sizes are a little thicker and heavier; it is, however, the smallest and lightest Visiting List published. Our many years' experience have enabled us to put it together in the best manner, and to add many im- provements during the past few years. It is arranged for 25, 50, 75 and 100 patients per day or week, inter- leaved and plain, dated and undated. Prices range from $1 to $3. Complete circular will be sent you upon application. P. Blakiston, Son & Co., Medi- cal Publishers and Booksellers, 1012 Walnut Street, Philadelphia. A COMPEND PRACTICE OF MEDICINE. DAN'L E. HUGHES, M.D., iM LATE DEMONSTRATOR OF CLINICAL MEDICINE IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA; FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, ETC. PHYSICIANS' EDITION. THOROUGHLY REVISED AND ENLARGED. BASED ON THE THIRD REVISION OF THE QUIZ-COMPEND EDITION, AND INCLUDING A VERY COMPLETE SECTION ON SKIN DISEASES.: PHILADELPHIA: ^'£ $~~~t/ P. BLAKISTON, SON & CO\]^tl No. 1012 Walnut Street. 1887. mne.£, hypoder- matically, followed with extractum opii, gr. j, every hour, and bold stimulation. TYPHUS FEVER. Synonyms. Contagious fever; ship fever; jail fever. Definition. An acute febrile, epidemic disease; contagious and characterized by sudden invasion, profound depression of the vital powers, and a peculiar petechial eruption ; favorable cases terminate by crisis in fourteen days. No lesion. Cause. A special infecting germ, the character of which is unknown, but which is influenced by filth and overcrowding. Pathology. Blood dark and thin, with lessened fibrin ; tissues dark, soft and flabby. Symptoms. Begins abruptly ; chill followed by violent fever; temperature within a few days reaching 1040 to 1050 F.; a frequent, bounding pulse, soon becoming compressible; severe headache, followed by violent delirium; from the fifth to the seventh day, a coarse, red, measly eruption, with a mottling of the skin all over the body, except the face, not disappearing on pressure ; constipation the rule. End of the second week, the temperature suddenly declines and the patient passes into a rapid convalescence. Complications. Pneumonia and swollen parotid glarfds are common. Diagnosis. From typhoid fever, the age, season, onset of the disease, temperature record, character of the eruption, and the intes- tinal symptoms. Measles begin milder, with coryza and cough, and seldom have FEVERS. 21 such pronounced nervous phenomena, but there occurs an early eruption appearing on the face. Prognosis. Unfavorable indications; high temperature, frequent pulse, early stupor, presentiment of death. Favorable; youth, mod- erate temperature and pulse, and mild nervous phenomena. Treatment. Symptomatic. As typhus is distinctly contagious, isolation is imperative, with immediate removal and disinfection of the patient's excreta. For high temperature, cold pack, cold bath, cold sponging, full doses of quinina or antipyrin. For the headache and delirium, cold to the head, in the young and strong, a few leeches to the temple, and chloral, with or without the bromides. For cotistipation, mild laxatives. Debility; alcohol early and in full doses, spiritus chloroformi in drachm doses, whenever danger of collapse. CEREBRO-SPINAL FEVER. Synonyms. Epidemic cerebro-spinal meningitis ; epidemic cere- brospinal fever ; spotted fever; cerebro-spinal typhus. •Definition. A malignant epidemic fever, characterized by pain- ful contractions of the muscles of the neck, retraction of the head, hyperesthesia, disorders of the special senses, and frequently an eruption of petechia or purpuric spots—a subcutaneous extravasation of blood. Lesions of cerebral and spinal membranes are found at the post-mortem. Cause. A special micro-organism, of oval shape, occurring mostly in pairs and faintly tremulous, resembling those found in pneumonia and erysipelas, though hardly identical. The disease seems to have a predilection for the young. Occurs most frequently in the winter months. Not contagious. Pathological Anatomy. Hyperemia, followed by an exuda- tion of lymph and an effusion of serum upon the membranes of the brain and spinal cord, causing pressure. Symptoms. Divided, according to the severity of the lesion, into three groups; to wit: the common form, the fulminant and the abortive. The Common Form begins with a chill, excruciating headache, >>0 PRACTICE OF MEDICINE. persistent nausea, vomiting, vertigo, and an overwhelming sense of weakness. Within a few hours the muscles of the neck become rigid and retracted, with decided pain upon moving the head ; this rigidity and retraction soon extends to the back, when opisthotonos occurs. The surface of the body becomes highly sensitive ( hyperesthesia) and convulsions or delirium occur. Intolerance of light, and in some cases amaurosis, more or less deafness, loss of sense of smell and taste soon following. The temperature and pulse records are irregular. From the first day to the fifth an eruption of petechiae or purpura occurs in the majority of cases. The disease reaches its height in from three to eight days, and passes into stupor and coma, or ameliorates and passes into a protracted convalescence. The Fulminant Form. Severe chill, depression, and in a few hours collapse. The patient is overcome by the poison and never reacts. The Abortive Form consists of one or more pronounced character- istic symptoms during the course of an epidemic. Sequelse. Result from thickening of either the cerebral or spinal membranes; persistent headache, blindness or deafness, partial or complete; epilepsy, or different forms of spinalpalsies. Complications. Pneumonia; typhoid fever; pleuritis; intes- tinal catarrh of infants. Diagnosis. Typhoid fever begins slowly, has a characteristic temperature record, without so intense headache, muscular rigidity, vomiting, early delirium, ending in coma and constipation. Typhus fever has higher fever, is of longer duration, and has a peculiar measly eruption, is not attended with muscular rigidity and retraction, hyperesthesia, nor disorders of the special senses. Tubercular meningitis is not epidemic, has no characteristic erup- tion ; is preceded by long prodromes, and runs a tedious course. A congestive chill resembles the fulminant cases in suddenness of depression, but the latter has not the history of the former. Inflammation of the meninges of the cord is due to exposure to cold, or syphilis, and is not attended with cerebral symptoms or an eruption. Prognosis. Varies according to epidemic; from twenty to fifty, and even seventy-five per cent. die. Treatment. Full doses of opium. Hypodermatic use of mor- phine, gr. X t0 K every two or three hours ; or extractum opii, gr. j every hour until stage of effusion, when quinina in tonic doses, and FEVERS. 2o potassii iodidum are indicated. Prof. Da Costa alternates potassii bromidum with opium, especially in children. Locally, cold to the head and spine. A generous diet from the onset. For sequele, potassii iodidum, a course of hydrargyrum, and flying blisters along the spinal column. RELAPSING FEVER. Synonyms. Famine fever; bilious typhoid fever. Definition. An epidemic, contagious, febrile disease, self-limited ; characterized by a febrile paroxysm, succeeded by an entire inter- mission, which is in turn followed by a relapse similar to the first seizure. No specific lesion. Cause. A specific poison; contagious; acquiring the greater activity the more filthy, crowded and unhealthy the population amid which it prevails. Pathological Anatomy. During the febrile paroxysm only, blood contains minute cork-screw-shaped organisms or spiral fila- ments—spirilli, constantly twisting and rotating. Liver and spleen greatly swollen. Symptoms. No prodromes. Onset abrupt, with fever, io2°-io4°; frequent, rather weak pulse, headache, nausea, vomiting, and lanci- nating pains in limbs and muscles, marked in the calf of leg; second day, feeling of fullness and pressure in right and left hypochondrium, due to swollen liver and spleen ; jaundice is frequent; seventh day fever ends by crisis; fourteenth day symptoms return in milder form, continuing about four days, when enters slow convalescence, much emaciated. No eruption. Several relapses may occur. Diagnosis. Yellow fever has many points of resemblance, but has a shorter febrile stage, remission not so complete, vomiting late and characteristic, normal spleen, and the late appearance of yellow color. Remittent fever begins with a decided chill, followed by fever and sweats, and not the progressive rise of temperature till the fifth or seventh day. Prognosis. Recovery the rule, but protracted, and decided emaciation results. Treatment. Expectant. Act on secretions; nourish patient and meet urgent symptoms. For fever, antipyretic doses oiquinina which, 24 PRACTICE OF MEDICINE. however, has no power to prevent the relapses; for pain, hypoder- matic injections of morphina ; nausea and vomiting, acidum carboIl- eum or cerii oxalas; during remission, ferrum and quinina in tonic doses. PERIODICAL FEVERS. These affections are characterized by the distinct periodicity of the phenomena, having intervals during which the patient is wholly or nearly free from fever. INTERMITTENT FEVER. Synonyms. Ague ; chills and fever; malarial fever. Definition. A paroxysmal fever, the phenomena observing a regular succession ; characterized by a cold, a hot and a sweating stage, followed by an interval of complete intermission or apyrexia, varying in length, according to the variety of the attack. Cause. Malaria. Bacillus Malaria ? Pathological Anatomy. Blood dark, from the formation of pigment (Mjlanemia). Spleen swollen (Ague cake). Liver engorged and swollen. Varieties. Quotidian when a daily paroxysm; tertian when every other day; quartan when it occurs first and fourth days ; octan when weekly ; duplicated quotidian when two paroxysms daily ; duplicated tertian, two every second day ; double tertian, daily paroxysm, but more severe every second day. Dumb ague, or masked ague, has irregularity of the characteristic phenomena. Symptoms. Each paroxysm has three stages, to wit: cold, hot and sweating. Cold stage begins with prodromes, to wit: lassitude, yawning, head- ache and nausea, followed by a chill; the teeth chatter, skin pale, nails and lips blue, the surface rough and pale, the so-called goose- skin or cutis anserina, nausea and great thirst, while the thermometer in the axilla or mouth shows a decided rise of temperature, 1020 F.- 1040; these phenomena continuing from one-half to an hour. Hot stage begins gradually, by the shivering ceasing, the surface becoming hot and flushed, the temperature rising to 1060 F., or more, pulse full, headache, nausea, intense thirst, dry, flushed, swollen skin, scanty urine and other phenomena of pyrexia, continuing from one to eight or ten hours. FEVERS. 2o Sweating stage begins gradually, first appearing on the forehead, then spreading over the entire surface; the fever lessens, the tempera- ture rapidly falling to 990 or 980, pulse less full, headache lessens, and a general feeling of comfort, sleep often following; duration from one to four hours, when the intermission occurs, the patient apparently well, except a feeling of general debility. The occurrence of the next paroxysm depends upon the variety of the attack. The paroxysm may be ushered in by a decided pain in one or more nerves, instead of the cold stage, to wit: "brow ague." Diagnosis. No difficulty when the characteristic chill, fever, and sweats occur. Hectic fever. Distinguished by its irregularity, and occurring secondary to an organic disease. Pyemia produced by other causes than malaria. Nervous chills show an absence of the temperature rise. Prognosis. Recovery the rule. Without treatment many cases end favorably after several paroxysms; others passing into the chronic form or malarial cachexie. Treatment. Cold stage can be averted and the other stages greatly modified by a hypodermatic injection of either morphine sulph., gr. %-%, or pilocarpine hydrochloras, gr. yi, or chloroformi spts., f£j, by the stomach. Hot stage, cool drinks and cold spong- ing. Sweating stage, when excessive, sponging with alumen and hot water. Intermission ; at once a brisk purgative, followed by cinchona in some form, the most efficient being quinine sulph., gr. xx-xxiv, in solution or freshly-made pills, in one or two doses, three to five hours before the expected paroxysm. Many substitutes are lauded to replace the salts of cinchona bark, but without avail. After the paroxysms are broken up, use liq. potassii arsenit., gtt. v-x, t. d., for a long time, or tinct. ferri. chloridi, gtt. xx, every four hours, or a combination like the following:— R. Ferri reducti Quininae sulph .................aa.................. gr. xlviij Acidi arseniosi...................................... gr. j Ol. pip. nigr......................................... gtt. xv. M. Ft. pil. No. xxiv. Sig.—One pill after meals, continued for one month, at least. C 26 PRACTICE OF MEDICINE. Relapses being common, quinina should be given on the second or third day, fourth to the sixth, twelfth to the fourteenth, and nineteenth to the twenty-first days. REMITTENT FEVER. Synonyms. Bilious fever; bilious remittent fever ; marsh fever ; typho-malarial fever ? Definition. A paroxysmal fever, with exacerbations and remis- sions ; characterized by a moderate cold stage (which does not recur with each paroxysm); an intense hot stage, with violent headache and gastric irritability; and an almost imperceptible sweating stage, which is frequently wanting. Cause. Malaria, aided by high temperature. Pathological Anatomy. Blood dark (Melanemia) ; spleen enlarged, soft, filled with blood, and of an olive color; liver congested and swollen, and of a bronze hue; the brain hyperaemic and olive- colored ; gastro-intestinal canal markedly hyperaemic. Symptoms. Cold stage ; moderate chill, the temperature rising 1° to 2°, oppression at the epigastrium, slight headache, and pains throughout the body. Hot stage; persistent vomiting, furred tongue, fullpulse, rising to ioo or 120, flushed face, injected eye, violent headache, pains in limbs and loins, hurried respiration, the temperature rising to 1040 F., or 1060. The bowels costive, stools tarry and offensive, and the surface becoming yellow. Delirium occurs when the temperature is very high. Sweating stage; after six to twenty-four hours, the above symptoms abate, and slight sweating occurs ; trie pulse, headache and vomiting subside, and the temperature falls to ioo0 F., or 990. This is the remission. After some two to eight or twelve hours the symptoms of the hot stage return, generally jninus the chill, and this is termed the exacerbation, which is in turn again followed by the remission. Duration. From seven to fourteen days, the average. Frequently the fever ceases to remit, and instead, becomes continuous, the symptoms resembling, if they are not identical with, the typhoid state, whence the term typho-malarial fever, or >nalario-typhoid fever. FEVERS. 27 Sequelae. The malarial cachexia results when the poison has not been eliminated. Persistent headache and vertigo are the results of the intense meningeal hyperaemia that sometimes occurs. Diagnosis. In intermittent fever each paroxysm begins with a chill, while the chill seldom recurs in remittent fever; a distinct intermission follows each paroxysm of the intermittent form, while a remission occurs in remittent, the thermometer showing that the fever does not wholly disappear; during the intermission the patient is ap- parently well; such is not the case in the remission of remittent fever. Typhoid fever is mistaken for remittent fever, but the absence of the characteristic temperature record, diarrhoea, eruption, tympanites, deafness and severe prostration, should prevent the error. Prognosis. Uncomplicated cases are favorable. Treatment.. Quinine sulph., gr. xvj-xx per diem, is the remedy. Better administered during the remission, if possible. If an irritable stomach prevents its administration by the mouth, use it by the hypo- dermatic method or in a suppository. During the hot stage, cool sponging, cold to the head, and if a tendency to cerebral congestion, dry or wet cups to the nape of the neck and— R. Tinct. aconit. rad.................................... gtt. j-ij Liq. potas. citrat.................. .................. %\) Liq. ammon. acetat............... ,................ 3 ij- M. Every two hours. Purgatioti during the remission, with— R. Hydrarg. chlor. mitis............................... gr. v Sodii bicarb......................................... gr. x Pulv.aromat.......................................... gr. v. M. In pulv. p. r. n. The same precautions are essential after the paroxysms are broken up, to prevent their return on the septenary periods, that were recom- mended for intermittent fever. PERNICIOUS FEVER. Synonyms. Congestive fever; malignant intermittent fever; malignant remittent fever. Definition. A malignant, destructive, malarial fever, which may be of the intermittent or remittent form; characterized by intense 28 PRACTICE OF MEDICINE. congestion of one or more internal organs, together with dangerous perversion of the functions of innervation. Cause. A high degree of malarial poison. Varieties. Gastro-enteric; thoracic; cerebral; hemorrhagic; algid. Symptoms. Any of these varieties may begin either as in inter- mittent or remittent fever; again, the first paroxysm is rarely per- nicious, but appears as the ordinary malarial attack. The gastro-enteric variety has as distinctive features, intense nausea and vomiting, purging of thin discharges mixed with blood, tenesmus, burning heat in stomach, intense thirst, frequent, weak pulse, face, hands and feet cold, with shrunken features, and intense depression of all the vital forces. This condition continues from half an hour to several hours, when either an inter- or remission occurs. Thoracic variety often combined with the one just described. Its characteristic features are due to overwhelming congestion of the lungs, such as violent dyspnea, gasping for air, fifty to sixty respira- tions per minute, oppressed cough with slight amount of blood-streaked sputa, frequent, weak pulse, cold surface, and terror-stricken features. Duration same as the above. Cerebral variety, due to intense congestion of the brain; sometimes effusion of serum into the ventricles, or even rupture of small blood vessels. Characterized by violent delirium, followed by stupor and coma, slow, full pulse, the surface either flushed or livid. Cases may either resemble apoplexy—comatose variety, or acute meningitis— delirious variety. Duration same as the other forms. Hemorrhagic variety, or the yellow disease, as it has been termed, begins as an ordinary inter- or remittent fever, soon followed by signs of internal congestion, to wit: nausea, vomiting, dyspnea, severe pains over liver and kidney, continuing for a few hours, when the surface suddenly turns yellow and bloody urine is voided, after which an inter- or remission and marked abatement occur, to be sooner or later fol- lowed by a second paroxysm, which is more severe, with additional signs of cerebral congestion. Blood may also escape from other parts than the kidneys. Algid variety is characterized by intense coldness of the surface, while the rectal temperature ranges from 1040 to 1070 F. The attack begins with a chill which is soon followed by fever of variable dura- tion, when the body becomes cold, the axillary temperature falling to FEVERS. 29 900, 88° or even 850 F., a cold sweat covers the surface, the tongue is white, moist and cold, the breath is icy, the voice feeble and indistinct, the pulse slow, feeble and often absent at the wrist, and with all these symptoms, the patient complains of a sensation of burning and intense thirst. The mind is clear, but the countenance is death-like. Duration. Pernicious fever, in any of its forms, may continue from a few hours until one, two or three days. Recovery is rare after a second, almost never after a third, paroxysm. Diagnosis. Yellow fever is most apt to be confounded with the hemorrhagic variety, and as they both occur in the same localities, the diagnosis is difficult; the early yellowness of the surface, with hematuria, and the absence of the black vomit, are the chief points of distinction. The cerebral variety may be mistaken for cerebral apoplexy, men- ingitis and uremic convulsions. Nor is it always an easy matter to differentiate between these conditions. The gastro-enteric variety may be mistaken for the early stage and the algid variety for the latter stage of cholera, but the prevalence of the latter should be of material aid in deciding the question. Prognosis. In all varieties the result is unfavorable, unless it can be controlled prior to the second paroxysm. Cases in which an inter- mission occurs are better controlled than where a remission follows. The mortality is one in eight from all forms of treatment. Treatment. The first indication in all varieties is to bring about reaction. If the cold stage, heat to the surface, with stimulating lotions; if the hot stage, cold to the surface and the hypodermatic injection of morphina, gr. }(, at once. After reaction, quinine sulph., not less than gr. xl, repeated p. r. n.; administer by stomach, rectum, or better still, by hypodermatic injection. Dr. Bartholow pronounces the following one of the best formulae for the hypodermatic use of quinina:— R. Quininae disulph....................................... gr. 1 Acid, sulph. dil......................................... tt\,c Aquse font............................................... ^j Acid, carbol. liq....................................... V\v. ^- The following formula, known as "Warburg's Tincture," has during the last few years gained considerable reputation in the various forms of malirial fevers :— 30 PRACTICE OF MEDICINE. R. Rad. rhei, P. aloe soc, and Rad. angelica officinalis..................aa.................. §iv Rad. helenii, Crocus Hispan., Sem. fceni- culi, and Cretse preparat.........aa........ ^ ij Rad. gentian, Rad. zedoar, P. cubeb, G. myrrh, G. camphor, and Boletus Lari- cis........................aa.................... ?,} Confect. damocratis*........................... 3 *v Quininse sulph.................................. glxxxij Spt. vini rect.................................... Oxx Aquae purse........................... ........... Oxij. Macerate in a water bath twelve hours, express and filter. Each half ounce contains quinine sulph., gr. vijss. If the stomach is too irritable to retain the tincture, the tincture may be evaporated to dryness and administered in capsules, each containing the equiva- lent of either one or two drachms. For the gastro-enteric variety, Prof. Da Costa suggests— R. Morph. sulph.................................... gr. \ Pulv. camph..................................... gr. j Mass. hydrarg................................... gr. ij Pulv. capsici...................................... gr. ss. M. In pills every half hour until the character of the stools change. For the thoracic variety, dry or wet cups and ammonii carbonas. For the cerebral variety, venesection,' or cups or leeches to the neck, cold to the head, prompt purgation, and acting on the kidneys and skin. * Formula of Con/ectio damocratis :— Cinnamon......................................................... xiv Gm. Myrrh.............................................................. xj Gm. White agaric, Spikenard, Ginger, Spanish saffron, Treacle, Mustard seed, Frankincense, and Chian turpentine........................lift.......................... x Gm Camel's hay, Cosuis arabacus, Zeodary, Indian leaf, Mace, French lavender, Long pepper, Seeds of harwort, Juice of rape cistus, Strained storax, Opponex, Strained galbanum, Balsam of Gilead, Oil of nutmeg, Russian castor...........aa........... viij Gm Water germunder, Balsam tree fruit, Cubeb, White pepper, Seeds of carrot of Crete, Poley raont, Strained bdellium...................aa..................... vij Gm Gentian root, Celtic hard, Leaves of Dittany of Crete, Red rose, seeds of Macedonium, Parsley, Sweet fennel seed, Seeds of lesser cardamon, Gum arable, Opium..................aa........................... v Gm Sweet flag, Wild valerian, Anise seed, Sagaper- num............................aa............................... iij Gm Spigrul, St. John's wort, Juice of acacia, Catechu, Dried bellies of skunk...............aa.................. ijss Gm Clarified honey.................................................. cmxv Gm. The roots to be finely powdered and the whole mixed thoroughly. FEVERS. 31 For the algid variety warmth to the surface, hypodermatic use of morphina and the free use of ammonii carbonas and alcoholic stimu- lants. For the hemorrhagic variety, purgatives, morphina hypodermati- cally, and either acid, sulph. dil., acid gallic, Monsell's solution, or terebinthina, for the hemorrhages. The following is highly spoken of for hemorrhages :— R. Ext. ergotae, fid................................. ^ss Acid, sulph., dil.,............................... f,"jss Acid gallic....................................... ^j Syr. zingib....................................... f.^'ij Aquse q. s..................ad.................. f ^iij. M. Sig.—Dessertspoonful every 4 hours, well diluted. After the paroxysms are controlled, a long course of ferritin, with quinina on the septenary days. YELLOW FEVER. Synonyms. Bilious malignant fever; typhus icterode ; Medi- terranean fever; sailors' fever. Definition. An acute, infectious, paroxysmal disease, of three stages, to wit: the febrile, the remission, and the collapse; character- ized by violent fever, yellowness of the surface, and " black or coffee- ground vomit." Tendency fatal; one attack confers immunity from a second. Cause. A specific poison, existing only with a high temperature and destroyed by frost. Not due to the malarial poison. Pathological Anatomy. Skin lemon or greenish-yellow color, due to dissolution of the red blood corpuscles; heart softened by granular degeneration ; stomach, veins deeply engorged, the mucous membrane softened-, and containing more or less "coffee-ground" matter, which consists of blood corpuscles deprived of their haemo- globin, white corpuscles, epithelial cells and debris. Intestines much the same as the stomach ; liver, yellow color and a fatty degeneration of the hepatic cells; kidneys, granular degeneration of the epithelium of the tubules. Symptoms. First stage, the febrile, beginning either with the prodromata of malaise, headache and anorexia, or suddenly with a chill, high fever, in a few hours reaching 1040 F., high pulse, brilliant 32 PRACTICE OF MEDICINE. eye, flushed countenance, coated tongue, irritability of the stomach, and severe neuralgic pains in the head, limbs, epigastrium, back and large joints. The patients are restless and anxious. In severe attacks delirium is frequent. Albumen in the urine, and a peculiar and char- acteristic odor is emited from the patient. Duration of the first stage from thirty-six houis to three or four days. Second stage, the remission, when the temperature declines to ioo0 or ioi° F., and all the distressing symptoms abate or subside and, with some critical evacuation, convalescence occurs, or, more com- monly, after from one to four days, the Third stage, the stage of collapse, is ushered in by a return of all the symptoms of the first stage in an exaggerated form, followed by 'yellowness of the skin, passing to a deep mahogany color, black vomit and hemorrhages from other parts, feeble pulse, cold surface, irregular respiration, and death from exhaustion, the mind remaining clear until the end. The above symptoms represent a sthenic case ; other varieties are the algid, hemorrhagic and typhus. Duration. Depends upon the variety ; from a few hours-to a few days. Rarely continues longer than one week. Diagnosis. Pernicious fever, hemorrhagic variety, is apt to be mistaken for yellow fever. Yellow fever is a disease of one paroxysm, and one remission, epidemic, with albuminuria and black vomit. Per- nicious fever has more than one paroxysm, not epidemic, rarely black vomit or albumen in urine. Prognosis. One in four perish. Short cases unfavorable, as are the hemorrhagic and algid varieties. Treatment. No specific ; a " self-limited " disease. The indica- tions are to treat the symptoms and nourish the patient. Good nursing, ventilation, early emesis and purgation, with diaphoretics and diu- retics, are apparently beneficial. Large doses of quinina, early in the attack, for high temperature ; for the irritable stomach, ice slowly dissolved in the mouth and acidum carbolicum, gr. ]^ in aqua menthe pip., every two hours, alternated with liquor calcis and milk, each an ounce, or— R. Hydrargyri chlor. mite.............................. gr. JL Morphinse sulph....................................... gr. i Every two hours until nausea controlled. FEVERS. 33 For the black vomit and hemorrhages, either liquor ferri subsul- phatis ox plumbi acetas. The pains, restlessness or delirium are best controlled by the hypodermatic use of morphina or atropina. Free stimulation from the onset is essential. ERUPTIVE FEVERS. As a group, the eruptive or exanthematous fevers have many fea- tures in common. All have a period of incubation, are characterized by a fever of more or less intensity preceding the eruption, by an erup- tion which is peculiar to each, occurring most commonly in childhood, rarely attacking the same person twice, very prone to occasion serious sequelae, and are contagious. Their origin is as yet undetermined. SCARLET FEVER. Synonym. Scarlatina. Definition. An acute, self-limited, infectious disease ; character- ized by high temperature, rapid pulse, a diffused scarlet eruption, terminating with desquamation, inflammation of the throat, and frequently more or less grave nervous phenomena. Serious sequelae frequently follow an attack. One attack confers immunity from the disease. Pathological Anatomy. An acute inflammation of the skin, with exudation—a true Dermatitis. A granular change in all the glandular structures, most marked in the Peyerian glands, although also occurring in the stomach and kidneys. Cause. A specific poison, maintaining its vitality for a long time. Eminently contagious, the contagion residing chiefly in the desqua- mated epidermis. Klebs' micrococci, the"monas scarlatinosum," may prove to be the poison. Incubation short, one to seven days. Varieties. Scarlatina simplex, scarlatina anginosa and scarlatina maligna. Symptoms. A mild case is a very trivial affection, but in its severest form there are few affections more malignant. Onset sudden with a decided chill and vomiting (in infants, con- vulsions), followed by high fever, soon reaching 1050 ; a rapid pulse, 110 to 140 being common. At the end of twenty-four hours a bright scarlet rash appears on the neck and chest, spreading over the entire D 34 PRACTICE OF MEDICINE. body within a few hours; the eruption is not raised, there is no inter- vening healthy skin, and scattered irregularly are points of a darker hue. With the appearance of the eruption occurs burning heat of sur- face, burning in the throat and. difficulty in deglutition are complained of, the throat on inspection presenting the appearance of a catarrhal inflammation. Tongue at first furred, later, red, with prominent papilke—the " strawberry tongue." There also occurs headache, great restlessness, and in severe cases delirium. Diarrhea quite common. On the fourth or fifth day the fever declines by lysis, the eruption fading, and on the sixth or eighth day desquamation begins, continu- ing for a week or more, the convalescence being slow, the patient emaciated and pale. Scarlatina anginosa are cases with great inflammation and swelling of the throat, tonsils and neighboring glands, the swollen glands pressing upon the surrounding parts, causing difficulty of breathing atid of deglutition. Scarlatina maligna are cases with decided nervous phenomena, to wit: convulsions, delirium and muscular twitching, the temperature reaching 1070 to no°, the pulse rapid, feeble and irregular, the erup- tion delayed, of a purplish color, and in patches. Sequelae. Chronic sore throat; conjunctivitis; otorrhoea ; chronic diarrhoea; subacute rheumatism; chorea; endocarditis; acute Bright's disease; cutaneous dropsy. Diagnosis. A typical case should cause no difficulty ; the high fever, rapid pulse, sore throat, and early scarlet eruption, followed by desquamation, should leave no doubt. Measles ; the above symptoms are absent, and catarrhal symptoms present. Smallpox ; eruption on the third day in spots, changing to pustules with secondary fever. Dengue or break-bone fever ; absence of the above typical symp- toms, and presence of severe pains hi the bones. Diphtheria; gradual invasion, great prostration, and no eruption. Meningitis may be suspected from the symptoms of scarlatina maligna; the epidemic influence, eruption, and rapid pulse, are points of difference. Prognosis. Depends upon the character of the attack. Never can be positive of the result. Mortality ranges from ten to twenty-five per cent. FEVERS. 35 Treatment. As with other eruptive fevers so with scarlatina; there are no specific remedies by means of which it can be arrested or controlled. Symptomatic treatment judiciously applied, however, may afford relief and diminish the fatality. The indications are for good ventilation, disinfection, cooling drinks, action upon the skin and light nourishment. For cases with high fever and rapidity of pulse, aconitum, digitalis, quinina or antipyrine, with cool sponging, cold bath, douche or pack. If the surface be pale, the circulation feeble, and the eruption tardy in appearing, benefit will follow the administration of tinclura bella- donne, gtt. j-x, according to age. For scarlatina anginosa, internal use of tinclura ferri chloridi and potassii chloralis, and stimulants. Externally, ice or cold com- presses, unless they cause chilliness; if so, heat. Astringent gargles and small pellets of ice dissolved in the mouth are of use. Dr. J. L. Smith warmly lauds the following mixture for cases with decided throat symptoms :— R. Acid boracic............................................. jjss Potass, chlor............................................. ^ ij Tinct. ferri chlor........................................ f zij Glycerinoe, Syrupi..............................aa.................... f ?j Aqua;......................................................f'ij ij. M. Sig.—One tablespoonful every two hours, to a child of five years. For scarlatina maligna, in addition to ferrum and quinina, the chief reliance must be on alcoholic stimulants, guiding the amount by their effects. In children wine-whey, milk-punch, and egg-nog are eligible for the administration of stimulants and nourishment. For the pruritus, the local use of oils ox fats in some form affords great relief, the following formula being most efficient, as well as a disinfectant:— R. Acidi carbolici............................................ gr. x-xxx Vaseline.........:......................................... ,^iij. M. Sig.—To be applied over the entire surface after sponging or bath. Convulsions result from the high grade of fever, or are the result of uraemia. If due to the former cause, the cold bath and cold affusion are the indications; if the latter cause, the inhalation of chloroformum is indicated. :>,('> PRACTICE OF MEDICINE. For the headache, disturbance of vision and coma, the result of uraemia, free purgation and diaphoresis are to be employed. Prof. Da Costa advocates the administration of ammonii carbonas, in small doses at frequent intervals, to prevent the liability of heart- clot, and for its salutary influence over the disease. It is claimed that a characteristic micrococci is found in the blood, and that, consequently, the disease can be favorably influenced by acidum carbolicum, thymol ox acidum boricum. For the various sequele, the treatment is the same as if they occurred primarily, plus tonics. The disease being infectious, every means should be taken to prevent its spread, to wit: isolation, cleanliness, disinfection and fumigation. Small doses of quinina, in those exposed, is said to prevent or modify the severity of an attack, but no true prophylactic is known. MEASLES. Synonyms. Morbilli; rubeola. Definition. An acute epidemic and contagious disease ; charac- terized by catarrhal symptoms, referable to the naso-broncho-pul- monary mucous membrane, fever, and a crimson eruption which terminates by desquamation. Cause. A specific poison, with a special susceptibility for child- hood. Contagious by contact, and has been communicated by in- oculation. One attack, as a rule, protects from a second. Incubation, ten days. Pathological Anatomy. There are no special anatomical characters exclusive of the eruption which is considered among the symptoms of the disease. Symptoms. Onset gradual, irregular chills, fever, the tempera- ture rising to ioi° or 1020, muscular soreness, headache, and intense nasal, pharyngeal and laryngeal catarrh ; on the evening of the second day a decided remission takes place in the fever, the catarrh continuing; on the fourth day occurs an eruption of a crimson color, on the face, soon spreading over the body, in the form of dots, slightly elevated, which coalesce into irregular circles or crescents, and with the appearance of the eruption the fever returns, the catarrh is aggra- vated, but the character of the discharge, instead of being clear and FEVERS. 37 watery, becomes turbid, thick and yellowish, and extends to the bronchial mucous membrane. About the- ninth day (the fourth of the eruption), the eruption fades, the symptoms abate, and slight desquamation occurs. Some cough and catarrh may remain for a long period. ( Black measles, sometimes called hemorrhagic rubeola, or camp measles is a variety occurring in camps and jails, in which occur dangerous chest symptoms, and black spots or petechiae from deteri- orated blood, and severe prostration. Rather common complications are lobar and catarrhal pneu- monia. Sequelae. In those of strumous diathesis, scrofula or phthisis may develop. Diagnosis. A typical case begins gradually, with chilliness, nasal catarrh, watery eye, and fever, which decline before the eruption, rising afterwards, the eruption crescentic in shape, and of a crimson color. Scarlet fever; absence of catarrh, and earlier appearance and dif- ferent character of the eruption with severe fever and rapid pulse. Prognosis. As a rule, a perfect recovery. If phthisis develop, the prognosis is bad. Black measles, the majority perish. Treatment. No specific. Mild cases require no medicine, simply regulating the diet and bowels, and cool sponging; the indications are to render the patient as comfortable as possible, the disease pur- suing a favorable course without therapeutical interference. If the febrile reaction is high, use— R . Liq. potass, citrat.............. Spts. sether. nitrosi ........... Tinct. aconit. rad.............. Every two hours, soon controls it For pruritus of the eruption, th,e local use of oils and fats. For catarrhal symptoms, inunction of the nose, neck and chest with cam- phorated oil and small doses oipulv. ipecac et opii, at bedtime; if the catarrh extends to the bronchial mucous membrane, expectorants. During convalescence, for the strumous, protect from exposure, and ol. morrhue with syr. ferri iodidi. For black measles, bold stimula- tion, with ferrum and quinina. 7>\ gtt. x-xv gtt. ss-j. M. 38 PRACTICE OF MEDICINE. ROTHELN. Synonyms. Epidemic roseola; German measles; French measles; false measles. Definition. An acute, self-limited disease; characterized by mild fever, suffused eyes, cough and sore throat, enlargement of the lym- phatic glands of the neck, and a rose-colored eruption, in patches of irregular size and shape, appearing on the first day. Cause. Propagated by infection. That a peculiar germ exists is probable, but thus far it has not been isolated. Incubation from one to three weeks. Symptoms. Onset sudden, with mild fever, suffused w,'wifh little or no coryza, sore throat, and enlargement of the cervical glands, not limited to those about the angle of the jaw, as in scarlatina. Any time from the first to the fourth day appear rose-colored spots, size of a pin head, slightly elevated, which coalescing, form irregular shaped and sized patches, with intervening healthy skin, fading on the upper part of the body while just appearing on the lower. Symp- toms all terminate within a week by lysis, the patient being none the worse for the attack. Diagnosis. From scarlet fever, by absence of the high fever, the rapid pulse, the color and character of the eruption and the sequelae. From measles, by absence of intense catarrhal symptoms, the late appearance of eruption and not of a crescentic shape. Prognosis. Most favorable. Treatment. Mild laxatives and restricted diet. li fever high, saline mixture. For itching of skin, sponging with vinegar and water. SMALLPOX. Synonym. Variola. Definition. An acute, epidemic and contagious disease; charac- terized by severe lumbar pains, vomiting, and an initial fever, lasting from three to four days, followed by an eruption, at first papular, then vesicular and afterwards pustular; the development of the pustule being accompanied by a secondary fever, during the presence of which grave complications are prone to occur. Causes. A specific poison whose nature is unknown, maintaining its contagious vitality for a long period. There is no period, from the initial fever to the final desquamation, when the disease is not con- FEVERS. 39 tagious, although the stage of suppuration is the most virulent. One attack, as a rule, protects from a second. Vaccination has a positive protective influence from the disease, an extensive observation having fully proven that in proportion to the efficiency of vaccination is the rarity and variety of variola. Incubation, fourteen to sixteen days. Pathological Anatomy. A granular and fatty degeneration occurs in the liver, spleen, kidneys and heart. The pustules are found in the larynx, trachea, bronchial tubes, and on the pleura. Varieties. Discrete ; confluent; malignant; varioloid or modified smallpox. Symptoms. Discrete form. Onset sudden, with a violent chill, vomiting, and agonizing paitis in the back, shooting down the limbs ; fever, in short time, rising to 1030 or 1040 F.'; full, strong and rapid pulse, ranging from 100 to 130; the face red, eyes injected, intense headache and sleeplessness; delirium and couvulsions occur at times. During the third day the characteristic eruption makes its appear- ance, first on the forehead and lips, consisting of coarse red spots; with the appearance of the eruption all the marked symptoms of the fever abate, the patient feeling quite comfortable. On the fifth day of the disease the spots become papules; on the sixth day, trans- formed into vesicles, which are soon umbilicated; on the eighth day the vesicles change to pustules; on the ninth day the pustules are entirely purulent, and each surrounded with a broad red band—the halo or areola, the face becoming swollen, and the features distorted; on the eleventh day, pus oozes from the pustules, and drying, forms the scab or crust, which, on the sevetiteenth to twenty-first day drops off, leav- ing a red, glistening depression or pit, soon changing into a white cicatrix. With the formation of the pustules (eighth day) severe rigors and fever set in, and a characteristic odor is emitted, all the original symptoms returning ; this secondary fever is the most critical period of the disease, and is generally attended with violent delirium. In favorable cases the secondary fever subsides after three or four days, and convalescence is established. Confluent smallpox differs from the discrete in being more severe, the eruption appearing during the second day, the pustules coalescing into large patches, causing great distortion of the features. Malignant smallpox is characterized by the intensity and irregu- larity of the symptoms, death resulting before the characteristic erup- 40 PRACTICE OF MEDICINE. tion appears, by convulsions or coma. In these cases hemorrhages are frequent and petechiae are observed. Varioloid, or modified smallpox, is the form modified by previous vaccination or by a former attack of smallpox. Its course is shorter and milder than the other forms, the eruption appearing a day later, and is not attended with secondary fever. Complications. During the course of the secondary fever there is a great tendency to grave inflammations, to wit: pleuritis, pneu- monitis and dysentery. During convalescence, boils and abscesses on the skin are frequent. Diagnosis. Cannot be confounded with any other disease if have typical symptoms, to wit: chill, vomiting, pains in back and legs, high fever and pulse, all declining on third day, when the eruption appears, first spots, then papules, then vesicles, finally pustules, drying and forming crusts, and with the marked secondary fever. Prognosis. Depends" upon the variety of the attack, the age of the patient, and whether vaccinated or not. Discrete mortality four per cent. ; confluent, fifty per cent.; malignant, all perish ; \xx\o\exfive years and ov ex forty years, fifty per cent. Treatment. No specific; the disease will run its course under any plan of medication, although cases seem to do better if acidum carbolicum or thymol axe used. For the initial fever and the full pulse— R. Tinct. aconit. rad................................ gtt. j-ij Spts. aether, nitrosi............................. ^ss Liq. ammonii acetat........................... f^ij Aquae.............................................. f^iss. M. Every hour or two. Or— R. Acid, salicyl..................................... gr. x Spts. vini rect.................................... gtt. xx Elix. simp........................................ ~ss. M. Every hour or two. If headache and backache are intense, hypodermatic injections of morphina, or ice bag to the head and back. For sleeplessness and restlessness or early delirium full doses of potassii bromidutn. For secondary fever the best remedy is quinina, gr. v, every three FEVERS. 41 hours, and for cerebral excitement of this period, either full doses of potassii bromidum, by stomach, or the following by rectum :— R. Chloral............................................ gr. xv-xx Mucil. acacia.................................... fjjij Aquae.............................................. f'^ij. M, p. r. n. The secondary fever being pyaemic in character, the depression should be anticipated by large doses of tinct. ferri chloridi and judi- cious stimulation, brandy in tablespoonful doses the most efficient. From the onset, milk, eggs, animal broth, oysters and beef juice should be administered every three hours. Ice is always grateful and should be given freely, and if pustules appear in the mouth, ice should be held in the mouth as long as possible, and washes of potassii chloras or acidum carbolicum employed. The disease being contagious, isolation, ventilation, cleanliness and disinfection are imperative. To prevent pitting keep patient in a dark rootn, well ventilated. Masks of some unctuous material, thoroughly applied, to exclude the air, have a beneficial effect, a good formula being, R. Ung. hydrarg., pulv. marante, equal parts, or glycerit. amylii, painted over eruption, changing to tinct. iodi as vesicles are about to develop. Success is claimed by a number of observers from the use of collodium applied once or twice daily. Cold water dressings constantly to face and hands are beneficial, besides allaying heat, pain and swelling. Hot water can be used if more grateful. VACCINATION. Definition. Inoculation with the matter of vaccinia or cow-pox —bovine virus. The person properly vaccinated is, as a rule, pro- tected from an attack of smallpox, and especially from a severe or fatal attack. Vaccination should be performed at least twice in every individual, to wit: during -infancy and at puberty; and it is safer to have it again performed if special exposure be liable to occur. In practising vaccination the skin should be rapidly scraped until the true skin is reached and is ready to bleed, the lymph being then brushed over the abraded surface ; or, instead, making three or four horizontal and transverse cuts, about four lines long, and rub the 42 PRACTICE OF MEDICINE. virus over them; a little blood, but not much bleeding, should be caused. Symptoms. If the vaccination "takes," on the third day a papule appears ; on the sixth day a vesicle has formed, with a central depression ; on the eighth day a pustule, fully formed and distended with lymph, with a reddish areola, which becomes very wide. The areola begins to fade on the tenth day, the pustule begins to dry, and by the fourteenth day a brown mahogany scab or crust has formed, which is detached about the twenty-third day. The cicatrix is circu- lar, depressed, radiated and foveated, becoming, after a time, paler than the surrounding integument. During the course of a vaccination, more or less constitutional dis- turbance occurs, especially in children. Eczematous and papular eruptions often develop in strumous chil- dren, for which the virus is unjustly held responsible. VARICELLA. Synonym. Chicken-pox. Definition. A mild, slightly contagious, febrile affection ; char- acterized by a moderate fever, and the appearance of a vesicular erup- tion, drying up and falling off in from three to five days. Cause. A peculiar poison ; attacking only children; occurring sporadically and as an epidemic. Symptoms. Moderate fever, thirst, anorexia and constipation, followed by the eruption of vesicles, which rapidly dry, and within the week drop off, leaving a slight pit. Pustules almost never occur. Symptoms are so slight, that, were it not for the vesicles, the affection would be often overlooked. The eruption appears on the trunk and extremities, very rarely on the forehead and in the mouth. Prognosis. Most favorable. Treatment. Entirely symptomatic. If vesicles on the face, efforts may be used to prevent pitting. ERYSIPELAS. Synonyms. Erysipelatous dermatitis; the rose; St. Anthony's fire. Definition. An acute, specific, infectious disease; characterized by a fever of low type, and a peculiar inflammation of the skin, gene- FEVERS. 43 rally of the neck and face. This inflammation exhibits a marked tendency to spread, to induce serous infiltration and suppuration of the areolar tissue, and to affect the lymphatic vessels and glands. Cause. A poison, the nature of which is unknown. Feebly con- tagious. One attack predisposes to another. The etiology of idio- pathic (medical) and traumatic (surgical) erysipelas are identical. Symptoms. Onset sudden; a chill, followed by fever, which soon reaches 1040 or 1050', frequent pulse, 100 to 130, coated tongue, nausea and vomiting, severe pains in the limbs, with epistaxis in adults and convulsions in children, and often diarrhea. Delirium is frequent, and in those of alcoholic habits it resembles delirium tremens. The eruption soon follows the fever, beginning in red spots, which rapidly coalesce and spread ; a sense of heal, tension and tingling is caused by the great edema, which presents a tense, shiny appearance, the swelling being so great at times as to close the eyes and distort the features. In many cases small vesicles develop, which may coalesce, forming blebs, of considerable size, containing a clear yellow serum. After five or six days the eruption begins to subside, the symptoms abate, the part affected becomes tender, and there is moderate desquamation. During the height of the attack albumen appears in the urine, so that the possibility of uremic symptoms must be remembered. When extensive infiltration into the areolar tissue occur, the swelling and tension become greater, and it is termed phlegmonous erysipelas. When the eruption spreads to different parts of the body, it is termed erysipelas ambulans. Complications. Thrombosis of cerebral capillaries or sinuses, or as it is sometimes called, " erysipelas of the brain," is explained by the intimate anatomical connection of the facial vein with the pterygoid plexus and cavernous sinus. QLdematous laryngitis, from extension to the larynx. Pneumonia, pleurisy and meningitis are frequent complications. Diagnosis. Not difficult. The fever, early spreading eruption, with burning, swelling, tension and tingling, and albuminous urine, separate it from the other eruptive fevers and erythema. Prognosis. Usually favorable. Unfavorable if it attack drunk- ards ; if it becomes gangrenous ; if thrombosis of sinuses occur, or if it extends to the larynx. 44 PRACTICE OF MEDICINE. The convalescence, even from the mildest attack, is slow, the patient continuing weak and anaemic for a long time. Treatment. Mildest cases only require a laxative, nourishing diet, and locally vaseline or bismuth oleat., to modify the heat and burning. According to Reynolds, aconitum will cut short an attack. He administers 1*1*4-}, every fifteen minutes for the first two hours ; then in hourly doses, until the surface is moist and the temperature lowered. The author corroborates this plan, from a personal experience. In severe cases, tinct. ferri chlor., gtt. xx-xxx, every third hour, well diluted. Also quinina in gr. ij, every third hour. Ext. bella- donne, gr. %, added, with benefit. The diet from the onset should be of the most nourishing character, and administered at regular intervals. Prof. Da Costa reports excellent results in cases with rapid spread- ing tendency, from the use of pilocarpine hydrochloras, gr. ]/(,, hypo- dermatically or ext. pilocarpifluidum, gtt. xx-xl, every two hours. Cerebral symptoms, stimulants, opium and chloral. Extension to throat, argenti nitras, brushed over parts. Locally, soothing applications are indicated, to wit: Vaseline, ung. zinci oxidi, ol. olive cum glycerine, bismuth oleat. or ungt. hydrar- gyrum. In phlegmonous variety, argenti nitras, J}j, spls. elheris nitrosi, 3ij, brushed over and beyond the affected part, with the internal use of large doses of quinina, ferrum and stimulants. DENGUE. Synonyms. Break-bone fever; neuralgic fever ; dandy fever. The word dengue is pronounced dangay. Definition. An acute, epidemic, febrile disease, consisting of two paroxysms of fever with an intermission. The first paroxysm is characterized by high fever, distressing pains in the joints and muscles, and a peculiar eruption ; the second paroxysm is charac- terized by a milder fever, an eruption of different character, attended with intense itching, by some recurrence of the joint pains, and by debility. Cause. Unknown ; but it is evident that a peculiar condition of the atmosphere has some influence in its development. DISEASES OF THE MOUTH. 45 Symptoms. Onset sudden—fever, 103° to 1050, intense headache, burning pains in the temples, backache, severe aching and swelling of the joints and stiffness of muscles, nausea, vomiting, constipation, and the appearance of a rash, resembling scarlatina, from which the disease has been mistaken for scarlatinal rheumatism. After some hours to two or three days, a distinct intet mission obtains, of one or two days' duration. The onset of the second paroxysm is also sudden, but the symp- toms are much less severe, although the patient is greatly debilitated; it is at this time that the characteristic eruption appears, being either erythematous or rubeolous, and attended with intense itching, remaining for about two days, when desquamation occurs and convalescence is established, but is prolonged by the great debility of the patient. Average duration of the disease eight days. Relapses are common. Diagnosis. Most apt to be mistaken for acute articular rheuma- tism, especially during the first paroxysm, but the course of the dis- ease and the epidemic influence should prevent such an error. The eruption might mislead for scarlet fever or measles, were it not for the severe joint and muscular pains. Prognosis. Favorable. Treatment. No specific. Entirely symptomatic. At the onset, free purgation and diaphoresis. For the fever, quinina, gr. v. every five hours. For the pains, opium or acidum salicylicum. For the itching, lotion of acidum carbolicum. DISEASES OF THE MOUTH. CATARRHAL STOMATITIS. Synonyms. Simple stomatitis ; erythematous stomatitis ; catarrh of the mouth. Definition. An acute catarrhal inflammation of the whole or a portion of the mucous membrane of the mouth and tongue, charac- terized by redness, swelling and disordered secretion. Most common in infants and children. Chronic stomatitis occurs mostly in adults, the result of alcoholic or tobacco excesses. 46 PRACTICE OF MEDICINE. Causes. Introduction of hot and irritating substances into the mouth ; difficult dentition ; secondary to disorders of the stomach, measles, scarlet fever or variola. Pathological Anatomy. The buccal mucous membrane and tongue have a dark red appearance, are much swollen, the tongue often appearing as if too broad to lie between the teeth, the sides showing the impressions of the teeth ; the secretions are at first less- ened, afterwards increased, a turbid mucus covering the cheeks, gums and tongue, thus giving a coated tongue. Symptoms. Oral catarrh begins with a burning, smarting pain, and tension in the mouth, in those old enough to describe their suf- fering. Very young children refuse to nurse or allow their mouth to be touched, have slight fever, disordered stomach, are fretful and sleepless, craving cooling drinks. The sense of taste is blunted, and there is usually an unpleasant bitter taste in the mouth. If the catarrh becomes chronic, the breath has a fetid odor and the tongue is coated in the morning, the taste is disordered, and there is generally more or less depression of spirits. Diagnosis. If the buccal cavity be examined, the condition is readily discerned. Prognosis. Recovery is the rule for the acute variety. The chronic cases are usually due to the use of tobacco or alcohol, and are only modified by the absolute withdrawal of the exciting cause. Treatment. The most important point in the treatment is the removal of the exciting cause, attention to the secretions and diet. Locally— R. Sodii boratis........................................... giss Aquae destillat........................................ f^j Mel. rosae.............................................. f'?j. FOLLICULAR STOMATITIS. Synonyms. Aphtha?; vesicular stomatitis ; croupous stomatitis. Definition. An acute inflammation of the follicles and mucous membrane of the mouth and tongue, characterized by a fibrinous or croupous exudation ; the exudation first appearing in isolated spots (aphthe discrete), afterwards coalescing, and forming large and irreg- DISEASES OF THE MOUTH. 47 ular-sized patches (aphthe confluens), which rupture, leaving an ulcer, that slowly heals. Causes. A disease principally of childhood. Difficult dentition ; disorders of digestion ; uncleanliness, such as neglect to rinse the child's mouth after nursing ; with measles and diseases of the buccal cavity. Pathological Anatomy. Begins as a small, whitish papulo- vesicular elevation, semi-transparent, hard and tender, with a distinct red zone about their base ; there may be as few as six or as many as twenty ; they may remain isolated {aphthe discrete) or coalesce (aphthe confluens); they are regarded as either a peculiar deposit or a local croupous exudation. After a day or two they rupture, leaving an irregular white or grayish ulcer, which slowly heals. The seat of the affection is the internal surface of the lips and cheeks, the gums, tongue and roof 6f the mouth. Symptoms. In infants, the pain is so severe that the child refuses to nurse. In older children, pain from talking, mastication and deglutition. Salivation is marked, the saliva dribbling from the mouth. There is slight feverishness, fretfulness and sleeplessness. Digestion is impaired, and quite commonly diarrhea occurs. A dis- agreeable, penetrating odor escapes from the buccal cavity. Diagnosis. Impossible to confound with any other affection if the buccal cavity is examined. Prognosis. Always favorable. Treatment. Removal of the exciting cause. Attention to the dietary and the secretions is paramount. Internally, excellent results follow the use of potassii chloras, gr. j to v, every three or four hours, according to the age. Protracted cases require tonic doses of quinine sulphas. Locally, good results are obtained from strong solutions of potassii chloras, infusum coptis or bismuth, applied directly to the ulcers. ULCERATIVE STOMATITIS. Synonyms. Diphtheritic stomatitis; gingivitis ulcerosa. Definition. An acute diphtheritic inflammation of the mucous membrane of the mouth, continuing until extensive and unhealthy ulceration occur. It usually begins on the margin of the lower gums, and often extends to the lips, cheeks or tongue. 4K PRACTICE OF MEDICINE. Causes. Usually seen in children only. Most frequently in the families of the poor, the result of unfavorable hygienic surroundings, personal uncleanliness and poor food. Often seen in those reduced by severe acute disease. Perhaps contagious, as epidemics are not rare. Pathological Anatomy. The gums first appear congested, swollen, bleeding readily and separated from the teeth; soon a firmly adherent deposit in the form of patches appears, at first whitish, speedily becoming gray or even black, from disintegration, becoming soft and pulpy, the separated slough leaving irregular-shaped ulcers, with raised margins, from oedema of the surrounding tissue. They are not deep, and their surface is covered with a pulpy, yellowish substance. The morbid process usually extends to the inner side of the lips, cheeks and to the tongue. Symptoms. Pain constantly, aggravated by mastication or deglutition ; food and drink must be of the blandest character. The mouth is hot, the saliva dribbles away, mixed with blood and shreds of pulpy matter, the breath is fetid, the appetite, digestion and bow- els disordered. The patient is feverish, fretful and sleepless. There is always enlargement and tenderness of the submaxillary glands. The affection is often associated with entero-colitis. Diagnosis. Apt to be confounded with gangrenous stomatitis, than which, however, there is less constitutional symptoms and a slower course of the malady. Prognosis. Favorable. If promptly and properly treated, the ulcerated surface rapidly heals, although quite commonly some teeth are lost. Treatment. The etiology of the affection must be borne in mind and remedied. Strict attention to the diet, to the secretions, and absolute cleanliness. Internally, the prompt use of potassii chloras, gr. j-v, frequently repeated, often acts like a specific. The general health often calls for quinina, ferritin and stimulants. Locally, a strong solution of potassii chloras, or keeping the ulcer covered with bismuth, or frequent applications of alumen exsiccatum are valuable. Cases which resist these remedies should have applied the following combination, proposed by the late Dr. Dewees :— DISEASES OF THE MOUTH. 49 R. Cupri sulphat.......................................... gr. x Pulv. cinchona; opt.................................... sjij Pulv. g. arab........................................... g) Mel. commun..........................................f ?ij Aquae font..............................................f^ iij. M. Ft. sol. Sig.—The ulceration to be touched twice daily, with the point of a camel's-hair pencil. If a spreading tendency occur, the application of argenti nitras dilutus, or a diluted solution of acidum nitricum is indicated. THRUSH. Symptoms. Muguet; sprue ; white mouth. Definition.—An inflammation of the mucous membrane of the mouth, associated with or caused by the growth of a parasitic plant, the oidium albicans; characterized by pain, disorders of digestion and of the bowels. Causes. The development of the thrush-fungus, oidium albicans, is promoted by all those conditions designated as unhygienic, by de- bilitated conditions of the general system, and by neglect to thor- oughly rinse the mouth after nursing or bottle feeding. The age is considered a predisposing cause, seldom being seen after two years of age. In adults, only toward the end of cancer or consumption. Pathological Anatomy.—The mucous membrane of the mouth assumes a dark red appearance in isolated patches, on which whitish points appear, which rapidly coalesce into large areas. The y closely resemble curdled milk, from their soft consistency. These whitish points consist of epithelium and fat, in which are embedded the sporules and filaments of the fungus. The deposit first appears about the angles of the mouth, soon extending to all parts of the cavity, often to the pharynx and oesophagus. The mouth is usually swollen and tender, the breath often fetid. Symptoms. Pain, aggravated by nursing or mastication. The lips are swollen, the saliva is increased, the breath hot and somewhat fetid. There is usually increased temperature. Diarrhea is frequent, the stools green and sour, causing an erythema of the buttocks. Diagnosis. The curd-like appearance of the deposit, showing the 50 PRACTICE OF MEDICINE. presence of parasites upon microscopical examination, will prevent error. Prognosis. Favorable, unless occurs toward the termination of exhausting diseases. Treatment. Absolute cleanliness of the mouth is all important. Internally, remedies should be directed to the removal of the dis- orders of the gastro-intestinal tract. Prompt relief has followed the use of Sodii hyposulphitis saturat. solut., gtts. iij-x every two or three hours, and the local application of the same solution. Locally, solutions of sodii boras often answer every indication, the best vehicle being glycerinum, and not mel or saccharum, a good formula being— R. Sodii boratis............................................. gj Glycerini.................................................f 3 ij Aquae...................................................... 3 vj • M. Sig.—Thoroughly applied four or five times daily, and continued for a week after the disappearance of the affection. GLOSSITIS. Definition. An inflammation of the parenchyma of the tongue; characterized by great swelling of the organ, with difficult mastication, deglutition and vocalization. The affection may be either acute or chronic. Causes. The acute variety is usually the result of some direct irritation to the tongue, such as direct injury, contact of boiling liquids, the action of acrid or corrosive substances, or the sting of the tongue by an insect, such as the bee or wasp. The chronic variety is generally circumscribed ; it may follow the acute ; be due to the sharp edges of the teeth, or the use of a tobacco Pipe- Pathological Anatomy. Acute glossitis begins with intense hyperemia, redness and swelling of the organ ; the size often be- comes so great that the tongue is too large for the mouth, and thus protrudes between the teeth; its surface is covered with a thick secre- tion, and it becomes of a pale or grayish color. The swelling may rapidly decline, or abscesses may form, which leave a more or less decided depressed cicatrix. DISEASES OF THE MOUTH. 51 Chronic glossitis occurs usually along the edges, the cicatricial changes being in circumscribed hard spots. If the entire organ is affected with chronic inflammation, the action is superficial, and has been termed " psoriasis of the mouth." Symptoms. Acute glossitis begins rather abruptly with fever, increased pulse, restlessness, anxiety, enlargement of the tongue, the sensation of heat in the mouth, with pain, and increased flow of saliva. Mastication and deglutition become difficult if not impos- sible, the voice muffled and dyspnea decided. The glands at the angles of the jaw are enlarged, which, in turn, compress the vessels of the neck. When suppuration supervenes, the constitutional symptoms be- come severe and the oral symptoms are intensified. Death has occurred from suffocation in severe cases. Chronic glossitis presents pain as the chief symptom, aggravated by movements of the organ. Diagnosis. The rapid course of acute glossitis should prevent its being mistaken for any other affection. Chronic glossitis, if severe, might be mistaken for cancer of the tongue, although the slow and mild progress of the former contrasts strongly with the rapid, severe and painful course of the latter, with its marked constitutional symptoms. Prognosis. Acute glossitis usually terminates in recovery within a week, although the danger of suffocation must always be remem- bered. Chronic glossitis is an incurable malady in the majority of in- stances. Treatment. For acute glossitis prompt measures are demanded. For the fever and rapid pulse, tinctura aconiti, gtt. j to iij every half hour or hour until its effects are produced. For the enlargement of the organ, either ice constantly applied internally and externally, at the angles of jaw, or the persistent use of hot water held in the mouth and externally ; if prompt relief does not follow these measures, or if the case is an aggravated one, the prompt deep scarification of the tongue must be resorted to. If abscesses form, promptly open them and administer quinina. If suffocation appear imminent, tracheotomy must be performed. For chronic glossitis, the removal of the exciting cause and the local use of argenti nitras to the ulcerated edges. 52 PRACTICE OF MEDICINE. " For psoriasis of the tongue," the local use of argentum or acidum carbolicum. The general health must always receive due attention. DISEASES OF THE STOMACH. ACUTE GASTRIC CATARRH. Synonyms. Acute mild gastritis; gastric fever ; bilious fever; acute indigestion ; subacute gastritis. Definition. An acute catarrhal inflammation of the mucous mem- brane of the stomach ; characterized by feverishness, loss of appetite, nausea, with occasional vomiting, painful digestion, irregularity of the bowels, and in severe attacks, vertigo [stomachic vertigo). Causes. Deficient quantity of or quality in the gastric juice. Errors in diet, insufficient mastication of food, swallowing liquids which are either too hot or too cold, and especially, the abuse of alcoholic drinks. Often secondary to infectious diseases, such as scarlet fever, measles, smallpox, diphtheria and typhoid fever. Occasionally the result of sudden changes of temperature. Pathological Anatomy. The mucous membrane is irregularly congested and engorged, and covered with a grayish, semi-transparent and tenacious mucus, having an alkaline reaction. The true gastric juice is secreted in lessened amount or is entirely suspended. Symptoms. At first, loss of appetite•, at times disgust for food, heavily coated tongue, bad taste and breath, persistent nausea, and at times, vomiting, first of undigested food, then viscid mucus, acid and bitter, and finally, bilious matter; moderate irritative fever is present, with headache, considerable thirst and flashes of heat with sensations of burning in the palms of the hands and soles of the feet; acid drinks eagerly sought after; digestion imperfect, giving rise to pain, tenderness, feeling of weight and eructations; bowels often loose, sometimes, however, constipated. Vertigo with pain in the nucha, is a prominent symptom in many cases, causing great anxiety. The urine is scanty, containing lithates and pigment. DISEASES OF THE STOMACH. 53 The symptoms are aggravated by errors in diet, and if saccharine or fatty articles are taken, heartburn occurs. Towards the termination of an attack, herpetic eruptions appear about the mouth. Diagnosis. Acute gastric catarrh with fever, may be confounded with remittent and typhoid fever of the first week, but all doubts will disappear as these maladies develop. The vertigo may be mistaken for cerebral disease, but the disappear- ance of this symptom when stomachic treatment is inaugurated dispels all doubt. Prognosis. Favorable. Duration about a week; recovery slow, even under treatment, as far as perfect digestion is concerned. Treatment. Give the stomach as complete rest as possible. If the stomach is overloaded, an ipecac emetic is indicated, or if vomit- ing has begun, it may be encouraged by swallowing large draughts of hot water, which will act as a sedative if the stomach be empty. Irritability of the stomach is readily controlled by— R. Hydrarg. chlor. mitis............................... gr. fa-fa Sodii bicarb.......................................... gr. ij Pulv. aromat......................................... gr. v. M. Every two hours, which has the additional advantage of relieving the bowels, or— R. Bismuthi subnit..................................... gr. xv Acid, hydrocyanici, dil............................ Vi\i] Mucil. acaciae........................................ f3ss Aq. menth. pip...................................... f^iss. M. Sig.—Every two or three hours. Weak alkaline mineral waters or liquor calcis, should be freely used. After the acute symptoms have subsided— R. Tinct. nucis vomicis............................... gtt. iv-x Acid, hydrochlor. dil............................. gtt. x Glycerini............................................ ^ss Aquae lauro-cerasi.................................. f^iss. M. Before meals, will improve the appetite and digestion. 54 PRACTICE OF MEDICINE. ACUTE GASTRITIS. Synonym. Toxic gastritis. Definition. An acute and violent inflammation of the mucous, submucous and muscular coats of the stomach, with loss of tissue; characterized by great pain, constant vomiting of blood-streeked or bloody mucus and symptoms of collapse. Causes. Ingestion of irritant and corrosive poisons, to wit: min- eral acids, arsenic, corrosive sublimate, copper and carbolic acid. Pathological Anatomy. The mucous membrane is vividly red and injected, more marked at some portions than at others; it is soft and friable; erosions are irregularly scattered, and the submu- cous, muscular, and at times serous coats show decided destructive changes. The gastric tubules are destroyed in large numbers. In many cases the oral mucous membrane presents signs of severe inflammation. Symptoms. Immediately or soon after swallowing the irritant there ensues a deadly nausea, rapid and persistent vomiting; first, of the contents of the stomach acted upon by the poison; afterwards, shreds of mucous membrane and blood clots; great anxiety and depression, a weak, rapid pulse, slow and shallow respiration, cold skin, covered with a cold sweat, intense burning heat at the epigas- trium, thirst with burning in the fauces and gullet, and exhaustive purging; the features are more or less retracted or sunken; these symptoms terminating in collapse and death, or slow convalescence and recovery with a crippled stomach. A diagnosis of the character of the poison swallowed is often afforded by the stain of the lips, face and mucous membrane, to wit: sulphuric acid, blackish eschar; nitric acid, yellowish eschar; caustic potash, spreading widely and softening the tissues; corrosive sublimate, whitish or glazed ; carbolic acid, white and corrugated. Prognosis. Very grave. Majority perish from shock, and de- struction of mucous membrane, which prevents nourishing. Early treatment when no perforation of the walls of the stomach and recovery is possible, the organ being ever after much weakened. Treatment. At once, hypodermatic injection of morphina, re- peated at regular intervals. Vomiting should be encouraged by the free use of demulcents. If the case be seen within a short period of the swallowing of the DISEASES OF THE STOMACH. 55 poison, the proper antidote should be used; but if some hours have elapsed, it is useless. Ice, internally and externally, gives great relief. The stomach should be washed out with the stomach pump, thereby removing any remaining poison, while at the same time it acts as a sedative to the inflamed membrane; also bismuthi subnit., grs. xx-xxx every hour or two, is beneficial. Milk and lime water is the only food that should be given by the stomach, enemata being used to support the system. CHRONIC GASTRIC CATARRH. Synonyms. Chronic gastritis; chronic dyspepsia; drunkards' dyspepsia. Definition. A chronic catarrhal inflammation of the stomach, with thickening of the coats and atrophy of the gastric glands; char- acterized by tenderness over the epigastrium, impaired appetite, pain- ful and imperfect digestion, thirst, and great depression of the mental powers. Causes. Repeated attacks of acute gastric catarrh; habitual use of spirituous liquors; disease of the heart, lungs, pleura or liver, pro- ducing chronic congestion of the stomachic vessels; cancerous or other degenerative diseases of the stomach. Pathological Anatomy. The mucous membrane is of a brown- ish or slate color, elevated into ridges from hypertrophy, the result of constant congestion ; the peptic glands first increase in size, then undergo granular change, atrophy of their cells resulting. The mu- cous membrane is covered with a thick, alkaline tenacious mucus. These changes may affect the entire organ or be limited in extent. Symptoms. Loss of appetite, disagreeable feeling of fullness in the stomach, tenderness at the epigastrium, but slightly influenced by eating, prominence of the epigastrium, from distention by decomposing gases, occasional nausea and vomiting, the latter more common in drunkards, occurring on arising, termed morning vomiting and con- sisting of glairy mucus raised after great retching; constant thirst, water and at times stimulus being craved ; often great burning at the pit of the stomach, the result of acidity; bowels constipated, urine high colored. A feeling of mental depression and sleeplessness, with occa- sional attacks of vertigo, add to the misery of the patient. Follicular pharyngitis of an aggravated type adds to the general distress of the 56 PRACTICE OF MEDICINE. patient. The imperfect digestion causes more or less loss of fiesh, the fat disappearing, the muscles relaxed and the skin dry. Prognosis. Favorable as to life, but not as to complete recovery, the atrophied glands more or less hindering digestion and assimilation. Treatment. Regulated diet. Avoid fatty, saccharine and starchy food. Also all tonics, bitters, or acids, unless specially indicated. Locally, few leeches, dry cups, a blister, or emplastrum belladonna. Purgatives are doubly indicated ; first, relieving the constipation; and second, clearing the stomach of the tenacious mucus, which neu- tralizes what gastric juice is secreted. Appropriate purgatives are the natural mineral waters, such as Saratoga or Friedrichshall, or— R. Magnesii sulph........................................ 3^i—ij Sodii et potass, tart................................... 3ss_j Acid, tartaric.......................................... gr. xx. M. Dissolved in a glass of water and drank, effervescing, an hour before breakfast. Digestion may be temporarily aided by pepsinum or lactopeptin with the meals. Great relief follows the systematic drinking of one-half to one pint of hot water an hour before meals. For the morbid condition itself may be used, liq. potassii arsenitis, gtt. i-ij before meals, or bismuth subnit., gr. x-xx, before meals, to which may be added sodii bicarb., gr. v; or argenti nitrat., gr. X~K> or argenti oxidum, gr. )4-j, in pill, before meals, or acidum hydro- chloricum dilutum, in water, before meals. Pain is so severe in some cases that resort must be had at times to opium or belladonna in small doses, after meals. Rest of the body is almost as imperative as rest of the stomach. GASTRIC ULCER. Synonyms. Chronic gastric ulcer; perforating ulcer. Definition. A solution of continuity, involving the mucous mem- brane and one or more layers of which the walls of the stomach are composed; characterized by pain, disorders of digestion and vomiting of blood. Causes. Anaemia or its sequelae the chief factor. Most common in young anaemic women. Virchow claims that emboli or thrombi DISEASES OF THE STOMACH. 57 form in the nutrient gastric arteries which have lost their tonicity, an ulcer forming at the point of obstruction. Pathological Anatomy. In the majority of cases the ulcer is solitary. The posterior wall near the pylorus is the most common site. In a typical case there is a circular hole, with sharp borders in the serous coat of the stomach; the loss of substance is greater in the mucous membrane than in the muscular coat, and greater in this than in the serous coat, so that the ulcer looks like a shallow funnel, the apex at the outer wall, the base at the inner wall of the stomach ; it is first round, growing, becomes elliptical, bulging at portions, becom- ing irregular; size, from X-K inch in diameter. When the ulcer heals before all the coats are perforated, a distinct cicatrix marks the location. During its progress nutrient vessels are eroded, causing profuse hemorrhage. Chronic gastric catarrh complicates the majority of cases. Symptoms. More or less prominent symptoms of indigestion. Pain constant at the " pit of the stomach," increased by taking food, especially of an irritant kind, the pain often felt in the back, of a burning, gnawing character. Tenderness at one or more points, ex- tending from the front to the back. Vomiting is almost as constant as pain, coming on soon after eating if the ulcer is at the cardiac ori- fice, an hour or so after if it is at or near the pylorus. Rejected mat- ter may be undigested or partly digested food, or simply acrid mucus. Vomiting of blood in large quantities and arterial in color is almost diagnostic of gastric ulcer ; the blood may be dark in color if it has remained in the stomach some time before being rejected. Severe and frequent attacks of gastralgia may add to the suffering of the patient. The general condition of the patient is not significant, some being greatly debilitated, while in others the nutrition is but little deranged. Duration. The ulcer is slow in forming, and runs a very chronic course, an average duration being, perhaps, a year. Cases are recorded in which the disease has suddenly developed and termi- nated by perforation, peritonitis and death within two weeks, but such are rare. Diagnosis. Duodenal ulcer presents symptoms so akin to those of gastric ulcer that a differential diagnosis is impossible. Chronic gastritis is often confounded with gastric ulcer; the dis- F 58 PRACTICE OF MEDICINE. tinctive points are, absence of vomiting of blood, no localized con- stant pain aggravated by food, and no tenderness in the back ; while the symptoms of indigestion are marked and persistent, with, as a rule, a history of spirit drinking, and the age of the patient—middle life ; ulcer in the young. The points of distinction between gastric cancer and gastralgia will be pointed out when considering those affections. Prognosis. Not very unfavorable Recoveries are frequent. The dangers axe perforation, peritonitis ox fatal hemorrhage. Treatment. Give the stomach as complete a rest as possible; this is accomplished by rectal alimentation, or where it cannot be carried out, exclusive milk diet, adding lime water, to enable the stomach to better retain the milk ; the amount of milk should be one or two ounces every two hours. Rest in bed is paramount, and should be insisted upon. Yox pain, small doses of morphina should be used as needed. Yox hemorrhage, hypodermatic injections of ergota are most reliable. Plumbi acetas, gr. j-iij arrests the bleeding and exercises a favorable influence over the ulcer. For the ulcer, liq. potassii arsenit., gtt. j-ij every five hours, has given excellent results in several cases treated by the author ; bismuth, subnitral., gr. xx-xxx, combined with sodii bicarb., gr. iij-v, three times a day, often does well; argenti nitras, gr. %-%, every four hours, or argenti oxidum, gr. ss, every four hours, are at times bene- ficial. If perforation and peritonitis result, full doses of opium are indicated. GASTRIC CANCER. Synonyms. Cancer of the stomach ; gastric carcinoma. Definition. A peculiar malignant growth, occurring for the most part at the pyloric extremity of the stomach, making constant pro- gress, destroying the gastric tissues and infecting the lymphatic glands; characterized by disorders of digestion, pain, vomiting, marked anae- mia, and terminating in all cases by the death of the patient. Cause. Hereditary. Develops after forty years, for the most part. Pathological Anatomy. Cancer of the stomach is the most common form of cancer. It is, as a rule, primary cancer. The variety is most commonly the scirrhus, next in frequency, medullary, DISEASES OF THE STOMACH. 59 the least frequent, colloid. As regards the location, eighty per cent. occur at the pylorus. It originates usually in the tubules, rapidly infiltrating the remain- ing tissues, thickening everywhere as it progresses, and either remains a hard nodulated mass or undergoes ulceration. The hard nodulated growth at the pylorus constricts the orifice, resulting in dilatation of the stomach. The lymphatic glands adjacent to the stomach are in- filtrated; secondary cancers resulting. Ulceration into an artery causes hemorrhage into the peritoneum, resulting in local peritonitis. Complications. Fatty heart; thrombosis; tuberculosis. Symptoms. Indigestion, progressive in character, with marked acidity, flatulency and a fetid breath. The majority of cases have vomiting immediately after eating, if at the cardiac orifice, and some hours after it at the pylorus, and if much dilatation of stomach, some days after. The rejected matter is food in various stages of digestion, with frequently black grumous masses of altered blood. Pain, marked and constant, dull, heavy, increased by pressure, seldom lancinating. Marked anemia, emacia- tion-, and towards the end dropsy, the surface having an earthy or fawn color. A tumor is found in three-fourths of the cases, occupying the epigastric region, not moving with inspiration. The duration of the disease is about one year, the patient dying from exhaustion, peritonitis or hemorrhage. Diagnosis. Chronic gastric catarrh differs from gastric cancer, in the absence of a tumor, bloody vomit, characteristic pain, peculiar color of the surface, dropsy and the rapid emaciation. Gastric ulcer differs in the character of the pain, age of the patient, large amount of bloody vomit, absence of a tumor and progressive emaciation. Still the diagnosis is often difficult. Abdominal tumors may raise the question of a gastric cancerous tumor; the points of distinction are the characteristic symptoms of gastric cancer, and that abdominal tumors, especially of the liver and spleen, the ones most apt to cause error in diagnosis, are influenced by inspiration, while tumors of the stomach are not so influenced. When a scirrhus of the pylorus lies upon the aorta, a pulsation may be communicated to it, raising the question of aneurism of the abdominal aorta, but the expansile pulsation of aneurism (Corrigan's sign) is wanting, as are the other symptoms of the affection, and if 60 PRACTICE OF MEDICINE. the patient is made to rest upon his hands and feet, the stomachic tumor falls away from the aorta and pulsation ceases. Mikuliez claims that, by the use of his gastroscope, regular rhyth- mical motions can be seen when the pylorus is not the seat of cancer, and that such movements are absent when it is the seat of cancer. Prognosis. Unfavorable. Internal medication offers no hope, the patient usually succumbing from starvation. Gastric carcinoma occurring under thirty years of age is rapidly fatal, not conforming to the usual symptoms as seen later in life; the characteristic cachexia is commonly absent and haematemesis is rare. Treatment. We possess no means of arresting the disease. " Six operations have been practiced for the relief of stenosis of the pylorus: ist. Pylorectomy ; 2d. Gastro-enterostomy ; 3d. Gastrectomy; 4th. Gastrostomy; 5th. Duodenostomy ; 6th. Digital divulsion of the pylorus." Professor Billroth has excisectthe pylorus, thereby prolong- ing life ten months. For acidity and fetor of the breath, acidum carbolicum, gr. %-]/■>,, or carbo animalispurificatus, gr. x-xxx, affords some relief. ¥'or vomiting, bismuth and opium, or the washing out of the stomach with the stomach pump. Yox pain, morphina. Avoid stimulants. GASTRIC DILATATION. Synonyms. Pyloric obstruction ; pyloric stenosis. Definition. An abnormal increase of the cavity of the stomach, with the walls either hypertrophied, or decreased in thickness ; char- acterized by pronounced indigestion, vomiting of partly digested and partly decomposed food at intervals of every few days, and moving of flatus in the abdomen (borborygmus). Causes. Most common, stricture of the pylorus, the result of cancer; pressure of tumor against the pylorus, preventing exit of stomach contents. Loss of muscular tone, occurring in anaemia. Prof. Bartholow cites cases resulting in excessive beer-drinkers, who drank thirty to forty glasses of beer habitually, every day. Pathological Anatomy. When obstruction exists at the pylorus, the whole organ is dilated, with hypertrophy of the muscular DISEASES OF THE STOMACH. 61 layer of the stomach. In dilatation without pyloric obstruction, the muscular layer is thinner than normal, pale in color, and presents signs of fatty degeneration ; the mucous membrane is also pale, thin, and without rugae. Symptoms. Those of the disease producing the obstruction plus those of obstinate chronic gastric catarrh, with characteristic vomit- ing; the cavity having a greatly increased capacity, large accumula- tions take place, which are rejected every few days, partly digested and partly decomposed. Regurgitation of partly digested aliment, acrid, acid and offensive, is very common. Bowels constipated, the stools hard and dry. Physical signs of gastric dilatation are: on inspection, abnormal prominence of the whole epigastric region, with a tumor in the pyloric region which seems to be connected with the stomach; percussion, if empty, tympanitic note extending to or below the umbilicus, having a metallic quality; if the stomach be filled, high pitched flat note; auscultation, splashing and rumbling sound, the succussion sound being distinct if the body be shaken. Diagnosis. The cause being ascertained, no difficulty is experi- enced in making a diagnosis. Treatment. Regulated diet. Restrict the use of fluids, using a " dry diet " almost exclusively. If the result of pyloric stenosis, one of the operations noted in pyloric cancer may be indicated. Regardless of the cause, washing out the stomach with the stomach pump, every day or two, gives relief, and, if no stricture, administer- ing strychnia or nux vomica, and very favorable results may follow. GASTRIC HEMORRHAGE. Synonyms. Haematemesis; gastrorrhagia. Definition. Gastric hemorrhage is not, strictly speaking, a dis- ease, but a symptom; still, vomiting of blood occurs under such a variety of conditions, that a separate consideration is desirable. Causes. Ulcer of the stomach ; cancer of the stomach ; scurvy ; purpura; hemorrhagic malarial fever; congestion of the liver or spleen ; vicarious at menstrual period ; yellow fever. Symptoms. Added to the symptoms of the cause of the hemor- rhage, are a feeling of faintness and sinking at the pit of the stomach, 62 PRACTICE OF MEDICINE. followed by the ejection of blood of a black, grumous, or coffee-ground appearance. Rarely, and then generally in gastric ulcer, the ejected blood may have a bright red appearance, the gastric juice not having had time to act upon it. If the amount of blood escaping into the stomach is large, blood will be voided by stool. Diagnosis. Hemorrhage from the lungs may be confounded with gastric hemorrhage. In the former, the blood is red, is coughed up, not vomited, and is associated with a history of pulmonary disease. The chief point of distinction between pulmonary hemorrhage and the vomiting of red blood is, that in the former you can discern rales on auscultating the chest, and they are absent in the latter. Prognosis. Depends entirely upon the cause, the most unfavor- able being the result of either gastric ulcer or cancer. Treatment. Perfect rest in bed. Ice, internally and applied in bladders over the epigastrium and along the spine. Hypodermatic injections of morphina quiet the patient's fear, and at the same time has a constringing effect upon the vessels. Extrac- tion ergote fluidum or ergotin hypodermatically after the patient is quieted, or liquor ferri subsulph., gtt. j-v, well diluted by stomach. Allow no food by the stomach for several days, nourishing the patient by rectal alimentation. The hemorrhage controlled, the future treatment is guided by the exciting cause. GASTRALGIA. Synonyms. Cardialgia ; gastrodynia; stomachic colic; spasm of the stomach ; neuralgia of the stomach. Definition. A painful condition of the sensory nerves of the stomach, induced by various sources of irritation ; characterized by violent paroxysms of gastric pain and spasm, associated with feeble cardiac action. Causes. The affection belongs to the group of neuralgiae. The most important factor in its causation is general nervous depression ; other causes are malaria, rheumatic or gouty diathesis, anaemia, and certain articles of diet. Symptoms. Like most neuroses, gastralgia is distinguished by its paroxysmal character. Romberg thus describes an attack :— "Suddenly, or after a feeling of pressure, there is severe griping pain in the stomach, usually extending to the back, with a feeling of DISEASES OF THE STOMACH. 63 faintness, shrunken countenance, cold hands and feet, and an inter- mittent pulse. The pain becomes so excessive, the patient cries out. The epigastrium is either puffed out, like a ball, or retracted, with tension of the abdominal walls. There is often pulsation in the epi- gastrium. External pressure is well borne, and not unfrequenfly the patient presses the pit of the stomach against some firm substance, or compresses it with his hands. Sympathetic pains often occur in the thorax, under the sternum, and in the oesophageal branches of the pneumogastric, while they are rare in the exterior of the body." " The attack lasts from a few minutes to half an hour; then the pain gradually subsides, leaving the patient much exhausted ; or else it ceases suddenly, with eructation of gas or watery fluid, or with vomiting, and with a gentle, soft perspiration, or with the passage of reddish urine." Besides such severe attacks, we often see painful sensations in the epigastrium, of various degrees of intensity, with passing faintness or sinking at the " pit of the stomach." Diagnosis. From myalgia of the abdominal muscles, by the pain of gastralgia being more acute and lancinating, accompanied by nau- sea and vomiting and the absence of tenderness on pressure. From intercostal neuralgia, by the fact that in this affection the pain is in the left hypochondrium, with painful spots along the course of the nerve trunk and at the spine, and absence of nausea and vom- iting. From gastric cancer, by the age, character of the vomited matter, constancy of the pain, the cachexia, emaciation and the tumor- From gastric ulcer, by the localized pain and its constancy, with tenderness and vomiting of blood, and constant dyspeptic symptoms, which is not the case in gastralgia. Prognosis. As to perfect recovery, unfavorable, but not danger- ous to life. A chronic affection, in that attacks are prone to return from time to time. The cause has much to influence a radical cure. Treatment. For the paroxysm, hypodermatic injections of mor- phina, gr. TV-i, or the stomachic administration of the " compound of anodynes," the so-called chlorodyne, in doses of rn„x-xxx p. r. n. The relief afforded by opium in some form is so decided that it is prone to lead to the opium habit when the attacks are frequent. In the interval, regulated diet and one or more of the following 64 PRACTICE OF MEDICINE. remedies: quinina, arsenicum, bismuth, ferrum, liq. iodi. comp., or small doses of potassii iodidum. ATONIC DYSPEPSIA. Synonyms. Dyspepsia ; indigestion ; heartburn ; pyrosis. Definition. A functional derangement of the stomach, with either deficient secretion in the quantity or quality of the gastric juice; char- acterized by disorders of the functions of digestion and assimilation. Causes. Imperfect mastication ; bolting of food; eating large quantities of food; same diet long continued; depressed nervous system, from worry and fatigue. It is often inherited. Symptoms. Perverted appetite, capricious or lost; difficult di- gestion, a feeling of weight or fullness in the epigastrium; acidity, from the decomposition of albuminoids ; heartburn, flatulency, regur- gitation, or vomiting of portions of partly digested food or acrid fluid—water brash or pyrosis. Pain or soreness at the "pit of stom- ach " during digestion. Tongue either clean or broad, flabby and pale, showing marks of the teeth. Bowels constipated; urine gener- ally scanty and high-colored, with excess of urates or oxalates, or, in persons of nervous type, it is pale, of low specific gravity, and con- tains phosphates. Drowsiness after meals, with wakefulness at night, defective memory, headache and absent mental vigor, with flashes of heat, followed by more or less perspiration. Palpitation of the heart with irregularity in rhythm. Prognosis. With careful living, dyspepsia, functional in charac- ter, is curable. It has been aptly termed "remorse of the stomach." Treatment. The most important indication is to regulate the diet. Forbid saccharine, starchy or fatty articles of food. Eat small amounts at a time. Perfect insalivation and mastication. Rest after eating, from a half to an hour. Allow but small quantities of liquids with the meals. In the vast majority of cases forbid the use of stimu- lants with the meals. Aid digestion with pepsinum, with or without acidum hydrochlori- cum dilutum. Stimulate stomachic peristalsis with nux vomica, gentian or cin- chona. For acidity, alkalies at time of acidity. For pyrosis, bismuth and pulvis aromaticus, in large doses. DISEASES OF THE INTESTINAL CANAL. Qo For constipation, rcsina podophyllum, at bedtime. For anemia, massa ferri carbonatis ox ferri lactas. For flatulency, tinclura nucis vomica, before meals, carbo animalis purificatus, or acidum carbolicum. DISEASES OF THE INTESTINAL CANAL. INTESTINAL INDIGESTION. Synonym. Intestinal dyspepsia. Definition. A derangement in the functions of intestinal diges- tion, resulting in the more or less complete decomposition of the chyme, from defects in the pancreatic, biliary or intestinal secretions, or from deficient peristalsis, one or more, singly or combined; char- acterized by abdominal pain, distention, tympanites, nervous pertur- bation, anaemia and emaciation. Causes. Imperfect diet; over eating; anaemia; deficient exer- cise; worry; immoderate use of tobacco; diseases of the intestinal tract, liver or pancreas. Frequently inherited. Symptoms. Intestinal indigestion may be either acute or chronic, the latter the more common. Acute variety, the result of an irritant in the duodenum ; rapidly developed pain, flatulency, borbofygmi, slight feverishness, coated tongue, loss of appetite, headache, pains in the limbs, usually termi- nating in a mild attack of diarrhea. If the attack develops rapidly, the sudden formation of gases results in a paroxysm of colic. Severe attacks are associated with disordered hepatic function, to wit: light-colored stools, slight jaundice and high-colored urine. Chronic variety, resulting from a greater or less decomposition of the partly altered food from the stomach. Pain, varying in char- acter, occurring from two to four or six hours after meals, with slight tenderness and some fullness in the right hypochondrium, epigas- trium or the umbilical region. Tympanites and borborygmi are marked, the result of gaseous accumulations which have resulted from the decomposition of the intestinal contents. Dyspnea, the 66 PRACTICE OF MEDICINE. result of pressure on the diaphragm, is of frequent occurrence. Marked nervous phenomena develop, the result of the anaemia from deficient assimilation and from the depressing influence on the nervous system of the absorption of the " gases of decomposition ;" depression of spirits, hypochondriasis, sleeplessness, disturbing dreams, headache, vertigo, buzzing in the ears, musce volitantes, deficient mental application, cardiac irritability, numbness and tingling in the extremities, anomalous pains throughout the body, and in marked cases, attacks of fainting, epileptiform and cataleptic attacks. The skin is harsh and dry, the bowels are sluggish or constipated, the urine is high colored, of increased density, decidedly acid, and on cooling deposits lithates, uric acid and oxalate of lime crystals. Functional derangement of the liver follows after a time, adding to the general distress. Anemia and emaciation result if the attack is protracted. Diagnosis. With our present knowledge it is usually impossible to designate forms of intestinal indigestion due to defects in the quan- tity or quality of either the pancreatic, biliary or intestinal secretions, Acute intestinal indigestion differs from gastric indigestion in the time of the various phenomena, in the latter the symptoms appearing almost immediately after meals, while in the former not appearing until two, four or six hours after. Chronic intestinal indigestion may mislead the physician if the various nervous phenomena are of a marked character, and a careful history of the case is not developed. Prognosis. Favorable if proper and early treatment is inaugu- rated, unless the result of an organic lesion. Treatment. Acute variety, the result of undigested food is best treated by opium in some form, to relieve the acute suffering, warmth to the abdomen, and a prompt cathartic to cause its rapid expulsion. Chronic variety. Of the first importance is the diet, which should be restricted in amount and confined almost entirely to such articles as are readily digested in the stomach. The hepatic, pancreatic and intestinal secretions should be stimu- lated by a course of alkalies, one of the most efficient being sodii phosphas., 3J-ij, three times a day. Aid intestinal digestion by the administration of the liquor pancre- aticus, f^j-iv, of the extractum pancreatis, gr. ij-vj, with sodii bicar- bonatis, gr. v-x, two or three hours after meals. DISEASES OF THE INTESTINAL CANAL. 67 For constipation, bitter waters, such as Friedrichshall, Pullna, or Hunyadi Janos, or resina podophyllum, at bedtime. INTESTINAL COLIC. Synonyms. Enteralgia; tormina; gripes. Definition. A spasmodic contraction of the muscular layer of the intestinal tube ;'characterized by acute paroxysmal pain near the umbilicus, relieved by pressure, and associated with feeble cardiac action. Causes. Constipation ; presence of indigestible food; collections of flatus; an abnormal amount of bile discharged into the intestines ; lead poisoning ; syphilis ; chronic malaria ; hysteria. Symptoms. Romberg thus describes a paroxysm: "There are attacks of pain, spreading from the navel over the abdomen, alter- nating with intervals of ease. The pain is tearing, cutting, pressing, most frequently twitching, pinching, accompanied by peculiar bear- ing-down pains. The patient is restless, and seeks relief in changing his position and in compressing the abdomen; his surface may be cold and his features pinched. The pulse is small and hard. The abdomen is tense, whether puffed up or drawn inward. There are often nausea and vomiting, and desire for stool. There is usually constipation, but sometimes the bowels are regular or even too loose. Duration from a few minutes to several hours, relaxing at intervals. The attack ceases suddenly, with a feeling of the greatest relief, although some soreness remains for a few days." Lead colic is always preceded by symptoms of lead poisoning, to wit: slate-colored skin, dark gums, showing blue line, heavy breath, with sweetish metallic taste, obstinate constipation, impaired appetite, slow pulse and contracted abdominal walls. Diagnosis. Gastralgia differs from colic, in the pain being in the epigastric region and associated with disorders of digestion. In hepatic colic, or the passage of gall stones, the pain is in the hepatic region, attended with soreness over the gall bladder, and retching and vomiting, followed by jaundice and the presence of bile in the urine. In nephritic colic the pain follows the course of one or both ureters, shooting to loins and thigh, with retraction of the testicle of the affected side, strangury and bloody urine. 68 PRACTICE OF MEDICINE. In uterine colic the pain is in the pelvis, and associated with men- strual disorders, in fact, a dysmenorrhcea. In ovarian colic or neuralgia, pain on pressure over the ovaries, with hysterical phenomena. Inflammatory disorders of the abdomen differ from colic by the presence of fever and tenderness on pressure. Prognosis. Most favorable. Death is the rarest termination possible. Treatment. Relief of pain is the first indication, and is best accomplished by a hypodermatic injection of morphina, gr. yi-1^, which has the additional advantage of relaxing the spasm, thereby favoring the action of purgatives, which should soon follow. One of the best in colic, no matter from what cause, is— R. Sodii bicarbonatis................................... gr. viij Hydrargyri chloridi mite.......................... gr. viij Pulv. zingib.......................................... gr. iij. M. After the relief of the pain and free action of the bowels, the cause of the attack should be ascertained and corrected, to prevent future suffering. For lead colic, morphina, for the pain ; magnesii sulphas, % j, every hour, for the constipation, and potassii iodidum, gr. v-x, t. d., to eliminate the metal from the system. CONSTIPATION. Synonyms. Intestinal torpor; costiveness. Definition. A functional inactivity of the intestinal canal, either due to atony of the muscular coat, causing lessened peristalsis, or to a deficiency of intestinal and biliary secretion; characterized by a change in the character, frequency and quantity of the stools. Causes. Dyspepsia; character of the food; habits of the patient; diseases of the stomach and liver; malaria; lead poisoning; syphilis. Symptoms. In the normal condition, the majority of persons have one stool each day, although it is not to be considered abnormal if more than that number occur. The bowels are moved every three ox four days, with great straining and distress, the face often flushed, the cerebral vessels full. Or in other cases the bowels may be relieved once a day, but the stool is small and hard, causing great pain. DISEASES OF THE INTESTINAL CANAL. 69 Another group of cases have frequent stools during the day, small and non-formed, due to retained hardened faeces acting as an irritant upon the rectum. The change in the character of the stools is soon followed by symp- toms of dyspepsia, and in many cases with great distention of the abdomen. Prognosis. Death never results from functional constipation. Treatment. The successful treatment depends upon the removal of the cause and the co-operation of the patient. First, the patient must have a regular hour each day for going to stool, and must remain a sufficient time to permit a thorough.evacua- tion of the bowels. Second, the diet must be carefully regulated. Third, purgative mineral waters or cathartic medicines are to be used with caution, their reckless administration often doing more harm than good. Fourth, either of the following formulae, aided by the enforcement of the above rules, will give good results:— R. Ext. nucis vomicae.................................... gr. )i Ext. belladonna? alco................................ gr. % Extract aloes aqua.................................... gr- ss Pulv. rhei............................................... gr- j Olei cajuputi........................................... gtt. j. M. In pill, at bedtime, and after a week, every second or third night. R. Resinae podophyl., Ext. physostig., Ext. belladonna? alco., Aloine..................................aa............... gr. %. In pill, every night, or second or third night. R. Tinct. physostig., Tinct. nucis vomicae, Tinct. belladonnae..................aa............... gtt. x Tinct. aloes et myrrh................................. gtt. xxx. M. At bedtime. DIARRHOEA. Synonyms. Enterorrhoea ; alvine flux ; purging. Definition. Frequent loose alvine evacuations, without tenes- mus; due to functional or organic derangement of the small intes- tines', produced by causes acting either locally or constitutionally. 70 PRACTICE OF MEDICINE. Causes. Those acting locally, such as indigestion, indigestible food, impure food and water, irritating matters or secretions poured into the bowels, or entozoa, cause the flux by a direct irritation of the mucous surface. Those due to constitutional derangement may be secondary to such diseases as tuberculosis, pyemia, albuminuria, typhoid fever, or dis- turbances of the functions of other organs, giving rise to vicarious fluxes. Forms. Acute and chronic. Symptoms. Acute diarrhoea presents itself in several varieties, the result of its cause, to wit:— Feculent diarrhea. A few hours after meals the patient feels colicky pains and flatulency, with a desire for stool. There is often nausea, coated tongue, but seldom vomiting. The pain is generally relieved by the purging which ensues. The stools have a feculent character, are of brown fluid, containing fasces, often offensive, the color becoming lighter after four or five evacuations. Constitutional symptoms are wanting. This form is the result of over eating, eating too rapidly, or indi- gestion of different forms, or worms in the intestinal canal, and patients generally recover in a day or two. Lienteric diarrhea. In this form there is, with the frequency of evacuations, a want of assimilation of food, which passes through the intestines more or less unaltered. The stools axe frequent, mucous or serous, more or less covered with bile, mixed with undigested food. In this form the patients emaciate rapidly, owing to the deficient assimilation, the digested portions of the food being hurried on by the irritated bowel. It is usually subacute in its course. Bilious diarrhea. The stools are frequent, green or yellow, with scalding sensations at the anus and griping pains in the abdomen. Excessive biliary secretion is the irritating cause. Any of the above forms may pass into chronic diarrhoea by excit- ing permanent diseases of the intestines. Diarrhoea due to constitu- tional causes will be mentioned when speaking of those conditions. Chronic diarrhea results from repeated attacks of the acute form, or the result of some cachexia. The symptoms, as far as the stools are concerned, are much the same as the acute disease, except they axe paler, whence it has been termed white flux ; in addition, dyspep- tic symptoms, aphthous condition of the mouth and tongue, flatulency, DISEASES OF THE INTESTINAL CANAL. 71 colic, emaciation and anemia. The appetite is at times capricious, again impaired. Prognosis. Favorable in feculent and bilious forms; unfavorable in lienteric and chronic forms when emaciation begins. Diarrhoea occurring as a symptom, the prognosis is controlled by the original disease. Treatment. Acute diarrhea. If caused by indigestion the indi- cation is for a laxative; for adults, tinct. rhei. or ol. ricini, or both ; for children between one and two years of age— R. Pulv. ipecac.......................................... gr .fa Pulv. rhei............................................. gr. %-}4 Sodii bicarb.......................................... gr. ss-ij. M. Every four hours until the character of the stools change. After the irritant is removed, for an adult, opium in some form, combined with kino or tannin; or the following modification of " Squibb's diarrhoea mixture : "— R. Tinct. opii deodorat................................. f^viss Tinct. camphorae..................................... f^j Tinct. capsici.......................................... f 3 v Chloroformi puros............,....................... f3 iiss Spts. vini gallici..................................... f^j Alcoholis.........................ad................. fo'v- M- Sig.—One teaspoonful, p. r. 11. For children— R. Bismuth................................................ gr. iij-v Cretse prsep............................................. gr. v. M. Every two hours. In adults, an opium suppository often checks a flux that is uninflu- enced by opium internally. For the bilious form— R. Hydrargyri chlor. mitis.............................. gr. */% Sodii bicarb............................................ gr. ij Pulv. opii................................................ gr. %. M. In powder, every two or three hours, until eight powders are used, fol- lowed by large doses of bismuth and pepsinum. In all acute forms restricted and regulated diet are imperative, pure milk with liquor calcis being the most suitable. 72 PRACTICE OF MEDICINE. Chronic diarrhea. Bismuth, gr. xxx-xl, in milk, every four hours ; Hope's camphor mixture, every four hours; cupri sulphas, gr. fa, ext. opii, gr. fa, every four hours ; argenti nitras, gr. x/2, ext. opii, gr. \, every five hours; may all be used with more or less success; when dry tongue and great flatulency, use— R. Ol. terebinthini.................... 01. amygdal. express............. Tinct. opii......................... . Mucil. acacias..................... Aq. lauro- cerasi................... Sig.—f gj every three or four hours The diet should be nutritious in character, and moderate stimulants are indicated. Activity of the skin and kidneys should be encouraged. CATARRHAL ENTERITIS. Synonyms. Ileo-colitis ; acute diarrhoea; inflammation of the bowels. Definition. A catarrhal inflammation of the mucous membrane of the small intestines; characterized by fever, pain, tenderness and looseness of the bowels. When the catarrh is limited to the duode- num, it is termed duodenitis, the symptoms being of a different char- acter. Pathological Anatomy. There first ensues hyperemia of the mucous membrane and intestinal glands, manifested by redness, swelling and edema; this is followed by increased secretion and an overgrowth and desquamation of the epithelium, together with a copi- ous generation of young cells. As a result of the hyperaemia, rupture of the capillaries and extravasation of blood often occur. The swollen glands show a strong tendency to ulcerate. This catarrhal process may involve the entire tube or be limited to portions of it. Causes. Improper and indigestible food ; summer temperature and exposure to cold and wet, while perspiring. Symptoms. Begins with languor, followed by chilliness and fever, the temperature ranging at io2°-io3°, this is followed by pain, colicky in character, situated above the umbilicus, localized tender- ness and loose evacuations. Nausea and vomiting often occur. The stools contain but little fecal matter, are yellow or greenish-yellow in L?ss fk»j f 5ss. DISEASES OF THE INTESTINAL CANAL. 73 color, mixed with undigested food; if the stools are numerous, they become whitish and watery, the so-called " rice-water" discharges. The appetite is impaired, and this, with the want of assimilation and great waste, soon produce extreme weakness and emaciation, whickis always more marked in children. Duration. In mild cases, four or five days; severe cases continue more or less marked, for a week or two. Diagnosis. From colic, by the absence of tenderness and fever, and presence of constipation and its paroxysmal character. From typhoid fever, by the absence of prodromes, characteristic temperature record and eruption. For points of distinction from dysentery or peritonitis, see those affections. Prognosis. Favorable, if early and proper treatment are ob- tained. Treatment. Rest the bowels by a restricted diet, to wit: milk and lime water, or weak mutton or chicken soups, with well boiled rice added. Keep the patient quiet in bed, a difficult matter in the case of children. For adults, opium is the remedy, in doses to control the symptoms; mild cases do well with— R. Ext. opii................................................ gr. X~^ Camphorse............................................ gr. iij. M. In pill, every three hours. Or— R. Tinct. opii deodorat................................. gtt- x Liq. potassii citrat.................................... gij- M. Every four hours. The strength and the frequency of administration of either of these formulae must be governed by the severity of the attack. For children— R. Tinct. opii deodorat................................. gtt-j Bismuth, subnit........................................ gr- v Mist, cretse............................................f^j- M- Every four hours, for a child of one year. If the case shows the least tendency to linger, the acid treatment G 74 PRACTICE OF MEDICINE. should be substituted for the above, the best of which is " Hope's Camphor Mixture," the formula being— R. Acidi nitrosi............................................ *3J Tinct. opii............................................ g"-*1 Aquae camphorse..................................... f3vllJ- **. The dose ranging from f^j to fgij, according to the age. Acidum sulphuricum dilutum may be substituted for the acidum nitrosum in the above formula. Locally, poultices, warm fomentations, or ung. belladonna or oleum camphorat., give great relief. CROUPOUS ENTERITIS. Synonym. Membranous enteritis. Definition. A croupous inflammation of the mucous membrane of the small intestines; characterized by tenderness, paroxysmal pain, moderate fever, and the formation and discharge of membranous shreds or casts. Causes. A disease of adult life. The female sex more liable than the male, and neuralgic, nervous, hysterical or hypochondriacal sub- jects are more subject to it than are other types. A peculiar state of the nervous system seems necessary to its pro- duction. Pathological Anatomy. A subacute inflammation of the small intestines, during which the mucous membrane becomes covered with a whitish or grayish-white, firmly adherent, membranous deposit, cemented together by a coagulable exudation, and prolonged by root- lets from its under surface into the intestinal follicles. Symptoms. Begins by feverishness, feeling of soreness and dis- tention of the abdomen ; these are followed by pains of a colicky character, severe and depressing, felt around the umbilicus, continu- ing for half an hour, an hour or longer, and after a longer or shorter interval occurring again ; these phenomena continue for a day or two, when looseness of the bowels, with distressing pain and tenesmus occur, the stools containing mucus, with or without blood, and shreds of mem- brane or cylindrical casts of the bowel. Great relief is then experi- enced, although a feeling of rawness or soreness persists for a day or two. DISEASES OF THE INTESTINAL CANAL. 75 Preceding the local manifestations of the disease are attacks of hysteria, hypochondriasis, neuralgia, nervousness or excitability. The paroxysms recur at intervals of a week or two, or after several months; as long an interval as three years between attacks is recorded. Diagnosis. Peritonitis may be suspected until the characteristic stools occur. Dysentery is excluded when the shreds and casts of membrane appear. • Prognosis. Favorable as to life, but one of the most difficult of diseases to eradicate. Treatment. The diet must be such as contains but a minimum of fecal-forming matter. For the pain and suffering, opium in some form is indicated, the most effective being a hypodermatic injection of morphina. For constipation during a paroxysm, an emulsion of oleum ricini and terebinthina is of benefit. To prevent a return of the paroxysms either liq. potassii arsenitis, gtt. j-ij, t. d., or hydrargyri chloridum corrosivum, gr. ^V> t. d., with a course of oleum morrhue, seems to answer in the majority of cases. Prof. Da Costa speaks highly of pix liquida in some form, as an alterative to the mucous mem- brane. Under no circumstances must the bowels become constipated. CHOLERA MORBUS. Synonyms. Sporadic cholera ; English cholera; bilious cholera. Definition. An acute catarrhal inflammation of the mucous membrane of the stomach and intestines, of sudden onset; character- ized by violent abdominal pains, incessant vomiting and purging, cold surface, rapid, feeble pulse, spasmodic contractions of the mus- cles of the abdomen and extremities, and prostration. Causes. A disease of summer and early autumn, climatic influ- ence being an important factor. Irritants of all kinds, unripe fruits and vegetables, and fermentation of food. Pathological Anatomy. Cases in which death has occurred within a few hours present no pathological changes. Generally, however, the gastro-intestinal mucous membrane is congested and denuded of epithelium; the Solitary and Peyerian 76 PRACTICE OF MEDICINE. glands are swollen and prominent. The blood is thick, and dark in color; the kidneys are enlarged and congested ; and in prolonged cases there are appearances of granular changes in the muscular system. Symptoms. Onset sudden and violent, and unfortunately, gene- rally after midnight, with chilliness, intense nausea, vomiting and purging, accompanied with distressing burning or tearing abdominal pains or colic. The vomited matter at first consists of the ordinary contents of the stomach, and the stools of ordinary faeces, but soon the discharges by vomit and stool are liquid, whitish or of a green or yellowish tint; if the attack is severe or protracted the discharges par- take of the "rice-water" character. The patient is rapidly emaciated and reduced in strength, the body shrinks, the surface cold and cov- ered with a clammy sweat, and the pulse feeble. Intense thirst is present, and when drink is given it is at once rejected. Aggravating the distress of the patient are severe cramps of the muscles, and especially those of the calves, and of the flexors of the thighs, forearms, fingers and toes. Termination. Mild cases often terminate favorably without treatment, the patient able to be around in a day or two, although weak. Severe cases, the vomiting and purging cease after some hours, but the patient remains weak, with an irritable stomach and bowels for a week or two. Grave cases, the true cholera type, recover from the prostration very gradually; reaction coming on slowly and usually passes into a typhoid condition of some weeks' duration. Diagnosis. Asiatic cholera and cholera morbus are easily con- founded during an epidemic of the former, and there are no positive points of discrimination, unless the comma bacilli of Koch axe proven to be always in the true cholera stools. Irritant poisons, such as tartar emetic, elaterium, or other substances, cause vomiting and purging, similar to cholera morbus, and are only discriminated from it by the history. Prognosis. In the majority of cases favorable. The mortality is about five per cent. Treatment. At once, regardless of the cause, a hypodermatic injection of morphine sulph., gr. yk-y3, and atropine sulph., gr. jfa, to be repeated in half an hour if no improvement; for patients who DISEASES OF THE INTESTINAL CANAL. 77 object to the hypodermatic mode, opium in some form by the mouth or rectum, giving the preference to the liquid preparations. Camphora and opium combined often act well, or the diarrhoea mixture mentioned on page 71, and if much depression, small doses of brandy or dry champagne. The intense thirst must not be gratified by the use of liquids, but small pellets of ice by the stomach are grateful. If the vomiting and purging continue, make use of— R. Bismuth subnit........................................ gr-xx Acid, carbol............................................ gr. ss Glycerini................................................ gtt. xx Aquae............................ad..................... ^Zxv- M- Every hour or two. Dr. Hartshorne strongly recommends— R. Spts. ammon. aromat................................. f.5J Magnes. optim.................................,.......f.^j Aq. menth. pip........................................ f^iv. M. SlG.— 3J every twenty minutes. If the case is seen early, and if the diarrhoea is copious, he adds tinct. opii camph., f^iv, to the mixture. The closer the case approaches the true cholera type, the more severe are the muscular cramps, and their treatment is indicated. Prof. Da Costa suggests— R. Chloral................. ................................ 3jv Cosmoline.............................................. ^j- M. To be rubbed over the affected muscles. Dr. Bartholow suggests— R. Chloral.................................................. 3nJ Morphinse sulph...................................... gr- lv Aqua?................................................... flJ- M- Sig.— Twenty minims, hypodermatically. Locally, sinapis in the form of poultices or the dry powder, should be applied from the onset. The after treatment depends upon the symptoms ; generally an acid mixture and a regulated diet, with tonic doses of quinina, are indicated. 78 PRACTICE OF MEDICINE. ENTERO-COLITIS. Synonym. Inflammatory diarrhoea. Definition. A catarrhal inflammation of the lower portion of the small—ilium—and the upper portion of the large intestines, with a great tendency to ulceration of the intestinal glands if the catarrh be- comes chronic ; characterized by moderate fever, nausea, vomiting, diarrhoea, swollen abdomen and emaciation. Causes. Improper and indigestible food; summer temperature; impure air ; uncleanliness ; exposure to cold and damp air. Forms. Acute and chronic. Pathological Anatomy. Acute variety ; hyperaemia, swelling, oedema and softening of the mucous membrane of the lower portion of the small and the upper portion of the large intestines, with hyper- plasia of the intestinal follicles, their excretory orifices enlarged and tumid, readily distinguished as grayish or blackish points in the mid- dle of the glands; the patches of Peyer are also enlarged, tumefied and project above the level pf the surrounding mucous membrane, the orifices of the follicles appearing as dark points ; these patches often have an ulcerated appearance, but upon close examination such is found not to be the case. Chronic variety; the thickening and infiltration has extended to the submucous and muscular coats, followed by induration of the tissues, so that the walls of the intestines are often abnormally rigid. Ulceration occurs, which extends through the entire thickness of the membrane. "These ulcers, when isolated, are from one to one and a half lines in diameter, oval or circular in shape, and either have sharp-cut edges, as though the piece of mucous menbrane had been cut out with a punch, or the mucous membrane bounding them is undermined." The small ulcers often coalesce, so that large, irregu- lar ulcerated patches are formed, having for their base the submucous or muscular coats, and have a grayish-white color. The mesenteric glands are enlarged, but seldom, if ever, undergo ulceration. Symptoms. Acute form ; may develop slowly, with restlessness and fretfulness, or suddenly with feverishness, loss of appetite, thirst, nausea, moderate vomiting, abdominal pain ; or diarrhea may be the first indication of illness on the part of the child. Regardless of the character of the onset, the stools soon present the characteristic appear- ance ; they are semi-fluid, heterogeneous, greenish, acid, mixed with DISEASES OF THE INTESTINAL CANAL. 79 yellowish fragments of ordinary faeces, and undigested casein, termed the " chopped spinach " stools. The abdomen is enlarged and tender. Emaciation is marked in proportion to the severity of the symp- toms, in marked cases the child is reduced to a condition of the greatest debility within a very few days. Chronic form ; usually follows the acute form, the character of the symptoms being less severe, but decidedly persistent, the strength fails, the temper is very irritable, the complexion grows dark, sallow and unhealthy, the skin dry and harsh, and in consequence of the marked emaciation, either hangs in folds around the shrunken limbs, or is drawn tightly over the joints ; the abdomen is enlarged and ten- der, the stools numbering from six to a dozen during the day and night, consisting of the products of an imperfect digestion mixed with mucus, serum, pus, and oftentimes blood, having a semi-fluid con- sistency, and an extremely offensive odor. Duration. Acute, from ten days to about two weeks, subsiding gradually ; chronic, from one to two or three months, or even longer. Diagnosis. The acute form can hardly be mistaken for any other condition, if the characteristic stools and other abdominal symptoms are present. The chronic form has been frequently mistaken for diarrhoea of tuberculosis, an error that can hardly occur if a physical examination of the chest has been made. Prognosis. Always a very serious malady, and proves fatal if it attacks the weak during midsummer, or when surrounded by unfavor- able hygienic conditions; in vigorous children, who have passed through their first dentition, the prognosis is quite favorable. Treatment. For the acute form, restricting the amount of food for the first few days is of importance. Fresh, pure air, cleanliness and rest are also of importance. Any one of the following formulae may be used with advantage :— R. Calcii carbon, precip.............................. 5jj Tinct. opii camph.................................. f.5ss Tinct. lavendulae comp........................... f.^ij Syr. gallae aromat.................................. f.?iss Syr. acacise.......................................... f^j. M. SlG.—Teaspoonful, repeated every hour or two. Or— R. Tinct. opii comp................................... f^iij Tifict. catechu comp.............................. ^3lv Mistura? cretse..................................... f3ix- M- Sig.—One or two teaspoonfuls, every hour or two. 80 PRACTICE OF MEDICINE. Or— R. Bismuth subnit..................................... 3iV Pulv. acacias, Sacc. alb........................aa.................. q- s- Syr. gallse aromat................................. o). Spts. vini gallici................................... L^'J Aqua...........................ad.................. fgiij. M. Sig.—One or two teaspoonfuls, every two hours. Or— R. Pulv. ipecac............,............................ gr. % Bismuth subnit .................................... gr-v Cretsepraep.......................................... gr- "j- M. SlG.—After each stool. Locally, warmth to the abdomen, with mustard, turpentine stupes or the spice poultice, made as follows : cloves, allspice, cinnamon and anise seeds, each half an ounce, pounded (not powdered) in a mortar, and placed between two pieces of coarse flannel about six inches square and quilted in ; soak this for a few minutes in hot brandy or hot whisky and water, equal parts, and apply to the abdomen, heating again as it becomes cool. For chronic form ; carefully regulated diet, rest and fresh air, and one of the following formulas :— R. Acidi carbolici....................................». g^-%-% Tincturae iodi...................................... gtt. j—ij Aquse menthse...................................... £jj. M. Sig.—Every three or four hours. Or— R. Tinct. calumbse.................................... f3^iij Liq. ferri nitratis.................................... TT^xxvij Syrupi zingib....................................... f ^ iij - M. Sig.—One or two teaspoonfuls, according to age. every three or four hours. CHOLERA INFANTUM. Synonyms. Choleriform diarrhoea ; summer complaint. Definition. An acute catarrhal inflammation of the mucous membrane of the stomach and intestines, together with an irritation of the sympathetic nervous system, occurring in children during their first dentition ; characterized by severe colicky pains, vomiting, purg- ing, febrile reaction and prostration. Cause. Age; bad hygiene, or as it is now entitled, "civic malaria ; " continuous high temperature ; improper food ; dentition; constitutional as in the feeble, delicate, nervous or irritable. DISEASES OF THE INTESTINAL CANAL. 81 Pathological Anatomy. Resembles closely, if not identical with the phenomena of catarrhal gastritis and enteritis, together with a powerful irritation of the fibres of the sympathetic system. Symptoms. The onset is sudden in a child previously well, or in a child suffering from a bowel affection. Begins with vomiting, purging, abdominal pain, fever, rapid pulse and intense thirst. The vomited matter is partly digested food, sero-mucus, and finally bilious, and is accompanied with distressing retching. The thirst is a marked phenomena of the disease, and ice and water will be taken incessantly, although rejected only a few moments after. The stools are first partly fecal, but soon watery or serous, soak- ing the clothing, leaving a faint greenish or yellowish stain ; their odor is musty, at times fetid ; their number is from ten to twenty in the day. Pains precede the vomiting and purging, colicky in character. The fever begins at once, the temperature varying from ioi° to 1050, with morning remissions. The pulse is rapid and feeble, rang- ing from 130 to 160. These symptoms continue but a few hours, before rapid wasting ensues, the body shrinks, the eyes are sunken and partly closed, the mouth partly open, the lips dry, cracked and bleeding. The child, at first irritable and restless, passes into a semi-comatose condition, the pulse becoming more and more feeble, the surface has a clammy coldness, the contracted pupils not responding to light, and the stupor deepens, death soon following, or the symptoms slowly ameliorate, convalescence being slow and tedious. Diagnosis. The entero-colitis or inflammatory diarrhoea of child- hood is constantly being mistaken for cholera infantum. The symp- toms of the former are : gradual onset, -with fretfulness, loss of appetite, feverishness, nausea, and moderate vomiting, soon followed by diar- rhea, the stools being semi-fluid, greenish, mixed with yellowish par- ticles of faeces and undigested casein, with a sour odor, the " chopped spinach " stools, the abdomen distended and tender, moderate fever and thirst, and having a duration of about two weeks. Prognosis. Difficult to predict the result, and so care must be used in giving a prognosis. The duration of the choleraic symptoms is short, under five days, but relapses are common, and the sequelae are protracted. H 82 PRACTICE OF MEDICINE. Treatment. The first indication is to arrest the vomiting and purging, for which use— R. Bismuth subnit...................................... gr-v-x Mucil. acaciae....................................... ;5SS Acidi carbolici...................................... gr- T2_s Tinct. opii deodorat............................... gtt- J Mist, cretse......................................... 3iss- M- Every two hours for a child between one and two years. Or— R . Hydrargyri' chlor. mit.............................. gr. fa Bismuth subnit..................................... gr. ij-v. M. Sig.—A powder every half hour. If these fail, or the stomach will not retain them, tinct. opii may be given by the rectum, with zinci sulph. and amylum. Cases that have resisted other remedies have rapidly improved under the following :— R. Tinct. verat. alb.................................... f 3 ij Morphine acetat................................... gr. ij Spts. vini gallici.................................... fjij- M. Et adde 3J to Aquae calcis, Aquoe menthae................. aa................. f^j. M. Sig.—One teaspoonful, repeated every hour, if needed. The diet must be restricted in amount: for the first day or two gtt. v-xxx brandy in barley water at frequent intervals will be all that is required. For fever, quinina or aconitum are indicated. For depression, regulated nursing or feeding, every two hours, and water or ice to quench the intense thirst, and cognac brandy, gtt. x-xxx, every hour or two, in water. Locally ; over epigastrium, mustard or a spice poultice, or turpen- tine stupes. If the nervous symptoms become aggravated, small dose of potassii bromidum, or valerian, which " reduces the reflex excitability, motility and sensibility," is indicated. ACUTE DYSENTERY. Synonyms. Colitis ; colonitis ; ulcerative colitis ; bloody flux. Definition. An acute inflammation of the mucous membrane of the large intestines, either catarrhal or croupous in character; charac- DISEASES OF THE INTESTINAL CANAL. 83 terized by fever, tormina, tenesmus and frequent, small, mucous and bloody stools. It occurs either in the sporadic, endemic or epidemic form. Causes. Sporadic and endemic dysentery is caused most com- monly by atmospheric changes, to wit, hot days and cool nights; also from malarial attacks, and rarely, errors in diet. Epidetnic dysentery prevails in armies, jails, and tenement houses, propagated by decomposition of dysenteric stools, and the unfavor- able hygienic surroundings. 77 is not contagious. Pathological Anatomy. Sporadic dysentery is catarrhal in character; congestion, swelling and oedema of the mucous membrane and sub-mucous tissue, with an over-production of mucus; the folli- cles are enlarged, from retention of their contents, the result of the swelling ; the congested vessels often rupture ; the mucous membrane softens in patches, and is detached, forming ulcers. Recovery follows, if the destruction of tissue is small, smooth cicatrices, minus gland structure, marking the site. Epidemic dysentery is croupous in character ; begins with intense congestion, swelling, and oedema of the mucous and sub-mucous tis- sue, with extravasations of blood and the whole mucous membrane covered with a firm fibrinous exudation; the mucous membrane softens and sloughs, leaving large ulcers and gangrenous spots. If recovery occur, large cicatrices form, which narrow the calibre of the intestinal tube. The mesenteric glands enlarge, soften, and abscesses form in them ; the liver becomes the seat of small abscesses, from embolic obstruc- tion of the radicles of the portal vein; the heart muscles are flabby and more or less fatty. Symptoms. Catarrhal form begins gradually, with diarrhea, loss of appetite, nausea, and very slight fever, which continues for two or three days, when the true dysenteric symptoms set in, to wit, pain on pressure along the transverse and descending colon, tormina or colicky pains about the umbilicus, burning pain in the rectum, with the sensation of the presence of a foreign body and a constant desire to expel it, or tenesmus, which is almost constant; the stools for the first day or two contain more or less fecal matter, but they soon change to a grayish, tough, transparent mucus, containing more or less blood and pus ; during the tormina, nausea and vomiting may 84 PRACTICE OF MEDICINE. occur; the urine is scanty and high colored; the number of stools range from five to twenty or more in the twenty-four hours. The duration is about one week, the patient being much emaciated and enfeebled. The croupous or epidemic form sets in suddenly, the stools being more frequent, containing more blood and pus, with patches of mem- brane, even casts of the bowel, together with more or less gangrenous mucous membrane; nausea, vomiting, and great prostration, cold skin, feeble pulse and emaciation with anxious expression, the odor surrounding the patient being fetid. The duration of the grave symptoms is three or four days, when collapse and death occur, or slow convalescence begins, continuing for weeks. Complications. Peritonitis; hepatic abscesses; phlebitis of the intestinal veins ; intestinal perforation. Diagnosis. Enteritis lacks the tenesmus and characteristic stools. Peritonitis, when idiopathic, shows higher temperature, greater ten- derness and constipation. Prognosis. Catarrhal form favorable. Croupous form, the prog- nosis is always grave, for if recovery does occur the bowel may be crippled, from loss of structure, or from narrowing of its calibre, the result of cicatrices. Treatment. Emaciation being rapid, the diet must be of the most nourishing character, to which stimulus should be added if much prostration occur. The most common treatment is opium, combined with one or more astringents, to wit:— R. Ext. opii............................................ gr. ss Plumbi acetat....................................... gr. ij. M. Every two hours; or— R. Pulv. opii ........................................... gr. ss Plumbiacetat....................................... gr. ij Pulv. ipecac......................................... gr. j. M. Every two hours; or— R. Pulv. ipecac et opii ............................... gr. x Bismuth subnit................................. er. xx M. Every two hours. DISEASES OF THE INTESTINAL CANAL. So If the case is seen early the very best prescription possible is— R. Magnesii sulph...... Acid, sulph. dil__ Tinct. opii deodorat Aquae menth......... Every two or three hours, until faeces appear in the stools, when small doses of opium and quinina may be used. Ipecacuanha in gr. xx-xl, is largely used in the first stages of dys- entery, until the characteristic ipecac stools appear; the first doses being often rapidly rejected by the stomach, the treatment is difficult to pursue outside of hospital practice; but of its efficacy in many cases there can be no doubt. Dr. Loomis speaks strongly of Ipecacuanha, gr. ]^ every half-hour, with sufficient opium to secure quietness. Ringer recommends hydrargyri chloridum corrosivum, gr. fa^, every hour or two, which " rarely fails to free the stools from blood and slime, although in some cases a diarrhoea of a different character may continue for a short time longer." In children the following combination is efficacious :— R. Pulv. ipecacuanha................................. gr. ]^ Bismuth subnit.................................... gr. v Cretae praep.......................................... gr. iij. M. Sig.—Every two hours. The patient should be confined to bed in even the mildest attacks, and the stools removed at once and disinfected. Washing out the rectum with either tepid, hot, cold or iced water, as suggested by Prof. DaCosta, adds greatly to the patient's comfort and to the decrease of the inflammatory process. TYPHLITIS. Synonyms. Inflammation of the caecum ; catarrh of the caecum. Definition. A catarrhal inflammation of the mucous membrane - of the caecum and ascending colon; characterized by pain, tender- ness, constipation, and in certain cases a characteristic vomiting. Causes. In a majority of cases mechanical, from the lodgment of seeds or hardened faeces. ol tt\v Vl\x zij. M. 86 PRACTICE OF. MEDICINE. Pathological Anatomy. Similar to the catarrhal inflammation of dysentery. Symptoms. Pain and tenderness in the right iliac fossa and along the ascending colon, with some prominence of this region ; the bowels are usually constipated, or small liquid stools may occur from time to time, due to the accumulation of hardened faeces in the saccu- lated periphery of the caecum, leaving a central canal through which the liquid contents of the upper bowel can pass. In severe cases, "the local pain, tenderness and swelling are greater, there are impaction of feces and no movements. There are decided fever, restlessness, and also nausea and vomiting. The vomited matters, at first the contents of the stomach, then the duodenum, with bilious matter, and ultimately, if the impaction persists, of material having the odor of faeces. With these symptoms occur great depres- sion of the vital powers. Peritonitis is finally developed by contiguity of tissue or by rupture of the bowel." Duration. The mild form lasts about one week. The severe form may terminate in subacute peritonitis, continuing about two weeks. Diagnosis. The mild form is distinguished from other intestinal affections, by the localized pain, tenderness and prominence, and the constipation. The severe form can only be distinguished from the other forms of intestinal obstruction by the history of the case and attack, and the results of treatment. Prognosis. Mild form favorable. Severe form grave, although not necessarily fatal. Treatment. The patient should be kept in bed, and placed on a strictly milk diet. In mild cases, act upon the bowels, with either oleum ricini or mag- nesii sulphas in small doses, followed by an opium influence, to be maintained until convalescence is well pronounced. In severe cases, begin an opium influence at once, by hypodermatic injections of morphina guarded with atropina, continued until all symptoms of inflammation have subsided, when attempts to remove the accumulated faeces may be made by irrigation of the bowel With warm soapsuds, and the cautious administration of magnesii sulphas in drachm doses, every two hours. Locally. Leeches over the caecum followed by hot fomentations or ice bags, or cold compresses. DISEASES OF THE INTESTINAL CANAL. 87 PERITYPHLITIS. Synonym. Perityphlitic abscess. Definition. An acute inflammation of the connective tissue around the caecum, tending to the formation of an abscess ; charac- terized by pain, swelling, and febrile reaction. Causes. Injuries to the abdomen over the caecum ; and also extension of the inflammation from the caecum by perforation. Often occurs with typhlitis. Symptoms. Begins with a feeling of weight, soreness and parox- ysms of acute pain extending into the hip, thigh and abdomen, with the development of a hard swelling in the right iliac region. Its special tendency is toward suppuration, which is announced by irreg- ular chills, feverishnsss, and sweats, and a feeling of tension and throbbing. Its development is slow, and if associated with typhlitis the symptoms of that affection are added. Diagnosis. Differs from typhlitis by the absence of the colicky pains, dyspeptic symptoms, costive bowels and tympanites preceding the development of a tumor ; in perityphlitis the tumor is present with the development of the symptoms. Psoas abscess is not associated with intestinal symptoms, and the dis- charge is free from a fecal odor. Renal and ovarian tumors should not be sources of error. The possibility of hernial tumors must not be overlooked. Treatment. If not associated with typhlitis, the treatment is to allay the inflammation in the first stage, by either ice, locally, or freely painting with tinct. iodi; if suppuration is evident, hasten by poultices, and follow by evacuation of the pus with the aspirator or a free open- ing, conjoined with the use of opium and quinina. PROCTITIS. Synonyms. Catarrh of the rectum ; dysentery ; rectitis. Definition. A catarrhal inflammation of the mucous membrane of the rectum and anus ; characterized by pain, tenesmus and frequent stools of hardened faeces, or of mucus, pus and blood. Causes. Chief cause constipation ; also sitting on damp ground or stone steps ; habitual use of enemata or of purgatives; diseases of the liver. Pathological Anatomy. Similar to those occurring in catar- rhal dysentery. 88 PRACTICE OF MEDICINE. Symptoms. Uneasy sensations and burning in the rectum, with a constant desire for stool, or tenesmus, often so severe as to cause a prolapse of the mucous membrane. The stools may be either hard- ened feces or scybala from the distended colon, which cause intense pain when they reach the rectum; or the stools may be of mucus, muco-pus, or bloody or blood-streaked. Generally there are present nausea, especially during the tenesmus, headache, feverishness and malaise. In severe cases there is strangury, and with the tenesmus, straining with urination. If the case be protracted and severe, inflammation of the con- nective tissue around the rectum occurs, causing periproctitis, which usually terminates in various kinds of fistulae. Complications. Periproctitis ; peritonitis ; hepatic abscesses. Diagnosis. In males, the disease cannot be confounded with any other affection, save, perhaps, hemorrhoids. In females, displace- ments of the uterus may somewhat simulate the symptoms of proc- titis. Prognosis. Uncomplicated cases favorable. Either of the com- plications adds greatly to the gravity of the affection. Treatment. In cases due to constipation the chief indication is to empty the bowels, for which the magnesia mixture mentioned for dysentery is the most suitable remedy ; after which emollient ene- mata, with opium, are indicated. Irrigation of the bowel with warm water once or twice daily assists in the liquefaction of the hardened faeces. Cases other than those due to constipation, emollient enemata and opiutn, one of the best being— R. Ol. oliva?............................................. * ij Tinct. opii deodorat............................... n\xv. M. Every three or four hours. If symptoms of periproctitis occur, use ice to the parts, and if sup- puration ensue, evacuation by a free opening and quinina. INTESTINAL OBSTRUCTION. Synonyms. Intestinal occlusion ; strangulated hernia ; invagi- nation ; intestinal stricture. Definition. A sudden or gradual closure of the intestinal canal; DISEASES OF THE INTESTINAL CANAL. 89 characterized by pain, nausea, vomiting, constipation, and finally collapse. Causes. The numerous causes are arranged as follows :— i. Accumulations within the bowel, of hardened faeces, or foreign bodies. 2. Strictures, the result of cancer, ulceration, or cicatrices. 3. Pressure against the bowel, from peritoneal adhesions, tumors, and abnormal growths. 4. Strangulations, due to the numerous forms of hernia, 5. Invagination or intussusception, the most common. 6. Twisting, volvulus or rotation of the bowel. Pathological Anatomy. Invagination is the only form calling for special description. It is usually caused by the lower portion of the ileum slipping down into the caecum, as the finger of a glove might be invaginated, causing thus an actual mechanical obstruction; this is produced by a spasm of the ileum, whereby its calibre is greatly diminished, thus permitting its descent into the lower bowel. Result- ing from this occlusion or compression, are congestion,'inflammation, with secondary constitutional reaction and death, or more rarely the invaginated bowel sloughs off, and is voided by stool, union taking place at its site and recovery following. Symptoms. The onset of the symptoms may be either sudden ox gradual, and are as follows :— Constipation, with more or less severe colicky pains, not relieved by either purgatives or injections; feeling of weight and soreness, with distention of the abdomen and nausea and vomiting; the symptoms all grow more pronounced, the pain becoming violent, tenderness in limited areas, the vomiting becoming stercoraceous, the abdomen hard and tense, the eyes sunken, the pulse quick and feeble, the skin cold and covered with a clammy sweat. The above continue more or less pronounced for a week or ten days, when collapse and death occur, or more rarely gradual return to health. Cases occur rarely in which small, fecal, muco-purulent stools con- taining more or less blood exist, instead of constipation. Diagnosis. One of the most difficult, and can only be solved by a careful study of the case along with the different causes producing the affection. The site of the occlusion can rarely be determined positively. 90 PRACTICE OF MEDICINE. Intestinal obstruction may be mistaken for intestinal colic, hernia, enteritis, peritonitis, hepatic or renal colic. Prognosis. Always grave, but guided by the cause. Impacted feces favorable. Invagination less favorable, but recoveries occur; the longer the symptoms continue, the more favorable the outlook. Strangulations unfavorable, but many recoveries recorded. Strictures, due to cancer, cicatrized ulcers and the like, are the most unfavor- able. Treatment. Stop all forms of purgatives as soon as the diagno- sis of obstruction is determined. Opium is indicated in all forms, and is best administered in the form of morphina, combined with small doses of atropina, hypoder- matically. The author has seen the most brilliant results follow the plan of washing out the stomach as suggested by Kussmaul. Cases resulting from impacted faeces are rapidly cured by the above plan combined with irrigation of the lower bowels with tepid soap- suds. If invagination, raising the buttocks and lowering the chest, and repeated injections of warmed oil, are recommended. Distention of the bowel by pumping air through long rectal tubes, or disengaging carbonic acid gas in the bowel, by first injecting a solu- tion of sodii bicarbonas, and follow this with a solution of acidum tar- taricum, about one drachm of each, pressure being made against the anus, to prevent escape; but the danger of rupture of the bowel must not be overlooked. Flatulent distention can be removed by the long aspirator needle. Laparotomy is no doubt the operation of the future, when our means of diagnosticating the location of the trouble is more perfect. The nutrition of the patient is best attained by injections of either peptonized foods or defibrinated blood, or both. INTESTINAL PARASITES. 91 INTESTINAL PARASITES. TAPEWORMS. Varieties. Tenia solium; Tenia saginata; Bothriocephalus latus. Causes. The Tenia solium, the "armed tapeworm," is the most common in this country, It is derived from the embryos contained in pork, known as the cysticercus cellulosus. The Tenia saginata, the " unarmed tapeworm," a not uncommon variety, is derived from the embryos contained in beef, known as cysticercus bovis. The Bothriocephalus latus, also an " unarmed tapeworm," the largest parasite infesting man, is supposed to be derived from an em- bryo found in fish. The embryo or ova is introduced into the intestinal canal with the food and drink. The parasite reaches its final growth after its en- trance into the intestines. Those handling fresh meats or eating uncooked animal food are most liable to be affected. Uncleanliness is also an important factor. Description. The tenia solium is from six to thirty feet in length, has a globular head, or scolex, a slender neck connecting its numer- ous flat segments or joints. The head, or scolex, measures about fa of an inch, has a double circle of hooklets,—whence the term " armed tapeworm,"—and is provided with from two to four suckers. The seg- ments or joints (strobila) are flat, and vary from one-eighth to one- half an inch in length, and each contain both male and female sexual organs, the uterus being a long, numerously branched tube, in which the ova develop; the ova measure about Tfao of an inch in diam- eter. An ordinary tapeworm contains some five million ova. The parasite is firmly imbedded in the mucous membrane of the upper third of the small intestines by its hooklets and suckers. The lower or terminal segments represent the adult and complete animal, and are termed the proglottides, which separate from the parasite and are discharged either alone or with the faeces. The tenia saginata is from ten to forty feet in length, has a rounded or oval-shaped head, measures about fa of an inch and has four strong and prominent suckers, but no hooklets,—whence the term 92 PRACTICE OF MEDICINE. " unarmed tapeworm; " the neck is short and thick and the segments are larger, stronger and thicker than those of the T. solium. The Bothriocephalus latus is the largest of the three Cestoda, the length ranging from fifteen to sixty feet, the head oval, measuring about fa of an inch, a short neck, the segments or joints being nearly three times as broad as they are long. Its color is a dull, bluish-gray. Zoologically considered, this variety is not a true tapeworm. Symptoms. Not unfrequently a tenia produces no symptoms whatever. Usually, however, there are colicky pains throughout the abdomen, inordinate appetite, disorders of digestion, emaciation, constipation, attacks of cardiac palpitation, faintness, disorders of the special senses and pruritus of the anus and nose. Any or all of these symptoms may be present. A large meal will often remove the majority of the symptoms present. In a large number of cases the discovery of the segments is the first intimation of the presence of the parasite. Treatment. A number of remedies—termed taeniafuges—are used more or less successfully for the expulsion of the tapeworm, to wit: extractum granati rad. cort. fluidum, f^ss-ij, or a decoctum granati rad. cort. (§ ij bark of root, aquae Oj), wineglassful every hour until all is taken, as suggested by Prof. Bartholow ; or oleoresina aspidii, ^ss doses repeated, or oleum pepo express, 3J-iv, followed by oleum ricini. A much pleasanter remedy is pelleterine, the active constituent of granatum, used in the form of the tannate, gr. x-xx, or Tanret'ssolu- tion of pelleterine. Cases which resist these means are often cured by the following:— R. Chloroformi, Ext. aspidii fid.................aa.................. f^j Emul. olei ricini...........(B. Ph.)............... ? iij. M. Sig.—To be taken in the early morning; no food until after thorough action of the bowels. An important precaution in the management is close attention to the " preparatory treatment " rendered essential to remove the mucus in which the head (scolex) is imbedded. It consists in the adminis- tration of a good purgative for one or two days, and a light diet, such as milk and broths, preceding the use of the taeniafuge. INTESTINAL PARASITES. 93 ROUND WORMS. Varieties. Ascaris lumbricoides ; Oxyuris vermicularis. Causes. The ascaris lumbricoides is one of the most common of the parasites affecting the human family, and develops in the intes- tines, either after the entrance of the ova of the same, or from the so- called " intermediate parasites." Their entrance is effected by means of the food and drink. The oxyuris vermicularis develops in the large intestines, from either its peculiar ova, or the so-called " intermediate parasite," these finding their way into the bowel with the food and drink, or by direct contact. Description. The ascaris lumbricoides, or the round worm, is of a brown color, a cylindrical body, from ten to twenty inches in length and from an eighth to a fourth of an inch in circumference ; the head terminates in three semilunar lips, each having about two hundred teeth. The ova are oval-shaped, are produced in immense numbers, some sixty million in a mature female, have wonderful vitality, resist- ing extreme heat or cold. The round worm inhabits principally the small intestines, although it often migrates to other parts. They are found in numbers from one to several hundred. The oxyuris vermicularis, thread or seal worm, resembles an ordi- nary piece of white thread, measuring from a sixth to a half inch in length, the head terminating in a mouth with three lips, the tail ter- minating as a sharp point. The ova are oval, produced in large num- bers, each female containing about ten thousand, are surrounded by a stout envelope, which increases their vitality. The seat worm, as its name indicates, inhabits the large intestines, especially the rectum, although they frequently migrate to the sexual organs. They vary in number, sometimes the parts frequented being entirely covered. Symptoms. The ascaris lumbricoides, or round worm, may be present in great numbers and yet produce no characteristic symptoms other than gastric and i7itestinal irritation, such as picking the nose, foul breath, colicky pains, nausea and vomiting, diarrhoea and dis- turbed sleep, such as tossing from side to side of bed and grinding the teeth. Any or all of these symptoms may be present or absent, the only positive proof being the passage of the parasite. The oxyuris vermicularis, or seat worm, produce intense itching 94 PRACTICE OF MEDICINE. about the anus, with a desire for stool, the passages often containing much mucus, the result of the irritation produced by their presence. Should they migrate to the sexual organs, intense itching of these parts results, which, unless speedily corrected, leads in children to masturbation. Treatment. The ascaris lumbricoides are readily removed by the following " worm powder " :— R. Santonini............................................. gr. %-y\] Hydrargyri chlor. mite........................... gr. ^-ij- M. Ft. chart. Sig.—At bedtime, followed by a dose of oleum ricini before breakfast. For the oxyuris vermicularis the above santoninum powder, with the use of enemata of quassia, alumen, sodii chloridum, or R., acidi carbolici, gr. v-x, aquae, Oj, according to the age, the injection not to be retained. Washing the anus and external genitals with a solution of acidum carbolicum should also be employed. DISEASES OF THE PERITONEUM. PERITONITIS. Synonym. Inflammation of the peritoneum. Definition. A fibrinous inflammation of the peritoneum, either acute or chronic in character, characterized by fever, intense pain, ten- derness, tympanites, vomiting and prostration. It may be limited to a part—local,ox it may involve the whole membrane—general,peritonitis. Causes. Acute variety : Intense cold; protracted irritation by blisters; blows upon the abdomen ; inflammation or perforation of the stomach, intestines, gall or urinary bladder ; inflammation of the pelvic viscera; septicaemia or pyaemia ; erysipelas. Chronic variety.- Tuberculosis ; albuminuria; scrofula ; cancer; sclerosis of the liver. Pathological Anatomy. Acute form ; hyperaemia of the serous membrane, the capillaries distended and occasional extravasations of blood from their rupture ; the normal secretion is arrested, and the shiny membrane becomes dull and opaque, from an exudation of pure DISEASES OF THE PERITONEUM. 95 fibrin, which is adhesive, gluing the parts together; if the inflam- matory action is now arrested, it is termed adhesive peritonitis ; if, however, the action progress, an effusion of serous fluid is poured out into the peritoneal cavity, the amount varying from a few ounces to several gallons ; this is termed exudative peritonitis. If recovery result, the fluid is absorbed, with much of the solid exudation, the unabsorbed portions forming adhesions between the membrane and the different abdominal organs, often causing great deformity and irregularity in their relations. The chronic form follows the acute, or is associated with tubercu- losis, scrofula, Bright's disease or sclerosis of the liver. The membrane is irregularly thickened and opaque, with strong adhesions to one or more coils of the intestine, the liver or spleen ; the quantity of fluid present is small, purulent or sero-purulent in char- acter, and encysted by the agglutinated membrane. Symptoms. Acute form ; when idiopathic, the onset is sudden, with a chill, fever, 102-3°, pulse 100-140, wiry and tense, severe pain, cutting or boring in character, and tenderness, becoming so great that the slightest touch aggravates it, the decubitus being on the back, with flexed thighs; the abdomen is distended and rigid, from constipation, effusion and meteorism; the diaphragm is pushed up as far as the third or fourth rib in severe cases, causing compression of the lungs, and displacement of the heart, liver and spleen. There is impaired appetite, and nausea and vomiting are almost constant, as in hiccough. Secondary form, from extension, begins with local and gradually increasing pain, the temperature increases, tense pulse and vomiting. If from perforation, it is announced by severe pain and all the symptoms of shock. These symptoms continue from six to eight days, when they begin to ameliorate and a tedious convalescence ensues, or pain and tender- ness grow more marked, strength fails, surface cold, pulse rapid, and collapse, with hippocratic face, to wit: anxious expression, pinched features, sunken eyes and drawn upper lip. Chronic form; irregular chills, fever and sweats; distended abdo- men, constipation, alternating with diarrhea; diffused tenderness, with points of intenseness and hardness ; colicky pains during diges- tion, rapid emaciation and failure of strength. Usually, the lower portions of the abdomen give a dull note on percussion, from the 96 PRACTICE OF MEDICINE. presence of fluid, or scattered points of dullness, showing the presence of encysted fluid. Diagnosis. Acute gastritis differs from peritonitis in having a history of corrosive poisoning, severe pain, limited to the stomach, with early and severe vomiting; while the latter has fever, diffused abdominal pain and tenderness, with decided distention. Acute enteritis has localized pain and tenderness with marked diarrhoea; constipation being the rule in peritonitis. Rheumatism of the abdominal muscles occurs with a rheumatic his- tory, is subacute, lacks the great abdominal distention of peritonitis, and while tenderness exists, it is not aggravated by deeper pressure. Biliary colic, or the passage of a gall-stone, has, as a prominent symptom, excruciating pain, localized over the common bile duct, which is of a paroxysmal character and followed by jaundice. In renal colic the acute pain follows the course of the ureters, with retracted testicle and altered urinary secretion. Prognosis. Idiopathic cases favorable, and especially if they continue longer than a week, as fatal cases usually end during the first week. Cases from perforation unfavorable. Chronic peritonitis being generally of tuberculous origin, the prog- nosis is unfavorable, although partial or complete recovery results in the cases following the acute form of the disease. Treatment. Acute form .- Idiopathic and robust cases, locally, leeches or wet cups, followed by cold or hot applications, as most agreeable to the patient, or covering the abdomen with a blister; adynamic cases, dry cups, followed by warm applications medicated with tinctura opii. Opium and quinina are the remedies indicated at the onset of the disease, to wit: at once hypodermatic of morphina, gr. %-}/$, main- taining the effect by hourly doses of either morphina or opium, by the mouth. Prof. Clark ascertained the tolerance of opium in this disease, by the tremendous amounts used in a case under his care; the first day he gave 200 grs., the second day 472 grs., the third day 236 grs., fourth day 120 grs., fifth day 54 grs., sixth day 22 grs., and on the seventh day 8 grains. Prof. Clark found that, as a rule, however, morphina, gr. */(,-%, every two hours, would maintain the effects of the drug. The opium should be guarded with sufficient doses of atropina. Quinina, gr. v, every four hours until exudation, after which gr. ij, four times a day, is of marked benefit. DISEASES OF THE PERITONEUM. 97 The decline of the vital powers must be averted by regulated nutri- tion and free stimulation. During convalescence, perfect quiet, nourishing diet, moderate stimulation, scattered flying blisters, and the following :— R. Potassii iodidi....................................... gr. v-x Ferri pyrophos..................................... gr. ij Tinctura lavandulaecomp........................ TTLxv Syr. aurantii corticis ...........ad............... 3 ij. M. Every six hours, should constitute the treatment, with tonic doses of quinina. Peritonitis from perforation, absolute quiet, hypodermatic injections of morphina, ice locally, and stimulants per mouth, rectum, or hypo- dermatically. Chronic peritonitis; locally tinct. iodi, and internally opium, for pain ; potassii iodidum as an absorbent, with nourishing diet, oleum morrhue and stimulants, and rest in bed. ASCITES. Synonyms. Dropsy of the abdomen ; peritoneal dropsy. Definition. A collection of serous fluid in the abdomen, or more correctly in the peritoneal cavity ; characterized by swollen abdomen, fluctuation, dullness on percussion, displacement of viscera, embar- rassed respiration, plus the symptoms of its cause. Causes. Ascites may form part of a general dropsy, to wit: car- diac or nephritic; the most common factor in its production is me- chanical obstruction of the portal system, from cirrhosis of the liver, tumors, diseases of the heart or lungs. Pathological Anatomy. The quantity of fluid in the peri- toneal sac ranges from a few ounces to many gallons. It is generally of a straw color, or at times greenish, and is transparent, having an alkaline reaction. When blood is present in any great quantity, it points to cancer as a cause. The peritoneum becomes cloudy, sod- den, and thickened, from long contact with the fluid. Symptoms. The onset is insidious, and considerable swelling of the abdomen occurs before the disease attracts attention. Consti- pation, from pressure of the fluid on the sigmoid flexure. Scanty urine, from pressure on the renal vessels. Embarrassed respiration 1 98 PRACTICE OF MEDICINE. and cardiac action, from pressure on the diaphragm upward. The umbilicus is forced outward. Physical signs; on palpation, a peculiar wave-like impulse is im- parted to the hand laying on the side of the abdomen, while gently tapping the opposite side. Percussion; patient erect, the fluid distends the lower abdominal region, with dullness over the site of the fluid and a tympanitic note above; if the patient turns on his side the fluid changes, and dullness over the fluid, tympanitic over the distended intestines. Diagnosis. Ovarian tumors differ from ascites in the history, in that the enlargement is limited to the iliac fossa, instead of a uni- form abdominal enlargement, not changing its position when the patient changes posture, and by the detection of a tumor by conjoined manipulation through vagina, or by rectal exploration. Pregnancy differs from ascites in the character of the enlargement, the history, absence of menses, increase of mammae, change in the neck of the uterus, absence of fluctuation, and the presence of the sounds of the foetal heart. Distention of the bladder has been mistaken for ascites ; the points of distinction are, in the former the history, presence of tenderness over the bladder, rounded outline of the percussion dullness, and the relief afforded by the catheter. Chronic peritonitis is differentiated by the history, pain, tenderness, more or less vomiting, thickened abdominal walls, and its generally being associated with tubercle or cancer. Chronic tympanites presents the enlarged abdomen, but lacks the history, the dullness and the fluctuation, giving instead a tense abdo- men and a universal tympanitic note. Prognosis. Influenced by the causes producing it. Idiopathic ascites, which is most rare, terminates in health within a few weeks. If peritoneal, generally favorable. If from organic disease, most unfavora- ble, for while the dropsy may be removed, it as rapidly returns. Treatment. The first indication is to treat the cause of the ascites, and the second to remove the fluid. Three modes of removing the fluid present themselves, to wit: first, by hydragogue cathartics, second, diuretics, and third, tapping. The first and second modes may be combined, as follows:— R. Pulv. jalapae comp................................. ^j-ij In water, an hour before breakfast; DISEASES OF THE BILIARY PASSAGES. 99 And—R. Potassii acetat...................... Tinct. scillae........................ Infus. digitalis..................... Every six hours. Or instead use the following :— R . Hydrargyri chlor. mite........... Ext. opii............................ Et ft. pil. Sig.—One every three or four hours If these fail, as they certainly will after a time, the embarrassed res- piration and cardiac action will call for tapping, which may be done with the ttocar, or better still, the aspirator. DISEASES OF THE BILIARY PASSAGES. CATARRHAL JAUNDICE. Synonyms. Catarrh of the bile ducts ; icterus. Definition. An acute catarrhal inflammation of the mucous membrane of the bile ducts and of the duodenum ; characterized by gastro-intestinal derangement, yellowness, itching of the skin, fever- ishness and mental depression. Causes. Excesses in eating and drinking; a debauch ; malaria; climatic, as cool nights succeeding warm days. Pathological Anatomy. The mucous membrane of one or more of the bile ducts or of the duodenum becomes hyperaemic, swollen and thickened, from an effusion of serum into the sub- mucous tissue; the result of this condition is the closure of the biliary passages, thereby impeding the outward flow of bile. The bile in the hepatic ducts being retained by the obstruction, the result is a stain- ing of the liver substance and an absorption of bile, and its appear- ance in the blood. Symptoms. Begins by epigastric distress, coated tongue, impaired appetite, nausea, with, perhaps, vomiting and looseness of the bowels and slightfeverishness, the phenomena of a gastro-intestinal catarrh. In from three to five days the eyes become yellow, and jaundice gradually appears over the whole body ; the feverishness disappears, the skin becomes harsh, dry and itchy, the bowels constipated, the gr. x-xx-xl 5 ss f^iss. M. Sr- i>j gr. fa. M. 100 PRACTICE OF MEDICINE. stools whitish or clay-colored, accompanied with much flatus and colicky pains; the urine heavy and dark, loaded with urates and con- taining biliary elements. A few drops of the urine placed on a whitish surface, and a drop or two of nitric acid made to flow against it, will exhibit the following "play of colors / " a greenish tint, from the conversion of bilirubin into biliverdin, quickly followed by blue, violet, red, and yellow, or brown. When the jaundice is complete, the surface is cold, the heart's action slow, the mind torpid and greatly depressed, and pain or ten- derness on pressure over the hepatic region. Duration. In from three to five days after the jaundice appears, the symptoms subside, save the torpid bowels, depression and discol- ored skin, which slowly disappear, often requiring a week or two. Diagnosis. After the appearance of the jaundice, mistakes are impossible. The numerous diseases of which jaundice is a symptom will be differentiated when treating of them. Prognosis. Always favorable; if the attacks are of frequent occurrence, however, they are apt to lead to organic hepatic changes. Treatment. At the onset quinina, gr. x, morning and night, may modify the disease, but as soon as the diagnosis is established the indications are for diaphoretics, diuretics and purgatives. For diaphoresis, the warm bath, to which potassii carbonas, f,], may be added, morning and night. For diuresis, potassii bitartras lemonade, every four hours. Yox purgation, either sodiipyrophos., 3 j—ij, every four hours, well diluted, or ammonii murias, gr. xv-xx, every five hours, well diluted. A special plan, which is said to be effective, is with "enemata of cold water. By means of an irrigating apparatus the large intestine is well distended with water once a day for several days. The first enema has a temperature of 6o° F., and subsequent injections are a little warmer. The increased peristalsis of the bowels and the reflex contractions of the gall bladder dislodge the mucous lining and ob- structing the gall ducts. When the bile flows into the intestine, diges- tion is resumed and the catarrhal inflammation subsides." Other remedies may be conjoined with the irrigation method. Restricted diet, avoiding all starchy, fatty or saccharine articles, milk being the most suitable. DISEASES OF THE BILIARY PASSAGES. 101 For convalescence— R. Acid, nitrohydrochlorici dil....................... gr. v-x Elix. taraxaci comp................................. oJ~iJ- M- Before meals. BILIARY CALCULI. Synonyms. Hepatic calculi; gall stones ; hepatic colic. Definition. Concretions originating in the gall bladder, or biliary ducts, derived partly or entirely from the constituents of the bile. Their presence is generally unrecognized until one or more attempt to pass along the ducts, when an attack of hepatic colic is produced. Causes. Gall stones result from the precipitation of the crystal- lizable choleslerine, and its combination with inspissated mucus in the gall bladder or ducts. A disease of middle life, and more frequent in the obese, and in women. Gall stones are said to be common in carcinoma of the stomach or liver. Pathological Anatomy. Cholesterine is the chief constituent of biliary calculi. Commonly several stones exist, and rarely one; as many as six hundred are recorded. They are generally found in the gall bladder or cystic duct, rarely in the liver or hepatic duct. Symptoms. Hepatic colic begins suddenly, at the moment a gall stone passes from the gall bladder into the cyst duct. The patient is seized with a piercing, agonizing pain in the region of the gall bladder, and spreading over the abdomen, right chest and shoulder; the abdominal muscles axe cramped and tender; there is nausea and vomiting, a small, feeble pulse, cool skin, pale, distorted, anxious face, with, may be, fainting, spasmodic trembling, chills, or convulsions. The paroxysm continues from an hour or two to several days, with remissions, but entire relief is not afforded until the stone reaches the duodenum, when the pain suddenly ceases. faundice usually follows the paroxysm of pain. When the calculi reaches the intestines, the pain, nausea and vomiting cease, the appe- tite returns, and the jaundice soon disappears. Should the calculi become impacted, ulcerative perforation and consequent peritonitis follow, the calculi discharging by the intestine, stomach, or through the abdominal walls. 102 PRACTICE OF MEDICINE. Diagnosis. The malady should not be mistaken if severe pain, nausea, and vomiting axe present, suddenly terminating, and followed by slight jaundice. Prognosis. Usual termination is in health. The prognosis be- coming more unfavorable if ulcerative perforation result. Treatment. For the colic, hypodermatic injections of morphina, gr. Ye-yi-yi, combined with atropina, gr. T|ff, and warm fomenta- tions over the hepatic region, are indicated. Prof. Bartholow strongly urges the following prophylactic treatment: Carefully regulated diet, abstinence from all fatty and saccharine sub- stances, daily exercise, stoppage of all excesses, and the long use of sodiiphosphas, 3J, before meals, well diluted, to which maybe added, if gastro-intestinal catarrh be present, sodii arsenias, gr. fa, or auriietsodiichloridum, gr. fa, together with either Vichy or Saratoga Vichy water. DISEASES OF THE LIVER. CONGESTION OF THE LIVER. Synonyms. Torpid liver; biliousness. Definition. An abnormal fullness of the vessels of the liver, with consequent enlargement of that organ ; it is termed active when arte- rial; passive -when venous. The condition is characterized by tor- pidity of the digestive and mental functions, and slight jaundice. Causes. Active congestion; malaria ; excess in eating and drink- ing; alcoholic or malt liquor. Passive congestion ; cardiac and pulmonary diseases. Pathological Anatomy. The liver is enlarged in all directions, and is abnormally full of blood. Cases due to obstructive diseases of the heart or lungs present the so-called " nutmeg liver," to wit: " At the centre of each lobule the dilated radicle of the hepatic vein, enlarged and congested, may be discerned, while the neighboring parts of the lobule are pale," the radicles of the portal vein containing less blood. Long-continued congestion establishes atrophic degeneration of the organ; the decrease in size is confounded with the condition of cir- DISEASES OF THE LIVER. 103 rhosis, but the " atrophic liver " is smooth, while the " cirrhotic liver " is nodulated. Symptoms. Active congestion; following cause, rapidly produced malaise, aching of limbs, evening feverishness, headache, yellowish tongue, disgust for food, nausea, and, may be, vomiting, constipation, scanty, high-colored urine, with a feeling of fullness, weight, and sore- ness in the hepatic region, and slight jaundice, the eye yellow, and the complexion muddy. Passive congestion; onset gradual, with a feeling of weight and fullness in the hepatic region, slight jaundice, and symptoms of gas- tro-intestinal catarrh. On percussion the hepatic dullness is increased in all directions. Diagnosis. Acute congestion is continually confounded with catarrhaljaundice; the latter begins with marked gastro-intestinal symptoms and distinct jaundice; in the former these are less marked. Obstructive congestion is diagnosticated by the clinical history. Atrophic or nutmeg liver will be differentiated from cirrhotic liver when speaking of the latter. Prognosis. Active congestion favorable, unless repeated attacks occur, rapidly succeeding each other, when " atrophic degeneration " results. Passive congestion controlled entirely by the cause. Treatment. Attacks due to excess in eating and drinking:— R. Sodii bicarb......................................... gr. v Pulv. ipecac....................................... gr. ss Hydrargyri chlor. mit............................. gr. iij-v repeated or sodii phosphatis 3 j every four hours until free catharsis, followed by R. Acidi nitrohydrochlorici dil..................... rr\vnss Elix. taraxaci comp............................... 31]. Before meals, and a milk diet. Attacks due to malaria; the above purgative followed by quinine sulph., gr. iv, every four hours. Attacks occurring with cardiac or pulmonary diseases must be managed by treating the cause. The tendency to constipation must be overcome by the saline laxa- tive waters, to wit: Congress or Hathorn, Pullna or Friedrichshall, or sodiiphosphas, gi-ij, three or four times daily, well diluted. 104 PRACTICE OF MEDICINE. Locally, in acute attacks, hot cloths or sinapisms, are of benefit. In chronic cases benefit follows, elix. quinine ferri et strychnine, 3j, three times a day, and great comfort and support is given by the use of the "hydropathic belt" which is made of stout muslin, shaped to the abdomen, with cross pieces of tape on the inner side, which keeps next to the skin a fold of cloth wrung out of cold water, and a piece of waterproof cloth or oiled silk, to prevent evaporation. ABSCESS OF THE LIVER. Synonyms. Parenchymatous hepatitis ; acute hepatitis; sup- purative hepatitis. Definition. A diffused or circumscribed inflammation of the hepatic cells, resulting in suppuration, the abscesses being sometimes single, at times double; characterized by irregular febrile attacks, hepatic tenderness and symptoms of deranged gastro-intestinal and hepatic functions. Causes. The result of the absorption of putrid material by the portal radicles in dysentery ; ulcers of the stomach ; malaria ; blows and injuries ; heat; pyaemia. Pathological Anatomy. Hyperaemia, swelling, effusion of lymph, degeneration and softening of the hepatic cells ; suppuration, beginning in points in the lobules and coalescing. The abscess walls consist of the liver structure, more or less changed. The abscess may advance toward the surface of the liver, bursting into the peritoneum, intestines, stomach, gall bladder, hepatic duct or vein, or into the pleura or lungs, or externally through the abdominal walls; after the discharge of pus, cicatrization occurs, or the pus may be> absorbed, the tissues around forming a dense cicatrix. Symptoms. Very obscure. Fever simulating markedly inter- mittent or remittent fevers ; disorders of the gastro-intestinal canal, with obstinate vomiting, debility, and great irritability of the nervous system, slight jaundice, and if of long duration, typhoid symptoms. Locally, if the abscess is near the surface, prominence of the hepatic region, tfirobbing, limited tenderness, and if it tends to the surface, redness, oedema and fluctuation. The abscess may burst into the intestines, stomach, lungs, or pleura, the symptoms of which will be pronounced. DISEASES OF THE LIVER. 105 Diagnosis. Hepatic abscess may be confounded with hydatids of the liver, hepatic or gastric cancer, abscess of the abdominal walls, and purulent effusion in the right pleural cavity. The differentiation is most difficult, but great aid is obtained from the use of the aspirator. Prognosis. Unfavorable. Recoveries, however, do occur. If the abscess bursts into the lungs, bowels, or externally through the abdominal wall, the case is more favorable. Treatment. Symptomatic, and when pus is present, the use of the aspirator to remove it, and sustaining treatment, to wit: quinina, ferrum, alcohol, and oleum morrhue. ACUTE YELLOW ATROPHY. Synonyms. General parenchymatous hepatitis ; malignant jaun- dice; hemorrhagic icterus. Definition. An acute diffused or general inflammation of the hepatic cells, resulting in their complete disintegration: characterized by diminution in the size of the liver, deep jaundice, and profound disturbance of the nervous system; terminating in death, usually, within one week. Causes. Unsettled. It occurs frequently in young pregnant women, from the third to the sixth month of pregnancy. Other causes are venereal excesses; syphilis; action of phosphorus, arsenic or antimony. Pathological Anatomy. Begins with hyperaemia of the he- patic cells, with a grayish exudation between the lobules, followed by softening, dull yellow color, and disappearance of the cells, fat glob- ules taking their place. The liver is reduced in size and in weight. The peritoneum covering the liver is thrown into folds. The spleen is enlarged. The kidneys undergo degeneration. The blood contains a large amount of urea and considerable leucin. The urine is loaded with bile pigment, and contains albumen. Symptoms. Prodromic period; begins as a gastro-intestinal catarrh, coated tongue, nausea, vomiting, tenderness over the epigas- trium, headache, quickened pulse, slight fever and slight jaundice. Icteric period; jaundice deepens, pulse slow, headache increases, and great and obstinate sleeplessness. Toxemic period ; fever, rapid pulse, more complete jaundice, pain, J 106 PRACTICE OF MEDICINE. nausea, vomiting of blackish, grumous blood, or " coffee grounds," tarry stools, ecchymotic patches, convulsions or epileptiform attacks, coma, insensibility, death. Percussion shows markedly decreased hepatic dullness. Duration. Short. After appearance of jaundice, about six days. Prognosis. Unfavorable. Treatment. Entirely symptomatic. Prof. Bartholow "advises the trial of very small doses of phosphorus, as early as possible, as this remedy affects the organ specifically, and an action of antagonism may be discovered between them." SCLEROSIS OF THE LIVER. Synonyms. Interstitial hepatitis; cirrhosis of the liver; hob- nailed liver; gin-drinkers'liver. Definition. An inflammation of the intervening connective tissue of the liver, chronic in its progress, resulting in an induration or hardening of the organ and an atrophy of the secreting cells; characterized by gastro-intestinal catarrh, emaciation, slight jaundice and ascites. Causes. The prolonged use of alcoholic stimulants, gin, whisky, beer, or porter ; syphilis. Pathological Anatomy. First stage ; hyperaemia of the con- nective tissue (Glisson's capsule) of the liver, and the development of brownish-red connective-tissue elements, whereby the organ is increased in size and density ; this increase of the connective tissue presses upon the hepatic cells, causing them to undergo fatty degene- ration. Second stage ; the newly formed, imperfectly developed connective tissue contracts, causing decrease in the size and induration of the organ, its surface being nodulated. The hepatic and portal circula- tion is obstructed, from obliteration of their radicles. The hepatic peritoneum is thickened and opaque, and adhesions are formed to the diaphragm, gall-bladder, and stomach. Cases occur in which the sclerosis takes place while the organ con- tinues enlarged ; these cases are known as hypertrophic sclerosis. Symptoms. No characteristic symptoms of the early stage of the affection. Persistent gastro-intestinal catarrh, with attacks of jaundice, in a drinking man, are suspicious. Symptoms of the second DISEASES OF THE LIVER. 107 stage are, abdominal dropsy, enlargenient of the superficial abdominal veins, dyspepsia, localized peritoneal pain, hemorrhages from the stomach or intestines, muddy or slightly jaundiced skin and decided emaciation. Diagnosis. Atrophy of the liver, or the nutmeg liver, is almost always confounded with sclerosis ; the former occurs most commonly with obstructive diseases of the heart and lungs, and the surface of the organ is not nodulated, nor is there a history of alcoholism. Cancer and tubercle of the peritoneum have many symptoms akin to sclerosis. The points of differentiation are, great tenderness over abdomen, rapidly developed ascites, rapid decline in strength and flesh, absence of jaundice, absence of long-continued dyspepsia, ab- sence of hepatic changes on percussion, and the presence of tubercle or cancer deposits in other organs. Prognosis. Terminates in death. Average duration after appear- ance of the dropsy, one year. Treatment. For the changes in the hepatic structure, little, if anything, can be done; the following are some of the remedies recom- mended, to wit: hydrargyri chloridum corrosivum, gr. fa-fa, three times a day ; hydrargyri chloridum mite, gr. T^, three times a day ; aurii el sodii chloridum, gr. fa, after meals ; sodiiphosphas, .^ss-j, after meals. The diet must be regulated, milk being the most suitable, and avoiding fatty and saccharine foods. The abdominal dropsy may be temporarily benefited by purgatives and diuretics, but sooner or later tapping becomes imperative. AMYLOID LIVER. Synonyms. Waxy liver; lardaceous liver; scrofulous liver; albuminous liver. Definition. A peculiar infiltration into, or a degeneration of, the structure of the liver, from the deposit of an albuminoid material, which has been termed amyloid, from a superficial resemblance to starch granules. Causes. The chief cause is prolonged suppuration, especially of the bones; coxalgia ; syphilis ; cancer. Pathological Anatomy. The liver is uniformly enlarged. It presents a pale, glistening, translucent appearance, and has a doughy 108 PRACTICE OF MEDICINE. consistency. On section, the surface is homogeneous, is anaemic and whitish. The deposit begins in the arterioles and capillaries, finally closing them. The reaction with iodine and sulphuric acid affords a certain test of the amyloid or albuminoid deposits. After further cleansing, brush over the parts a solution of iodine with iodide of potassium in water, when they will assume a mahogany color, and if diluted sulphuric acid be added, a violet or bluish tint is produced. A pretty reaction is to take a one per cent, solution of anilin violet, which strikes a red or pink color with the amyloid or albuminoid material, while the unaltered tissues are stained blue, thus showing a beautiful contrast. The amyloid change involves the spleen, kidney, intestines, and other organs. Symptoms. Nothing characteristic. Hepatic dullness increased, with prominence over the liver. Absence of pain. Splenic dullness increased. Emaciation and anaemia. Urine increased in amount, pale, and containing some albumen, due to amyloid changes in the kidneys. Disorders of digestion, with diarrhoea, due to amyloid changes in the intestines. Jaundice is rare. Ascites seldom occurs. Prognosis. Unfavorable. The progress is rapid or slow, depend- ing upon the cause. Treatment. No specific. Symptomatic, with prolonged use of ferrum; syr. calcii lacto-phosphas and oleum morrhue. HEPATIC CANCER. Synonym. Carcinoma of the liver. Definition. A peculiar morbid growth, progressively destroying the hepatic tissue ; characterized by disorders of digestion, anaemia, emaciation, jaundice and ascites, and terminating in the death of the patient. Causes. Hereditary, when it is termed primary cancer ; from extension from other organs, when it is termed secondary cancer. It is a disease of advanced life, from forty to sixty years. Pathological Anatomy. The most common variety of cancer of the liver is a compound of the medullary and scirrhus. The cancer cells develop from the interlobular connective tissue, and as they grow the hepatic cells atrophy, the result of the pressure DISEASES OF THE KIDNEYS. 109 of the new growth. The branches of the hepatic artery enlarge and permeate the growth, while the branches of the portal vein are com- pressed and atrophied, thereby blocking up the portal circulation. The cancer may develop in nodules or masses, or maybe diffused ; the nodules vary in size, and those on the surface are rounded, with a central umbilication. The peritoneum is adherent, cloudy and thickened. Symptoms. The development of hepatic cancer is preceded by a history of dyspepsia, flatulency and constipation. The uneasiness, weight and pain, increased by pressure, are noticed ; jaundice, ascites, occasional intestinal hemorrhages, emaciatioti, feebleness, anemia, cold, dry, harsh skin, pinched features, with dejected, worn expression. Fever never occurs. The hepatic dullness is increased, with pains on palpation, and the liver is indurated, irregular and nodulated. The duration is less than a year from the time the disease is recognized. Diagnosis. The points of differentiation are the age, cachexia, pain and tenderness, enlarged liver with hard nodules, and rapid progress. Prognosis. Always terminates in death. Treatment. Early symptomatic. Sooner or later opium must be used, to relieve the terrible and persistent pain. DISEASES OF THE KIDNEYS. THE URINE. The normal quantity of urine varies from twenty to fifty ounces in the twenty-four hours; it is decreased by free perspiration and increased by chilling of the skin. The normal color is light amber, due to urobilin ; the color deepens if the quantity voided be decreased, and vice versa. The normal reaction is slightly acid, due to the acid sodic phos- phate, uric and hippuric acids. After meals it may be neutral or even alkaline. The normal specific gravity varies from i .008 to 1.020 ; it is low 110 PRACTICE OF MEDICINE. I. Quantitative test for urea, by hypobro- miteofsodium(Davy's Method). when an increased quantity is passed and high when the quantity is diminished. The most important organic and inorganic solid constituents held in solution are, urea (the index of nitrogenous excretion), from 308 to 617 grains daily ; uric acid, from 6 to 12 grains ; urates of sodium, ammonium, potassium, calcium and magnesium, from 9 to 14 grains ; phosphates of sodium, etc., from 12 to 45 grains, and chlorides of sodium, etc., from 154 to 247 grains daily. Fill a graduated glass tube one-third full of mercury, and add one-half drachm of the 24 hours' urine ; then fill the tube evenly full with a saturated solution of hypobromite of sodium, and close it immediately with the thumb ; invert the tube and place its open end beneath a sat. sol. ofchloride of sodium; the mercury flows out and is replaced by the solution of salt; nitrogen gas is disengaged from the urea in the upper part of the tube. Each cubic inch of gas represents .645 gr. of urea in the half drachm, from which the amount passed in 24 hours may be cal- [_ culated. Urine containing an excess of urates and uric acid, on cooling, precipitates them (viz.: " brickdust deposits " in " pot de chambre "). Heat dissolves them to a certain extent. Nitric acid deprives the soluble neutral urates of their bases, and produces, at first, a faint, milky precipitate of amorphous acid urates ; adding more acid, the still less solu- \ ble red crystals of uric acid are deposited. Put a small quantity of nitric acid in a test tube, and pour the urine carefully down the sides of the tube upon it, and a zone of yellowish-red uric acid and altered coloring matter will form at their union ; and a dense, milky zone of acid urates above this, which, however, dissolves upon agitation. (See [ albumen test.) II. Tests for urates and uric acid by nitric acid. DISEASES OF THE KIDNEYS. Ill III. Quantitative test for uric acid by nitric acid. IV. Test for the earthy and alkaline phosphates by the magnesian fluid. To three ounces of the 24 hours' urine (after being slightly acidulated, boiled and filtered while hot) add one-tenth as much nitric acid; place in a cool place for 24 hours, then collect the deposit of uric acid on a weighed filter, wash it thoroughly, and dry at 2120 F. The increased weight repre- sents the uric acid in part excreted, approxi- [ mately. V'. Test for the chlo- rides by nitrate of sil- ver. VI. Test for mucus by acetic acid and li- quor iodi comp. Heat or liquor potassa increases the cloudiness caused by earthy calcium and magnesium phosphates. Acetic or nitric acid clears it, by dissolving them. To two ounces of urine add one-third as much of the following solution, to wit: R. Magnesii sulph., ammonii chloridum purae, liquor ammonias, each one part; aquaedestil., eight parts; if the precipitate has a milky, cloudy appearance, the quantity of phos- phates is normal; if creamy, the phosphates are in excess. To a convenient quantity of urine add a small amount of nitric acid, to prevent the formation of the phosphates and other salts of silver; filter this, if cloudy; add to this one drop of a solution of nitrate of silver (1 part to 8) and the precipitate of white cheesy lumps of chloride of silver denotes that the amount of chlorides are normal; if, however, only a faint milkiness occurs, the chlorides are diminished. Mucus alone is not visible, but causes cloudiness, from having entangled mucus or pus corpuscles, epithelium, granules of sodi- um urate, crystals of oxalate of lime and uric acid in various amounts. Add to the urine a little acetic acid, or, in addition, a few drops of liquor iodi comp., 112 PRACTICE OF MEDICINE. VII. Tests for albu- men by heat and nitric acid. VIII. Quantitative test for albumen. Ap- proximately. IX. Test for blood by heat and nitric acid. X. Test for blood by heat and caustic pot- ash (Heller's). l when threads and bands of mucin are made I visible. The addition of nitric acid dis- l_ solves them. f Slightly acidulate the urine, if necessary, by addition of nitric or acetic acid, and boil; this causes a white deposit of coagulated albumen, which is not dissolved by nitric acid, unless the acid is in excess. Nitric acid causes a white deposit of coagulated albumen, which is dissolved if a large excess of acid be added. A delicate test is to put the nitric acid in the tube first, and then gradually pour the urine down the side of the tube upon it, when a white zone, or ring of coagulated albumen appears. Pre- caution, see tests Nos. 3, 4, 9 and 11. Add a few drops of nitric acid to a pro- portion of the urine, and boil; set this away for 24 hours, and the proportionate depth of the resulting deposit is the comparative [ indication, viz., %-%, etc. Heat or nitric acid causes deposit of albu- \ men, with the coloring matter changed to a I. dirty brown. Heat the urine, then add caustic potash and heat anew. The phosphates are thus precipitated, taking with them the coloring matter of the blood, which imparts a dirty, yellowish-red color to the sediment, viewed by reflected light, and when seen by trans- mitted light, gives a splendid blood-red color. Neither the coloring matter of the blood, nor that of the bile, is precipitated with the phosphates, so that coloration of urine which shows this reaction cannot be ascribed to the presence of the latter pigments. When the quantity of blood in the urine is very large, it is of a dark or brownish red, DISEASES OF THE KIDNEYS. 113 XI. Test for pus by liquor potassa. XII. Test for bile by "fuming" or red nitric acid. XIII. Test for bile pigment by pure hy- drochloric and pure nitric acids (Heller's). XIV. Test for sugar | and, after standing, forms a coagulum of [ blood at the bottom of the vessel. Caution. Heat or nitric acid causes coagu- lation of the albumen in pus. Add to the urine, or preferably to its de- posit from standing, an equal volume of liquor potassa; when well mixed, a viscid gelatinous fluid or mass is formed, which pours like the white of an egg, or jelly. Allow a specimen of urine and a few drops of red "fuming" nitric acid to gradually intermingle on a porcelain dish, and a "play of colors," green, blue, violet, red and yellow or brown, occur, if biliary coloring matter be [ present. Pour into a test tube about 1.6 f^ of pure hydrochloric acid, and add to it, drop by drop, just sufficient urine to distinctly color it. The two are mixed. Then drop down the side of the test tube pure nitric acid, which will " underlay " the mixture of hydro- chloric acid and urine. At the point of contact between the mixture and the color- less nitric acid a handsome "play of colors - appears." If the "underlying" nitric acid is now stirred with a glass rod, the set of colors which were superimposed upon one another will appear alongside of each other in the entire mixture, and should be studied by transmitted light. If the hydrochloric acid, on addition of the biliary urine, is colored reddish-yellow, the coloring matter is bilirubin ; if it is col- ored green, it is biliverdin. Add to the urine half its volume of liquor potassa. (Caution. This may give a white, flaky precipitate of the earthy phosphates, which should be removed by filtering.) Now 114 PRACTICE OF MEDICINE. by liquor potassa and heat (Moore's). XV. Test for sugar by subnitrate of bis- muth, liquor potassa and heat. XVI. Test fox sugar by a solution ofcupric sulphate, liquor po- tassa and heat (Trom- mer's). XVII. Quantitative test for sugar byPavy's solution, to wit:— R. Cupric sulphate, gr. 320 Neutral potassic tartrate.........gr. 640 Caustic potash... gr. 1280 Distilled water... f 3 20 Keep corked. -j boil; this causes, at first, a yellow-brownish color, becoming darker if much sugar is present, due to glucic, and finally to melas- [ sic acid. Add to the urine half its volume of liquor potassa, and then a little bismuth subnitrate, shake and thoroughly boil; the presence of - sugar reduces the salt and black metallic bismuth is deposited, or if but little sugar, a gray deposit occurs. [ Caution. Albumen must be absent. Add to the urine a few drops of a solution of cupric sulphate, and then its own volume of liquor potassa. (Caution. On first addi- tion a light greenish precipitate occurs, which, on further addition of the reagent, if sugar or certain other organic matters are dissolved, giving a transparent blue liquid.) Now boil, and a yellowish precipitate of hydrated cupric suboxide, occurring at once, denotes thepresence of sugar. Caution. Albumen must be absent. f Take of Pavy's solution of cupric protox- ide, recently prepared (see margin), 200 minims or a multiple of this quantity, and boil in a porcelain dish; while boiling, add, minim by minim, from a measured portion of the 24 hours' urine, and it gives a yellow- ish precipitate of hydrated cupric suboxide, if sugar be present. -j Note carefully the gradual disappearance of the blue color, and when completed (best determined by looking through the margin of the fluid against the white porcelain dish), from the amount of urine used, determine the amount of sugar passed daily. The quantity of urine containing one grain of sugar being just sufficient to reduce the 200 { minims of the copper solution. DISEASES OF THE KIDNEYS. 115 f Take two measured specimens from the 24 hours' urine, and to one add a little yeast. Place each specimen in a temperature of 750 to 8o° Fah. ; in 24 hours, fermentation hav- ing destroyed the sugar'm. the one containing the yeast, the difference in the specific grav- ity of the two specimens expresses the number of grains in each ounce of the urine. I Approximately. CONGESTION OF THE KIDNEYS. Synonyms. Renal hyperaemia; catarrhal nephritis. Definition. An increase in the amount of blood in the vessels of the kidneys; when arterial, it is termed active congestion; when venous, passive congestion ; characterized by pain, frequent desire for urination, the amount of urine scanty, high-colored, occasionally containing albumen or blood. Causes. Active; from cold; irritating substances eliminated by the kidneys, to wit: turpentine, copaiba, cantharides ; during the eruptive or continued fevers ; injuries over the kidneys. Passive ; obstructive diseases of the heart or lungs, and pressure of the pregnant uterus. Pathological Anatomy. The kidneys enlarge and increase in weight; increased redness (the color being bluish if passive), with points of vascularity, corresponding to the Malpighian bodies, and occasionally minute ecchymoses. The abnormal hyperaemia causes a catarrhal state of the ducts of the pyramids, with shedding of their epithelium. If mechanical (passive) obstruction continues for some time, increase of the connective tissue, with consequent induration and contraction results, or a form of chronic Bright's disease. Symptoms. Active variety; pain over kidneys and following the course of the ureters into the testicles and penis, irritable bladder, almost constant and pressing desire for urination, the urine scanty, high-colored, and occasionally bloody, with fibrin, casts and albumen. If the condition persist, inflammation of the kidney results. Passive; the kidney changes are masked by the lung or heart trouble, until dropsy, scanty, high-colored, albuminous urine is observed. XVIII. Quantitative test for sugar by fer- mentation and the specific gravity. 116 PRACTICE OF MEDICINE. Prognosis. Active ; if recognized and properly treated, favorable Passive, controlled by the cause, and if prolonged, terminating in interstitial nephritis. Treatment. Rest of the body ; dry or wet cups over the loins; dilute the urine by increasing the quantity of bland fluids consumed; saline purgatives ; warm bath or other mild diaphoretics; if great irritability of the bladder, camphora, gr. ij-iv, every four hours, com- bined with morphine sulph., gx.fa-\, or the hypodermatic injection of tnorphina, gr. fa. ACUTE BRIGHT'S DISEASE. Synonyms. Acute desquamative nephritis ; acute parenchyma- tous nephritis ; acute tubal nephritis. Definition. An acute inflammation of the epithelium of the uriniferous tubules; characterized by fever, scanty, high-colored or smoky urine, dropsy, with more or less constant nervous phenomena, the result of acute uraemia. Causes. The young more liable than the aged; cold and expo- sure ; scarlatina ; persistent use of irritants, to wit: turpentine and cantharides. Pathological Anatomy. The kidneys are generally swollen, engorged, more vascular, and of a red color; in the second stage the organ remains large, irregularly red, especially the cortex; the tubules are engorged and filled with epithelium, blood corpuscles and fibrin. The capsule is easily detached, and is more opaque than normal. If a favorable termination, the swelling lessens, the vascularity diminishes, the tubules returning to a normal condition. Symptoms. Usually begins suddenly. Fever, with nausea and violent and persistent vomiting, dull pain over the kidneys, following the ureters ; skin harsh and dry ; pulse quick, tense and full. Soon dropsy appears, the eyelids and face becoming puffy and swollen, fol- lowed by general oedema of the extremities, scrotum and abdominal walls. If the attack follow scarlatina there are from the onset much greater pallor and general debility. The urine is of high specific gravity, scanty, smoky (like beef wash- ings) in color, due to the presence of blood. Albumen is present in large quantities, and the microscope reveals casts of the uriniferous DISEASES OF THE KIDNEYS. 117 tubules, blood corpuscles, uric acid, urates and oxalate crystals and epithelium. Duration from one to four weeks. Complications. Pericarditis, pleurilis, pneumonitis, peritonitis, or acute uremia, from retention and decomposition of urea in the blood. Diagnosis. The history, fever, scanty, smoky, albuminous urine, with dropsy beginning in the face, should prevent any error. Albuminuria may be confounded, on account of the presence of albumen in the urine, but lacks the clinical history, usually occurring in the course of some constitutional affection, to wit: diphtheria, cholera, yellow fever or erysipelas. Prognosis. Favorable. Majority of cases recover under prompt treatment. Rarely passes into chronic Bright's disease. Uremic symptoms add to the gravity of the prognosis. Treatment. Absolute rest in bed. Milk diet, or if much depres- sion, also weak animal broths and oysters. Drink freely of water, but neither tea, coffee nor stimulants. Counter-irritation over the kidneys by dry or wet cups, and poultices of digitalis. For the dropsy, purgation by pulv. jalape comp., %'), in water, be- fore breakfast, or elaterium, gr. \. Diaphoresis by warm baths, or infusumpilocarpi, 5 j-ij, every three or four hours, or vinum ipecacuanhe, gtt. j-ij, every half hour. Diuresis, by— R. Potass, acetas....................................... gr. x-xx Infus. digital........................................ f^ij Infus. juniperi..................................... ^3y- M- Every two or four hours. As soon as the blood disappears from the urine, a course of ferrum, in the shape of Basham's mixture, until albumen disappears and health is restored. The following is the formula of Basham's mix- ture :— R. Liq. amnion, acetat................................ f,lvj Acid, acetic......................................... 3 iij Tinct. ferri chlor................................... f 3 v Alcoholis............................................ §ij Syrup............................................... f ^ iv Aquae............................................... fg iv. M. Sig.—Dose f^j-f^j- 118 PRACTICE OF MEDICINE. CHRONIC PARENCHYMATOUS NEPHRITIS. Synonyms. Chronic Bright's disease ; chronic tubal nephritis ; chronic albuminuria ; large white kidney. Definition. A chronic inflammation of the cortical and tubular structure of the kidneys ; characterized by albuminous urine, dropsy, increasing anaemia, with attacks of acute uremia. Causes. Occasionally follows the acute form ; syphilis; chronic malaria; chronic alcoholism ; chronic mercurialism ; lead poisoning; protracted suppuration. It is a disease of the young, rarely occurring after forty. Pathological Anatomy. A large white, or yellowish-white, smooth kidney often twice the normal size. The capsule is nowhere adherent to the organ. Upon section, considerable tumefaction of the cortical substance and the rarity of vascular striae are recognized. The medullary substance shows no appreciable alteration, its color being normal. The convoluted tubes are irregularly dilated and thickened, and filled with broken-down, granulated epithelium and fibrinous casts. In pronounced cases there is fatty degeneration of the tubular epithelium. " The intertubular matrix is greatly thickened—a change due to hyperplasia of the connective-tissue elements, to the migration of the white corpuscles and their subsequent multiplication and fatty trans- formation, and to a quantity of fluid exudation, the product of the increased pressure in the veins." Symptoms. The onset is gradual and insidious, and the affec- tion is seldom recognized until the appearance of dropsy, which, beginning under the eyes and in the face, extends all over the body, causing dyspnea from ascites or hydrothorax. The urine is scanty, high-colored, albuminous, and under the microscope showing hyaline and granular tube casts, granular epithelium, and if fatty degeneration occur, fatty tube casts and oil globules. The increase above the nor- mal amount of the urine as the disease progresses must not be forgot- ten, when the specific gravity is low, i.010-1.015, and the quantity of albumen is increased. Anemia is pronounced, from the large waste of albumen. Gastro- intestinal disorders and vague neuralgic pains are common occur- rences. Cardiac hypertrophy is of common occurrence. Bronchial catarrh, with slight edema of the larynx, causing husky voice, are frequent complications. Amaurosis, the result of neuro-retinitis, DISEASES OF THE KIDNEYS. 119 occurs in a greater or less degree in all pronounced cases. Uremic symptoms occur, and especially uremic asthma (renal asthma). Complications. Pneumonitis, pleuritis, pericarditis, peritonitis, and meningitis. Prognosis. Not unfavorable, unless urine persistently contains a large number of fatty tube casts and oil globules. Relapses are fre- quent, but many complete (?) recoveries are recorded. Treatment. It is to be borne in mind that the course of a case of chronic Bright's disease is not continuously downward ; periods of remission often follow the most aggravated symptoms, the patient and his friends being buoyed into the hope of an early and complete recovery, when, as suddenly, an attack of acute uraemia terminates life. Rest and diet are important elements in the treatment. A patient with chronic Bright's disease should, as far as possible, be relieved from all cares of business and spend a goodly portion of time in bed. The diet should be entirely, or as nearly so as possible, a milk diet, the daily amount used being from two to four quarts. The moderate use of a light wine is at times of advantage if taken with the food, although a fair number of cases do better without stimulants. The use of diaphoretics and hydragogue cathartics are only indi- cated when the dropsy is marked, the skin harsh and dry, the urinary secretion scanty and uraemic symptoms are threatening. Diuresis should be promoted, if the secretion is small, by digitalis, caffein or arbutin internally, and dry cups and poultices over the loins. The anemia is to be treated by oleum morrhue, arsenicum and fer- rum, an excellent formula for the latter being— R. Strychninse sulph.................................. Sr- X Tinct. ferri chloridi................................ f^ss Acidi acetici purse...........................•...... f^iss Curacose alba....................................... f 3 j Liq. ammonii acetat............ad............... L5VJ- M- SlG.—Tablespoonful every five hours, followed by a glass of cold water. To check the waste of albumen, a difficult matter, the following remedies have been used with more or less success : ergota, quinina, acidum gallicum, acidum benzoicum, tinctura cantharidis, potassii, PRACTICE OF MEDICINE. iodidum, and, lastly, the Russian remedy, blatta orientalis (cock- roach). For dropsy, purgatives, such as pulvis jalape compositus, hydra- gogue cathartics and alkaline mineral waters. If there be great dis- tention of the serous cavities, interfering with the respiration, the aspirator should be used. Puncture of the skin may be necessary at times, and is well accomplished with an ordinary cambric needle. Cases due to syphilis, if the loss of renal structure is slight, are cured by a course of- hydrargyri corrosivum chloridum and potassii iodidum with oleum morrhue. INTERSTITIAL NEPHRITIS. Synonyms. Chronic Bright's disease ; sclerosis of the kidneys; contracted kidneys ; small red kidney ; gouty kidney. Definition. An inflammation of the intervening connective tis- sue of the kidney, chronic in its progress, resulting in an induration or hardening, with contraction of the organ ; characterized by fre- quent passing of large amounts of pale, albuminous urine, of low specific gravity, disorders of the gastro-intestinal and nervous sys- tems, and a strong tendency to cardiac hypertrophy and changes in the vessels. Causes. A disease of middle life, from forty to sixty years. Gout a very common cause; lead cachexia ; syphilis ; alcoholism; alterations in the renal ganglionic centres (DaCosta and Longstreth). Pathological Anatomy. The kidneys are reduced in size. The capsule is thickened, opaque and adherent. The surface of the kidney is granular, with cysts of various sizes, of transparent color, irregularly over the surface. On section the tissue of the kidney is tough and resistant. The cortical portion is thin, from atrophy, being only a line or two in thickness. The connective tissue is greatly thickened, compressing the tubules into mere threads, the glomeruli being grouped together in bunches, owing to the wasting of the intermediate tubes. The color varies, from a darkish-brown to a yellowish-gray, according to the amount of blood in the organ. The left side of the heart is hypertrophied, and there is also hyper- trophy of the muscular fibre of the arterioles throughout the body ; if the case is protracted the hypertrophied tissues undergo fatty degene- ration. DISEASES OF THE KIDNEYS. In many cases there occur fatty degeneration of the retinal tissues, or sclerosis of the nerve-fibre layer, changes which are termed retinitis albuminuria. The "ganglionic centres" undergo fatty degeneration and atrophy (DaCosta and Longstreth). Apoplexy is a frequent termination of interstitial nephritis, the rupture of a cerebral vessel suggesting it to be a disease of degener- ation. Symptoms. Onset insidious, and often marked alterations in the kidneys, heart and vessels have occurred before the disease is recognized. Any of the following symptoms may first attract attention, to wit: frequent micturition, increased amount of urine, of a pale color, containing a small amount of albumen, which may be absent for days, occasional epithelial cells and hyaline casts. No dropsy, but a little puffiness and edema of the conjunctiva—the Bright's eye. Disor- ders of vision. Forcible cardiac action with high arterial tension. And any of the following symptoms, the result of uremia : Persis- tent dyspepsia, occasional vomiting, regardless of food ; headache, vertigo and stupor, or drowsiness; violent itching of the skin ; tremors, convulsions, epileptic seizures, or apoplectic attacks. The body weight declines, the skin is dry and scurfy, the strength fails, and shortness of breath on exertion is present. The termination is usually by convulsions, coma and death. Complications. Bronchitis ; pneumonia ; pleuritis ; pericarditis. Diagnosis. Differs from parenchymatous nephritis in the fol- lowing : large quantity of urine, clear, of low specific gravity, small amount of albumen, with few hyaline casts ; the hypertrophied heart and tense arteries and marked disorders of vision. Prognosis. Pursues a very chronic course; cases recorded under observation eleven years; but the termination is always fatal. Treatment. Regulated diet. Diaphoretics. Diuretics. Avoid alcoholic stimulants. As nearly absolute rest as patient's general health will permit. To prevent the growth of the connective tissue, the following reme- dies are recommended, to wit: potassii iodidum, hydrargyri corrosi- vum chloridum, gr. fa, aurii et sodii chloridum, gr. fa ferri iodidum and arsenicum. K 122 PRACTICE OF MEDICINE. For uremia, if patient is conscious, purgatives, diaphoretics and diuretics. If unconscious, morphina hypodermatically or chloroform inhalations. AMYLOID KIDNEY. Synonyms. Chronic Bright's disease ; waxy kidney ; lardaceous kidney. Definition. A peculiar infiltration into, or a degeneration of, the structure of the kidney, from the deposit of an albuminoid material, having a superficial resemblance to starch granules. Simi- lar changes occur in the liver, spleen, intestines, and other organs. Causes. The chief cause is prolonged suppuration, especially of the bones ; coxalgia ; syphilis ; cancer. Pathological Anatomy. The kidney is uniformly enlarged. It presents a pale, glistening, translucent appearance, and has a doughy consistency. On section, the surface is homogeneous, anaemic and whitish. The deposit occurs along the renal vessels and in the vascular tufts of the glomeruli, progressing until all parts of the organ are infiltrated. When the organ is thus infiltrated, the proper structure undergoes an atrophic degeneration, the result of pressure. The reaction with iodine and sulphuric acid affords a certain test of the amyloid deposit. Brush over a section of the affected kidney a solution of iodine with iodide of potassium in water, when a mahogany color will be produced, and if diluted sulphuric acid is now added, a violent or bluish tint results. A very pretty reaction is to take a one per cent, solution of anilin violet, which strikes a red or pink color with the amyloid material, while the unaltered tissues are stained blue, making a beautiful contrast. Similar changes occur in other organs of the body. With the amyloid change may be associated either parenchymatous or inter- stitial nephritis. Symptoms. Associated with wasting are edema of the lower extremities and ascites, with an increased flow of urine, pale, watery and of low specific gravity, containing albumen and hyaline casts which are transparent. If the amyloid change be associated with other forms of renal change, the urine will show the characteristics of such condition. A profuse, watery and persistent diarrhea adds to the suffering, caused by amyloid changes in the intestinal canal. DISEASES OF THE KIDNEYS. 123 Diagnosis. Differs from parenchymatous nephritis in its clinical history, and the fact of its always being associated with a suppurating disease. From interstitial nephritis, in its history, character of the urine, absence of uraemia, cardiac hypertrophy, changes in the vessels, and the fact of its association with suppurating diseases and similar changes in other organs. Prognosis. Controlled by the suppurating disease with which it is associated ; the termination, when the amyloid change is fully developed, is unfavorable, death occurring within a few months, or under favorable conditions, not for one or more years. Treatment. Sustaining and symptomatic in character. Gener- ous diet, and the persistent use of ferrum and oleum morrhue. If caused by syphilis, a thorough course of potassii iodidum, ferri iodidum and hydrargyri corrosivum chloridum, with oleum morrhue. PYELITIS. Synonyms. Suppurative nephritis; pyelo-nephritis. Definition. An acute catarrhal inflammation of the pelvis of the kidney ; the term pyelo-nephritis is used when suppurative inflamma- tion is superadded to the catarrhal inflammation. The disease is characterized by lumbar pains, irritability of the bladder, the urine neutral, or alkaline in reaction, and milky in appearance ; it pyelo- nephritis occur, symptoms of hectic fever and exhaustion are added, the urine containing pus. Causes. Cold, or exposure; cystitis; obstruction of the ureters by renal calculi; pressure from a tumor. Pathological Anatomy. The inflammation is catarrhal; it is characterized by injection of the mucous membrane of the pelvis of the kidney, with slight extravasations of blood ; relaxation and soft- ening, shedding of the epithelium, and the subsequent discharge of mucus and pus. If the morbid condition has existed for some time, the kidneys, one or both, are in a process of suppuration, they are enlarged, deeply congested, except where suppuration is proceeding, when they are of a yellowish-white color—pyelo-nephritis. Pus is constantly forming, and, if there be no obstruction, flows away with the urine ; should there be an impediment to its escape, pus accumu- lates in the pelvis of the kidney, causing its distention, giving rise 124 PRACTICE OF MEDICINE. to the condition known as pyelo-nephrosis. The pressure caused by the obstruction finally leads to destruction of the entire organ, a mere sac, or renal cyst remaining. Symptoms. If caused by cystitis, symptoms of this condition occur first ; if from renal calculi, its characteristic symptoms precede those of pyelitis. Begins by chilliness, feverishness, lumbar pains following the course of the ureters, frequent micturition, the urine milky in appear- ance when voided, acid or neutral in reaction, and depositing a copious sediment, whitish or yellowish-white in color, containing only a small amount of albumen, no more than is due to the pus. If pyelo-nephritis follow, symptoms of pyaemia supervene, to wit: fever, typhoid in character, low, muttering delirium, subsultus tendi- num, stupor, decline in strength, and loss of flesh, with perhaps a tumor in the lumbar region. If both kidneys are affected uremic symptoms are frequent. Diagnosis. From cystitis, by history, lumbar pains and acidity of purulent urine, the urine in cystitis being always alkaline. Peri-nephritis, a disease of loose tissue, around about the kidneys, terminating in abscess, causing lumbar pain, increased by motion or pressure, hectic fever, sense of fluctuation over kidneys, the urine remaining normal. Prognosis. Simple cases, where no obstruction to flow of pus, recover in a week to ten days. If obstruction of the ureter, the prog- nosis is grave. Suppurative cases unfavorable. Treatment. Rest in bed. Milk diet. Free use of water to dilute the urine, and free diaphoresis. Quinina to keep down tem- perature, prevent formation of pus, and maintain the powers of life. To change the character of the secretion, Prof. DaCosta strongly recommends pix liquida ; other remedies are oleum santali, copaiba, eucalyptol, terebinthina and cubeba. If abscess results, aspiration, quinina and stimulants. ACUTE URAEMIA. Synonyms. Uraemic poisoning; uraemic intoxication; uraemic coma; uraemic convulsions. Definition. A group of nervous phenomena, which occasionally develop during the course of acute or chronic Bright's disease, and DISEASES OF THE KIDNEYS. 125 other maladies, the result of the retention or accumulation in the blood of an excrementitious material, supposed to be urea ; the flow of urine being either normal, lessened or increased. Causes. Suppression of urine, from acute or chronic Bright's disease; cystic, tubercular or cancerous kidney; the puerperal state ; operations on the uterus, bladder, urethra or rectum. Symptoms. Uraemic intoxication is the result of the failure of the kidneys to perform their normal function of eliminating some one or all of the poisonous elements of the urine. The toxaemia may develop suddenly, by a convulsive seizure fol- lowed by coma, or slowly and gradually. Usually the attack is pre- ceded by a decrease in the urinary secretion ; although it must be borne in mind that in rare instances, during, or immediately prior to, the appearance of the uraemic phenomena, the normal urinary flow has been largely exceeded. The onset is usually with headache, dimness of vision, dilated, sluggish pupils, drowsiness, vertigo, deafness, dusky countenance, nausea, vomiting, and either a chill followed by fever, or a cool skin from the onset; the mind is dull, deepening into stupor, to be followed by coma, or convulsions precede the coma, which terminates in death, unless the poison causing the attack is rapidly eliminated. If the amount of accumulated urea is small the phenomena may not approach the pronounced coma described, the patient being able to be aroused. When convulsions occur they rapidly succeed one another, consciousness seldom being complete between the fits. Diagnosis. Cerebral apoplexy may be mistaken for uraemic coma, or the reverse. The chief points of distinction are, in the latter the attack is usually in patients suffering from dropsy, and that the coma is not sudden in its appearance, but is generally preceded by other nervous phenomena, such as headache, vertigo, dimness of vision, obstinate vomiting, and convulsions. Again, the uremic stertor is a sharp, hissing sound, whilst that of apoplexy is " snoring." Apoplexy is followed by paralysis, uraemic coma is not. An epileptic seizure is preceded by the sharp cry and extreme pallor of the face, the countenance being dusky in uraemic convulsions. Prognosis. An attack of acute uraemia is always a very grave condition. The prognosis depends upon the amount of retained poison, the length of time it has been retained, and the condition of the organs of elimination. 12<; PRACTICE OF MEDICINE. Treatment. The indications in acute uraemia are: first, to arrest the nervous phenomena ; secondly, to promote elimination. Prof. Loomis has succeeded in meeting both of these indications by hypodermatic injections of morphina, gx.Yf>-%-Y*< repeated, if needed, every two hours. He says, " the most uniform effect of mor- phine so administered is, first, to arrest muscular spasms; second, to establish profuse diaphoresis; third, to facilitate the action of cathar- tics and diuretics, especially, the diuretic action of digitalis." Following the injection of morphina, diaphoresis should be pro- moted by means of the vapor-bath, or the hot wet-pack, or the hypo- dermatic use of pilocarpine hydrochloras, gr. fa-/6-}{, provided no counter-indication to its use exists. The convulsive phenomena are rapidly controlled by inhalations of chloroformum. Diuresis should be promoted by infusum digitalis, and dry or wet cupping, and poultices over the loins. Catharsis is best produced by elaterium, gr. fa-yi. RENAL CALCULI. Synonyms. Nephrolithiasis ; gravel; renal colic. Definition. Renal calculi are concretions formed by the precipi- tation of certain substances from the urine, around some body or substance acting as a nucleus. Their presence may not be recognized until one or more attempt to pass along the ureters, when an attack of renal colic results ; or, by irritation, pyelitis is produced ; or more rarely, they are voided by the urine without exciting any symptoms. By gravel is meant very small concretions, which are often passed in the urine in large numbers. Causes. Occur at all ages ; frequent before the fifth year, and from five to fifteen. Males are more liable than females. A special liability seems to exist in some families, but the precise etiology of calculi is not yet determined. Varieties, i. Uric acid, as calculi and gravel, and especially associated with the gouty diathesis. 2. Urates, chiefly urate of ammonia; nearly always in childhood. 3. Oxalate of lime or mulberry calculus; characterized by hardness, roughness and very dark color. DISEASES OF THE KIDNEYS. 127 4. Phosphatic calculi form as frequently in the bladder as in the kidney, and present a chalky or earthy appearance. 5. Alternating calculi, consisting of alternate layers of two or more primary deposits. Anatomical Characters. In structure, a urinary calculus usually consists of a central nucleus, surrounded by the body, and outside of all there may be a phosphatic crust. The nucleus may or may not be of the same material as the rest of the stone, sometimes being a foreign body, mucus or blood. A section generally shows a stratified arrangement, or it may be partly or completely radiated. Symptoms. The clinical signs of renal calculi are those con- sequent on the results of their presence, to wit: renal hemorrhage, renal congestion, inflammation, terminating in abscess, pyelitis or pyelo-nephritis, cystitis or renal colic. The symptoms of renal colic begin abruptly, by severe, agonizing pain in the lumbar region, following the ureters into the corres- ponding groin and thigh. Pain and retraction of corresponding testicle, also of glans penis. Face pale and features pinched, the surface cold and damp. Irritability of the bladder, the urine passed in drops containing some blood. So severe is the pain at times that the patient may faint or pass into unconsciousness, or have a general convulsion. If both ureters are obstructed, uremic symptoms will arise. The paroxysm usually terminates suddenly after some minutes or hours, the stone escaping into the bladder. Prognosis. Renal calculus is attended with many dangers. It may produce extensive disorganization of the kidneys, or its passage along the ureter may prove fatal. If the stone be very large, or if more than one, the prognosis is graver. Calculus is a disease very apt to recur. Renal sand (gravel) and small concretions may, after more or less delay, be voided with the urine. Treatment. An attack of renal colic is best relieved by a hypodermatic injection of morphina and a warm bath or a sup- pository of ext. opii, gr. j, ext. belladonne alco., gr. ss., repeated if needed. For attacks of gravel, liquor potassii citratis, f.^ss, every three hours, and, if much vesical irritability, adding tinct. opii camph., f-jss-j. 128 PRACTICE OF MEDICINE. For renal hemorrhage, Prof. Bartholow reports success with R. Extracti ergotse fluidi, Tincture krameria?................aa................ 31J. M. Sig.— 3J every two or more hours. For uric acid calculi, as a solvent, Buffalo Lithia Springs Water or the Rockbridge Alum Springs Water of Virginia, or potassii tartra- borates, " obtained by heating together four parts of cream of tartar, one part of boracic acid, and ten parts of water. A scruple may be given three or four times a day, in water, largely diluted." For phosphatic calculi, as a solvent, ammonii benzoas, well diluted and long continued. CYSTITIS. Synonym. Catarrh of the bladder. Definition. An inflammation of the mucous membrane lining the urinary bladder, acute or chronic in its course, and of either a catarrhal, croupous or diphtheritic character ; characterized by rigors, moderate fever, hypogastric pain, frequent but scanty micturition and severe vesical tenesmus, the urine containing pus. Causes. Acute variety ; long retention of urine ; foreign bodies in the bladder ; pyelitis; urethritis ; blows over the pubes ; myelitis, and secondary to fevers or diphtheria. Chronic variety; following the acute variety; retention the result of enlarged prostate or an urethral stricture; calculi; gout; chronic Bright's disease. Pathological Anatomy. In acute catarrhal cystitis, there first ensues hyperaemia of the mucous membrane of the entire or a por- tion of the bladder, manifested by redness, swelling and oedema; followed by an increased secretion of the small glands at the base of the bladder, and an increased growth and consequent desquamation of the vesical epithelium, together with a copious generation of young cells; if the hyperaemia be decided, rupture of the capillaries and extravasation of blood occur. If the inflammation be intense suppuration of the sub-mucous con- nective tissue may result, and ulceration of the mucous membrane permit the sub-mucous abscesses to empty into the bladder. If the inflammation be of a croupous or diphtheritic character, the morbid anatomy does not differ from the same variety of inflamma- tions in other mucous membranes. DISEASES OF THE KIDNEYS. 129 In chronic cystitis "the mucous membrane is thick, blue gray in color, and very tough. Muco-pus and viscid mucus are formed in large quantities upon its surface. The muscular wall of the bladder may sometimes be half an inch thick, and the fasciculi give a ribbed appearance to the internal surface, called the ' columnar bladder.' The hypertrophy of chronic cystitis may be eccentric or concentric. In some cases diverticuli are formed, in whose walls are dilated and tortuous veins. In nearly all cases bacteria are found in abundance." (Loomis.) Symptoms. Acute cystitis ; the onset is usually abrupt, by rigors, slight fever, loss of appetite, sleeplessness, a feeling of depression ; frequent micturition, but the uri7ie is only voided drop by drop, its passage followed by distressing vesical tenesmus, the result of spasm of the bladder; pain over the pubis and in the iliac regions, of a dull character, at times becoming sharp and agonizing; burning along the urethra adds to the distress of the patient. The urine is cloudy, of an alkaline reaction, and at times is fetid, the microscope showing epithelium, pus and red blood corpuscles. Chronic cystitis ; the onset is gradual and insidious, and is excited by some obstacle to the evacuation of the urine, such as stricture, the presence of a stone in the bladder, or enlargement of the prostate gland. There are present dull pain, frequent but scanty micturition, the urine is alkaline, containing large amounts of muco- pus or pus; on standing, it deposits a thick, glairy, viscid sediment, in which, under the microscope, triple phosphates and large pus corpuscles, extremely regular both in contents and in shape, may be detected. Although the quantity of urine voided by the patient is small, yet if immediately after micturition the catheter is used, several ounces of fetid, cloudy, alkaline urine may be removed. Patients with chronic cystitis usually present decided constitutional debility. Severe local pain, emaciation and occasional bloody urine, indi- cate ulceration of the vesical mucous membrane. Diagnosis. Pyelitis has lumbar pains following the course of the ureters, frequent micturition without the severe vesical tenesmus ; the urine, although cloudy, has an acid or neutral reaction. Prognosis. The acute variety is, as a rule, good, being controlled by the cause. L 130 PRACTICE OF MEDICINE. The chronic variety continues for years, and after hypertrophy of the bladder is incurable. Treatment. Rest is paramount. The diet must be restricted, all highly seasoned articles being particularly interdicted ; milk is the most suitable diet. Warm applications over the pubic region are of benefit; and leech- ing and cupping over the bladder are of service. The urine should be well diluted by large draughts of pure water and particularly the alkaline mineral waters, to wit: Farmville lithia, Buffalo lithia or the Rockbridge alum, or Vichy waters. The follow- ing formulae are of decided benefit:— R. Acidi benzoici, Sodii borat..................aa............... ..... jij Infusi buchu, vel Infusi uvte ursse................................... f,^vj- M. Sig.—Tablespoonful every 2 hours, well diluted. Or— R. Liquor, potassse.................................... f5iij Mucil. acacise.................ad.................. fj>vnj- M. Sig.—Tablespoonful every 4 hours, well diluted. For the pain and tenesmus relief is afforded by a suppository of extractum opii and extractum belladonne, repeated as needed. The vesical tenesmus is often benefited by extractum cannabis indiee fluidum, f 3 ss, every three or four hours. Chronic cystitis. The bladder should be completely emptied with the catheter several times in the twenty-four hours. The use of eucalyptol, gtt. x-xv, every four hours, well diluted, and washing out the bladder with the following mixture, has been of decided benefit in the hands of the author:— R. Sodii borat.......................................... ^j Glycerini............................................ fSjij Aquae................................................... f^ij. M. Sig.—f ^ss-iss added to warm water and injected into the bladder once or twice daily. The diet should be nutritious, but without spices of any kind. The free use of the alkaline mineral waters is of advantage. ACUTE GENERAL DISEASES. 131 ACUTE GENERAL DISEASES. PAROTITIS. Synonyrn. Mumps. Definition. An acute specific infectious inflammation of one or both parotid glands, with a very strong tendency to migrate into the mammae or testes; characterized by pain, swelling and disordered function of the gland. Causes. A specific poison. Occurs in epidemics, although iso- lated cases are seen. Males more liable than females. The most common ages between five years and puberty. As a rule, it occurs but once in the same individual. The period of incubation is from two to three weeks. Pathological Anatomy. There is inflammation of one or both parotid glands, and in severe epidemics the cellular tissue pervading the gland is involved. The catarrhal inflammation begins in the gland ducts and rapidly extends to the gland proper. There is congestion, swelling and an infiltration of serous fluid, with more or less infiltration of the ad- jacent tissues. The swelling may suddenly reach an enormous size and as suddenly decline, the gland returning to its normal condition, or, rarely, an abscess results, with partial or complete destruction of the gland. Occasionally the submaxillary gland is involved, also the mammae and testes. Metastatic parotitis occurs secondary to severe blood poisoning, as in pyaemia, typhoid or typhus fevers or diphtheria. The usual ter- mination of secondary parotitis is by suppuration and destruction of gland structure. Symptoms. The onset is rather sudden, by malaise, chill, fever, ioi°-io3° F., quick pulse, headache, dry skin, scanty urine, followed within a day or two by stiffness at the angles of the jaw, swelling of the parotid, pain, increased by moving the jaws, with general edema of the affected side of the face, at times the skin being reddened. Salivation is frequent, and occasionally deafness occurs. The swelling and other glandular symptoms subside about the sixth or seventh day, to be followed by restoration to health, or what is more common, the involvement of the opposite gland. At any time during the disease metastasis to the mamme, ovaries or 132 PRACTICE OF MEDICINE. testes is apt to occur, when the symptoms peculiar to such affection will be added. It has been noted that a continuance of the tempera- ture after the decline of the parotid symptoms has begun,"usually is significant of metastasis. Diagnosis. An error seems impossible. Prognosis. Simple mumps, favorable; the chief danger being from the altered function of the mammae, ovary or testes after metastasis. Treatment. The disease being self-limited, the indications are entirely symptomatic, with attention to the secretions, although ex- tractum pilocarpi fluidum, mjc-xxx repeated, has been used with varying success as a specific. Locally, warmth to the affected gland may be agreeable. DIPHTHERIA. Synonyms. Putrid sore throat; malignant ulcerous sore throat; malignant quinsy; membranous angina. Definition. An acute, specific, constitutional disease, both epi- demic and contagious, beginning by an affection of the throat, char- acterized by a local exudation and glandular enlargements; attended with great prostration of the vital powers and albuminuria, and having for its sequelae various paralyses. Causes. A specific poison, the character of which is unknown. It is preeminently a disease of childhood. It is apt to recur in those who have once been affected. All conditions of bad hygiene increase its virulence and diffusion, although the chief cause of its spread is contagion. The poison exists in the exudations and secretions of the fauces and in the breath, and floats in the atmosphere at a considerable dis- tance from the original source. The theory of " No bacteria, no diphtheria," is not proven. The period of incubation is from three to five days. Pathological Anatomy. The diphtheritic inflammation differs from either the croupous or catarrhal form, in that the exudation is not only upon, but also within, the substance of the mucous membrane. At first there is redness, which may begin in any part of the throat, associated with swelling and an increased secretion of viscid mucus. The redness spreads over the entire mucous surface, when the exuda- ACUTE GENERAL DISEASES. 133 tion makes its appearance. The deposit may commence from one or several points, such as on one tonsil, the soft palate, or the back of the fauces, which, however, speedily extend and coalesce, forming extensive patches, or cover uniformly the entire surface. The patches are of variable thickness, which is increased by suc- cessive layers being formed underneath. The color is usually gray, white or slightly yellow, but may be brownish or blackish, the consistence ranging from " cream to wash leather." On removing the membrane, which is accomplished with more or less difficulty, a raw, bleeding surface is exposed, and at times an ulcer, which is speedly covered with a fresh deposit. If the exudation separate itself, it is either not renewed at all or only in thinner films. The exudation or membrane, examined by the microscope, is composed of fibrin, pus corpuscles, epithelial granular cells and bacteria. If the larynx, trachea, or nasal mucous membranes participate in the disease, the croupous and not the diphtheritic form of inflamma- tion occurs. The lymphatic glands of the neck, whose vessels originate in the faucial tissues, are enlarged and inflamed, and contain large numbers of bacteria, probably originating as the result of decomposition. The muscular tissue of the heart becomes soft, is easily torn, and its fibrillae are far advanced in granular degeneration. Ulcerative endocarditis has been frequently observed. The kidneys undergo a granular degeneration in severe attacks. The blood undergoes alteration, being black and fluid. Symptoms. Following the law of contagious diseases, the symp- toms vary in intensity in different cases, the prominent symptoms being often disproportionate to the gravity of the attack. The invasion may be mild, with rigors succeeded by moderate fever, headache, languor, loss of appetite, stiffness of the neck, tender- ness about the angles of the jaw, or slight soreness of the throat. In other cases the invasion is more abrupt and severe, with chilli- ness followed by great febrile reaction, 1030 to 1050 F., pain in the ear, aching of the limbs, loss of strength, painful deglutition and swelling of the neck, compelling the patient to take to bed from the onset. 134 PRACTICE OF MEDICINE. The appetite is poor, the tongue slightly coated, sometimes more or less exudation appearing upon it, the bowels being either regular or slightly relaxed. The pulse, at first full and strong, soon becomes either frequent or slow, but compressible. The urine is scanty, high colored and contains albumen. The local symptoms in the majority of cases are associated with the throat. The patient complains of a frequent and persistent desire to hawk, in order to clear the throat. On inspection the fauces are seen red and swollen and more or less covered with the diphtheritic exu- dation; sometimes the tonsils and uvula are greatly swollen and spotted with exudation. In bad cases, more or less ulceration or sloughing may be observed. Not unfrequently fragments of exudation, the false membrane, are expectorated, with particles of the ulcerated tissues, having an offensive odor, which is transmitted to the breath. The lymphatic glands of the neck are enlarged and tender, and in severe cases the tissues of the neck are greatly tumefied. Extension to the nasal cavities causes a sanious and offensive dis- charge from the nose, with attacks of epistaxis. Extension to the larynx is indicated by hoarseness or complete loss of voice, croupy cough and obstructive dyspnea, which often become urgent, the breathing being noisy and stridulous, and subject to par- oxysmal exacerbations. If the inflammation extend to the bronchi, the breathing becomes still more embarrassed. Duration. Ranges from two to fourteen days, an average being about nine days, although complications and sequelae may prolong its course. Relapses are not uncommon. Sequelae. Those who recover from a severe attack remain often for weeks with a pale and cachectic appearance, due to the profound blood alteration. Paralysis is a common sequelae, following the mild as often as the severe attacks. Usually not occurring until the patient seems fully convalescent. Pharyngeal paralysis is the most common, causing difficulty or in- ability of deglutition, fluids regurgitating through the nose. Cardiac paralysis is not unfrequent, the pulsations descending to 60, 50, 40, and in a case seen by the author, to 20 per minute. Diphtheritic paralysis may affect the motor muscles of the eye, causing strabismus; the muscles of one side, hemiplegia; of the legs, ACUTE GENERAL DISEASES. 135 paraplegia; and of the bladder, leading to retention of urine or difficulty in passing it. Sensation is also diminished in the paralyzed parts. Diagnosis. From follicular ulceration of the tonsils, which is frequently termed diphtheria, by the slight or absent systemic symptoms, the ulcerated condition being limited to the tonsils, but often one, and the absence of glandular enlargement and following palsies. From pharyngitis, by the absence of exudation and loss of faucial tissue and constitutional symptoms. From scarlatina, by the presence of the eruption and the absence of membrane in the fauces. From membranous croup, by the difference in the constitutional symptoms ; croup appears sporadically and is not contagious, diph- theria being highly contagious and frequently occurs in epidemics; in diphtheria of the larynx, the depression is clearly that of blood poisoning, while in croup, the depression is in proportion to the me- chanical obstruction of the respiration by the membranous exudation. The pathology of croup is simple and easy of investigation ; diph- theria is obscure in its etiology and progress. The temperature record of croup is a high one until carbonic acid poisoning is imminent from the mechanical obstruction of respiration, while in diphtheria, the tendency to a decline in the temperature after the second day is nearly characteristic, regardless of the amount of laryngeal obstruc- tion. In croup the pharynx contains no membrane, and is but slightly, if at all, inflamed, and associated trouble in the nose is of the rarest occurrence, the very reverse obtaining in diphtheria. In croup the laryngeal symptoms are from the onset, while in laryngeal diph- theria, the pharyngeal symptoms almost always precede. In croup glandular involvement is a clinical novelty, as are subsequent palsies, while glandular involvement and various palsies are the rule in diphtheria. Albuminuria is the rule in diphtheria, seldom occurring in croup. Prognosis. Always grave, but more so in children than in adults. Its gravity, in the majority of cases, is proportionate to the local symptoms. The average mortality is about ten per cent. Favorable indications are, moderate fever, strength slightly im- paired, a good constitution, and moderate exudation. Unfavorable indications are, great depression, spreading exudation, 136 PRACTICE OF MEDICINE. great swelling of the cervical glands, large amount of albumen, extension to larynx and nasal mucous membranes, hemorrhages from the fauces and nose, and an epidemic character. Treatment. No specific plan of medication has been found uni- formly successful. It is a disease of debility. The blood being more or less altered, it follows that sustaining measures must be resorted to in all cases. The diet must be of the most nutritious character from the onset, such as milk, eggs, broths and oysters, at intervals of every two or three hours. If deglutition be too painful, resort must be had to nutritious enemata, the following formula being suitable :— R. Milk.................................................. fgj Spts. frumenti...............'....................... f£>iv Egg................................................. One. M. Sig.—Little salt added, beaten up and warmed. Stimulants must be used boldly from the onset, guiding the dose by the effect; usually, a child of two years requires from thirty to sixty minims of spiritus vini gallici or spiritus frumenti, every two or three hours; an adult from two to four drachms every three hours. Ferrum and potassii chloras, in full doses, frequently repeated, have seemed, when begun early in the attack, to modify the course of the malady, and they have the additional advantage of acting locally upon the throat as they are swallowed. A good formula is— R. Tinct. ferri chlor................................... gtt. v-x-xx Potassii chlor....................................... gr. iij-v Glycerini............................................ f^ss Syr. zingib..................ad.................... ft^j-ij. M. Sig.—In water every three hours, for a child of two or three years. The efficacy of the above is greatly enhanced, in the author's expe- rience, by the addition to each dose of tinctura belladonne, gtt. j-v. Quinina, gr. xvj-xxiv per day for a young adult, and gr. v-x for a child, should be used throughout the disease; if irritability of the stomach prevent its administration by the mouth, it can be used as a suppository or locally in the form of the oleate. Calomel in small doses, combined with sodii bicarbonas every hour until the breath becomes fetid, is beneficial, and especially in cases showing a tendency to spread toward the larynx. Indeed, a tolerance to calomel seems to exist in diphtheria of the larynx. ACUTE GENERAL DISEASES. 137 Hydrarg. chlor. corros., gr. fa-fa, repeated every second or third hour, also acts well in many cases, combined as follows:— R. Hydrargyri chlorid. corrosiv..................... gr. fa Tinct. ferri chlorid................................. Tt^v-x Glycerini............................................. rt^x Aquae .......................ad...................... ^j. M. Sig.—One teaspoonful every hour or two, well diluted. Locally. Cleanliness of the fauces is of the utmost importance, and if a non-irritating disinfectant be added, its value is enhanced. Prof. Bartholow " has seen excellent results from the frequent application of a solution of acidum lacticum, strong enough to taste sour, by means of a mop." The following, used as a gargle, or applied by a mop, is useful:— R. Acid, salicyl........................................ gr. xx Glycerini............................................. f?j Aquae destil.......................................... f 5iij. M. Or— R. Potass, chloras...................................... ^iv Acid, carbol......................................... gr. ij-iv Tinct. myrrh....................................... ~j Inf. cinchonre....................................... * ij. M. Or— R. Ext. pancreatis..................................... ^j Sodii bicarb........................................ ^iij. M. Sig.—Add jj to aquae 3 vj, and apply with camel's-hair pencil. Inhalations of steam and hot water, and allowing the patient to suck pellets of ice, give relief. Sponges dipped in hot water and applied to the angles of the jaw are beneficial. For laryngeal diphtheria the same general treatment, especially the mercurial, with inhalations of lime by slaking freshly-burned lime in a vessel and directing the vapor to the child by a newspaper, or some similar contrivance, or using three parts of liquor calcis and one part of glycerin, in an atomizer, every half hour or hour, or liq. trypsin, as a spray. If these means fail, resort must be had to tracheotomy, which has succeeded in many desperate cases. For nasal diphtheria the same general treatment, and syringing the nose every two or three hours with a weak solution potassii chloras, or acidum carbolicum, or the following :— R. Sodii sulphit........................................ £iij Glycerini............................................ f.^ij Aquae................................................ f3iv- M. 138 PRACTICE OF MEDICINE. For the paralysis, strychnina and ferrum internally, or strychnina hypodermatically, with the galvanic current locally. ACUTE ARTICULAR RHEUMATISM. Synonyms. Rheumatic fever ; inflammatory rheumatism. Definition. A constitutional disease, characterized by fever, in- flammation in and around the joints, occurring in succession, and a great tendency to inflammation of either the endocardium or peri- cardium. Causes. The predisposing causes are inherited tendency, scarla- tina, and the puerperal state. The exciting causes, exposure to cold and chilling of the body. Rheumatism rarely occurs before seven or after fifty years. The liability to the disease is increased by having had an attack. Pathological Anatomy. The blood contains an excess of lactic acid. The joints bear the brunt of the attack; the synovial membrane is reddened, the vascularity of the synovial fringes is increased, so with the synovial fluid, which is thinner, of a reddish color, containing some gelatinous coagula of fibrin, and under the microscope nucleated cells, ordinary pus cells being rarely seen. The swelling visible about the affected part depends mostly on inflammatory oedema of the connective tissue around the joint. The pain is probably due, in all cases, to stretching of and pressure on the elements of the tissues by the dilated capillaries and the inflam- matory oedema. For the changes which ensue when the endo- and peri-cardium are attacked, the reader is referred to the sections on those diseases. Symptoms. Begins suddenly, generally at night, with a.chill or chilliness, pain and stiffness in the joints, loss of appetite, at times, nausea and vomiting, followed by fever, the temperature soon reach- ing 1020, F., to 1040, in rare cases 1080 to no0 (the hyperpyrexia), the pulse seldom exceeding 95, great thirst, profuse acid sweats, scanty, high colored, acid urine, at times showing traces of albumen, the bowels constipated. The fever continues throughout the attack, show- ing marked remissions. Delirium is absent, except the hyperpyrexia occur. Sleep is prevented by the pain and the profuse perspirations. The strength is moderately well preserved. The skin is often covered with an eruption of miliaria rubra, red ACUTE GENERAL DISEASES. 139 papule and miliaria alba, the result of irritation at the orifices of the perspiratory glands, from the excessive sweating. The local phenomena are pain, tenderness, increased heat, swell- ing and redness of one or more joints ; if but one joint, it is termed monoarthritis, if more than one, polyarthritis. Pain is aggravated by motion and pressure. Swelling is most apparent in those joints not covered with muscle, to wit: knee, wrist, elbow, ankle, and the hands and feet, and is proportionate to the acuteness of the attack. The inflammation may abruptly cease at one or more joints, and as suddenly attack others. The disease is extremely irregular as regards the number of joints affected, although the local manifestations are controlled by an im- portant pathological law, to wit: the law of parallelism. Correspond- ing joints are often affected together, and when not, the different affected joints are either on one side of the body, or those on both sides which are analogous, as, the knee, elbow, wrist, ankle, hip and shoulder, are attacked together. Complications. Pericarditis, endocarditis, myocarditis, cerebral endarteritis, bronchitis, pneumonitis and pleuritis. Duration. The duration of acute rheumatism is governed entirely by the presence or absence of complications. Uncomplicated cases recover in from thirteen to twenty-one days, although they may be prolonged to five or six weeks. Relapses are frequent. Diagnosis. A typical case cannot be mistaken for any other disease, but cases running a subacute course may be mistaken for acute rheumatoid arthritis, gonorrhoeal rheumatism, or pyaemia. Acute rheumatoid arthritis attacks one joint at a time and becomes permanent, has slight if any fever, no sweats or cardiac lesions. Gonorrheal rheumatism is associated with a gleety discharge attacks either the ankle or wrist only, is slowly influenced by treat- ment, and lacks the febrile phenomena. Pyemia is usually manifested at a single joint at the time, and is followed by suppuration and all the symptoms of hectic fever. Prognosis. Recovery is the rule in uncomplicated cases, the mortality being about three per cent. When death occurs it usually depends upon hyperpyrexia, cardiac complication, or cerebral end- arteritis. Treatment. Owing to our imperfect knowledge of the exact nature of this most painful disease, its treatment still remains either 140 PRACTICE OF MEDICINE. empirical or is directed toward certain prominent symptoms or com- plications of the disease. Garrod claims that "colored water" is about as potent as anything else, for it is, he says, a "self-limited disease," sometimes running a long and sometimes a short course. Rest in bed, whether the pain forces it or not, is imperative. Warmth is as imperative, for which purpose the patient should be kept in blankets—no sheets—and wear woolen garments. The diet must be easily digested food, milk being the most suitable. Strong and vigorous patients do well with acidum salicylicum or the salicylates in large and frequently repeated doses, to wit:— R. Acidi salicylici...................................... gr. xx Liq. ammonii acetat................................ L3iss Spts. setheris nitrosi................................. W\,xx Syr. simplicis...........................,............ T or trie early use ofpulvis ipecacuanhe et opii, gr. x-xv. The following errhine used at the very onset has proved successful in aborting severe cases:— I£. Amyli, finely powdered............................ 3J Cocaine hydrochlor................................ gr. ij-iv. M. Sig.—Every half hour. If the attack has already developed, relief is soon afforded by tinctura belladonne, gtt. ij every hour until six doses are taken, after which one drop every two or three hours until the physiological actions of the drug are produced ; if much fever be present, tinctura aconiti, gtt. i-ij, may be added. An efficient plan of treating acute coryza is by producing free diaphoresis with " Dover's powder," gr. x, repeated, if need be, followed by— R. Potassii citratis....................................... 3^ij—Iv Syrupi ipecac, Tinct. opii camph................aa................. 3 ij—iv Syr. limonis............ ............................. ,^iv Aqu?e.........................ad....................... §iij. M. Sig.—One or two teaspoonfuls every hour or two. 182 PRACTICE OF MEDICINE. With either of the above plans may be added one of the following errhines :— R. Bismuth, subnit...................... Pulv. acacire......................... Morphinse hydroch lor.............. SlG.—Every hour or two.—(Ferrier.) Or— R. Pulv. cubebse........................................ 3J Bismuth, subnit...................................... £ij Morphinse muriat.................................... gr. ij. M. SlG.—Used by insufflation every two or three hours. Or— R. Pulv. fol. belladonnse............................. ^j Pulv. morphinse sulph............................... gr. ij Pulv. g. acacise.................ad.................... ^jss. M. Sig.—Use, with powder blower, to anterior and posterior nares. (Robinson). Acute coryza occurring in infants at the breast is controlled by either one of the following errhines: throw into the nose, with a powder blower, finely powdered saccharum alba, or equal parts of finely powdered saccharum album and camphore, or Robinson's er- rhine of saccharum alba and camphora, each half ounce finely pow- dered and acidum tannicum, gr. xl. Attacks of nasal catarrh due to the poison of syphilis should at once be placed upon the proper constitutional treatment. Attacks of nasal catarrh associated with the eruptive or mild fevers require no special treatment. It is well to remember that attacks of nasal catarrh occurring in very young children are generally the result of hereditary syphilis, and should be treated accordingly. CHRONIC NASAL CATARRH. Synonyms. Chronic rhinitis ; chronic coryza. Definition. A chronic inflammation of the mucous membrane lining the nasal passages, with more or less alteration of structure; characterized by a sensation of fullness in the nares, increased secretion and a perversion of the special sense of smell and of hearing. 3VJ gr- »J- DISEASES OF THE NASAL PASSAGES. 183 Causes. The result of repeated attacks of the acute variety; inhalation of irritating vapors and dust; syphilis and scrofula. Pathological Anatomy. The mucous membrane of the nares is thickened, of a dark-red, sometimes grayish color, the superficial veins dilated and varicose, often forming polypoid enlargements. In many cases there is ulceration of the structure, with more or less loss of substance; the secretion is thick, tough, of a greenish character, and often very fetid; large collections of dried mucus are often formed upon the turbinated bones and septum. Symptoms. A feeling oi fullness in the nares, increase of the secretion, the character being thick and greenish, which, dropping posteriorly into the pharynx, causes paroxysms of " hawking," which are more marked in the morning immediately after arising. The special sense of smell is more or less impaired, and, in many cases, entirely abolished; the special sense of hearing is more or less diminished, from an extension of the inflammation to the Eustachian tubes ; the voice has a peculiar nasal intonation. Sudden changes of temperature cause acute exacerbation of these symptoms, when thereis superadded difficult nasal respiration. If ulceration of the nares occur, the discharge has a fetid odor. This condition is termed ozena. From extension of the inflammation to the nasal duct or its ob- struction, the tears flow over the malar eminence (epiphora), leading to more or less congestion of the eyes. Diagnosis. Hypertrophy of the turbinated bones and naso- pharyngeal catarrh are constantly misnamed chronic nasal catarrh. The rhinoscope readily determines the diagnosis. Prognosis. Permanent cure is seldom obtained, the disease being so decidedly chronic and obstinate, the treatment is of neces- sity protracted, and the majority of patients tire of it before a com- plete cure is effected. Treatment. If it depends upon diathetic conditions, the cause must be ascertained and treatment directed accordingly. When no diathetic cause can be determined, attention should be paid to the general health, the secretions constantly attended to, and the diet be nutritious and digestible. Cleanliness of the nasal passages is of the utmost importance, and is best effected by the post-nasal syringe, with either simple or medi- cated tepid waters, or a cleansing solution, such as Dobell's, to wit:— 184 PRACTICE OF MEDICINE. R. Acidi carbolici......................................... gr-j Sodii bicarbonat, Sodii borat......................aa..................... gr. v Glycerini................................................ 7> j Aquse.................................................... ^j- M. Sig.—As a spray or with a proper syringe. after which decided benefit follows the use of one of the following :— R. Sodii borat............................................. jij Bismuth, subnit....................................... .^ ij Morphinse muriat..................................... gr.j. M. Or— R. Iodoformi............................................... gj Acid, tannici.......................................... gr. v Pulv. camphorse....................................... 3J Bismuth, subnit........................................ gj. M. SlG.—To be used by insufflation or as a snuff, every three or four hours; Or— R. Ammonii muriat....................................... £j Glycerini................................................ £ij Vini picis, liq.......................................... 3 ij. M. SlG.—Five to ten drops, dropped into each nostril two or three times a day. DISEASES OF THE PHARYNX. ACUTE CATARRHAL PHARYNGITIS. Synonyms. Catarrhal tonsillitis; angina catarrhalis; acute " sore throat." Definition. An acute catarrhal inflammation of the mucous membrane of the tonsils, uvula, soft palate and pharynx ; character- ized by rigors, fever, painful deglutition, coughing, or constant desire to clear the throat, with a more or less decided nasal intonation of the voice. Causes. Exposure to cold and damp ; swallowing hot fluids or food ; during the prevalence of scarlatina, measles or variola. Pathological Anatomy. The mucous membrane and sub- mucous tissues of the uvula, soft palate, fauces, tonsils and pharynx are congested, red and swollen, the secretion is at first lessened or DISEASES OF THE PHARYNX. 185 , entirely arrested, later it is increased, but of a thick, tenacious, opaque character. The swelling is most evident at the uvula, due to the amount of relaxed sub-mucous tissue, which is especially thick and long, often resting on the root of the tongue (" the palate is down "). Frequently one or both tonsils are swollen to such an extent that the fauces are completely occluded, and the condition is mistaken for the graver phlegmonous tonsillitis. In severe attacks of catarrhal angina, white or grayish white mem- branous masses, form in small, irregular, roundish spots on the red- dened mucous membrane of the tonsils, soft palate and pharynx, causing the affection to be frequently mistaken for diphtheria. Symptoms. The onset is usually sudden, with rigors, fever, thirst, headache, loss of appetite, coated tongue, bad taste, foul breath, dryness in the throat, painful deglutition, and constant desire to clear the throat, due to the increased length of the uvula ; as the inflammation proceeds the secretions are increased, the fluid often filling the mouth and also causing a constant desire to swallow, each act being associated with acute pains. Not infrequently earache adds to the patient's distress, from extension of the "catarrh "to the Eus- tachian tubes and tympanum. In severe attacks of catarrhal pharyngitis, cases which, from the intense hyperaemia, have been termed erysipelatous or erythematous pharyngitis, the muscles of the palate are infiltrated with serum, which greatly interferes with their function. Under normal conditions the contraction of the muscles of the anterior half arches of the palate prevents the return of the food and drink into the mouth ; while the contraction of the muscles of the posterior half arches, together with the uvula, closes the passage to the nose ; if the function of these muscles be impaired, fluids would be driven through the nose or back into the mouth by the contractions of the pharynx in the act of deglutition. In all affections of the pharynx a nasal tone is pathognomonic, especially if the muscles of the half arches are interfered with. Diagnosis. On account of the great swelling of the tonsils, it may be mistaken for acute tonsillitis; but the mild inflammatory symptoms should prevent the error. Cases with membranous deposits upon the tonsils, soft palate and pharynx are no doubt often misnamed diphtheria ; the marked differ- ence in the constitutional symptoms should prevent the error. 186 PRACTICE OF MEDICINE. Prognosis. Favorable, the affection terminating in three or four days by the raising of a quantity of thick, opaque mucus. Treatment. Perhaps the most successful treatment of this affec- tion is by insufflation, every hour or two, with sodii bicarbonas. If the inflammatory symptoms are severe, tinctura aconiti, gtt. j-ij, at short intervals, is of decided advantage. At times tinctura bella- donne may be added. Locally, small ice pellets are useful, or heat or cold to the angles of the jaw. Gargles or sprays of aluminis, ammonii murias or potassii chloras, used at frequent intervals, often allay the congestion and consequent swelling. ACUTE TONSILLITIS. Synonyms. Amygdalitis ; quinsy; phlegmonous pharyngitis. Definition. An acute parenchymatous inflammation of one or both tonsils, with a strong tendency toward suppuration ; character- ized by moderate fever, pain in the throat, a constant desire to relieve the throat, painful and difficult deglutition, impeded respiration, and more or less muffling of the voice. Causes. Generally attributed to exposure to cold, but, in the ma- jority of cases, the exposure is so slight that there must be a predis- position to the affection; for persons once affected are particularly prone to repeated attacks, upon the slightest exposure. Pathological Anatomy. One or both tonsils will be seen, on inspection, to project from its bed, as a rounded, deep red body, which may even extend beyond the median line, when they may entirely occlude the isthmus of the fauces; the half arches and posterior border of the soft palate are reddened and somewhat swollen. The surface of the tonsils is often covered with small, yellowish points, which closely resemble patches of false membrane, but careful inspection will show that they are beneath the mucous membrane, being only the distended follicles of the gland. The mucous membrane of the fauces and pharynx is more or less red and swollen. Symptoms. Onset more or less sudden, with rigors, rise in tem- perature 1020 to 104° F., full, frequent pulse, 100 to 120, headache, | thirst, pain and swelling at the angle of the jaw, with a constant desire to clear the throat, difficult and painful deglutition, from the enlarged tonsils almost closing the fauces, when the respiration is more or less DISEASES OF THE PHARYNX. 187 impeded; the voice is more or less muffled, and attempts at phonation increase the pain. Darting pains along the Eustachian tubes are of frequent occur- rence, the patient complaining of earache and more or less deafness. If suppuration be imminent, the throat becomes more painful, the character of the pain throbbing, the febrile phenomena increased, with more or less depression, the symptoms seeming to be of great danger, when suddenly, after an effort at vomiting, or spontaneously, the ton- sillar abscess bursts, a quantity of pus escapes from the mouth, and prompt relief follows. Duration. The disease lasts from three to seven days, terminating either by suppuration or the gradual resolution of the enlarged glands. Diagnosis. Tonsillitis can hardly be mistaken for any other affection, if the fauces are inspected. Prognosis. In the majority of cases the result is favorable, it very rarely proving fatal, except in children, and only then by ob- structing the respiration, and, at the same time, so seriously interfer- ing with nutrition that the child's strength fails. Treatment. If seen early scarification should be performed, thereby relieving the engorged gland. The external use of ice over the site of the glands, and small pellets allowed to dissolve in the mouth, afford great relief. If the application of cold be objection- able, heat may be substituted, in the form of warm compresses or poultices. If administered at the very onset, the inflammation may be aborted by quinine sulphas., gr. x-xx, combined with morphine sulphas., gr. )i~Y; free emesis is also recommended, for the same purpose. After the inflammation is established, the administration of tinclura aconiti, in small doses, frequently repeated, rapidly reduces the tem- perature and frequency of the pulse, and, by its local action, lessens the pain and swelling. If from any cause the internal use of aconitum be contraindicated, the tinctura aconiti may be diluted with gly- cerinum and painted over the affected parts. The author has seen excellent results follow the use of sodii salicylat., gr. x-xv, in solution, every hour, until four doses are taken, when the remedy is omitted for three hours, and again administered, as at first, or relief may fol- low hydrargyri chloridum mite., gr. fa, every two hours. Relief often attends the use of tinctura guaiaci ammoniat., f^j in milk, every two hours; or 188 PRACTICE OF MEDICINE. R. Tinct. ferri chlor................................... f^ij Glycerini.....................ad..................... f% ij. M. Sig.—Teaspoonful every two hours. The following gargle is highly spoken of by those using it:— R. Tinct. guaiaci ammon., Tinct. cinchonoe comp...............aa........... f^ij Mel. despumati..................................... ^vj. M. and shake together until the sides of the containing vessel are well greased, then Adde R. Potassii chlorat..................................... T) iv Aquae destil......................................... ^iv. M. and add gradually, continuing shaking. This should be used by the patient at intervals of every half an hour to an hour. Insufflation with sodii bicarbonas is recommended. If suppuration be impending quinina should be used, gr. iij-v, every three or four hours. Locally, the application of poultices over the affected gland hastens the process of suppuration when once begun. The diet must be in the shape of gruels, as it is impossible for the patient to swallow any solid substance, and in cases where even gruels cause painful deglutition, thin oatmeal gruel can be used with ad- vantage. DISEASES OF THE LARYNX. ACUTE CATARRHAL LARYNGITIS. Synonyms. Catarrhal laryngitis ; " sore throat." Definition. An acute catarrhal inflammation of the mucous membrane of the larynx; characterized by feverishness, diminished or suppressed voice, painful deglutition, and more or less difficulty of respiration. Causes. Atmospherical changes; the inhalation of irritating DISEASES OF THE LARYNX. 189 vapors, such as gas, smoke, or ammonia, and in children, from vio- lent attacks of crying. Pathological Anatomy. In mild cases there is a transient congestion (hyperaemia) of the mucous membrane over the entire, but more commonly, circumscribed portions of the larynx, with more or less swelling and diminished secretion ; the mucous membrane soon returns to its normal condition, the secretion being slightly increased. Symptoms. The onset is rather sudden, with irregular rigors, a feeling of heat, rawness and tickling, referred to the larynx and pharynx, with a sensation of the presence of a foreign body in the throat. Swallowing causes pain by the upward movement of the larynx and by the pressure of the food on the larynx as it passes along the gullet. Coughing, from the onset, of a noisy, harsh, hoarse, or toneless character; in children the cough has a ringing, sonorous, so-called " croupy" character, the act of coughing causing a sensation of scratching in the larynx. The first day or two there is scanty expec- toration, but in a short time the secretion is increased, giving the cough a loose character. In the early stages the sputa may be slightly streaked with blood. The voice is at first decidedly hoarse, soon followed by complete aphonia. Duration. Usually about one week ; if very severe, two or three weeks may elapse before the larynx returns to its normal condition. Prognosis. Simple catarrhal laryngitis never terminates fatally. Treatment. Confinement to an apartment of uniform tempera- ture, the air kept moist by the vapor of water disengaged in it. Locally, a hot or cold pack should be kept constantly wrapped about the throat, and if its application is preceded by the temporary use of a weak mustard plaster, the relief afforded is more rapidly obtained. At the very beginning of an attack the feet should be placed in a hot mustard foot bath, and a saline cathartic adminis- tered. Internally, tinctura aconiti, gtt. j-ij every half hour until three or four doses are taken, after which every hour or two, combined with tinctura opii deodorat., gtt. j-v, relieve the inflamed mucous mem- brane, or instead, the use of antimonii et potassii tartras, gr. fa—fa every hour. If a tendency to spasm of the glottis obtains, full doses of the bromides should be administered at once. 190 PRACTICE OF MEDICINE. (EDEMATOUS LARYNGITIS. Synonym. Uidema of the glottis. Definition. An inflammation of the mucous membrane of the larynx and that about the glottis, with a serous effusion into the sub- mucous connective tissue ; characterized by obstruction to the respi- ration and difficult phonation. Causes. The result of acute laryngitis ; abscess in or about the throat or tonsils; erysipelas of the face; scarlatina; smallpox; Bright's disease. Pathological Anatomy. Infiltration into the loose connective tissue of the ary-epiglottic folds, the glosso-epiglottic ligament, the base of the epiglottis, and the inter-arytenoid space. If the true vocal cords are inflamed, their color changes, and instead of appear- ing white, glistening and brilliant, they are dull, grayish-red or violet- red in patches. If the swelling be the result of purulent infiltration, the parts affected present a deeply congested color, with here and there spots of a yellowish hue. Serous infiltration, sufficient to cause fatal cedema, disappears with death, leaving but slight traces to account for the formidable symptoms. Symptoms. At the onset the same as those of catarrhal laryn- gitis, soon followed by a sensation of distress, and pain in the throat, with difficulty of breathing and paroxysms of impending suffocation. The cough at first is dry and harsh, but as the infiltration increases it becomes stridulous and suppressed. The voice, at first muffled, is soon suppressed. The difficulty of respiration in some cases becomes so great that the face becomes blue, the eyes protruding, the patient gasping for breath, these symptoms continuing for a few moments, when relief is temporarily afforded, the paroxysms soon recurring however, in one of which, unless decided relief be promptly afforded, the patient perishes. Diagnosis. The points of difference between oedema of the glottis and capillary bronchitis, asthma and croup will be pointed out when discussing those affections. But the history of the case, the sudden occurrence of suffocative attacks, an examination of the throat by passing the index finger carefully over the base of the tongue, will generally prevent the disease being mistaken for any other affection. Prognosis. As a rule unfavorable ; if early and vigorous treat- DISEASES OF THE LARYNX. 191 ment be instituted, recovery is possible, but without it death is the inevitable result, the patient dying asphyxiated. The duration of in- filtration of the larynx varies from a few hours to several days. Treatment. At the onset, if the fever be high, the use of tinc- tura aconiti, gtt. ij—iv, repeated, with the administration of an active purgative, may prevent the serous effusion. If the infiltration has already occurred and is slight in amount, scarification, guiding the instrument by the index finger of the oppo- site hand, may afford relief, or the hypodermatic injection of pilo- carpine nitratis, gr. y%, repeated. If these means fail, tracheotomy is indicated; in those cases of sudden and rapid infiltration of the glottis or larynx occurring in Bright's disease, erysipelas or scarla- tina, and especially the former, tracheotomy should be performed at once. In all cases of infiltration of the larynx stimulants should be boldly administered per rectum, if stomachic administration be impossible. If the infiltration be composed of pus, quinine sulphas., gr. v doses every four hours, and stimulants are indicated. SPASMODIC LARYNGITIS. Synonyms. Spasmodic croup ; false croup ; catarrhal croup. Definition. A catarrhal inflammation of the mucous membrane of the larynx, associated with spasmodic contraction of the glottis; characterized by paroxysmal coughing, difficulty of breathing and attacks of threatening suffocation. Causes. Delayed or difficult dentition ; excesses in eating and drinking ; excitement; violent emotion and atmospherical changes, are all given as causes for simple croup. It is often hereditary. Pathological Anatomy. Congestion of the mucous mem- brane of the larynx, with slight swelling and deficient secretion, are the only changes that have thus far been noted. Symptoms. The attack occurs chiefly during the night, the child on retiring having either its usual health, or, perhaps, being a little fever- ish. After several hours of sleep the child is suddenly awakened'by a paroxysm of suffocation, and a dry, harsh, ringing cough. After half an hour or an hour or two the breathing becomes easier, the cough less " croupy," the skin is covered with more or less perspiration, and the child falls asleep. The next day there is present cough of a loose 192 PRACTICE OF MEDICINE. character, the respiration being about normal. If no treatment be instituted, the same phenomena occur on the second night, the child being apparently well during the second day, the cough being less in amount; phenomena of a similar character, but of much less sever- ity, are present the third night, after which the disease usually dis- appears. If the symptoms of the first paroxysm continue pronounced for two or three days, there is a strong probability that the inflam- mation may become fibrinous in character, or that true croup may develop. Diagnosis. The symptoms are so characteristic that it seems im- possible for the affection to be mistaken for any other disease. Prognosis. Spasmodic or simple croup always terminates favor- ably. Treatment. During the paroxysm, the child should at once be placed in a hot bath and hot or cold compresses wrapped about the throat. These means may be preceded or followed by a mild emetic. The air of the room should be moistened by the vapor of steam con- stantly disengaged in it. For the prevention of an attack of spasmodic croup, a mild cathartic, followed by potassii bromidum, gr. x-xv, combined with minute doses of antimonii et potassii tart., or ipecac, are serviceable, the child, of course, being confined to the house for several days, on an easily assimilated diet. CROUPOUS LARYNGITIS. Synonyms. Membranous croup ; true croup. Definition. An acute inflammation of the mucous membrane of the larynx, attended with the exudation of a tough secretion—the false membrane—and the occurrence of spasm of the glottis ; charac- terized by febrile reaction, frequent ringing cough, dyspnoea, with loud inspiratory sound, and altered or extinct voice, showing a strong ten- dency toward death by asphyxia. Causes. A disease of childhood, most common in strong, vigor- ous, well-nourished males. Certain families present a strong, hered- itary tendency. Most common during a humid winter. Pathological Anatomy. Intense hyperemia of the mucous membrane of the larynx, associated with swelling, edema and marked DISEASES OF THE LARYNX. 193 redness. There soon appears on the surface of the mucous mem- brane a grayish pellicle, rapidly coalescing and becoming thicker— the opaque, false membrane—which differs in extent, thickness and adhesiveness in different portions of the larynx. In all cases the false membrane is found on the vocal cords and inner surface of the epiglottis. The first exudation (membrane) softens by the serum which is exuded, and is then mechanically dislodged by acts of coughing or vomiting, but is followed by successive deposits upon the mucous membrane. When the false membrane is detached the mucous membrane of the larynx is found unaffected, so far as the loss of structure is con- cerned. Several successive crops of membrane may occur after the detachment, or it may entirely cease to form after the removal of the first exudation. On microscopical examination the false membrane is found to be composed of a fine network of fibrillae, holding in their interstices leucocytes of an albuminous or fibrinous nature. The false membrane may extend into the pharynx, but especially is it liable to extend into the trachea and bronchial tubes, and, as the inflammation extends downward, the character of the exudation changes from fibrinous to muco-purulent. Symptoms. The onset of " true croup " is either suddenly, by an attack of spasmodic croup, or gradually, as an acute catarrh of the larynx, rapidly increasing in severity, with a feeling of heat in the throat, huskiness of the voice, harsh cough, fever and thirst, the hoarse- ness soon becoming marked, and the cough having a metallic, ,lcroupy" character, rapidly changing to a stridulous, husky sound; every few minutes the child takes a sudden, deep stridulous inspiration, the voice becoming more and more husky. Difficulty of breathing now follows, the child is unable to lie down, or if, exhausted by the efforts at inspiration, it is quiet for a moment, it soon starts up in fright, breathing more heavily, with a shrill, whistling inspiration. Soon, from the narrowing of the glottis, from the presence of the membrane, the expiration becomes difficult and noisy, and suffocation seems im- minent, from the paroxysmal attacks of spasm of the glottis, when the child tosses wildly about, tears at its throat, as if to remove some obstacle, the face becoming cyanosed, the alae of the nose working rapidly, the mouth wide open, the inspiratory efforts gasping, the body covered with a profuse sweat, and death seems imminent, when the Q 194 PRACTICE OF MEDICINE. spasm is relaxed, air enters the chest, the breathing becomes some- what easier, and the child, exhausted and partially stupefied, drops into a fitful sleep of a few moments' duration. The suffocative attacks return at short intervals, or there occur de- cided remissions between them, considerable portions of the false mem- brane being expelled, when the child falls into a refreshing sleep. In those cases which tend to a favorable termination, the appear- ance of improvement noted between the suffocative attacks is main- tained, the paroxysms of suffocation becoming less frequent, the expectoration of membrane more marked, the difficulty of breathing lessens, the cough looser, the voice gradually returning, the fever, which has been more or less high during the attack, disappearing. If, instead of improvement, the case tends toward a fatal termina- tion, the suffocative attacks become more frequent, expectoration is absent, the voice and cough inaudible, although the efforts at speak- ing and coughing are visible, the difficulty of breathing continues, the respirations becoming more frequent and shallow, but without whist- ling and stridor, cyanosis deepens, the countenance has an indifferent, drowsy and stupid look, the eyes dull and nearly closed, with symptoms of depression, the pulse rapid and weak, the surface cov- ered with a cold, clammy sweat, the extremities cold, stupor and in- sensibility more marked, the child dying of carbonic acid poisoning or asphyxia. Duration. The duration of true croup is about one week, rarely continuing ten days. Diagnosis. QLdema of the glottis may be mistaken for croup until the period of the formation of the characteristic membrane. The chief points of distinction from the onset are, however, absence of fever, paroxysmal attacks of difficult respiration, followed by a com- plete return to the normal condition. Laryngeal diphtheria differs from true croup in its history, its epi- demic character, the marked depression, even before obstruction of the larynx produces imperfectly aerated blood, the presence of albu- men in the urine, and the sequelae. Prognosis. A very fatal disease. The danger is great in pro- portion to the age and feebleness of the child. The unfavorable symptoms are : Loud, stridulous, inspiratory and expiratory sounds, laborious and prolonged expiration, depression of the base of the thorax during inspiration, whispering voice or com- DISEASES OF THE LARYNX. 19-3 plete aphonia, congestion of the face and neck, stupor, weak, rapid and irregular pulse, cold extremities, and a cold, clammy perspiration. The favorable symptoms are : Expectoration of false membrane, decrease of the stridulous respiration, voice changing from whisper- ing to hoarseness, looseness of the cough, moderation of the fever, and an improvement in the general condition. Treatment. The indications for treatment are to detach and remove the false membrane, to prevent its formation, to prevent the attacks of spasm of the glottis, and to maintain the strength. To detach and remove the membrane emetics are of the highest utility, the favorite of this class being the one first used in this disease by Dr. Fordyce Barker, consisting of hydrargyri subsulphas flavus (turpeth mineral), gr. ij for a child of two years of age, repeating the dose as often as rendered necessary by the obstructed breathing; but the unnecessary administration of emetics should be avoided, as the strength of the patient must be maintained. To prevent the formation of the membranous exudatioti a number of remedies have been recommended and highly lauded by their re- spective proposers. If seen early, as the fever and husky voice are developing, tinctura aconiti, Ttv. Y~}> every fifteen minutes, and qui- nina sulphas, gr. ij-v, every hour until cinchonism is produced, are of unquestionable utility ; another plan strongly urged is with ammonii bromidum in full doses alternated with quinina sulphas, gr. iij-v, every three hours ; still another and popular remedy is hydrargyrum, which is certainly one of the most reliable agents we possess; it may be used as hydrargyri chloridum corrosivum, gr. fa-fa, every two or three hours, or in the following formula:— R. Hydrargyri chloridi mite........................... gr-Y~Y~Y Sodii bicarbonat....................................... gr.ij Pulvis ipecac.......................................... gr-iV*!- M. SlG.—One powder every two hours. Antimonii et potassii tartras, a remedy that some years ago was popular in large doses, is again brought forward in doses of gr. ■sir-fa- Quinina sulphas, gr. v, every three hours until six doses have been taken, if given before the exudation has formed, it is claimed will prevent its formation. To prevent the paroxysms of spasm, small doses of opium in the form oi pulvis ipecac et opii (Dover's powder), or full doses of the 196 PRACTICE OF MEDICINE. bromides, preference being given to ammonii bromidum, as suggested by Prof. Bartholow, on account of its being "eliminated by the bron- chial and faucial mucous membrane, thus acting locally." To maintain the strength of the patient, alcoholic stimulants in full doses, nutritious but easily digested aliment, quinina in tonic doses, and ammonii carbonas, are particularly indicated. Locally, the use of all caustic or irritating applications to the fauces or larynx is emphatically contraindicated. The inhalation of the vapor of slaked, freshly burned lime is one of the most ready and efficient means for assisting in the detachment of the false membrane. The application of cold or hot compresses, according to the feelings of the patient, around the throat, have a strong tendency to prevent the recurrence of the spasms. After the formation of the membrane, great relief follows the use of the vapor inhalations and oxygen gas, which with stimulants and liquid nour- ishment may safely carry the patient through the disease. Cases in which the membrane presents a tendency to slowly loosen itself, if the patient's strength does not contraindicate it, are greatly benefited by the application of sinapis, or even small flying-blisters, to the larynx. Relief from the obstructed respiration is obtained and the affection beneficially influenced by the use of " O'Dwyer's tubes." If the exudation still continues, regardless of the means employed, the propriety of tracheotomy must be decided. LARYNGISMUS STRIDULUS. Synonyms. Spasm of the glottis; pseudo-croup; " Kopp's asthma." Definition. A temporary spasm of the muscles of the larynx innervated by the inferior or recurrent laryngeal nerves; character- ized by a sudden development of dyspnoea and the appearance of deficient oxygenation of the blood. Causes. Most common in children, the result of teething, laryn- gitis, indigestion, scrofula or other cachexia. Attacks in adults are not uncommon. Pathological Anatomy. Death the result of spasm of the glottis is such a very rare occurrence that the changes in the larynx are illy understood. DISEASES OF THE LARYNX. 197 The mechanism consists in an irritation of the superior laryngeal nerve—the afferent nerve—whose function is to supply the mucous lining of the larynx with sensibility, whence is reflected through the inferior laryngeal nerve—the efferent nerve—the motor influence re- sulting in the spasm of the laryngeal muscles. Symptoms. The spasm of the laryngeal muscles is of sudden onset, and usually after nightfall. The child may have been in perfect health, to all appearances, on retiring, or it may have shown symptoms of catarrh of the upper air passages, or been suffering from gastro-intestinal or dental irritation. The child awakes suddenly, coughing in a metallic, resonant tone— the croupy cough—and with great dyspnea, with loud, crowing, stridu- lous inspirations, the result of narrowing of the larynx from spasm, with wheezy, stridulous expirations. The entrance of air is so greatly obstructed that all the accessory muscles of respiration are called into use, the lips and finger nails become blue, the surface cold, the countenance anxious, and the in- ferior portion of the chest is drawn in, instead of being expanded, during inspiration. General convulsions occur at times, during a par- oxysm, also strabismus, and involuntary discharge of the faeces and the urine. The paroxysm continues from half an hour to an hour or more, to return after a few hours' sleep, or during the following night; -the cough, during the day, has the croupy character. Diagnosis. The non-febrile and distinctly intermittent nature of the affection differentiates it from croup, and its own distinctive char- acters, from all other diseases. Prognosis. Favorable. Death from suffocation during the par- oxysm, may occur in very young children, but it is certainly a very rare termination. Treatment. For the paroxysm, the inhalation of a few drops of chloroformum is the most prompt method, due care being exercised; complete anaesthesia is unnecessary. Success is reported from the prompt inhalation of amyl nitris, also from nitro-glycerinum, in small, but frequently repeated doses; the following combination is a prompt antispasmodic :— 198 PRACTICE OF MEDICINE. R. Potassii bromidi............................................ ^ij Chloral...................................................... gr.xxxij Syr. aurantii corticis...................................... f ^ j Aquse menth.............................................. f^j. M. Sig.—One teaspoonful every half hour. After the paroxysm has been suspended by the above combination, the tendency to a recurrence of the attacks is obviated by the steady and continued use oi potassii bromidum, in moderate doses. Emetics are often useful in suspending an attack, especially if it be due to indigestion. Locally, the hot, alternating with the cold pack, should be con- stantly applied to the throat. DISEASES OF THE BRONCHIAL TUBES. ACUTE BRONCHITIS. Synonyms. Bronchial catarrh; acute catarrhal bronchitis; " cold on the chest." Definition. An acute catarrhal inflammation of the bronchial tubes of the larger, middle and third size; characterized by fever, sub-sternal pain, a feeling of thoracic constriction, oppression in breathing, and at first scanty, followed by more or less profuse expectoration. Causes. Most common in childhood and old age. More com- mon in climates characterized by considerable moisture of the atmos- phere combined with a low temperature, and especially where there are sudden and marked variations. Pathological Anatomy. Hyperemia of the mucous mem- brane of the bronchial tubes, manifested by a diffused redness, swell- ing, edema and diminished secretion ; this is followed by an increasea secretion and overgrowth and desquamation of the epithelial cells, together with a copious generation of young cells, the expectoration then becoming of a yellowish color. As a result of the hyperaemia, rupture of the capillaries of the mucous membrane frequently occurs, when the slight expectoration of the first stage is streaked with blood. DISEASES OF THE BRONCHIAL TUBES. 199 In cases of bronchitis following the exanthemata, or in scrofulous patients, the bronchial glands participate in the inflammation, they becoming hyperaemic, swollen and filled with secretion, and not unfrequently the glandular elements undergo a hyperplasia, and finally the "cheesy " degeneration. Symptoms. The invasion is usually characterized by the occur- rence of either nasal or laryngeal catarrh, or both, the patient feeling chilly, followed by flushes of heat, the limbs, joints, and even the body, are affected with pain of an aching, contused character, and with a sense of fatigue and want of energy ; there may be a furred tongue, anorexia and constipation. In nervous, irritable persons, and in children, there may be slight delirium, and often in very young children, especially during the period of dentition, convulsions may usher in an attack. After a day or two of these initiatory symptoms, those characteristic of bronchial catarrh develop. Pain is experienced beneath the sternum, especially toward its upper part, of a raw, burning, or tearing character, aggravated by a deep inspiration or by coughing; the pain also radiates toward the sides, following the course of the primary bronchial tubes. Tenderness over the sternum is often experienced. Cough from the onset, at first in paroxysms of a hard, dry char- acter, changing as the disease progresses, and becoming looser, fol- lowed by free expectoration. The expectoration at first is small in quantity, almost transparent, frothy, and having a salty taste, often streaked with blood. As the disease progresses it becomes more abundant, of a yellowish or a greenish-yellow color, and of a tenacious consistency. There are present slight fever, hot, dry skin, frequent pulse, loss of appetite, moderate thirst and constipation. A feeling of languor and weariness, and often considerable depres- sion, quite out of proportion to the febrile state, are not infrequent. Percussion. Normal, except in those rare cases in which the bronchial glands are involved, when irregular spots of dullness can be developed. Auscultation. First Stage: The bronchial membrane being swollen and dry, the respiratory murmur is harsh or vesiculo-bronchial in character, associated with diffused sonorous and sibilant rales. Second stage : The secretion from the bronchial mucous membrane 200 PRACTICE OF MEDICINE. being increased, the respiratory murmur is less harsh in character but is associated with large and small moist or bubbling rales. Diagnosis. The points of resemblance and difference between acute bronchitis and other diseases of the chest will be pointed out when those affections are described. Prognosis. Acute bronchitis of the larger tubes usually termi- nates in complete resolution within two weeks. In children and the aged, the course is more protracted, and the symptoms more severe, but recovery is the rule. Treatment. During the invasion, quinine sulphas, gr. x, com- bined with morphine sulph., gr. Y(>> wl^ usually prevent or abort an attack of acute bronchitis. In the first stage, in adults, when the mucous membrane is swollen and dry, either of the following prescriptions will give prompt relief:— R. Antimonii etpotassii tart................................. gr. ij Liquor, ammonii acetatis................................. f^br Spts. setheris nitrosi....................................... fgj (Tinct. aconiti, if indicated)............................ f?!ss Syr. simplicis..........................ad.................. f 3 vj. M. Sig.—One teaspoonful every two or three hours. Or— R. Liquor, potassii citratis.................................. fj|ij Vini velsyr. ipecacuanhse................................ f.^ss Succi limonis................................................ f^iss. M. Sig.—Tablespoonful every two or three hours. If the cough of the dry stage be severe, or if looseness of the bowels follow the use of either of the above combinations, tinctura opii cam- phorata may be added with advantage, For young children, the above in proportionately reduced doses, or the following:— R . Pulv. ipecac et opii........................................ gr.x Pulv. scillse................................................. gr.xij Hydrargyri chlor. mite................................... gr.iv Sacch. lact................................................. gr-x. Ft. et chart. No. xij. SlG.—One every two hours. Locally : Hot mustard foot bath, and sinapis or terebinthina stupes over the chest, the patient being confined to an apartment in which the air is moistened by the vapor of hot water. DISEASES OF THE BRONCHIAL TUBES. 201 Second Stage : The secretion of the bronchial mucous membrane* being copious, marked benefit follows the use of— R. Ammonii muriat......................................... 3 iv Mist, glycyrrh. comp.................................... ^ iv. M. SlG.—Tablespoonful every three or four hours. During the attack, attention must be given to the secretions and the diet of the patient. CAPILLARY BRONCHITIS. Synonyms. Broncho-pneumonia; " suffocative catarrh." Definition. An acute catarrhal inflammation of the terminal bronchial tubes, or bronchioles ; characterized by fever, impeded and increased respiration, impeded circulation, slight cough and scanty expectoration. Causes. Most common in childhood, following exposure to cold or sudden changes of temperature ; associated with measles and whooping cough. Pathological Anatomy. Hyperetnia, redness and swelling of the lining membrane of the bronchioles, with the exudation of a tough, tenacious secretion. The air vesicles may remain unaffected, but in the majority of cases they are involved, producing the complication known as " catarrhal pneumonia." In those cases in which the air cells are not involved in the inflam- matory changes, the air passes, during the act of inspiration, through the secretion blocking the smaller tubes, but is prevented from escaping during the act of expiration, the secretion in the smaller tubes acting as a valve ; the result is distention of numerous vesicles, producing a circumscribed or diffused functional emphysema. If the secretion produces complete closure of any of the smaller tubes, the air previously drawn into the vesicles will be absorbed, causing collapse (atelectasis). If the inflammation extends to the alveoli of the lungs, it produces the condition known as broncho-pneumonia, a frequent complication in children and feeble elderly people; it is most commonly lobular in character, whence the term " lobular pneumonia." Symptoms. Usually preceded by more or less ordinary bron- chitis, followed by rise of temperature, 102-1030 F., difficult and R 202 PRACTICE OF MEDICINE. increased respiration, with paroxysms in which the dyspnoea is markedly aggravated, when cyanosis rapidly develops. The circulation through the lungs is impeded by the dyspnoea, the pulse becomes feeble and flickering, and there results general con- gestion of the venous system, the countenance livid, the lips and nails blue, the surface cold, and often covered by a clammy perspiration, the mind dull, and in children stupor and convulsions rapidly super- vene, the result of the non-aeration of the blood. The cough is slight, but of a suppressed character, the expectoration scanty. When cyan- osis occurs the cough may almost entirely cease ; expectoration also ceases, death soon following, from apnea and depression. Percussion. Normal, except over those portions of the lungs which are in a condition of collapse, when dullness rapidly develops and may as rapidly disappear, changing to other portions of the lung. Auscultation. First stage, harsh or vesiculo-bronchial, soon followed by diminished respiratory murmur, associated with subcrepi- tant rales. Diagnosis. Capillary bronchi'is is often mistaken for true catar- rhal pneumonia, the points of distinction between which will be pointed out when discussing that affection. Prognosis. In children, on account of their inability to expecto- rate, which leads to rapid collapse of the lungs, and in the aged, the prognosis is most grave. In the strong and vigorous recovery follows prompt and energetic treatment. Treatment. From the very onset of the attack the treatment must be supporting, with the addition of such measures as seem to possess a controlling influence over the catarrhal process. The patient must be confined to bed, well covered and the tem- perature varying between 750 and 8o°, the air moistened with steam. In the first stage dry cups, mild sinapis applications or terebinthina stupes should be applied to the chest, after which it should be covered with an oil-silk jacket or the jacket poultice, if the child be not too young to permit so heavy an application without adding to the distress in the breathing. The diet must be of the most nutritious character, the great aim being to sustain the powers of life until the catarrhal process has passed through its different stages, hence milk, eggs, chicken, mutton and beef broths, with the free use of stimulants, commenced early DISEASES OF THE BRONCHIAL TUBES. 203 and in amounts large enough to overcome the signs of depression which are present early in the attack. If the fever be high, over 1020 F., quinine sulphas is indicated in full doses, for a child ; the following is a good formula:— R. Quininae sulphatis.................................. gj Acid, sulphurici dilut.............................. q. s. Spts. setheris nitrosi................................ f^iv Syr. tolu.............................................. f.^iv Aquae menth. p.................................... f^ j. M. SlG.—One teaspoonful every two or three hours. For the catarrhal process either of the following, regulating the dose in accordance with the age of the patient:— R. Syr. ipecac......................................... rriv-xx Spts. astheris nitrosi............................... TTLv-xv Tinct. opii camph................................. TTVv-xx Tinct. scilke......................................... rtVv-xx Liq. potassii citrat................................. nixl-ijij. M. SlG.—Every two hours. Or— R. Ammonii iodidi.................................... gr.ij-v Ammonii carbonat................................. gr.iij-v Syr. glycyrrh...................................... f^ss Syr. tolu............................................. f£>ss. M. Sig.— Every two or three hours. If suffocation is imminent the use oi emetics are indicated; the most suitable are ipecacuanha or hydrargyri subsulphas flavus, care being taken not to repeat emesis so often as to produce exhaustion. CROUPOUS BRONCHITIS. Synonyms. Membranous bronchitis; plastic bronchitis ; diph- theritic bronchitis. Definition. An acute inflammation of the mucous membrane of the larger and middle-sized bronchial tubes, attended with an exudation, forming a membraniform layer, which is closely adherent to the mucous surface; characterized by febrile reaction, cough, diffi- cult breathing, scanty expectoration, followed by the expulsion of the false membrane in the form of patches or casts. Causes. Associated with membranous laryngitis from extension downward; asthma; emphysema; phthisis; but most commonly the 204 PRACTICE OF MEDICINE. result of exposure to cold and damp, in those of strong and vigorous constitutions. Pathological Anatomy. Hyperemia of the mucous mem- brane of the bronchial tubes, associated with swelling and edema, during which the surface is covered with a whitish or grayish-white, firmly adherent, membranous deposit, cemented together by a coagu- lable exudation, and prolonged by rootlets from its under surface into the bronchial follicles, which sooner or later is loosened and de- tached by suppurative process and is expectorated after a violent fit of coughing or vomiting. When expectorated, the false membrane, as it has been termed, has either the form of patches or is thrown off entire from the bronchial tube, and may be found to consist of casts representing more or less of the bronchial subdivisions, and present- ing an appearance not unlike "boiled macaroni." On microscopical examination, the detached membrane presents fibrillae which characterize fibrine or lymph in other situations, and if placed in a solution of acetic acid, it becomes greatly swollen, while ordinary mucus contracts and becomes more dense if added to the same solution. Symptoms. There are no symptoms or signs by means of which this variety of bronchitis can be distinguished from ordinary catarrhal bronchitis, prior to the expectoration of the false membrane. Expectoration is preceded and accompanied by violent paroxysms of coughing, and after more or less of the membrane has been raised a muco-purulent expectoration, streaked with blood, may be present for several days. Duration. The inflammation may be either acute, sub-acute or chronic, expectoration of patches or strips of the membrane being repeated at intervals of days, weeks, months, or even years. Prognosis. In adults, favorable, if not associated with other grave affections, such as phthisis, pneumonia or emphysema. In young children it may cause obstruction to the respiration, and not unfrequently proves fatal. Treatment. As the character of the inflammation can seldom be determined until the membrane or portions of it have been expec- torated, the treatment is at first the same as in cases of ordinary acute bronchitis. As soon, however, as the character of the inflammation can be de- termined, active emesis is the most effective means of removing the DISEASES OF THE BRONCHIAL TUBES. 205 obstruction caused by the false membrane, the best agents of this class being either hydrargyri subsulphas fiavus, ipecacuanha, or zinci sulph., to be repeated as indicated. Inhalations oi the vapor of water, and especially of lime water, axe highly serviceable. To prevent the formation of membrane, Prof. Bartholow strongly urges the use of ammonii iodidum and carbonas combined, in small doses every hour or two. In a case treated by the author after this method, excellent results followed. In cases showing a tendency to become chronic, good results will follow the application of flying blisters to the chest and the internal administration of arsenicum and some preparation of pix liquida. CHRONIC BRONCHITIS. Synonyms. Chronic bronchial catarrh; winter cough ; second- ary bronchitis. Definition. A chronic inflammation of the mucous membrane of the larger and middle-sized bronchial tubes ; characterized by cough and more or less profuse expectoration, plus, in many cases, the symptoms oi emphysema of the lungs, which complicates the majority of cases. Chronic bronchitis may be either primary or secondary. Causes. Primary, the exposure to wet or cold, or the repeated inhalation of dust, vapors, or other irritants. Secondary, due to gout, rheumatism, syphilis, cardiac, renal or pulmonary diseases, or alco- holism. Varieties. I. Mucous catarrh, associated with moderate expecto- ration. II. Bronchorrhea, profuse expectoration. III. Dry catarrh, scanty expectoration. IV. Fetid bronchitis. Pathological Anatomy. The mucous membrane of the bron- chial tube is discolored, being of a more or less dull red, often of a deeply venous hue, mingled with a grayish or brownish color. These changes may be either in patches or extensively diffused. The ves- sels of the membrane are dilated. The mucous membrane is thick- ened, resulting in the reduction in the calibre of the tube and a roughening of its internal surface. The submucous tissue becomes infiltrated, contracted and indurated. The elastic and muscular coats of the tubes become hyper- 206 PRACTICE OF MEDICINE. trophied, lose their elasticity, and the cartilages become the seat of calcareous deposits. As the result of the loss of elasticity and muscular tone of the tubes they become irregularly dilated, " bronchial dilatation." The dilata- tions may be uniform in character, resembling somewhat the fingers of a glove, or they may be sacculated or globular, forming actual cavities in the bronchial structure. In the mucous variety the secretion consists of young cells and mucous corpuscles, having a yellowish color; in the dry variety, the " catarrh sec " of Laennec, or " dry bronchial irritation," the secre- tion is scanty, tough, semi-transparent, and occurs in defined globular masses; in bronchorrhea, which is usually associated with bronchial dilatation, the secretion is abundant, greenish-yellow in color, and often fetid. Symptoms. The most characteristic symptoms of chronic bron- chitis are the cough and expectoration. Unless associated with other diseases, the general health suffers but little, if at all, constitutional symptoms being present only during acute exacerbations. Mucous catarrh, or, from its occurring most commonly during the winter months, "winter cough," is characterized by paroxysms of cough, more or less violent, followed by the expectoration of a yel- lowish mucus. Dry catarrh is characterized by a harsh cough, a feeling of sore- ness or rawness under the sternum, and the expectoration of small globular masses; this variety occurs with emphysema, gout, rheuma- tism and asthma. Bronchorrhea, which is associated with bronchial dilatation, and most common in the elderly, is characterized by paroxysms of severe coughing, followed by the copious expectoration of greenish-yellow, often fetid, mucus; the amount expectorated often amounts to four or five pints in the twenty-four hours. Fetid bronchitis, often associated with bronchial dilatation, has an excessively fetid odor of the breath and expectoration. The decom- position of the secretion may cause gangrene of the bronchial mucous membrane, and even of the lung structure. Percussion. Unless complicated with other affections, normal; if bronchial dilatation occur, there are diffused spots of the tympanitic or amphoric percussion sound, the physical condition being a circum- scribed cavity containing air and connecting with a bronchial tube, DISEASES OF THE BRONCHIAL TUBES. 207 Auscultation. Harsh or vesiculo-bronchial respiration, asso- ciated with more or less profuse, sonorous, sibilant, and large and small bubbling rales ; in bronchial dilatation, in addition to the harsh respiration, is found broncho-cavernous breathing, with large and small gurgling rales. If emphysema complicate chronic bronchitis, the physical signs are somewhat modified, and will be pointed out when discussing that affection. Prognosis. If unassociated with disease of the lungs or heart, chronic bronchitis is never dangerous to life, although the symptoms are present more or less continually, and aggravated upon the least exposure. If associated with phthisis, emphysema, disease of the heart, or of the kidney, the prognosis is governed by those affections. Treatment. Cases of chronic bronchitis, of whatever variety, should observe the following general rules : I. Attention to the gen- eral health. 2. The clothing ; wearing flannel the year round, or, what is better, silk under-clothing, taking care that the opposite extreme of too much clothing be not practiced. The medical treatment is guided by the cause, character and severity of the disease. If secondary to other affections, in the majority of cases remedies directed to the bronchial mucous membrane are contra-indicated. If the result of the rheumatic or gouty diathesis, in addition to the remedies directed to the disease itself, should be combined change to a warm climate, if possible, and a more or less protracted course of potassii iodidum, or lithii citras, or a residence at one of the alkaline springs. For mucous catarrh, with,acute exacerbations:— R. Ammonii muriat................................... gr. xv-xx Vini picis, liq....................................... %']. M. Three or four times in twenty-four hours. Dry catarrh is greatly benefited by— R. Potassii iodidi....................................... gr.v-x Ext. eucalypt. fid................................... n\xx Vini picis, liq...........,........................... gj. M. Three times a day. 208 PRACTICE OF MEDICINE. Or— R. Ext. cimicifugae. fid ............................... Tl^xx Tinct. opii deodorat............................... mjij Syr. prun. virg...............ad.................... ^ij. M. SlG.—Every four hours. For bronchorrhea, copaiba, gtt. v-x every three hours, or spts. terebinthine, gtt. v, every four hours, or acidum carbolicum. gr. ss, four times a day, and at the same time using, ol. morrhue and arsenicum, or, if these means fail, inhalations of alumen, acidum gallicum or acidum tannicum. If the expectoration be fetid, " fetid bronchitis," Prof. Da Costa recommends the internal use of acidum carbolicum, gt. j every third hour, with inhalations of acidum carbolicum, gr. v, aqua, £j, two or three times a day. Locally, irritation with tinctura iodi, or flying blisters, repeated once or twice weekly, is of advantage. ASTHMA. Synonyms. Nervous asthma ; bronchial asthma. Definition. A paroxysmal spasmodic contraction of the muscular layer surrounding the bronchial tubes, and perhaps associated with a tonic spasm of the diaphragm, and more or less bronchial catarrh ; characterized by spasmodic attacks of great dyspnoea, continuing usually for several hours. Causes. A true neurosis of the respiratory apparatus. The result of peripheral or local disturbances in the nervous system, often hereditary; pressure on the pneumogastric nerve; dyspepsia and constipation, resulting in irritation of the end organs of the pneumogastric; uterine, hepatic, or nephritic disease; inhalation of various substances, as ipecac, turpentine, or irritating dusts ; climate; mental and moral influences. Asthma is more common in men than in women ; in childhood and young adults than those of middle life and old age ; in the well-to-do and wealthy than in the poor. Symptoms. The onset of a first attack of asthma is abrupt and sudden, the succeeding attacks being preceded by prodromes, which the individual rapidly learns to appreciate, to wit: coryza, bronchial irritation, thoracic constriction, marked dyspepsia, or a large passage of pale, limpid urine, the "hysterical urine." DISEASES OF THE BRONCHIAL TUBES. 209 The paroxysm begins, in the majority of cases, in the early morn- ing hours or during the afternoon, with a feeling of anguish and con- striction in the chest and an intense desire for air. The breathing is accompanied with loud wheezing, the face is flushed, at times even cyanosed, and bathed in perspiration, the eyes stare, the eyeballs pro- trude, and the muscles of the neck become prominent as they aid in the effort for air. The dyspnea soon becomes so severe that the in- spiration is but a gasp, the lips are pallid, cyanosis deepens, and the patient feels as if death were impending. After some minutes or hours the respiration becomes easier, more air enters the lungs, the cyanosis disappears, and gradually the paroxysm ceases, the patient feeling exhausted and the chest fatigued. During the paroxysm there is a short dry cough, becoming looser as the attack subsides, the expectoration either consisting of white pellets of mucus, at times streaked with blood or profuse watery mucus. The duration of an attack varies from three to ten hours. Instead of single paroxysms, slight remissions may occur at intervals of one, two or three hours, to be followed by exacerbations lasting from four to six hours, continuing for a week or two, preventing the patient lying down or taking food. Percussion. During the paroxysm, hyper-resonance over both lungs, termed vesiculotympanitic, the "bandbox tone" of Bamberger. Auscultation. First stage feeble or absent vesicular murmur, with prolonged expiration associated with loud wheezing, whistling, sibilant and sonorous rales; as the paroxysm subsides the vesicular breathing becomes more apparent and is associated with moist rales. Prognosis. In itself asthma is not fatal to life ; but if the parox- ysms are frequently repeated there results either emphysema, cardiac dilatation, with subsequent dropsy, or even cerebral hemorrhage. Attacks of asthma frequently occur as a complication in emphy- sema, chronic bronchitis and valvular diseases of the heart. Treatment. There are two indications, to wit: the relief of the paroxysm, and to prevent its recurrence. To relieve the paroxysm, no medication is so effective as the hypo- dermatic injection of morphine sulph., gr. Y> t0 Y> combined with atropine sulph., gr. T^. Chloral, gr. x, repeated, where no heart complication exists, is often effective ; chloroformum, ether or amyl 210 PRACTICE OF MEDICINE. nitris inhalations have been recommended ; also nauseant expecto- rants, to wit: lobelia, ipecac, scilla, or ext. grindelie fid., gtt. xx, repeated every two or three hours. Dr. Pepper speaks highly of the following for the paroxysm :— R. Ammonii bromidi.................................. ^ij ^ij Ammonii muriat.................................... 3Jss Tinct. lobeliae...................................... f^iij Spts. astheris comp................................. fjj Syr. acaciae q. s.................................... f5iv- M. Sig.—Dessertspoonful in water every hour or two. Inhalations of the fumes of belladonna, stramonium, nitre-paper, chloroform, ethyl bromidum, or the use of various pastilles or cigar- ettes, are of immense benefit in many cases. Paroxysms of asthma are said to be relieved by rectal injections oi sul- phuretted hydrogen after the manner suggested by Bergeon of Paris. If an attack is impending it may often be aborted by drinking freely of strong black coffee, or by full doses of the bromides. To prevent recurrence of the paroxysms, the general health must be strictly watched, any of the complications or causes of the attack attended to, systematic exercise, bathing, regulated diet, and change of climate when possible. Internally, good results are sometimes attained by a long course of belladonna, arsenicum or potassii iodidum. HAY ASTHMA. Synonyms. Hay fever ; autumnal catarrh ; rose fever. Definition. An acute catarrhal inflammation of the upper air passages, extending to the bronchial tubes, associated with spasmodic contraction of their muscular layer ; characterized by coryza, croupy or wheezy cough and difficult respiration. Causes. An affection of the nervous system ; often hereditary. Persons in whom the predisposition exists have attacks excited by the inhalation of the pollen of grasses, rye, corn, wheat or roses. Pathological Anatomy. Hypertrophy of the inferior and middle turbinated bones; a peculiar hyperaesthesia of the mucous membrane covering the inferior and middle turbinated bones, the middle meatus, the floor of the nose and that part of the septum below the limit of the olfactory membrane are frequently associated with the disease. DISEASES OF THE BRONCHIAL TUBES. 211 Symptoms. Begins by severe coryza, with sneezing, a clear, watery, nasal discharge, congested eyes and Eustachian tubes, rapidly extending to the larynx and bronchial tubes, when occur a hoarse, croupy and wheezing cough, and difficulty of breathing. The dyspnoea occurs in paroxysms, which are often as severe as those occurring during a regular asthmatic attack. The paroxysms remit after a few days, returning again for several days or weeks, and again remitting, the bronchial catarrh persisting for a month or more. The constitutional symptoms are mild, unless complications occur. Complications. The affection may extend to the finer bronchial tubes (capillary bronchitis); congestion or oedema of the lungs and pneumonia are not infrequent. Duration. Unless a change of climate is resorted to, paroxysms of hay fever continue more or less severe for six, eight or ten weeks of the year; each year the paroxysms growing more severe. Prognosis. The affection never proves fatal in itself, but one or more of the following sequele may result, to wit: Asthma, chronic bronchitis, or loss of the special sense of hearing or of smelling. Treatment. No specific, unless the hypertrophy of the turbin- ated bones be a constant phenomena, when removal by the galvano- cautery would at once produce a cure. An attack of hay asthma is often prevented by a change of climate during the season of the year when the attacks are most common, to wit: the early autumn. Any of the following locations may be selected, White Mountains, Catskills, Adirondacks, Rocky Mountains, or a sea voyage. Attacks are sometimes aborted and always relieved by the appli- cation to the nares of tablets of cocaine hydrochlorat gr. Y(> every hour. Success has followed the use of quinina, gr. v, three times a day, beginning one month before the expected paroxysm. After the attack has fairly begun, potassii iodidum, gr. xv, three times a day, seems to modify somewhat the severity of the paroxysms ; or the following powder, by insufflation :— R. Bismuth, subnit.................................... 5pj Acid, tannic......................................... gj Iodoform!............................................ gr. xv. M. Sig.—Every three or four hours, 212 PRACTICE OF MEDICINE. Prof. Bartholow "has seen several cases benefited greatly" by a solution oi quinina applied to the nares, as suggested by Helmholtz; "but to achieve success the application must be thorough and timely." The following applied thoroughly to the nostrils has a high repute :— R. Menthol.............................................. jj Cerat. simpl......................................... 31J 01. amygd. dulcis.................................. 3iss Zinci oxidi purse.................................... 3J Acid, carbolici...................................... gss. M. SlG.—Apply every few hours. Cases accompanied by a profuse watery discharge have this symp- tom at least modified by minute doses of atropine sulph., with morphine sulph., every three or four hours. A long course of arsenicum in minute doses sometimes removes the susceptibility to the disease. WHOOPING COUGH. Synonyms. Hooping cough ; pertussis. Definition. A convulsive, paroxysmal cough, consisting of a number of forcible expirations, followed by a series of deep, loud, sonorous inspirations (the whoop), repeated several times during each paroxysm, and associated with catarrh of the bronchial tubes. Causes. Chiefly a disease of childhood, one attack generally removing the susceptibility ; contagious; the result of an unknown poison, perhaps atmospheric, affecting the nervous system. Pathology. The changes, if any, occurring in the nervous sys- tem are unknown. It is said that " irritation of the internal branch of the superior laryngeal nerve produces relaxation of the diaphragm, spasm of the glottis and a convulsive expiration, the series of phe- nomena present in a paroxysm of asthma." Hyperemia of the mucous membrane of the nares, pharynx, larynx and bronchial tubes, with diminished secretion, followed by an in- creased secretion of a transparent mucus, afterward becoming puru- lent, the mucous membrane pale and anaemic. Symptoms. Divided into three stages, to wit: catarrhal, spas- modic and terminal. Catarrhal stage originates as an ordinary naso-laryngo-bronchial catarrh with a loose cough. Duration one or two weeks. DISEASES OF THE BRONCHIAL TUBES. 213 Spasmodic stage: The cough becomes paroxysmal, consisting of a succession of short, rapid, expiratory efforts, the face becoming red, the eyes swollen and protruding, the body bending forward, and when these expiratory efforts have exhausted the breath, they are followed by a deep, loud, crowing inspiration—the whoop. Each paroxysm being composed of three such spells, the last one followed by the expectoration of a small amount of tough, viscid mucus. The attacks of cough may be so severe as to cause vomiting, and if the vomiting occur shortly after food has been taken, the nutrition of the patient will suffer. Profuse epistaxis is not infrequent. Duration about four weeks. Terminal stage. The paroxysms recur at longer intervals, are of shorter duration and less intensity, the catarrhal symptoms being more marked, the expectoration freer. Duration, one or two weeks, often followed by the " cough of habit." Complications. Congestion of the lungs, capillary bronchitis, pneumonia and emphysema, or, rarely, convulsions, hydrocephalus, or apoplexy. Diagnosis. During the catarrhal stage, whooping cough cannot be distinguished from a common cold, but on the advent of the characteristic whoop the diagnosis is evident. Prognosis. Depends upon the age and strength of the patient, the severity of the paroxysms, and the presence or absence of com- plications. Ordinary cases, favorable. Moderately severe attacks during infancy are followed by cerebral symptoms, while attacks occurring in adults are followed by chest symptoms. Treatment. No specific. A self-limited disease. Remedies will not cure the disease, but often modify the severity of the symptoms. Prof. Da Costa prefers quinine sulph., in full doses, or chloral in good-sized doses, often advantageously combined with the bromides, and the use of a spray of sodii bromidum, gr. xx, and aquae, f ^ j, to which may be added extractum belladonnefluidum, ttijj. A remedy of great utility is atmnonii bromidum. The paroxysms are lessened in severity by the following:— R. Codeinae sulph...................................... gr. fa-fa Acid, hydrocyanici dilut......................... 1^VlA~) Syr. tolu............................................. 3j. M. Sig.—Every two or three hours. 214 PRACTICE OF MEDICINE. Belladonna may be added to any of the remedies named with advantage. The use of cocaine lozenges modifies the paroxysms in some cases. Dr. Keating reports "remarkable improvement in four cases of whooping cough by the use, four or six times daily, of a spray com- posed of"— R. Ammonii bromid., Potassii bromid..................aa................. g) Tinct. belladonnae................................ f^j Glycerini ........................................... f.^j Aquae rosae................q. s ad................ f^'v- The diet of the patient must be regulated, the clothing to be warm but not too heavy, and the patient kept in the open air as long as possible. HEMOPTYSIS. Synonyms. Bronchial hemorrhage ; broncho-pulmonary hemor- rhage; bronchorrhagia. Definition. The expectoration of pure or unmixed blood, usually of a bright red color, following the act of coughing. Causes. In the majority of cases, the result of tubercular deposi- tion in the walls of the minute bronchial arteries ; excessive cardiac action; bronchial congestion; excessive bodily exertion, straining, lifting or running; a symptom oi hemophilia ("bleeder's disease"). Pathological Anatomy. Haemoptysis rarely causes death in itself, so that few opportunities for observing post-mortem appear- ances are obtained, and when they do occur, the location of the hemorrhage is seldom found. The air passages are more or less filled with clotted blood, the mucous membrane is swollen, and of a dark red color, rarely, pale and bloodless. The air cells contain blood clots, or are distended with air, the bronchi being filled with clots preventing its escape. Unless the clots are rapidly removed by expectoration or absorption, a secondary inflammation originates around about them. Symptoms. "Spitting of blood "occurs suddenly; rarely, it is pre- ceded by epistaxis, cardiac palpitation and some difficulty of breathing. It begins with a sensation of warmth under the sternum, tickling in the throat, a sweetish taste in the mouth, which, upon attempting to remove by the act of coughing, a warm, saltish, bright red, frothy liquid gushes from the mouth and nose. The quantity of blood raised DISEASES OF THE BRONCHIAL TUBES. 215 varies from an ounce to a pint. The appearance of the blood de- presses the individual, he becoming pale, tremulous, often fainting. The attack may subside within half an hour to several hours, re- turning for several days, in the meantime the expectoration being either bloody or streaked with blood. A slight febrile reaction, with chest pains, supervenes upon the hemorrhage, the result of the inflammation at the site of the bleeding, which soon subsides, except where blood clots develop a secondary pneumonia, which may undergo the cheesy metamorphosis. Auscultation. Coarse, bubbling rales are discerned in circum- scribed portions of the chest. Diagnosis. From epistaxis, or hemorrhage from the posterior nares, it is distinguished by the absence of air bubbles and an inspec- tion of the fauces and the nasal cavities. Hemalemesis, or hemorrhage from the stomach, differs from haemoptysis in the blood being vomited instead of expectorated, of a dark color, clotted, mixed with the acid contents of the stomach, fol- lowed with black, tar-like stools, and the absence of rales in the chest. Exceptions to the above occur when the blood from the lungs is first swallowed and afterwards raised by vomiting, or when the hemor- rhage in the stomach is caused by the erosion of a large artery, the result of ulcer of the stomach; in these cases, however, the raising of blood is preceded by epigastric pain and the blood is not frothy. Prognosis. Haemoptysis in itself rarely terminates fatally, al- though causing much depression ; the patient rapidly recovers, unless secondary pneumonia results. In nine cases out often it is the prog- nostic sign oi phthisis. Treatment. Perfect rest in bed, the head and shoulders elevated, and perfect quiet, the diet to be bland, the drinks cool, the patient slowly swallowing small particles of ice. Common salt, slowly dis- solved in the mouth, is a popular remedy, and if of no real benefit, serves to occupy the attention of the patient and friends until medical advice is obtained. The hypodermatic injection of ergotin, gr. x-xxx, or the internal administration of ext. ergote, fid., or,— R. Acid, gallic.......................................... gr. xv Acid, sulph. dil.................................... tti x Aqua cinnamon.................................... ^iv. M. Repeated every fifteen or twenty minutes. 216 PRACTICE OF MEDICINE. Or tinctura matico, 3J, or extractum hamamelis fid., ttlxx-^j, or alumen, gr. xx, frequently repeated. If the hemorrhage causes great nervous excitement, or depression, opium, either hypodermatically or internally, to quiet the patient, is indicated. Inhalations, by means of the steam atomizer, of either MonseVs solution or tinct. ferri chlor., are recommended when the above means fail. Prof. Da Costa recommends, for frequent small hemorrhages, con- tinuing day after day, cupri sulph., gr. fa, ext. opii, gr. fa, p. r. n. DISEASES OF THE LUNGS. CONGESTION OF THE LUNGS. Synonym. Hyperaemia of the lungs. Definition. An increase in, or abnormal fullness of, the capil- laries of the air cells ; active when the result of an accelerated circu- lation ; passive when caused by an impeded outflow from the capil- laries. Causes. Active. Increased cardiac action ; over exertion ; alco- holic excesses ; mental excitement; inhalation of cold or hot air. Passive. Obstruction to the return circulation. Dilated heart; valvular diseases ; low fevers (hypostatic congestion); Bright's diseases. Pathology. The hyperaemic lung has a bloated, dark red ap- pearance, its vessels are distended to the uttermost, the tissues succu- lent and relaxed, blood flowing freely over the cut surface ; a bloody, frothy liquid is present in the bronchi, and the alveolar walls are so much swollen that the condensed lung shows scarcely any indication of its cellular structure, resembling the tissue of the spleen (splenifica- tion). Symptoms. Active. Rapidly developing oppression of the chest and difficulty of breathing, flushed face, strong, full pulse, throbbing carotids and congested eyes, with a short, dry cough, followed by scanty, frothy expectoration slightly streaked with blood. DISEASES OF THE LUNGS. 217 Passive. Developed slowly, with difficulty of breathing, blueness of the surface, almost continuous hacking cough, followed by scanty, blood-streaked expectoration. Percussion. The resonance of the lungs slightly diminished, the quality of the sound being somewhat tympanitic. Auscultation. The vesicular murmur is diminished and accom- panied with sub-crepitant rales. Duration. Active. Usually from three to five days, terminating either by resolution, hemorrhage, or, rarely, pneumonia. The onset may be so severe and sudden that death rapidly supervenes. Passive. Developed slowly and subject to great variations, depend- ing upon the cause. Diagnosis. Active congestion of the lungs cannot be distinguished from the stage of engorgement of a true pneumonia, in the majority of cases. Prognosis. An acute congestion of the lungs may prove fatal within a few hours, but under prompt treatment it generally termi- nates favorably. The passive form is controlled entirely by the cause. Treatment. Active. In the strong and vigorous wet cups to the chest, or, if the symptoms are pronounced, a general venesection. Internally, tinctura aconiti, gtt. j-ij every half hour or hour, as indi- cated, with free purgation. Passive. Dry or wet cups over the chest, hydragogue cathartics, and the internal administration of digitalis. CEDEMA OF THE LUNGS. Definition. An effusion of serum upon the free surface of the lung, to wit: in the pulmonary vesicles; characterized by dyspnoea, cough, and frothy, blood-streaked expectoration. Causes. Increased cardiac action ; over-exertion ; alcoholic ex- cesses ; mental excitement; inhalation of cold and hot air. Pathological Anatomy. The lung tissue is swollen, and does not collapse when the chest is opened. The elasticity of the tissue has disappeared, and it pits upon pressure. If following congestion of the lungs, the color is red ; if a symptom of a general dropsy, its color is pale. On cutting into the cedematous spots an enormous quantity of s 218 PRACTICE OF MEDICINE. liquid, sometimes clear, at other times of a red color, mixed more or less with blood, flows over the cut surface. The liquid is filled with bubbles, is frothy, from being copiously mixed with air, providing the air cells have not been entirely filled with serum, thereby excluding the air. Symptoms. Following a more or less rapidly developing hyper- aemia of the lungs axe great difficulty and extreme rapidity of breath- ing, with a strong sense of oppression, great anxiety, rapid and tumult- uous cardiac action, throbbing carotids and temporals, fullness of the head and headache, flushed face and congested eyes, with a constant, short cough, and the expectoration of a tough, frothy mucus, streaked with blood. If the effusion into the air cells be sufficient to prevent the entrance of air, symptoms of cyanosis rapidly supervene, the pulse becoming feeble, the surface cold, the breathing shallow and hurried, the cough suppressed, stupor replacing the restlessness, soon deepening into coma. Percussion. Slightly impaired or vesiculo-tympanitic. Auscultation. The vesicular murmur is supplanted by sub-crepi- tant and bubbling rales. Diagnosis. Pneumonia in the earlier stages is the only condition ikely to be confounded with oedema of the lungs, and the subsequent course of the two maladies soon determines the diagnosis. Prognosis. CEdema of the lungs is always a serious malady, and frequently, unless promptly relieved, terminates fatally. Treatment. If the oedema be of an active kind, prompt blood- letting, either by venesection or wet cups to the chest, is indicated. The internal administration of tinctura aconiti, gtt. j-ij, repeated every fifteen minutes, until the cardiac action is markedly reduced, after which every hour or two, with the use of the preparations of am- monium, either the carbonas or iodidum, to liquefy the effusion, pro- duce marked relief. The above means may be aided by counter-irritation to the chest, hot 7iiustard foot-baths, and active saline purgatives. CROUPOUS PNEUMONIA. Synonyms. Lobar pneumonia; pneumonitis; pleuro-pneumonia; lung fever ; winter fever. Definition. An acute croupous inflammation involving the vesi- cular structure of the lungs, rendering the alveoli impervious to air; DISEASES OF THE LUNGS. 219 characterized by a severe chill, fever, pain, dyspnoea, cough, rusty sputum and great prostration. Causes. The question of pneumonia being a constitutional dis- ease is still sub judice. It is most common in winter, at times occur- ring epidemically, the result of atmospheric conditions; exposure to draughts and cold; injuries to the chest walls; alcoholic excesses ; gout or rheumatism. Pathological Anatomy. The inflammatory changes most commonly affect the lower right lobe, rarely the upper lobe, very rarely corresponding lobes in both lungs. The changes are, I. Hyperemia (engorgement) ; II. Exudation (red hepatization) ; III. Resolution (gray hepatization) ; or it may undergo purulent transformation or the development of abscesses (yellow hepatization). I. Stage of hyperemia or engorgement consists in the vessels of the alveoli being distended to their utmost, encroaching upon the cavity of the air vesicle ; the lung has a reddish-brown color, is heavier, sink- ing somewhat lower in water than a normal lung, and having a slight exudation upon the vesicular surface. The same changes are per- ceived in the adjacent bronchioles. II. Stage of exudation, consists in the exudation of a viscid, fibrin- ous fluid, admixed with white and red corpuscles and blood, which rapidly coagulates, firmly enclosing the corpuscles and completely filling the alveoli. When the exudation and coagulation are com- pleted, the lung is red, sinks at once when placed in water, and its elasticity is destroyed. When cut into, the color, density and gran- ular appearance so closely resembles the cut surface of a section of the liver, that Laennec termed it red hepatization. III. Resolution, or gray hepatization, follows the above condition in the majority of cases, the coagulated albuminous exudation under- going liquefaction and absorption, the cellular element undergoing a fatty degeneration, the greater part being absorbed, the remainder expelled during acts of expectoration, the alveoli returning to their normal condition, both as to capacity, function and elasticity. If resolution be retarded and portions of the coagulated exudation undergo purulent transformation, changing from a yellowish to a greenish-yellow color (yellow hepatization), pus cells are rapidly formed, the part becoming a granular, fatty mass. The portions of the lung not undergoing this purulent transformation retain the red- 220 PRACTICE OF MEDICINE. dish color with intermixed yellowish patches, the lung structure proper remaining intact. The purulent contents may be ejected in part, the remainder undergoing fatty degeneration and finally absorption. Abscess of the lung may result from the lung structure becoming involved in the purulent disintegration. Abscesses may be solitary or in great numbers, which by disintegration of intervening structure form one or more large abscesses; these abscesses either terminate fatally, or open into the pleural cavity, causing empyema and exhaus- tion, or open into the bronchi and are expectorated, or an interstitial pneumonia is developed and the abscess encapsulated in a firm cica- tricial tissue. Gangrene of the lungs may result from blocking up of the bronchial or pulmonary arteries by coagula, during any stage of the disease. The uninflamed portions of the lungs are hyperaemic and their functional activity is increased. Death sometimes results from a general edema of the unaffected lung, such cases being often erroneously termed " double pneumonia." If inflammation oi the pleura be associated with a pneumonia, the so-called pleuro-pneumonia, the changes in the pulmonary pleura are characteristic. " An uneven, thin, downy-looking layer of plastic exudation covers its surface. This plastic layer may conceal the liver-brown color of the pneumonic lung. As the third stage is reached the opposing surfaces of the pleura may become agglutinated. The pleuritic changes follow very closely those which occur within the lung. The cells in the pleuritic exudation are mainly pus. The pleuritic membrane is opaque, congested and ecchymotic. It may become so thick as to give a dull note on percussion, after resolution is reached." Duration of Stages: stage of congestion, from one to three days; stage of exudation, from three to seven days ; stage of resolution, from one to three weeks. In severe cases or in the very young, the aged or the depressed, the stage of red hepatization may be fully developed within forty-eight hours. Seat: The most frequent seat of croupous pneumonia is the lower right lobe; the next most frequent seat is the lower left lobe; the next, the upper right lobe, although in children and the aged this lobe is affected equally as often as the right lower lobe. Symptoms. Begins with a severe and unusually protracted chill DISEASES OF THE LUNGS. 221 (in children often convulsions), followed by a rapid rise of tempera- ture, io3°-io4° F., a strong, full, but rapid pulse, either a dull or sharp pain near the nipple, aggravated by pressure, breathing or coughing, shortness of breath, the number of respirations increasing to 40, 50 or more per minute, causing interrupted speech ; cough, first short, ring- ing and harsh, soon followed by a scanty, frothy mucus, soon becom- ing semi-transparent, viscid, and tenacious, about the second day changing to the familiar rusty sputum, becoming more copious and of a yellow color as the disease advances. There are present headache, sleeplessness, rarely delirium, save in drunkards, flushed countenance, and especially over the malar bones is a well-defined mahogany blush; gastric disturbances and scanty, high-colored urine, with diminished chlorides. The above symptoms continue more or less marked until either the fifth, seventh, ninth or eleventh day, when a crisis occurs, and within twenty-four hours convalescence is established, recovery rapidly fol- lowing. Typhoid pneumonia is a term applied to those cases which are accompanied by signs of extreme prostration, very high temperature and profuse and prolonged exudation. They may also terminate by a crisis. Bilious pneumonia occurs in cases accompanied by congestion of the liver, the result of venous stasis from pulmonary obstruction or from an accompanying acute catarrhal jaundice. In malarial dis- tricts pneumonia and malaria are often associated, when jaundice, more or less pronounced, occurs. Such cases are termed malarial or intermittent pneumonia. If purulent infiltration follow the stage of red hepatization, instead of a crisis, symptoms of exhaustion occur, with profuse purulent ex- pectoration, high temperature, severe sweats ; the tongue brown and dry, sordes collecting on the teeth, recovery slow and convalescence tedious. Pneumonia occurring in persons of intemperate habits usually begins with symptoms closely resembling an attack of delirium tremens, cough, expectoration, the pain very slight, or even absent. Inspection. First stage, deficient movement of the affected side, due to the pain. Second stage, the healthy side rises normally, the affected side lag- ging behind. If both lower lobes are impervious to air, the diaphragm 222 PRACTICE OF MEDICINE. cannot descend and the epigastrium does not project during inspira- tion, the breathing being conducted by the upper part of the chest (superior costal respiration). Palpation. First stage, the vocal fremitus more distinct than normal. Second stage, the vocal fremitus is markedly exaggerated, except in those rare instances of occlusion of the bronchi by secretion. The cardiac impulse is felt in the normal position. Percussion. First stage, the percussion note is slightly impaired; indeed, at times having a hollow or tympanitic quality. Second stage, dullness over the affected parts, with an increased sense of resistance. Auscultation. First stage, over affected part, feeble vesicular murmur, associated with the true vesicular or crepitant (crackling) rale, most distinct during inspiration. Second stage, harsh, high pitched bronchial respiration, at times resembling a to and fro metallic sound, except in those rare instances in which the bronchi are more or less filled with secretion. Bronchophony, or distinctly transmitted voice, at times pectoriloquy, or distinct transmission of articulated sounds. Third stage, breathing changing from bronchial to vesiculobron- chial, the crepitant (crepitatio redux) rale returning, and if resolution proceed, the breath sounds are associated with large and small moist and bubbling rales. Terminations. Asthenic cases recover within two weeks. When purulent infiltration supervenes, the disease pursues a tedious course of several weeks' duration, with a low exhaustive fever. If death occur during the first or second stages it is usually the result of a collateral edema of the uninflamed lung, or cardiac ex- haustion. If abscesses occur, there are exhausting sweats, frequent cough, with a large amount of yellowish-gray, at times blood-streaked, expectora- tion. Gangrene of the lungs is a rare termination ; it is associated with symptoms of collapse, the expectoration of a blackish, fetid sputum, and the physical signs of a pulmonary cavity. Diagnosis. OEdema of the lungs may be confounded with the first stage of pneumonia, but the subsequent history, its presence on both sides, and the waterish expectoration and absence of chill and DISEASES OF THE LUNGS. 22o pain and the physical signs of pneumonia soon determine the diagnosis. Pleurisy is oftener confounded with pneumonia than any other dis- ease, the points of distinction between which will be pointed out when discussing that affection. Prognosis. Depends upon the extent of the inflammation, double pneumonia being very grave, but is not near so frequent as was at one time supposed. A temperature of 1050 F., and a pulse above 120 are of bad omen. Pneumonia of drunkards almost invariably ter- minates fatally. Typhoid pneumonia, the so-called bilious pneumonia, purulent infiltration, abscesses of the lungs and gangrene, all give a grave prognosis. Treatment. First stage, wet or dry cups over the chest, followed by the application of poultices. Internally, either tinct. verat. virid., gtt. j-iij, or tinct. aconiti, gtt. ij—iv, or tinctura digitalis nvx, repeated every half hour or hour, until a decided impression is made upon the circulation, and at the same time quinine sulphas, gr. v, every three or four hours. If the patient be strong and vigorous, the circulation full, the arterial tension high, the dyspnoea early and marked, the surface flushed, and the pain severe, marked relief is obtained by a good venesection. Second stage, the arterial sedative should be replaced by quinine sulphas, gr. iij, every three hours, and ammonii carbonas, gr. v, every two hours, and a good, nutritious diet. Local applications are useless at this stage. Third stage, ammonii carbonas, gr. v, every three hours, quinine sulphas, gr. xij-xx, during the day, nutritious diet, stimulants, and if the hepatization shows signs of lingering, flying blisters over the chest. For typhoid pneumonia, purulent infiltration, abscess of the lungs, or pneumonia in drunkards, the weak or aged, quinina, ferrum, strong, nourishing diet, bold stimulation, and the free use of ammonii carbonas, are the indications. CATARRHAL PNEUMONIA. Synonyms. Broncho-pneumonia ; lobular pneumonia ; capillary bronchitis (?) Definition. An acute catarrhal inflammation of the bronchioles 224 PRACTICE OF MEDICINE. and alveoli of the lungs characterized by fever, cough, dyspnoea, copious expectoration and great depression. Causes. From an extension of a bronchial catarrh downward; following the eruptive fevers, especially measles ; complicating whoop- ing cough. Persons of the rickety or scrofulous diathesis, in whom there is a greater irritability of the epithelial elements, are particularly predisposed to this form of pneumonia on slight exposure; emphy- sema ; diseases of the heart; childhood and old age. Pathological Anatomy. Hyperemia of the mucous membrane of the bronchi, and also of the bronchioles and air cells, with swelling and succulence of these tissues, accompanied by an abnormal secretion and an immense production of young cells from the proliferation of the bronchial and alveolar epithelium, admixed with a yellowish, creamy, mucoid material, which blocks up the bronchioles and air cells. The affected parts first have a reddish-gray, soon changing to a yellowish-gray color, due to the rapid metamorphosis of the newly developed cells. If the fatty change be completed, absorption takes place, and the consolidation is removed; if it remain incomplete the cells atrophy, the little mass becoming caseous, and the disease passes into a chronic state. The bronchial tubes also participate in the disease, the walls become thickened, from a hyperplasia of the connective tissue {peri-bronchitis), and their calibre is often dilated. Symptoms. Catarrhal pneumonia is preceded by catarrhal bron- chitis. It may be either acute, sub-acute or chronic in its course. Acute variety : Its onset is announced by a gradual rise oi tempera- ture to io2°-io3° F., with rapid, laborious and shallow breathing, as shown by the widely dilated nares and violent action of all the accessory muscles, while the insufficient distention of the lungs is shown by the great recession of the lower part of the chest walls and sinking in of the intercostal spaces. The inspiration is short and im- perfect, the expiration noisy and prolonged ; the pulse is frequent, 100-120 or more, and somewhat compressible ; the cough, which, during the bronchitis, was loose, now becomes short, hacking, dry and painful, soon followed by more or less copious muco-purulent expectoration ; the appetite is impaired, bowels somewhat loose, urine scanty, high-colored, and the surface frequently covered with a more or less profuse perspiration. DISEASES OF THE LUNGS. 225 The sub-acute and chronic varieties have the same general symp- toms, but the duration is longer and the exhaustion greater. The progress of catarrhal pneumonia is sometimes, although not often, a very acute one. The disease may prove fatal in a few days, especially if it attack feeble children ; in such the countenance becomes pale and livid, the lips bluish, the eyes dull, and restlessness giving place to apathy and a continually augmented somnolence. Resolution, when it occurs, is by lysis, several weeks elapsing before complete recovery. Percussion. Dullness, scattered in patches, over both lungs, the intervening healthy lung often giving a more or less hollow or tym- panitic note. Auscultation. Vesiculo-bronchial breathing, changing to moist bronchial breathing, associated with small bubbling (sub-crepitant) rales. As the disease progresses toward resolution, the rales become larger (large bubbling) and more copious. If pneumonic phthisis result, physical signs indicative of that condition are soon evident. Sequelae. Attacks of catarrhal pneumonia complicated with atelectasis, or collapse of the lobules, when recovery occurs, are fol- lowed by emphysema of the lungs. If the catarrhal products which fill the alveoli and bronchioles and intervening connective tissue do not rapidly undergo complete fatty metamorphosis and consequent absorption, pneumonic phthisis re- sults. Diagnosis. Ordinary bronchial catarrh differs from catarrhal pneumonia by the absence of dyspnoea, fever, and dullness on per- cussion, and the presence of the large bubbling rales, and also by the subsequent history of the two affections. Croupous pneumonia is a unilateral disease ; catarrhal pneumonia is bilateral and diffused over both lungs; the former a self-limited disease, the latter having no fixed duration. Acute tuberculosis at its onset is characterized by the presence of a capillary bronchitis, a differentiation being possible only by a study of clinical history and course of the two maladies. (Edema of the lungs is a bilateral disease associated with a short, dry cough and dyspnoea, but lacks the previous catarrhal history and high temperature of catarrhal pneumonia. Prognosis. Fully one-half of the cases of true catarrhal pneu- monia terminate fatally. The prognosis must be guarded in scrofu- T 226 PRACTICE OF MEDICINE. lous or rachitic subjects, or those enfeebled by other diseases, for, unless prompt resolution can be effected, it will terminate fatally early, or develop pneumonic phthisis. Treatment. Confinement to bed is paramount, although the position of the patient is to be frequently changed. The diet must be of the most nutritious character, administered at frequent intervals; milk, eggs, chicken, beef, mutton and oyster broths are the most suit- able. The steady use of brandy or whisky throughout the attack is of importance; regulating the amount by the age of the patient and the severity of the attack. For the fever, quinine sulphas, gr. xv-xx each day, is the most re- liable of all antipyretics, or antipyrin in full doses may be substituted. For the catarrhal process, the air of the apartment should be main- tained at an even temperature and moistened by disengaging the vapor of water in it. The following combination is of great utility in nearly all cases :— R. Ammonii carbonat................................. gr. v Ammonii iodidi.................................... gr. v-x Mucil. acaciae....................................... q. s. Syr. glycyrrh....................................... % i-ij Syr. prun. virg.............................q. s. ad ^ ij—iv. M. Sig.—Every three hours. A much pleasanter way of administering the ammonia salts is in capsules, each containing about two and one-half grains of each salt with an aromatic oil. For convalescence, nutritious food, ferri iodidum, quinine sulphas, and oleum morrhue. Locally : repeated application of mustard poultices or turpentine stupes followed by demulcent poultices. If the inflammatory process tends to become chronic, scattering blisters should be used. PULMONARY CONSUMPTION. Synonyms. Phthisis pulmonalis; phthisis; consumption. Definition. Four varieties of pulmonary consumption are now admitted to exist: Pneumonic phthisis; tubercular phthisis; fibroid phthisis ; acute miliary tuberculosis. As these forms present differences at all points, they will be de- scribed separately. DISEASES OF THE LUNGS. 227 PNEUMONIC PHTHISIS. Synonyms. Chronic catarrhal pneumonia ; catarrhal phthisis ; caseous pneumonia ; caseous phthisis. Definition. A form of destruction of the pulmonary tissue caused by the caseation or cheesy degeneration of inflammatory products in the lungs and the subsequent softening and destruction of the caseous matter, with greater or less destruction of the pulmonary tissue; characterized by hectic fever, cough, shortness of breath, purulent expectoration, and more or less rapid prostration. Causes. The predisposing factor in the etiology of pneumonic phthisis is a strumous or scrofulous diathesis, or a condition of lowered health, the result of various unfavorable hygienic influences. The exciting causes are catarrhal pneumonia in any portion of the lung, but especially at the apex; inflammation occurring about a blood clot; inhalation of irritant particles occurring in certain occu- pations, to wit: weaving, grinding, mining, hatters, millers, cigar makers and the like. Pathological Anatomy. When a pneumonia terminates in resolution the inflammatory products are absorbed by first undergoing a fatty metamorphosis. If the fatty metamorphosis be incomplete, the cells are atrophied and undergo the caseous degeneration, which con- sists in the absorption of the watery parts and the fatty degeneration of the cellular elements and the granular disintegration of the fibrin- ous material, so that ultimately a soft, solid mass is produced, yellowish in color, having the appearance of cheese. The destructive changes are thus described by Niemeyer: " Cells, the products of inflammation, accumulate in the alveoli and minute bronchi, crowd upon each other, becoming densely packed, and thus by their mutual pressure they bring about their own decay, as well as that of the lung textures, by interfering with their nutrition, the alveolar walls being also themselves damaged by the inflammatory process." The position of the catarrhal pneumonia resulting in the above changes is usually at the apex, but it may occur at any portion of the lungs, or a whole lung becomes infiltrated, and undergoes the cheesy degeneration (phthisis florida). In many cases tubercle is deposited in the inflamed lung, hastening its destruction and the formation of cavities. Symptoms. Pneumonic phthisis occurs in three forms, to wit: chronic, sub-acute and acute. 228 PRACTICE OF MEDICINE. Chronic form. The origin is rather insidious, the individual being susceptible to " colds " on the slightest exposure; gradually a per- sistent cough, with the expectoration of muco-pus, is established, each severe cold being accompanied with chill, fever, pain in the chest, and either slight hemorrhage or blood-streaked sputa. Finally the attacks become persistent, with morning chills, evening fevers and rather profuse night sweats, distressing cough, profuse muco-purulent sputa, great weakness and exhaustion, loss of appetite and feeble digestion, the symptoms growing persistently worse, death occurring from exhaustion after one or two years' duration. Sub-acute variety. History of an acute attack of pneumonia of one or two weeks' duration, followed by a decided improvement, but not complete recovery. After a lapse of some weeks or months, symp- toms of pulmonary softening begin, destroying the lung structure and forming cavities, accompanied by chills, fever, night sweats, emaci- ation, cough, 7nuco-purulent and blood-streaked expectoration, the patient dying from exhaustion within a year. Acute variety, the so-called phthisis florida, runs a rapid course, beginning as a catarrhal pneumonia, involving the whole of one or part of both lungs, associated with rapid loss of flesh and strength, high but variable temperature, io3°-io5° F., with remissions, profuse night sweats, shortness of breath, severe cough, profuse, purulent and blood-streaked sputa, loss of appetite, feeble digestion, rapid emaciation, the patient succumbing in a few weeks or months, from exhaustion. A decided remission in the local and general symptoms of the acute variety may occur, the disease afterward pursuing a more chronic course. Inspection. Shows deficient respiratory movements of the dis- eased portion of the lungs. Palpation. Increased vocal fremitus over the consolidated lung tissue and cavities. Percussion. The percussion note varies from a slight impair- ment of the normal note to dullness, and when cavities are formed, associated with scattered points of the tympanitic or hollow note. If the cavities communicate with a bronchial tube the cracked-pot or cracked-metal sound is elicited. If the cavities are filled with pus the percussion note is dull. If the pus be expelled, the tympanitic or cracked-pot sound returns. Auscultation. The vesicular murmur is unimpaired in those DISEASES OF THE LUNGS. 229 parts free from disease : it is feeble or indistinct if many bronchioles are obstructed; and is harsh or blowing if the bronchioles are nar- rowed. The inspiratory sound will be jerking, and the expiratory sound prolonged and blowing when the lung has lost its elasticity. Associated with the impaired vesicular murmur is a fine, dry, crack- ling sound (crepitation), appearing at the end of inspiration. If bron- chitis be associated, large and small moist or bubbling rales are heard during the respiration. When cavities form, either bronchial or broncho-cavernous respira- tion is heard, associated with more or less distinct gurgling rales. If the cavity be free from pus and have rather firm walls, the breath- ing is more amphoric in character. Diagnosis. Catarrhal bronchitis has many points of resemblance to pneumonic phthisis. The subsequent course of the latter, with the high temperature, prostration, emaciation, and physical signs, should prevent error. Tubercular phthisis is often confounded with pneumonic phthisis, an error difficult to prevent in many cases. Prognosis. Acute variety, the phthisis florida, usually terminates fatally within a few months. The sub-acute and chronic varieties may, under judicious treatment and favorable hygienic conditions, be arrested, the caseous matter partly expectorated and partly absorbed, leaving more or less loss of structure, cicatricial tissue supplying its place, which after a time con- tracts, causing more or less retraction of the chest walls. Cases not properly treated, either from carelessness or poverty, suc- cumb after a year or two. Treatment. An attempt should always be made to remove the caseous matter by absorption and expectoration. The following pre- scriptions will sometimes prove successful:— R. Ammon. carb....................................... gr. v Ammon. iodidi...................................... gr. v-x Syr. tolu............................. ............... gij Syr. prun. virg...................................... gij. M. Every five hours, alternating with R. Liq. potass, arsenitis Mass. ferri carb...... Vini xerici............ Aquae dest............. ......... rtlv .......... gr:v ,q. s. ad f^ss. M. 230 PRACTICE OF MEDICINE. The diet should be of the most nutritious character, the clothing warm, and, if practicable, change of residence should be made to a dry and elevated climate. If the digestion will permit, oleum mor- rhue, ^i-ij, three times a day. For the fever, quinine sulphas, gr. xv-xx, is more successful than the combination of quinina and digitalis in small doses. Night sweats are best controlled by atropine sulphas, gr. fa, at bedtime, or R. Extract, belladonna............................... gr. ss Zinci oxidi........................................... gr-iij- M. At bedtime. For the cough and sleeplessness, codeine sulphas, gr. ss-j, p. r. n. TUBERCULAR PHTHISIS. Synonyms. Tuberculosis; consumption ; incipient phthisis. Definition. The deposition of tubercle in the lung structure, which undergoes softening, followed by more or less loss of the pulmonary tissue proper ; characterized by fever, cough, dyspnoea, emaciation and exhaustion. Causes. Chiefly hereditary; closely associated with scrofula and struma ; probably contagious under certain conditions ; secondary to catarrhal (caseous) pneumonia; the theory of the "bacillus tubercu- losis" of Koch is still sub judice. Pathological Anatomy. Tubercle is a grayish-white, trans- lucent and semi-solid granulation, about the size of a millet seed, most commonly deposited in the walls of the bronchioles, exciting a low form of inflammation, the result of its own death. The masses of tubercle soon undergo softening (cheesy transformation); the lung structure is secondarily affected, undergoes softening, which results in more or less destruction of the tissue, whence cavities are formed. The inflammation may extend to the small arteries, causing hem- orrhage. The deposit of tubercle is generally at one of the apices, soon spreading to other parts ; depositions may also occur in the brain, intestines and liver. The pleura is usually the seat of a chronic inflammation (dry pleurisy), resulting in the obliteration of the pleural cavity. DISEASES OF THE LUNGS. 231 Symptoms. The symptoms correspond closely to the stages of deposition, of softening, and of the formation of cavities. The development is insidious, with increasing dyspepsia, iri-itable heart, a light, dry, hacking cough, referred to the throat or stomach, scanty, glairy expectoration, gradual loss of weight, impaired muscular strength, pallid appearance, more or less copious hemoptysis often following. Pain, sharp in character, below the clavicles, is often present. The beginning of softening is announced by increased cough, freer expectoration, dyspnea increased on exertion, morning chills, evening fever, night sweats—the so-called hectic fever, diarrhea, increased emaciation and weakness, the patient, however, continuing very hopeful. With the formation of the cavities, the cough is more aggravated, with profuse and purulent expectoration, at times containing yellow striae, the amount depending upon the number and size of the cavi- ties ; haemoptysis not common at this stage; the pulse rapid and weak, increased hectic, burning of the soles and palms, copious night sweats, greater debility and emaciation, with edema of the feet and ankles, denoting failure of the circulation, death soon following from asthenia, the mind clear and hopeful to the end. Inspection. First stage, often shows slight depressions in the supra-clavicular, and at times in the infra-clavicular regions. . Palpation. Second stage, the vocal fremitus is slightly increased. Percussion. First stage, slight impairment of the normal per- cussion resonance can sometimes be elicited. Second stage, the resonance is impaired, and may be even dull. Third stage, dullness with circumscribed spots of the amphoric, or tympanitic or cracked- pot sound. Auscultation. First stage, inspiration jerky, expiration pro- longed, the pitch higher than normal, the inspiration associated with crackling rales. Second stage, vesiculo-bronchialbreathing, associated with sub-crepi- tant and large and moist or bubbling rales. Third stage, bronchial, broncho-cavernous and cavernous respiration, associated with large and small moist or bubbling, and localized gurg- ling rales. Bronchophony in its various degrees is associated with the second and third stages of tuberculosis. 2o2 PRACTICE OF MEDICINE. Complications. Tubercular diseases of the brain, larynx, pleura, intestines and peritoneum ; perineal abscess leading to fistula. Diagnosis. The early diagnosis of tubercular phthisis rests mainly on the history, together with the symptoms and physical signs. In the first stage it is often mistaken for dyspepsia, anaemia, malarial fever, or disease of the heart. Prognosis. In the main unfavorable, although under proper treatment, change of climate and like favorable conditions, life may be prolonged for years. The question of perfect recovery is, to say the least, doubtful. Treatment. First stage, life may be prolonged, and perhaps the further deposition of tubercle delayed, by a change of climate, nutri- tious food, warm clothing, out-door exercise, and the internal admin- istration of ol. morrhue, ferri iodidum, arsenicum, hypophosphites, or the elixir quinine ferri et strychnine. Great improvement in the symptoms of phthisis follow the rectal injection of sulphuretted hydrogen after the manner suggested by M. Bergeon, of Paris, but that recovery will occur is hardly probable. Dr. H. C. Wood suggests the administration of the remedy by the stomach, claiming as great success by that means as when admin- istered per rectum. To cover the disagreeable taste of the remedy he uses a saturated solution of the sulpuretted hydrogen, using : "At first a half ounce, afterwards an ounce, of the saturated solution of the sulphuretted hydrogen should be placed in a tumbler, and two or three ounces of carbonic acid water be run into it from a highly- charged siphon, the whole being drunk while effervescing. This may be given three to five times a day, so that the patient will receive daily between a half-pint and a pint of the sulphuretted hydrogen gas." Special symptoms require treatment only when indicated, care being exercised to avoid everything which tends to impair the appe- tite, disorder digestion, or lower the vital powers. For the fever the " Niemeyer pill " is usually recommended ; its formula being— R. Quininae sulph..................................... gr. ij Pulv. digitalis...................................... gr. ss-j Pulv. opii............................................ gr. i^-ss Pulv. ipecac......................................... gr. JL. M. From a very considerable experience with this " famous " pill, I DISEASES OF THE LUNGS. 2:\:\ can recall few cases in which it has proven of the least benefit. The following is much more effectual:— R. Quinina; sulph..........................,........... gr. x Quininae muriat.................................... gr. x Pulv. opii et ipecac............................... gr. iij. M. Ft. capsul No. ij. Sig.—One capsule five hours, and the other three hours before the de- cided rise of temperature. For night sweats, not the result of the diurnal fever, atropine sulphas, gr. fa-fa, at bedtime, is an effective agent. For cough, if not modified by the arrest of temperature and night sweats, the following is of use :— R. Codeinae sulphat................................... SJ-Y~Y Acid, hydrocyanici dil........................... rnij Syr. tolu............................................. jrj. M_ Sig.—Several times a day. The dyspeptic symptoms are wonderfully relieved by the following:__ R. Pepsinicryst.................... ................... gr. ij Acid, muriat. dil................................... rti x Glycerini............................................ rtvxx Succi limonis....................................... rti xv Aquae aurantii flor. ad........................... zij. M. SlG.—With meals. FIBROID PHTHISIS. Synonyms. Chronic interstitial pneumonia; cirrhosis of the lungs ; Corrigan's disease. Definition. A hyperplasia (thickening) of the pulmonary con- nective tissue, resulting in atrophy and degeneration of the vesicular structure, associated with bronchial inflammation ; characterized by cough, profuse expectoration, fever, emaciation, and ultimately death by asthenia. Causes. Hereditary ; inhalation of irritants ; chronic bronchitis ; alcoholism. Pathological Anatomy. Thickening of the bronchial mucous membrane and dilatation of the air tubes ; hyperplasia of the pulmon- ary connective tissue, resulting in the compression and consequent destruction of the vesicular structure, which is assisted by the contrac- tion of the newly formed tissues. Sooner or later catarrhal pneu- 231 practice of Medicine. monia results, the product undergoing the cheesy degeneration, cavi- ties being formed, and as a result of the long-continued suppuration, tubercular depositions occur, hastening the destruction of the lung tissue. Prof. Da Costa has reported a number of cases of "grinder's phthisis" in whose sputum was found the " bacillus tuberculosis " in whose family history there were no traces of consumption. Symptoms. The course is chronic, beginning as a bronchial catarrh, worse in winter, better in summer, when, after several years, the cough becomes more continuous, the expectoration freer, and muco-purulent, often raised in paroxysms, in large amounts, hectic fever develops, night sweats, dyspnea and rapid emaciation, soon fol- lowed by edema of the feet and ankles, the result of failing circula- tion, death occurring by asthenia. Inspection. Depression of the chest walls. Percussion. Impaired resonance, followed by dullness, with irregular spots of amphoric or tympanitic percussion note over the points of depression. Auscultation. First stage, vesiculo-bronchial, or harsh respira- tion associated with large and small moist or bubbling rales, followed by bronchial, broncho-cavernous and cavernous respiration, with cir- cumscribed gurgling rales. Diagnosis. Beginning as a bronchial catarrh, slowly progressing, with the remission of the symptoms during the summer months, finally becoming progressively worse, with the formation of cavities, and symptoms of asthenia, are the chief points in the diagnosis. Prognosis. The duration of fibroid phthisis is most protracted, six or twelve years being the average duration ; death, however, is the inevitable termination. Prof. Da Costa has records of one hundred deaths from " grinder's consumption " whose average life was twelve years. Treatment. To prevent the hyperplasia of the connective tissue, hydrargyri corrosivum chloridum, potassii iodidum or aurii et sodii chloridum, are recommended. Oleum morrhue is of benefit. The bronchial catarrh, hectic fever and night sweats should be treated only when their severity becomes marked. DISEASES OF THE LUNGS. 2.">.J ACUTE PHTHISIS. Synonyms. Acute miliary tuberculosis ; galloping consump- tion. Definition. An acute febrile affection, due to the rapid deposi- tion throughout the body, but especially in the lungs, of the gray tubercle-granule: characterized by high fever, cough, profuse expec- toration and rapid prostration. Causes. Most common between puberty and middle life. " That the gray granulation is deposited throughout the body under the influence of certain conditions of irritation, it is necessary that a peculiar vulnerability of the constitution exist, in other words, that it be of the scrofulous type." The result of caseous or suppurative changes in the lungs. Pathological Anatomy. "The gray granulation or miliary tubercle consists of a fine reticulation of fibres, with a mass of epi- thelioid cells and granules, and often having a giant cell for its centre." The deposit is generally over both lungs and the bronchial tubes, and is followed by hyperaemia, increase of secretion, having a viscid and adhesive character, and the destruction of all the tissue with which it comes in contact. Deposits also take place in the brain, pleura, intestines, peritoneum and kidneys. Symptoms. The onset is usually sudden, with a chill or chilli- ness, followed by fever, io2°-io4° F., rapid, dicrotic pulse, 120-140, cough, with scanty, glairy sputum, increased respiration, 30-50 per minute, pain in the chest, hot skin, dry tongue, deranged digestion and great prostration, the severity of the symptoms rapidly increas- ing, the sputum becoming more abundant and often rusty in color, with more or less frequent attacks of hemoptysis, soon followed by headache, vertigo, sleeplessness, often delirium, coma and death. If deposits have occurred in the meninges or the intestines, symp- toms of these affections are superadded. Percussion. The percussion resonance is normal until consider- able deposits have occurred, when it is either slightly impaired or even slightly tympanitic. With the development of cavities the amphoric percussion note is present. Auscultation. Vesiculo-bronchial breathing, associated with large and small, moist or bubbling rales, soon followed by bronchial 23G PRACTICE OF MEDICINE. and broncho-cavernous breathing, with large and small, moist and circumscribed gurgling rales. Duration. Acute phthisis terminates fatally in from four to twelve weeks. Diagnosis. Commonly mistaken for typhoid fever with lung complications, an error that is readily made unless a close study of the history, symptoms and physical signs be made. Treatment. There are no means of retarding the progress of this malady. The various symptoms should be met as they occur, the patient at the same time being supplied with large quantities oi stimu- lants. EMPHYSEMA. Synonym. Vesicular emphysema. Definition. Dilatation of, or increase in the size and capacity of, the air vesicles, characterized by enlargement of the chest, difficulty of breathing, especially on exertion, and associated sooner or later with dilatation of the heart. Causes. The predisposing cause of emphysema is a hereditary nutritive derangement of the lung structure, often associated with a rigid enlargement of the thorax. The exciting cause is the result either of a too forcible and long con- tinued inspiration—the theory of inspiration—or the excessive mechan- ical distention of the vesicular walls by forced expiration—the theory of expiration. What is known as vicarious emphysema is a distention of the air cells of the healthy portion of the lung, some other part being the seat of consolidation. Interlobular emphysema is the presence of air in the spaces between the lobules of the lungs underneath the pulmonary pleura. Pathological Anatomy. The situation of vesicular emphysema is, in the majority of cases, the superior portions of the chest, and is more marked on the left side than on the right. An emphysematous lung feels remarkably soft to the touch, and upon cutting, a dull, creaking sound is barely perceptible. It is of a pale red color, the vesicular walls are thinner and slighter, the vesicles are greatly enlarged, sometimes to the size of a pea or bean, and have an irregular shape, and traversing most of these large cysts (dilated vesicles) a few delicate bands, the remains of the lacerated inter- DISEASES OF THE LUNGS. 2:57 alveolar septa, are visible. With the destruction of the septa many of the capillaries are destroyed, whereby the emphysematous tissue is remarkably bloodless and dry. In consequence of the destruction of so many of the capillaries, the obstruction to the pulmonary circulation becomes so great that the pul- monary artery and right cavities of the heart are greatly distended ; finally, the muscular tissue of the heart undergoes granular, followed by fatty degeneration. The distention of the veins results in a gen- eral venous stasis, to wit: nutmeg liver, congested kidneys, and gastro-intestinal catarrh. Symptoms. The chief symptoms of vesicular emphysema are difficulty of breathing, greatly aggravated on exertion, more or less cough, the result of an attending bronchitis, and the various symp- toms resulting from dilatation of the heart. The distress of the patient is often increased by paroxysms of asthma. Inspection. The shoulders are rounded, the intercostal spaces widened, the vertical diameter elongated, with circumscribed promi- nences between the clavicles and nipples, often increased by the act of coughing—the peculiar " barrel-shaped" chest characteristic of this disease. The character of the respiratory movements is marked, there being l but slight movement observed on forcible respiration, the chest hav- ing the constant appearance of a full inspiration. Palpation. The vocal fremitus is diminished, and the cardiac impulse depresssed and nearer to the sternum. Percussion. The resonance is increased (hyper-resonant) over all the emphysematous portions, and if the whole lung be involved, ex- tends to the seventh or eighth rib anteriorly, and to the twelfth rib posteriorly. The hepatic dullness may not begin until the inferior margin of the ribs is reached; the cardiac dullness is lessened, on account of the emphysematous lung nearly covering the heart. Auscultation. The vesicular murmur is weakened, and in pro- nounced cases almost absent. If bronchitis be present the inspiratory sound may be rough or sibilant in character, but its duration is always shortened. Expiration is always prolonged, and if bronchitis be present, may be associated with more or less pronounced moist or bubbling rales. The first sound of the heart is lessened in intensity and duration, the second sound being sharply accentuated. 238 PRACTICE OF MEDICINE. Diagnosis. Bronchitis is distinguished from emphysema by the absence of dyspnoea, hyper-resonance of the chest, changes in its shape, size and movements, and the disturbance of the circulation. Spasmodic asthma by the paroxysmal character of the affection, emphysema being a permanent malady, with attacks of asthma. Cardiac diseases due to other causes than emphysema do not have the characteristic physical signs of that affection. Prognosis. Vesicular emphysema is essentially a chronic dis- ease. In itself it rarely proves fatal, but if aggravated, from any cause, or if associated with frequent or prolonged asthmatic paroxysms the cardiac changes are hastened, general dropsy supervenes, death occurring from exhaustion, or, more commonly, as the result of inter- current attacks of pneumonia. Treatment. It being impossible to restore the altered lung struc- ture, the indications for treatment are to relieve the symptoms and to endeavor to prevent its further progress. For the relief oi the asthmatic paroxysms, morphine sulphas com- bined with atrophine sulphas may be used hypodermatically, or ext. quebracho fid., ,^ss-j, every hour until relief, or large doses oi potassii bromidum, frequently repeated. To prevent the progress of the affection, remove the bronchial catarrh, relieve the difficulty of breathing, and strengthen the cardiac action, no one combination seems comparable with the following:— R. Potassii iodidi......................................... gr. v Strychninae sulph....................................... gr. fa Liq. potassii arsenit................................... Xc\y Aq. lauro-cerasi........................................ fsjj. M. Sig.—Four times a day. But of all means hitherto proposed for the relief of emphysema, nothing has approached the inhalation of compressed air, by means of the apparatus of Waldenberg. The dropsy arising from failure of the heart to compensate for the circulatory derangement in the lungs, may be relieved for a time by the use of digitalis, or, if this fails, scilla combined with hydragogue cathartics. DISEASES OF THE PLEURA. 239 DISEASES OF THE PLEURA. PLEURISY. Synonyms. Pleuritis ; "stitch in the side." Definition. A fibrinous inflammation of the pleura, either acute, subacute or chronic in character, occurring either idiopathically or secondarily; characterized by a sharp pain in the side, a dry cough, dyspnoea and fever. It may be limited to a part, or may involve the whole of one or both membranes. Causes. Idiopathic pleuritis is said to be due to cold and expo- sure, to injuries of the chest walls, or the result of muscular exertion. Secondary pleuritis occurs during an attack of pneumonia, peri- carditis, rheumatism, smallpox, Bright's disease, or puerperal fever. Chronic pleurisy follows an acute attack, or is the result of tuber- culosis, Bright's disease, or alcoholism. Pathological Anatomy. The course pursued by an inflam- mation of a serous membrane is hyperemia followed by exudation of lymph, the effusion of fluid, its absorption and the adhesion of the membranes. The first or dry stage of pleurisy is hyperaemia or diffused, irreg- ular redness of the membrane, with little specks of exudation. The second stage is characterized by the copious exudation of lymph, more or less completely covering the membrane, giving it a dull, cloudy, or shaggy appearance. If the inflammation ceases at this point, it is termed dry pleurisy. The third, or stage of effusion, is characterized by the pouring out of a semi-fibrinous liquid ; more or less completely filling and distending the pleural cavity, and floating in the fluid are fibrinous flocculi, blood and epithelial cells. Absorption of the fluid and more or less of the exudative lymph soon occurs, the unabsorbed portion becoming organized, forming adhesions which obliterate the pleural cavity. The effusion, if on the right side, pushes the heart further to the left; if on the left side, the heart is displaced to the right, the impulse often being seen to the right of the sternum. The lungs are also compressed and displaced upward and against the spinal column, and, on removal of the fluid, expand again, except in cases of chronic pleurisy, when the functional activity of the pulmonary structure is more or less permanently impaired. 240 PRACTICE OF MEDICINE. ChY-qnic pleurisy results when the fluid is not absorbed or when it is effused into the cavity in a slow and insidious manner. The mem- brane is irregularly thickened, with firm adhesions, fluid being found in the meshes, and depressions of the thoracic walls also occurring. The fluid may be serum, pus {empyema), or pus and blood. Openings may form, through which there is a permanent discharge, either ex- ternally (fistulous empyema) or into the bronchi, or rarely, into the bowels. Symptoms. Acute attack; Begins with a chill, followed by a sharp lancinating pain (stitch) near the nipple or in the axilla, aggra- vated by coughing and breathing, associated with slight tenderness on pressure. The respirations are rapid and shallow, 30—35 per minute, a short, dry, hacking cough, moderate fever, compressible pulse, 90- 120. With the effusion of liquid the dyspnea becomes aggravated, the cough more distressing, the cardiac action embarrassed, the coun- tenance wearing an anxious expression, the patient usually lying on the affected side. With the absorption of the fluid the symptoms gradually ameliorate, convalescence being more or less rapid. Subacute attack; Begins insidiously after cold, exposure and fatigue in those enfeebled. Patients usually complain of a sense of weariness, shortness of breath, aggravated on exertion, evening fever, followed by night sweats, short, harassing cough, none or very scanty sputum; the pulse is small, feeble but frequent, 100-120 beats per minute. The characteristic pain in the side is usually wanting. Chronic variety, irregular chills, fever, night sweats, dyspnoea, palpitation, embarrassed circulation, with more or less prostration. Inspection. First stage, deficient movement of the affected side, on account of the pain induced by full breathing. Second stage, bulging or fullness of the affected side, with oblitera- tion of the intercostal spaces and displacement of the cardiac impulse. Palpation. Second stage, vocal fremitus feeble or absent over the site of the effusion, exaggerated above the site of the fluid. Rarely■, fluctuation may be obtained. Percussion. First stage, may be slightly impaired. Second stage, dullness or even flatness over the site of the effusion ; tympanitic percussion note above the fluid. Auscultation. First stage, feeble vesicular murmur over the affected side, the patient breathing superficially, to prevent the pain ; a friction sound, slight and grating or creaking, becoming louder as DISEASES OF THE PLEURA. 241 the exudation of lymph increases, limited usually to the angle of the scapula of the affected side, rarely heard over the entire side, accom- panies the respiratory movements. Second stage, feeble or absent vesicular murmur on the affected side, depending upon partial or complete compression of the lungs by the fluid. Above the fluid puerile breathing, and just at the upper margin of the fluid a friction sound may be heard. The vocal resonance is diminished or absent over the site of the fluid and markedly increased above, egophony being present at the upper margin of the fluid. With the absorption of the fluid the vesicular murmur gradually returns, associated with a moist friction sound. Diagnosis. Acute pneumonia is often mistaken for the effusion stage of pleurisy. The points of distinction are,' in pneumonia there is the pronounced chill, high fever, and characteristic sputa, bronchial breathing, exaggerated vocal fremitus and resonance, and no displace- ment of the heart, the reverse occurring in pleurisy. Enlargement of the liver may be mistaken for pleurisy with effusion, the chief point of distinction being that, in enlargement of the liver, the superior line of dullness is depressed upon full inspiration, while in pleurisy with effusion inspiration does not modify the location of the dullness. Prognosis. Idiopathic pleurisy usually terminates in recovery within three weeks. Pleurisy the result of constitutional causes has its prognosis modified by the condition with which it is associated. Empyema, unless the result of a diathesis, terminates favorably. Double pleurisy is unfavorable. Treatment. At the onset, in plethoric patients, wet cups over the affected side; if great dyspnoea, severe pain and high arterial tension, even venesection, and in anaemic or weak persons, dry cups. The severe pain is promptly relieved by the hypodermatic injection of morphine sulphas, over its site, repeated as indicated. Tinct. verat. virid., or tinctura aconiti, in small doses, frequently repeated, in the plethoric, and digitalis in the weak, control the circu- lation, and lessen the amount of blood distributed to the affected membrane. After effusion has begun, extractum pilocarpi fluidum, gtt. xx, every two or three hours, or— u 242 PRACTICE OF MEDICINE. R. Potassii acetat....................................... gr. xxx Infus. digitalis....................................... 3'j- w- Every three or four hours. If the effusion be uninfluenced by the above, use potassii iodidum, gr. xv, every four hours, with flying blisters over the affected side ; or the fluid may be evacuated by aspiration, using at the same time full doses of mistura ferri et ammonii acetatis (Basham's mixture). The effusion of pleuritis is rapidly removed by the method of treat- ment suggested by Prof. Mathew Hay, of Scotland, consisting in the use of a concentrated solution of saline cathartics, "order the patient to take nothing after the evening meal, and then, an hour or so before breakfast, the salt is given dissolved in as little water as possible. Usual dose from 3 iv-vi to % i-ij magnesii sulphates to an ounce or two of water, no fluids to be used after the dose ; this usually produces from four to eight watery stools without pain or discomfort and also acts as a diuretic." The essence of the "Hay method " consists in getting the concen- trated solution into the intestines at a time when the fluid contents are scanty. If double pleuritic effusion, evacuate the fluid at once with the aspi- rator, and use the potassium and digitalis mixture mentioned above. Chronic pleurisy : if the effusion be still serous, it is often absorbed by the internal use oi potassii iodidum, alternating with "Basham's mix- ture," and blisters, the secretions being regularly attended to. If, how- ever, the liquid is pus (empyema), the aspirator should be used at once, the patient placed upon "Basham's mixture," stimulants and quinina. Usually, however, within a very few days after aspiration, another accumulation of pus will have taken place. Should this occur, the purulent pleurisy should then be treated as an abscess, an incision being made between the fifth and sixth ribs, the pus evacuated, a drainage tube introduced and an antiseptic dressing applied. If the tendency to pus secretion still remains the pleural cavity must be washed out with an antiseptic solution, the constitutional treatment being continued. HYDROTHORAX. Synonym. Dropsy of the pleura. Definition. The effusion of fluid into the pleural cavities (bilat- eral), the result of a general dropsy from renal or cardiac disease. DISEASES OF THE PLEURA. 243 Pathological Anatomy. More or less clear serous fluid in both pleural sacs, compressing the lungs. No signs of inflammation are present. Symptoms. Following dropsy of the abdomen occurs dyspnea, with signs of deficient blood aeration, both lungs being compressed. Palpation. Absent vocal fremitus over the site of the field. Percussion. Dullness over the site of the fluid. Auscultation. Absent vesicular murmur over the site of the fluid. Diagnosis. Easily determined by association of the symptoms with a general dropsy. Prognosis. Controlled by the cause producing the general dropsy. Treatment. Depending upon the condition causing the dropsy. Dry cups over the chest afford relief. If the symptoms of non-aera- tion of the blood are severe, the fluid should be at once evacuated with the aspirator. PNEUMOTHORAX. Synonyms. Air in the pleural cavity; hydropneumothorax. Definition. The accumulation of air in the pleural cavities, with the consequent development of inflammation of the membranes ; characterized by sharp pain, followed by rapidly developing dyspnoea and cough. Causes. Generally the result of tubercular phthisis, causing per- foration of the pleura. Perforation may take place from the pleura into the lung, in connection with empyema or abscess of the chest walls. Direct perforation from without, by laceration of a fractured rib or severe contusion. Pathological Anatomy. The gas in the pleural cavity consists of oxygen, carbon anhydride, and nitrogen in variable proportions. It may fill the pleural sac completely, compressing the lung, or is sometimes limited by adhesions. The gas tends to excite inflamma- tion, the resulting effusion being either serous or purulent. Symptoms. Symptoms of pneumothorax, the result of perfora- tion, are sudden or sharp pain in the side, intense dyspnea, attended with symptoms of collapse, coldness of the surface and cold sweats. The above symptoms, in many instances, follow a severe or violent paroxysm of coughing. In severe cases there is never a moment's 244 PRACTICE OF MEDICINE. cessation of the acute pain and distressing dyspnoea, causing orthop- noea from the onset until death. Inspection. Enlargement of the affected side, the intercostal spaces being widened and effaced, or even bulged out so that the surface of the chest is smooth. Respiratory movements of the affected side are diminished or absent. Percussion. Immediately after the rupture the percussion note is hyper resonant, or even tympanitic or amphoric in quality. If the amount of air in the pleural cavity become extreme there is dullness on percussion, associated with a feeling of great resistance or density. When effusion of blood occurs dullness is observed over the lower part of the chest, hyper-resonant or tympanitic percussion note over the upper portions of the chest, these sounds changing as the patient changes his position. Auscultation. The normal vesicular murmur may be diminished or absent. The typical amphoric respiratory sound is heard when the fistula is open, usually associated with a metallic echo. Metallic tinkling, or the bell sound, is sometimes distinctly pro- duced by breathing, coughing or speaking, after the development of inflammation of the pleura. The vocal resonance may be diminished or absent, or, rarely, it may be exaggerated, with a distinct metallic echo. After the development of inflammation in the pleura, suddenly shaking the patient gives rise to a splashing sensation, the succussion sound, if both air and fluid are present in the pleural cavity. Prognosis. When occurring as the result of tuberculosis, the prognosis is extremely unfavorable; rarely, the fistulous opening being enclosed by inflammatory action ; the case then becomes one of chronic pleurisy. Treatment. At once a hypodermatic injecti6n of morphine sulphas, which relieves the severe pain and somewhat modifies the distressing dyspnoea, followed by the evacuation of the fluid and air with the aspirator. If the fistulous opening be closed by inflammatory action, the case resolves itself into one of chronic pleurisy, the treatment indicated for that affection plus the treatment of tuberculosis, being the indication. DISEASES OF THE CIRCULATORY SYSTEM. 24-"i DISEASES OF THE CIRCULATORY SYSTEM. The methods employed in making a physical examination of the heart are: I. Inspection. II. Palpation. III. Percussion. IV. Aus- cultation. Inspection indicates the exact point of the cardiac impulse, and whether there be any abnormal pulsations or any change in the form of the precordium. Normally the impulse is visible only in the fifth interspace, midway between the left nipple and the left border of the sternum, its area covering about one square inch, most distinct in the thin, while often barely seen in the very fleshy; often displaced downward by full in- spiration and elevated by complete expiration. Disease may alter the position and area oi the impulse. The position of the impulse is moved to the right by left pleuritic effusions ; downward by hypertrophy or emphysema ; upward by pericardial effusion. The area oi the impulse is changed and enlarged by pericardial adhesions, cardiac dilatation, or hypertrophy. Palpation confirms the observations of inspection, and also deter- mines the force, frequency and regularity of the cardiac impulse. The impulse is diminished by cardiac dilatation, fatty degeneration of the heart, emphysema, pericardial effusion, and adynamic diseases. The impulse is increased by cardiac hypertrophy, during the first stage of endocarditis and pericarditis, functional cardiac disturbances and sthenic inflammations. Percussion will indicate the boundaries of the superficial and deep cardiac space, the so-called precordium. It is essential that the upper, lower, and two lateral boundaries of the pericardial region be memorized, to wit: superior boundary, the upper edge of the third rib ; the lower boundary is a horizontal line passing through the fifth intercostal space; the left lateral boundary is about or a little within a vertical line passing through the nipple, the linea mammalis ; and the right lateral boundary is an imaginary vertical line situated one- half an inch to the right of the sternum. These boundaries vary somewhat in health, but are sufficiently accurate for all practical purposes. 246 PRACTICE OF MEDICINE. The superficial cardiac space represents that portion of the heart uncovered with lung; it is triangular in form, its apex being the junc- tion of the lower border of the left third rib with the sternum, its area not exceeding two inches in any direction. The superficial space is increased by cardiac hypertrophy, dilatation or pericardial effusion. Diminished at the end of full inspiration or by emphysema. The deep cardiac space represents that portion of the heart covered by lung, and extends from the upper border of the third rib to the lower edge of the fifth interspace, and from half an inch to the right of the sternum to near the left nipple. It is increased by hypertrophy or dilatation of the heart, left pleuritic effusion, and apparently increased by consolidation of the anterior border of the investing lung. Auscultation indicates the character of the normal cardiac sounds and the point of greatest intensity at which they are heard, and should be thoroughly familiarized if abnormal sounds are to be fully appreciated. The ear or stethoscope applied to the praecordium distinguishes two sounds, separated by a momentary silence—the short pause, and the second sound followed by an interval of silence—the long pause. The first sound, corresponding to the contraction of the heart—the systole—is louder, longer and of lower pitch and a more booming quality than the second sound, and has its point of greatest intensity at the cardiac apex or a little to the left. It corresponds closely to the pulsations as felt in the carotid or radial arteries. The second sound'is shorter, weaker and higher in pitch than the first sound, and has a clicking or valvular quality, having its point of greatest intensity at the second right costal cartilage and a little above, and corresponds to the closure of the aortic and pulmonary valves. The sound made by the closure of the tricuspid valves is best isolated at the ensiform cartilage. The sound made by the closure of the pul- monary valves at the third left costal cartilage. The extent of surface over which the cardiac sounds are heard varies, according to the size of the heart and the condition of the adjacent organs for transmitting sounds. The cardiac sounds may be altered in intensity, quality, pitch, seat and rhythm, or they may be accompanied, preceded or followed by adventitious or new sounds, the so-called endocardial murmurs. DISEASES OF THE CIRCULATORY SYSTEM. 247 The inte7isity is increased'by cardiac hypertrophy, irritability of the heart or consolidation of adjacent lung structure. The intensity is diminished by cardiac dilatation or degeneration during the course of adynamic fevers, emphysematous lung overlap- ping the heart, or pericardial effusion. The quality and pitch of the first sound may be sharp or short and of higher pitch when the ventricular walls are thin and the valves normal; its pitch and quality are also raised during the course of low fevers. The second sound becomes duller and lower in pitch when the elasticity of the aorta is diminished or the aortic valves thickened. Either or both sounds have a more or less metallic quality in irritable heart and during gaseous distention of the stomach. The seat of greatest intensity of the cardiac sound is changed by displacement of the heart, pleuritic effusion, pericardial effusion, and abdominal tympanites. The rhythm is often interrupted by a sudden pause or silence, the heart missing a beat, or the sounds are irregular, confused and tumul- tuous, the result of organic changes in the cardiac muscles, valves, or orifices ; or a reduplication of one or both sounds of the heart may occur. The adventitious cardiac sounds or murmurs are of two kinds, those made external to the heart, as pericardial, exocardial or frictional murmurs, and those made within the cardiac cavity, endocardial murmurs. Pericardial murmurs, or friction sounds, are made by the rubbing upon one another of the roughened surfaces of the pericardial mem- brane during the early stage of inflammation. The sounds have a rubbing, creaking, or grating character, and are differentiated from a pleural friction sound by their being limited to the praecordium, syn- chronous with every sound of the heart, and not influenced by respi- ration. They are distinguished from an endocardial murmur by their super- ficial rubbing, creaking or grating character, and by not being trans- mitted beyond the limits of the heart, either along the course of the vessels, or to the left axilla, or back. Endocardial murmurs are of two kinds, to wit : organic and func- tional. Functional endocardial or blood murmurs are the result of some change in the natural constituents of the blood. 248 PRACTICE OF MEDICINE. Their character is soft, they are heard most distinctly at the base to the left of the sternum, during the systole, are not transmitted beyond the limits of the heart, either to the left axilla or the back, and are associated with general anaemia. Organic endocardial murmurs are produced by blood currents pur- suing either a normal ox an abnormal direction. In health there are two direct blood currents upon each side of the heart, to wit: the current from the left auricle to the left ventricle, the mitral direct current; the current from the left ventricle to the aorta, the aortic direct current; the current from the right auricle to the right ventricle, the tricuspid direct current, and the current from the right ventricle to the pulmonary artery, the pulmonic direct current. When, from disease, the valves are not properly closed, the blood is allowed to flow back against the direct current, producing abnormal blood currents, to wit: when the mitral valve is incompetent, the blood flows from the left ventricle back to the left auricle during the cardiac systole, producing the mitral regurgitant or indirect current; when the aortic valves are incompetent, the blood is permitted to flow from the aorta into the left ventricle during the cardiac systole, producing the aortic regurgitant or indirect current; when the tricuspid valves are incompetent, the blood flows from the right ven- tricle back into the right auricle during the systole, producing the tricuspid regurgitant or indirect current; when the pulmonary valves are incompetent, the blood flows from the pulmonary artery into the right ventricle, producing the pulmonic regurgitant or indirect current. The mitral direct current occurs during the contraction of the left auricle, or just before the first sound of the heart and immediately after its second sound. The aortic direct current is produced by the contraction of the left ventricle, and occurs with the first sound of the heart. The tricuspid direct current occurs during the contraction of the right auricle, or just before the first or immediately after the second sound. The pulmonic direct current is produced by the contraction of the heart, occurring during its first sound. The ?nitral direct, or presystolic murmur, occurs before the first sound of the heart and immediately after the second sound. It is caused by a narrowing of the mitral orifice, has a blubbering quality, well imitated by throwing the lips into vibration by the breath, of a low pitch, and it has its seat of greatest intensity at the cardiac apex, and is not transmitted to the left axilla or to the base of the heart. DISEASES OF THE CIRCULATORY SYSTEM. 249 The mitral regurgitant, or systolic murmur, occurs with the first sound of the heart, resulting from the failure of the mitral valves to close the mitral orifice during the systole, in consequence of which the blood flows back, or regurgitates into the left auricle. It is usually of a blowing or churning character, and has its seat of greatest in- tensity at the cardiac apex, being well transmitted to the left axilla and inferior angle of the left scapula. The aortic direct murmur dccurs with the first sound of the heart. It is caused by a narrowing of the aortic orifice, has a rough or creak- ing character, is of high pitch, having its seat of greatest intensity in the second intercostal space, to the right of the sternum, and is well transmitted over the carotid artery. The aortic regurgitant murmur occurs with the second sound of the heart, and is caused by the failure of the aortic valves to close the aortic orifice during the diastole, whereby the blood flows back or regurgitates into the left ventricle. It is usually of a blowing or churning character and of low pitch, having its seat of greatest in- tensity over the base of the heart, and is well transmitted downward toward or below the cardiac apex. It is the only organic murmur produced in the left side of the heart which occurs with the second sound of the heart. The tricuspid direct murmur occurs before the first sound of the heart and immediately after the second sound. It is caused by a nar- rowing of the tricuspid orifice, has a blubbering quality, and is low in pitch, having its seat of greatest intensity near the ensiform cartilage. This murmur is exceedingly rare. The tricuspid regurgitant muntiur occurs with the first sound of the heart, the result of the failure of the tricuspid valves to close the tricuspid orifice during the systole, thus allowing the blood to flow 'back or regurgitate into the right auricle. It is usually of a blowing or soft, churning character, having its seat of greatest intensity at the ensiform cartilage. This murmur is also very infrequent, and occurs mostly when the right ventricle is considerably dilated, without the existence of any valvular disease. The pulmonic direct murmur occurs with the first sound of the heart. It is generally connected with congenital lesions. It occurs at the same instant that the aortic direct murmur occurs, and is distin- guished from the latter by its not being transmitted into the carotid artery, whereas the aortic direct murmur is always thus transmitted. v 250 PRACTICE OF MEDICINE. The pulmonic regurgitant murmur occurs, like the aortic regurgi- tant murmur, with the second sound of the heart. This murmur is exceedingly rare, and its presence is only positively differentiated from aortic regurgitant by the absence of aortic lesions and symptoms. ACUTE PERICARDITIS. Definition. An acute fibrinous inflammation of the pericardium ; characterized by slight fever, pain, praecordial distress and disturbed cardiac action and circulation. Causes. May follow injuries of the chest walls, but generally secondary to either acute articular rheumatism, pneumonia, pleurisy, erysipelas, Bright's disease or pyaemia. Pathological Anatomy. The same as serous membranes in other situations. Hyperemia of the membrane, most marked on the visceral layer, followed by the exudation of lymph scattered in irregular patches, giving it a rough and shaggy appearance (dry pericarditis), followed by the effusion of a sero fibrinous fluid, with flocculi floating on it, and at times mixed with blood. Rarely, the fluid is purulent. The fluid and lymph undergo absorption with resulting adhesions identical with those described under pleurisy. Sympt6ms. Acute pericarditis may be well marked and still present none of the characteristic subjective symptoms. It usually begins with rigors, fever, precordial distress, acute shooting pains, increased by breathing and coughing, tenderness, dry, suppressed cough, increased cardiac action, sometimes violent palpitation. Dura- tion of this early stage from a few hours to a day. Effusion stage : the symptoms of this stage depend upon the amount and rapidity of the effusion : precordial oppression, tendency to syn- cope, dyspnea, sometimes amounting to orthopnoea, dysphagia, hic- cough, nausea and vomiting, feeble, irregular pulse, sometimes either melancholia, delirium, or acute maniacal excitement, Absorption is generally rapid, the heart remaining " irritable " for a long time after. If instead of absorption, the fluid accumulates, and life is not destroyed, the pericardial sac becomes dilated, chronic pericarditis resulting. Inspection. Early stage, excited cardiac action is evidenced by the impulse. DISEASES OF THE CIRCULATORY SYSTEM. 251 Effusion stage, feeble, undulatory or absent impulse, its position displaced upward, or rarely, downward ; bulging of the praecordium and protruding abdomen. Palpation. Early stage, excited or tumultuous impulse; peri- caxdiaX friction fremitus rare. Effusion stage, feeble or absent impulse, and if present its position is changed. Percussion. Early stage, normal. Effusion stage, cardiac dullness enlarged vertically and laterally, and if considerable fluid, of a triangular shape, with the base of the triangle on a line with the sixth rib, extending from the right of the sternum to the left of the left nipple, narrowing as it proceeds upward to the second rib, or above, which represents the apex of the triangle. The shape of the dullness is sometimes altered by changing the position of the patient. Auscultation. Early stage, excited cardiac action, and usually a friction sound (exocardial murmur) synchronous with cardiac sounds and uninfluenced by respiration, but often increased by pressure with the stethoscope. Effusion stage, cardiac sounds feeble and deep-seated at the cardiac apex, becoming louder and distinct toward the cardiac base. The friction sound is sometimes heard at the cardiac base. If absorption occur the above signs gradually give place to the normal, the friction sound returning, of a churning, or clicking, or grating character, gradually disappearing. Diagnosis. Endocarditis is often confounded with pericarditis, the points of distinction between which will be pointed out when discussing that affection. Cardiac hypertrophy or dilatation is sometimes confounded with pericardial effusion ; the difference between them will be pointed out when discussing those affections. Hydropericardium may be mistaken for pericardial effusion ; see that affection. Prognosis. Controlled by the severity of the inflammation and coexisting affections. If slight effusion, favorable. Death has rapidly occurred when a large quantity of fluid has been rapidly effused, the result of cardiac paralysis. Adherent pericardium is a frequent sequela. Treatment. Perfect rest in bed ; for vigorous patients, the appli- 252 PRACTICE OF MEDICINE. cation of leeches or wet cups to the praecordium, followed by the application of either ice or poultices ; in the feeble dry cups to the praecordium, followed by poultices. Early stage; in the strong, control the excited cardiac action by small doses of aconitum or veratrum viride, in the feeble using digi- talis ; in all cases quinina is indicated. Effusion stage; as the effusion progresses the free administration of alkalies, to wit: ammonii carb., gr. v, every two hours, with liquor ammonii ace tatis, or potassii ace tat, ox potassii carbon., with quinina, nutritious liquid diet and stimulants, being cautious with the use of cardiac sedatives or tonics. If the effusion has a tendency to linger, blisters to the praecordium, ox paracentesis, is indicated. CHRONIC PERICARDITIS. Definition. A chronic inflammation of the pericardium, with either distention of the sac by fluid or adhesions of the pericardium (adherent pericardium) ; characterized by impaired cardiac action and disturbances of the circulation. Causes. Almost always the result of an acute attack. Pathological Anatomy. If the effusion be absorbed, the peri- cardial surfaces are agglutinated by several layers of lymph, which increase the thickness of the membranes half an inch or more, and the outer surface of the pericardium becomes adherent to the chest walls. If the fluid be not absorbed it may progressively accumulate, dis- tending the sac in all directions, displacing the diaphragm, interfering with the functions of the surrounding viscera, or a low grade of inflammation supervenes, the fluid becoming purulent, the disease terminating fatally after a variable period. As much as eight to ten pints of fluid have accumulated in the sac. Symptoms. Precordial pain and distress, irregular, feeble car- diac action, dyspnea, aggravated by movement and disturbed circu- lation. An agglutinated pericardium seriously increases the danger from an attack of any pulmonary inflammation. Inspection. If the effusion be present, bulging of the praecor- dium and displacement of the impulse. DISEASES OF THE CIRCULATORY SYSTEM. 253 If adhesions are formed between the praecordial surfaces as well as with the chest walls, inspection reveals depression of the precordium, narrowing of the spaces, increased extent but displaced impulse, un- influenced by deep inspiration, and recession of the intercostal spaces (systolic dimpling) and epigastrium with every systole of the heart, the result of the adhesions. Palpation. If effusion, displaced, feeble or absent impulse ; if adhesion, displaced and tumultuous impulse; occasionally a peri- cardial fremitus is distinguished. Percussion. If effusion, the dullness has more or less the char- acter described for acute pericarditis. If adhesions, the cardiac dullness is but slightly modified. Auscultation. If effusion, cardiac sounds feeble and deep-seated at the apex, louder and more distinct at the cardiac base. If adhesions, cardiac sounds are heard with equal distinctness in their several positions, associated with a rough friction sound (exo- cardial murmur). Treatment. If effusion, blisters to the praecordium, with potassii iodidum to hasten absorption, the patient supported by nutritious diet, quinina, ferrum and stimulants, and perfect quiet. If these means fail to remove the fluid, or if the fluid be purulent, paracentesis should be performed at once. If adhesions of the pericardium have resulted, the application of blisters to the praecordium with the administration of potassii iodi- dum, alternating with ferrum and quinina are indicated, with nutri- tious diet, stimulants and perfect quiet. HYDRO-PERICARDIUM. Synonym. Pericardial dropsy. Definition. The accumulation of water in the pericardial sac, minus inflammation ; characterized by praecordial distress, disturbed cardiac action, dyspnoea and dysphagia. Causes. Usually a part of a general dropsy ; Bright's disease; sudden pneumothorax ; pressure of an aneurism or other mediastinal tumor; disease or thrombosis of the cardiac veins. Pathological Anatomy. The fluid may range in quantity from an ounce to one or two pints, and is of a clear, yellowish or straw- colored serum, at times turbid or bloody, and of an alkaline reaction. 254 PRACTICE OF MEDICINE. If the amount of fluid be large the sac is dilated, its walls thinned by the pressure, and has a sodden appearance. Symptoms. Dropsy of the pericardium is so generally associated with hydrothorax that the symptoms are but an aggravation of those attending upon that condition, to wit: disturbed cardiac action, dysp- nea, dysphagia, dry cough, and feeble circulation. The physical signs are exactly those of the stage of effusion of pericarditis, minus a friction sound. Diagnosis. Pericarditis with effusion and hydro-pericardium present nearly the same signs and symptoms, a differentiation being possible only by a history of the case and the symptoms of the attack. Prognosis. Controlled entirely by the cause. Treatment. Depends upon the cause of the attack. If the amount of fluid in the pericardial sac be great, paracentesis will give relief. ACUTE ENDOCARDITIS. Synonym. Valvulitis. Definition. An acute fibrinous inflammation of the serous mem- brane lining the cavity of the heart and forming its valves ; charac- terized by cough, dyspnoea, nausea and vomiting, disturbed cardiac action, resulting in changes in the valves or orifices of the heart. Causes. Usually secondary to acute articular rheumatism, pleu- ritis, pneumonia, pericarditis or Bright's disease. Pathological Anatomy. Inflammation of the endocardium is usually limited to the left side of the heart after birth, during foetal life the reverse being the case. The inflammation is limited or espe- cially marked at the valvular portions of the endocardium, owing probably to the presence of fibrous tissue beneath the membrane in these situations, and to the strain which falls upon the valves during the performance of their functions. Hyperemia from congestion of the vessels beneath the membrane, with considerable swelling of the valves, the result of an exudation of lymph and serum beneath and on the free surface of the membrane covering the valves and chorde tendinee, resulting in the roughening of the surfaces and the agglutination of the mitral valves to each other, and of the aorta segments to the walls of the aorta, or the pro- liferation of the endocardial connective tissue, forming the nuclei of the so-called warty excrescences or vegetations, their size being in- DISEASES OF THE CIRCULATORY SYSTEM. 255 creased by the deposit of fibrin from the blood within the cavities of the heart. These vegetations may be detached by friction, giving rise to emboli which may be washed by the blood current on the left side of the brain, into the kidneys and spleen. Rarely, ulceration of the endocardium follows the above phe- nomena. Symptoms. This affection is usually masked by the course of another disease until disturbances of the circulation direct attention to the heart. The onset is often by increase of temperature, precordial distress, short cough, slight dyspnea, more or less persistent vomiting, in- creased cardiac action, often rapid and tumultuous, with throbbing carotids and noises in the ear. As the inflammation progresses, the cardiac action and pulse decline in rapidity, with more or less con- gestion of the lungs and venous stasis. Auscultation. Shows a change in the character of the sounds or the development of murmurs at the various orifices, the character and points of distinction between which will be pointed out when discussing valvular diseases of the heart. Duration. Between one and three weeks. Diagnosis. Pericarditis is distinguished from endocarditis by the character of the physical signs. In pericarditis the murmur or friction sound is heard with either sound, is near to the ear and influenced by pressure of the stethoscope, besides being associated with more or less alteration in the size and shape of the cardiac dullness, and is not transmitted, while in endocarditis the murmur takes the place of, or is associated with, the cardiac sounds, and is transmitted, with the absence of change or increased dullness on percussion. Prognosis. Acute endocarditis is not very dangerous to life, hence a favorable prognosis may be given ; regarding the ultimate results of valvular lesions, however, the prognosis is grave. Treatment. Perfect rest in bed. At the onset leeches or wet cups to the praecordium, followed by ice, or, what is preferable, poultices. The excited circulation should be controlled by aconitum, veratrum viride, or digitalis. The free administration of alkalies, to wit: ammonii carbonas, potassii acetas or carbonas, until the urine is decidedly alkaline, may prevent permanent changes of the valves or orifices. 250 PRACTICE OF MEDICINE. If alkalies fail and the inflammation shows a tendency to linger, good results are often obtained by a slight hydrargyrum impression. If signs of oppressed circulation appear, the hands becoming blue, the face and extremities oedematous, with congestion of the lungs, the free use of ammonii carbonas, digitalis and stimulants are indi- cated. The free use of ammonii carbonaswill often prevent or break up heart clots. After the acute symptoms have subsided, more or less absorption of the exuded lymph has followed the free use of potassii iodidum. During the entire course of the affection the diet should be of the most nutritious character. ACUTE MYOCARDITIS. Definition. An inflammation of the muscular tissue of the heart, by extension from an inflamed pericardium or endocardium, or secondary to pyaemia; characterized by pain, feeble circulation, symptoms of blood poisoning and collapse. Causes. The result of endocarditis or pericarditis; pyaemia ; typhoid fever; emboli of the coronary arteries. Pathological Anatomy. Discoloration and softening of the cardiac substance and the infiltration of a sero-sanguinous fluid, fibrinous exudation and pus, leading to the formation of abscesses in the muscular structure of the heart. The disease leads to the formation of either a cardiac aneurism or to rupture of the walls of the heart. If recovery occur, cicatrices or depressed scars may mark the site of a former abscess. Symptoms. The clinical evidences of inflammation of the car- diac muscle are very obscure. If, during the course of one of the maladies mentioned, there are developed pain, irregular and feeble cardiac action, pyrexia of a low type, with symptoms of blood poison- ing, and a tendency to collapse, or the symptoms of the so-called typhoid state, myocarditis may be suspected. Diagnosis. The existence of myocarditis can scarcely ever be anything but a presumption, the signs being all negative rather than positive. If during the course of rheumatism, pyaemia, puerperal fever, typhoid fever, pericarditis or endocarditis, symptoms of cardiac failure appear suddenly, associated with signs of blood poisoning and collapse, inflammation of the cardiac muscle may be suspected. Prognosis. The course of acute myocarditis is very rapid, death DISEASES OF THE CIRCULATORY SYSTEM. 257 being the usual termination, in from three to five days. Chronic myocarditis pursues a very latent course. Treatment. Largely symptomatic. Perfect rest of mind, generous diet, free stimulation and the administration of quinina and ferrum. CARDIAC HYPERTROPHY. Definition. An overgrowth or increase in the muscular tissue which forms the walls of the heart; characterized by forcible impulse, over-fullness of the arteries, diminished blood in the veins and accelerated circulation. Causes. Obstruction to the outflow of blood, to wit: aortic sten- osis; emphysema; Bright's disease ; functional over-action ; excessive use of tobacco, tea, coffee, or excessive muscular action. Varieties. I. Simple hypertrophy, or a simple increase in the thickness of the cardiac walls; II. Eccentric hypertrophy, increase in the cardiac walls and dilatation of the cavities, to wit :—Dilated hypertrophy; III. Concentric hypertrophy, increase in the cardiac walls and decrease of the cavities, a very rare form. Pathological Anatomy. Hypertrophy of the heart is usually limited to the left side, the ventricles more commonly than the auricles, the latter dilating. The shape of the heart is altered by hypertrophy; if the right ventricle, the heart is widened transversely and the apex blunted ; if the left ventricle, the heart is elongated and, as a rule, the cavity is dilated ; if both ventricles are hypertrophied, the heart has a globular shape. From increase in weight the heart may sink lower during the recumbent position, thereby lessening the area of cardiac dullness, but during the sitting or upright posture it sinks lower in the chest and to the left, causing more or less prominence of the abdomen. The increase in the size of the organ is a true increase or hyper- trophy of the muscular tissue, and not a hyperplasia. The tissue is firmer and the color brighter and fresher than when the size of the organ is normal. Symptoms. Depend upon the amount of hypertrophy. The most common are increased and forcible cardiac action, the arteries becoming fuller, the veins less full and the circulation accelerated, pulsating carotids and aorta, headache, often vertigo, frequent epis- taxis, congestion of the face and eyes, tinnitus aurium, dyspnea on 258 PRACTICE OF MEDICINE. exertion, dry cough, restless nights, with more or less jerking of the limbs, occasional praecordial pains shooting toward the left axilla, full, firm, bounding pulse, and pulsations in the superficial arteries. A sphygmographic tracing shows the line of ascent vertical and abrupt, but the apex is rounded, and the line of descent is oblique, unless there is more or less insufficiency of the valves. Inspection. Often fullness or prominence of the praecordium, with distinct impulse. Palpation. The impulse is felt one or two intercostal spaces lower down and to the left, and is stronger and more or less diffused— the heaving impulse. Percussion. The area of cardiac dullness is increased vertically and transversely upon the left side of the sternum, unless the right ven- tricle is also hypertrophied, when the cardiac dullness is increased to the right of the sternum. Auscultation. If simple hypertrophy without any coexisting changes in the valves or orifices, the first sound has a loud and some- what metallic quality, the second sound being strongly accentuated. Sequelae. Cerebral hemorrhage; miliary cerebral aneurisms; dilatation of the heart; fatty changes in the cardiac tissue. Diagnosis. Hypertrophy of the heart can scarcely be mistaken for any other disease if a careful study of the physical signs be made. Prognosis. When the result of valvular disease, the hyper- trophy is said to be compensatory. If the result of Bright's disease, emphysema of the lung, or if occurring late in life, or associated with atheromatous degeneration of the vessels, the prognosis is unfavorable; when the result of functional over-action in the strong and robust, a further enlargement can often be prevented by active and persistent treatment. Treatment. The indications are to lessen the force and number of the cardiac pulsations and to remove the cause whenever possible. The former indications are best met by the persistent use of aconi- tum in small doses, gtt. i-ij, three times a day, or veratrum viride, gtt. i-ij, three times a day, at the same time keeping the bowels, kid- neys and the skin acting freely. The habits of the patient are to be corrected, all laborious or active exercise to be restricted, the patient to be in the recumbent posture several hours during the day if possible, the diet being restricted, DISEASES OF THE CIRCULATORY SYSTEM. 259 avoiding all forms of stimulants, to wit: liquors, tobacco, tea and coffee. Cases of cardiac hypertrophy associated with anaemia should, in addition to the above, be placed upon a course oi ferrum. DILATATION OF THE HEART. Definition. An increase in the size of one or more of the cavities of the heart, without any increase or thickening of the cardiac walls; in fact, the walls are frequently thinner ; characterized by feebleness of the circulation, terminating in venous stasis, oedema and exhaustion. Causes. Over-exertion in those of feeble resisting powers, as youths or soldiers, as first pointed out by Prof. Da Costa; insufficiency of the valves; emphysema; chronic bronchitis ; gout; Bright's diseases. Varieties. I. Simple dilatation, the cavities being enlarged, the walls normal. II. Active dilatation, corresponding to eccentric hyper- trophy; the cavities being enlarged and the walls increased in thick- ness, the so-called "dilated hypertrophy." III. Passive dilatation, the cavities being enlarged and the walls thinned or stretched. Pathological Anatomy. The right side of the heart is far more frequently involved than the left side. The shape of the organ is altered, according to the part affected. The weight of the organ is, as a rule, increased, as hypertrophy almost always accompanies or precedes dilatation. The muscular tissue is generally pale, mottled and softened, and under the microscope presents evidences of degeneration. The orifices also participate, and especially the auriculo-ventricular, resulting in the valves becoming incompetent to close the orifices, and this latter effect is added to by the removal of the basis of the papillary muscles to a great distance from the orifice, in consequenee of the extension of the wall. When the auricles dilate, the large venous trunks opening into them unprotected by valves commonly participate in the dilatation, and may become greatly enlarged. The passive congestion of the organs that follows the feeble circu- lation produces changes in their structure. Symptoms. Those associated with enfeebled circulation, to wit: feeble pulse, veins distended, arteries emptied, headache, aggravated by the upright position, attacks of syncope, cough, with any of the fol- 260 PRACTICE OF MEDICINE. lowing phenomena of venous congestion; of the lungs, dyspnea; liver, jaundice; stomach, dyspepsia; intestines, constipation; kid- neys, scanty often albuminous urine ; brain, dullness of the mind and vertigo, often relieved by a copious epistaxis; and, finally, dropsy, beginning in the lower extremities, the patient dying from exhaustion. Great relief often temporarily follows any of the above symptoms under treatment; sooner or later, however, the venous stasis produces the final symptoms noted. Inspection. Veins of the surface distended and enlarged ; in- distinct cardiac impulse, often diffused and wavy ; if associated with tricuspid insufficiency, there is pulsation of the jugular. Palpation. Feeble and irregular fluttering but heaving impulse. Percussion. Cardiac dullness extended transversely, and espe- cially increased on the right side. Auscultation. If no valvular lesion accompany the dilatation the cardiac sounds are weaker than normal, the first sound having a sharper quality than normal ; if accompanied by valvular lesions, cardiac murmurs are present. Diagnosis. Hypertrophy of the heart shows increased cardiac dullness, and is a disease of powerful cardiac action, while dilatation is an affection of feeble action associated with dropsy. Pericardial effusion has many points of resemblance to cardiac dilatation, but it begins suddenly, associated with some acute malady; and while the heart sounds are indistinct or feeble at the apex, they both have their normal qualities at the cardiac base, while dilatation of the heart has a chronic history, results in general venous stasis, the cardiac sounds being of the same intensity over the entire praecordia. Prognosis. Unfavorable, death resulting from gradual exhaus- tion, or suddenly by cardiac paralysis if there be undue excitement. Treatment. The general nutrition of the patient must be pro- moted to the uttermost. Generous diet, moderate exercise, with bitters to increase the appetite and ferrum to improve the blood, and, in a majority of cases, the more or less free use of a good red wine. The heart tonics are digitalis in powder or infusion ; ext. conval- larie,fid., gtt. v, t. d., quinina, caffeina and morphina sulph., in small doses, the latter when the dropsy becomes great and associated with marked cyanosis, hypodermatically, as suggested by Prof. Bartholow, " often acts like magic in restoring the circulation." DISEASES OF THE CIRCULATORY SYSTEM. 261 The following pill is often of great advantage, to wit :— R. Ferri redact................................... ___ gr-j-ij Quininas sulph..................................... gr-j-ij Pulv. digitalis...................................... gr.j Morphinae sulph................................... gr.-1 . M. Sig.—Three times a day. The secretions should be stimulated by purgatives, diuretics and diaphoretics. If pulmonary congestion, dry cups, digitalis and stimulants. For cardiac asthma, dry cups, morphine sulph. hypodermatically, or spts. etheris compositus (Hoffman's Anodyne). For hepatic congestion, blue mass or podophyllin. For dropsy, dry cups over the kidney, digitalis or potassii acetas, with scoparius and juniperus, and pulv. jalape comp., 3 j-ij, in water, before breakfast. If the dropsy is uninfluenced by the above means, success will follow the use of hydrargyri chlor. mite, gr. iij, guarded with pulv. opii, gr. fa, three or four times a day, as I have frequently witnessed. FATTY DEGENERATION OF THE HEART. Definition. A change in the muscular fibres of the heart, in which the transverse striae are replaced by granules and globules of fat; characterized by feeble cardiac action, venous stasis and dyspnoea. Causes. Impaired nutrition in the elderly ; prolonged anaemia ; chronic gout; alcoholism; phosphorus poisoning; cancer, tubercu- losis and scrofula; disease of the coronary arteries. Pathological Anatomy. The distinction must be made be- tween a deposit of fatty tissue upon or around the heart, and the degeneration of its muscular tissue. The fatty metamorphosis may affect the whole organ, or the entire ventricles, or be limited to portions of them. If the degeneration be marked the color is yellowish, the tissues soft and easily torn, and to the touch have a greasy feeling, oil being yielded on pressure. The microscopic changes are characteristic. The striae of the muscle are easily rendered indistinct by fat and oil globules, gradually becoming more and more obscured, and finally disappearing alto- gether, the fibres being replaced by fat granules. 262 PRACTICE OF MEDICINE. Symptoms. Those of weak heart, anaemia of organs and venous stasis, to wit: feeble, irregular, but slow cardiac action, compressible pulse, precordial distress, often aggravated by attacks of angina pec- toris ; dyspnea, aggravated on exertion, with anaemia of the various organs from the feeble propulsive power ; if of brain, vertigo, swoon- ing, or pseudo-epileptic attacks, especially marked on suddenly rising from a recumbent position ; if of lungs, dry, hacking cough ; if of gas- tro-intestinal tract, dyspepsia and constipation ; if of kidneys, scanty urine, at times albuminous; and finally, dropsy, beginning in the lower extremities. A formidable symptom, causing much inconvenience as well as alarm to the patient, is what he will term his constant " sighing," the Cheyne-Stokes breathing—"A pause in the breathing, a complete suspension of the respiratory acts for a period of time (during which breathing might occur several times in the normal manner), then the resumption of respiration very feebly and slowly, and a gradual and progressive increase in the number and depth of respirations until the maximum is reached, and then again a gradual and progressive diminution, in the same order, in the number and depth of the res- pirations, until another pause occurs"—the "oscillating respiration." Concomitant symptoms are atheromatous change in the vessels, and the arcus senilis. Palpation. Weak cardiac impulse. Percussion. Not markedly changed unless preceded by enlarge- ment of the heart. Auscultation. First sound feeble, toneless, almost inaudible, the second sound being normal, unless changes in the valves are present. Diagnosis. If aged persons, or those exposed to the causes, have feeble heart, associated with atheroma of the vessels and the arcus senilis, the diagnosis of fatty heart is almost positive. If dropsy occur, however, it is difficult to distinguish from dilatation of the heart. Prognosis. Incurable, the affection pursuing a more or less chronic course. Life may be prolonged at times by treatment, but death finally results from exhaustion, or suddenly, from cardiac paralysis or rupture of the heart. Treatment. Palliative. Generous diet, very moderate exercise, stimulants, oleum morrhue, and the " triple elixirs,"—elixir ferri, quinine et strychnine. DISEASES OF THE CIRCULATORY SYSTEM. 263 To sustain the cardiac action, caffeina or morphina in small doses, or hypodermatically for the so-called cardiac asthma. Digitalis is contra-indicated in advanced cases. VALVULAR DISEASES OF THE HEART. Definition. Alterations in the cardiac valves or orifices, render- ing the former incapable of properly closing the latter, or causing the latter to interrupt the blood current in its normal movement. The lesions are of two kinds, to wit: obstructive and regurgitant. A regurgitant lesion, termed also insufficiency, is such change in the valves as to permit a portion of the blood to flow backward instead of onward, the true direction of the blood current. An obstructive lesion, termed also stenosis, is a narrowing of the orifice, thereby obstructing the passage of the blood. Varieties. I. Mitral regurgitation. II. Aortic regurgitation. III. Tricuspid regurgitation. IV. Pulmonic regurgitation. V. Mitral obstruction. VI. Aortic obstruction. VII. Tricuspid obstruction. VIII. Pulmonic obstruction. Causes. In the young, usually the result of endocarditis, and generally affecting the mitral orifice or valves; in the elderly, chronic endocarditis or atheromatous degeneration, most commonly affecting the aortic orifice or valves. Prof. Da Costa has clearly established the production of aortic dis- ease in early life by overwork and strain of the heart. Syphilis; dila- tation of the heart; atrophy or contraction of the valves, and con- genital malformations. MITRAL REGURGITATION. Pathological Anatomy. The most common conditions ob- served are more or less contraction and narrowing of the tongues of the valves, with irregular thickening and rigidity ; atheroma or calci- fication of the segments ; laceration of one or more segments; adhe- sion of one or more segments to the inner surface of the ventricle; rupture of the chorde tendinee, and also contraction and hardening of the musculi papillares. As a result of the regurgitation of the blood into the left auricle, there is dilated hypertrophy. Symptoms. Insufficiency of the mitral valves soon leads to car- 264 PRACTICE OF MEDICINE. diac hypertrophy to compensate for the diminished amount of blood sent onward by the ventricular systole. When the " compensation ruptures" occur, precordial distress, cough, dyspnea, feeble, soft, rapid, irregular pulse; finally pulmonary congestion, oedematous limbs, the abdominal cavity filled, liver congested, urine scanty and albuminous, the patient dying "drowned in his own fluid." Inspection. Cardiac impulse lower than normal, the heart being enlarged. Palpation. Early, forcible and diffused impulse; later, feeble diffused impulse. Percussion. Transverse and vertical cardiac dullness increased. Auscultation. Systolic blowing or churning murmur, audible in the mitral area, propagated to the apex, left axilla and under the angle of the scapula, either occurring with or taking the place of the first sound of the heart; the second sound markedly accentuated. Prognosis. So long as the compensating hypertrophy can be maintained the prognosis is not unfavorable ; when dilatation super- venes, however, the patient soon perishes, either from congestion of the lungs or dropsy and exhaustion. AORTIC REGURGITATION. Pathological Anatomy. The valves or segments adhere to the walls of the aorta, or a segment is lacerated or may be perforated, or, more commonly, the segments are shrunken, deformed and rigid, per- mitting the regurgitation of the blood. These deficiencies in the valves are usually associated with more or less narrowing of the orifices. The cardiac muscle rapidly hypertrophies, its cavity enlarging— " dilated hypertrophy." Symptoms. Those of marked hypertrophy, to wit: forcible cardiac action, headache, tinnitus aurium, congestion of the face and eyes, with pulsating vessels, even small ones pulsating that before were not visible to the eye; pulsations of the retinal vessels can be recognized with the ophthalmoscope ; the receding pulse, which is par- ticularly characteristic—forcible impulse but rapidly declining, called "water-hammer" pulse; also, the " Corrigan pulse." When " compensation ruptures," dyspnoea, cough, hepatic enlarge- ment, congestion of the kidneys, with scanty, albuminous urine, ascites and dropsy. If mitral insufficiency is now superadded, general venous stasis and death rapidly occur. DISEASES OF THE CIRCULATORY SYSTEM. 265 Inspection. Forcible cardiac impulse. Palpation. Strong, full cardiac impulse. Percussion. Cardiac dullness increased transversely and verti- cally. Auscultation. First sound, forcible ; second sound, replaced or associated with a churning, rushing or blowing murmur of low pitch, distinct at the second right costal cartilage, but most distinct at the junction of the sternum and the fourth left costal cartilage, transmitted downward toward and below the apex. Prognosis. The one valvular disease most likely to occasion sudden death; still, so long as the compensating hypertrophy remains intact, compatible with quite an active life. TRICUSPID REGURGITATION. Pathological Anatomy. This form of valvular insufficiency is either associated with right-sided cardiac dilatation from pulmonary obstruction, or is the result of mitral disease. The tricuspid orifice is dilated in the majority of cases ; occasion- ally the segments of the valves are contracted or adherent to the ventricle. Symptoms. Venous stasis with its various consequences, and especially pulsation of the jugular, synchronous with the cardiac movement, and finally general venous pulsation, especially of the liver, pulmonary congestion, engorgement of the kidneys and dropsy. These symptoms are superadded to those of the affections with which tricuspid insufficiency is always associated. Inspection. Diffused, wavy, cardiac impulse; jugular pulsation synchronous with the cardiac movement, uninfluenced by respiration, also more or less prominent hepatic pulsation. Palpation. The cardiac impulse extended, but feeble. Percussion. Dullness on percussion, extending to the right and below the sternum. Auscultation. The first sound is accompanied by a blowing murmur most intense at the junction of the fourth and fifth ribs with the sternum, distinct over the xiphoid appendix, becoming feeble or lost in the left axillary region ; often associated, however, with a mitral systolic murmur. w 266 PRACTICE OF MEDICINE. PULMONIC REGURGITATION. Pathological Anatomy. Insufficiency of the pulmonary valves is of rare occurrence, but when present the changes correspond more or less to those described for aortic regurgitation. Symptoms. Those of dilatation of the right side of the heart and consequent pulmonary congestion, to wit: dyspnoea, deficient aeration of the blood, and cyanosis, distention of the superficial vessels, palpitation of the heart, praecordial distress, sudden suffoca- tive attacks and dropsy. Percussion. The cardiac dullness extending to the right of the sternum. Auscultation. A loud blowing murmur associated with the second sound of the heart, most distinct at the junction of the third left costal cartilage and the sternum. Prognosis. Death results, sooner or later, from dropsy and exhaustion. MITRAL OBSTRUCTION. Pathological Anatomy. Mitral stenosis is caused by deposits around the orifice, the result of endocarditis, or else the segments of the valves are "glued together by their margins," leaving but a funnel- shaped opening, the so-called "button-hole" mitral valve. Vege- tations on the valves lead to more or less obstruction of the blood current. Symptoms. Hypertrophy of the left auricle results from ob- struction at the mitral orifice, the symptoms of stenosis being unob- servable until the " compensation ruptures," when occur irregular, small and feeble pulse, dyspnea, cough, bronchorrhoea the result of bronchial congestion ; dilatation of the right side of the heart, soon leading to general venous stasis, dropsy and death. Inspection. Normal until auricular hypertrophy, when an undu- latory impulse is observed over the left auricle. Palpation. When cardiac dilatation occurs, a diffused, feeble and irregular cardiac impulse is felt near the xiphoid appendix. Auscultation. First sound normal in character but often irregu- lar in rhythm. The second sound normal. A blowing, sometimes rasping, sound is heard, immediately after the second sound of the heart ceases, and immediately before the first sound begins—a pre- systolic murmur, heard most distinctly in the mitral area, lessening in DISEASES OF THE CIRCULATORY SYSTEM. 267 intensity toward the cardiac base. The cardiac sounds are all more or less enfeebled if cardiac dilatation occur. Prognosis. The prognosis is controlled by the hypertrophy. Under favorable circumstances mitral stenosis is compatible with a long and rather active life. AORTIC OBSTRUCTION. Pathological Anatomy. Stenosis of the aortic orifice depends upon the projection of the valves inward, and their becoming rigid and thickened, or atheromatous or calcareous, so that they cannot be pressed back by the blood, but remain constantly in the current of the circulation. Occasionally the valves are covered with fibrinous masses, the opening into the artery being thus more or less com- pletely closed, or the segments may be adherent by their lateral sur- faces, leaving a central opening, which may be so contracted as to only permit the passage of the smallest article. Symptoms. Hypertrophy of the left ventricle rapidly super- venes upon aortic stenosis. The pulse is small, slow and hard. The supply of blood to the brain is insufficient in many cases, and hence attacks of vertigo, syncope or slight epileptiform seizures occur; finally, dilatation of the left ventricle and incompetence of the mitral valve result, with subsequent pulmonary congestion, dyspnoea and general venous stasis, the pulse soft and feeble. Palpation. Lowered cardiac impulse, strong in the early stage, feeble when dilatation occurs. Percussion. The cardiac dullness is increased vertically, the transverse dullness being slightly affected. Auscultation. The first sound replaced or associated with a harsh, rasping sound, whistling at times, having its greatest intensity at the junction of the second right costal cartilage with the sternum, transmitted along the vessels ; the murmur may sometimes be heard a short distance from the patient. Usually aortic stenosis is associated with more or less aortic regur- gitation, whence a double murmur occurs, having its greatest intensity at the base of the heart, the so-called see-saw murmur. Prognosis. So long as compensation is maintained the symp- toms of aortic stenosis are nil. When the compensation is ruptured, the usual symptoms of dilatation, venous stasis and dropsy soon follow. 268 PRACTICE OF MEDICINE. TRICUSPID OBSTRUCTION. This condition is one of the rarest affections of the heart, and if it ever does occur with or following an attack of endocarditis, the anatomical changes are similar to those of mitral obstruction. This condition soon leads to auricular dilatation ; venous stasis rapidly supervenes, associated with venous pulsations similar to those de- scribed when speaking of tricuspid regurgitation. PULMONIC OBSTRUCTION. Pathological Anatomy. Always a congenital malady, the changes consisting in " constriction of the pulmonary artery, un- closed foramen ovale, unclosed ductus Botalli, stricture at the ductus Botalli, with hypertrophy of the right cavity and frequent association with tuberculosis of the lungs," Hypertrophy of the right ventricle may ensue, the walls becoming almost as thick as those upon the left side. Those in whom these congenital defects in the cardiac structure occur are otherwise weak, develop slowly, have flabby tissues, soft bones and seem poorly nourished. Symptoms. The hypertrophy which often ensues may keep life apparently comfortable for some time, but sooner or later " compen- sation ruptures," when cough, dyspnoea, cyanosis and death occur. Prognosis. The duration of these congenital affections is short, usually from a few days to a few months ; although several well authenticated cases record a much longer duration. DIAGNOSIS OF VALVULAR DISEASES. In making a differential diagnosis between the various forms of valvular diseases of the heart, strict attention must be paid to the points of greatest intensity at which the several murmurs are heard. A murmur occurring with or taking the place of the first sound oi the heart—the ventricular systole—heard most distinctly at the apex, transmitted to the left axilla, and to the inferior angle of the scapula, signifies mitral regurgitation—a mitral systolic 7nurmur. A murmur occurring with or taking the place of the first sound of the heart, with its point of greatest intensity at the xiphoid appendix, signifies regurgitation at the tricuspid orifice—tricuspid systolic murmur. A murmur heard with the first sound of the heart, high-pitched, DISEASES OF THE CIRCULATORY SYSTEM. 269 rasping or grating in character, with its point of intensity greatest at the second right costal cartilage, signifies obstruction at the aortic orifice—an aortic systolic murmur. A murmur heard with the first sound oi the heart, soft in character, with its point of intensity most distinct at the junction of the third left costal cartilage with the sternum, signifies obstruction at the pul- monic orifice—a pulmonic systolic murmur. A murmur occurring immediately after the second sound of the heart, and immediately before the beginning of the first sound of the heart signifies obstruction at the mitral orifice—a presystolic mitral murmur. A murmur heard with or taking the place of the second sound of the heart, most distinct at the second costal cartilage, to the right of the sternum, and well transmitted toward the apex or below, signifies in- sufficiency or regurgitation at the aortic orifice—an aortic regurgitant or diastolic murmur. Although eight distinct valvular murmurs have been described as occurring in the heart, those on the right side are of rare occurrence, and hence of little clinical importance. If a murmur be heard with the first sound of the heart, it is almost certainly aortic obstructive or mitral regurgitant; and if heard with the second sound, it is probably aortic regurgitant. A presystolic mitral murmur is also of comparatively rare occurrence, the force with which the blood passes from the left auricle into the left ventricle being, under ordinary circumstances, insufficient to excite sonorous vibrations. Functional or anemic murmurs may he confounded with the various forms of valvular disease of the heart. The chief points of distinction between them are, that an anaemic murmur, which is always heard at the base of the heart, is always systolic in time, not transmitted away from the heart, and is soft in character, low in pitch, and of variable intensity, now being heard, now entirely absent. Treatment. There is no special plan of treatment for each form of valvular disease. The important point to bear in mind is that they are associated either with cardiac hypertrophy or dilatation, and the treatment, if any at all is required, is directed toward this secondary condition. If compensation be complete, attention to the condition of the bowels, kidneys and digestion, with some general directions as to exercise, is all that is required. 270 PRACTICE OF MEDICINE. If the hypertrophy become marked and excessive, it is best con- trolled by either aconitum or veratrum viride. If dilatation have occurred, the heart weak and feeble, the circula- tion impeded, and venous stasis has followed, digitalis, with more or less active purgation, are indicated. PALPITATION OF THE HEART. Synonym. Irritable heart. Definition. A functional disturbance of the heart; characterized by increasing frequency of its movements and more or less irregular- ity of the rhythm, with a strong tendency toward hypertrophy. Causes. Over-exertion, "the heart strain" of Da Costa; dyspep- sia ; uterine diseases ; excesses in tea, coffee, tobacco, alcohol or venery; moral and emotional causes, grief, anxiety and fear. Symptoms. Usually palpitation of the heart has a sudden onset after some one of the causes mentioned, precordial oppression or pain, rapid, tumultuous beating, the impulse being visible through the patient's clothing, dyspnea, anxiety, and a sense of choking or full- ness in the throat, the recumbent position impossible, vertigo, faint- ness, flashes of light, the pulse full and strong or feeble, the face flushed or pale, the patient having a feeling of anxiety with a sense of impending danger and a fear of sudden death. These attacks are paroxysmal, lasting from a few. moments to several hours, or a day, the patient often voiding a large quantity of limpid urine after the paroxysm has subsided, when there is a strong tendency to sleep. Diagnosis. Irritability of the heart is differentiated from the various forms of cardiac disease by the absence of all the physical signs mentioned as occurring in those conditions. Prognosis. If early and properly treated, favorable. Treatment. The first point in the treatment of irritability of the heart is to remove the cause; the next, to prevent the recurrence of the attacks of palpitation. The majority of cases do well by a combination of digitalis and belladonna. Permanent relief is often afforded by a combination of potassii bromidum and veratrum viride. Chloral is also useful. If the patient be anaemic, the author has had excellent results follow the prolonged use of the elixir ferri, quinine et strychnine. Locally, emplastrum belladonne to the praecordium affords relief. DISEASES OF THE CIRCULATORY SYSTEM. 271 ANGINA PECTORIS. Synonym. Neuralgia of the heart. Definition. Paroxysms in which there occur sharp cardiac pains, extending usually into the left shoulder and down the left arm, ac- companied by a feeling of constriction of the thorax and a strong sense of impending death. Causes. Often hereditary; associated with chronic cardiac changes, as diseases of the coronary arteries or calcification of the valves ; the excessive use of tobacco ; according to Trousseau, it is a form of masked epilepsy, and may alternate with true epileptic attacks; often associated with hysteria. Pathological Anatomy. " The pathological changes which stand in a causative relation to the attacks are those of the cardiac plexus of the phrenic and of the pneumogastric nerves. Pressure of enlarged lymphatics, inflammation of parts of the cardiac plexus, with changes in the coronary artery, seem to be most constant." Symptoms. A paroxysmal affection, the attacks occurring irreg- ularly ; in the interval entire absence of symptoms. "The patient suddenly sits up in his bed; with a cry of horror indicates the sense of pain at the praecordium. This pain is of great intensity, but is of a cold and sickening character; the chest is fixed, the breathing quickened, and the hand placed over the epigastrium finds that the heart's action is slight and enfeebled. The face wears a look of horror, pale and slightly leadened ; a cold sweat breaks out upon the forehead ; worse than the pain is the feeling of fearful sick- ening and depression. The poor patient gasps, ' I shall die ! I shall die!' and sometimes his short but concentrated sufferings in a few moments end in death." The unpleasant sensations of these patients during an attack, and the nervous disorder associated with it, slowly bring about a mental change. They are depressed and gloomy, sometimes suicidal, often developing epilepsy. Diagnosis. The points to be remembered are that the attacks are always paroxysmal, the patient having a sense of coldness, and frequently a cold sweat, the heart's action not increased, the chest fixed and the breathing slow. Prognosis. Unfavorable, the patient, sooner or later, either suc- cumbing during a paroxysm or from exhaustion, the result of the cardiac changes. 272 PRACTICE OF MEDICINE. Treatment. As far as possible attempt to remove the cause. Prompt relief follows the use of amyl nitris, rtiiij, inhaled at the instant, or morphine sulphas, gr. Yt~Y> t0 which may be added with advantage atropine sulphas, gr. T|u, hypodermatically. To prevent the paroxysms, liquor potassii arsenitis, tt\,v, three times a day, also ol. morrhue, or hypophosphites, and elixir ferri, quinine et strychnine. DISEASES OF THE NERVOUS SYSTEM. CONGESTION OF THE BRAIN. Synonyms. Cerebral hyperaemia; cerebral congestion. Definition. An abnormal fullness of the vessels of the brain; active, when arterial fullness ; passive, when venous fullness ; char- acterized by headache, vertigo, disorders of the special senses, and if the hyperaemia be decided, convulsions. Causes. Active. Increased cardiac action, the result of hyper- trophy of the left ventricle; general plethora; excesses in eating and drinking; alcoholism ; sunstroke; prolonged mental labor; diminished amount of arterial blood in other parts, the result of the compression of the abdominal aorta; ligation of a large artery, and the suppression of an habitual bleeding hemorrhoid are examples. Passive. Dilatation of the right heart; pressure upon the veins returning the cerebral blood. Pathological Anatomy. The postmortem appearances are, overloading of the venous sinuses and of the meningeal vessels, including the finer branches ; the pia mater appears vascular and opaque ; the gray matter oi the convolutions unduly red; the convo- lulions may be compressed and the ventricles contracted, with the displacement of a corresponding amount of cerebro-spinal fluid. Long-continued or repeated congestions lead to enlargement and tortuosity of all the vessels, a moist and slimy condition (oedema) of the cerebral substance, and an increase in the sub-arachnoid fluid. Symptoms. " Rush of blood to the head " may be gradual or sudden in its onset, the symptoms aggravated by the recumbent position. Headache with paroxysmal neuralgic darts, disorders of visio7i and hearing, buzzing in the ears and sparks before the eyes, DISEASES OF THE NERVOUS SYSTEM. 273 contracted pupils, vertigo, blunted intellect, inability to concentrate the mind, irritable te77iper and curious hallucinations. The face is red, the eyes congested, and the carotids pulsating. The sleep is dis- turbed by dreams and jerkings of the li//ibs. In children convulsio/is occur. If the attack be sudden (apoplectiform), sudden unconscious- ness with muscular relaxation occur. Prognosis. Mild cases terminate favorably in a few hours to a day or two, but show a strong tendency to recur. Severe cases (apo- plectiform) may terminate in health, but usually foretell cerebral hemorrhage. The passive form is controlled by the lesions giving rise to it. Treatment. Active form. Remove the cause if possible. Elevate the head and apply cold, either cold cloths or the ice cap, at the same time warmth to the feet. Leeches to the mastoid, or cups to the neck, or in the apoplectiform variety venesection, to diminish the inter- cranial blood pressure; compression of the carotids, or ligatures about the thighs, have been recommended. An active purgative is also indicated, to lessen the vascular ten- sion. In mild cases the application of cold and potassii bromidum, gr. xxx-xl, repeated, controls the congestion ; extractu7n ergotefluidum is often beneficial; in more severe cases any or all of the above- mentioned means, together with full doses of tinctura veratri viridis or tinctura aconiti, may be needed. Passive form. Becomes a part of the treatment producing the hyperaemia. CEREBRAL ANEMIA. Definition. An abnormal decrease in the quantity of blood in the cerebral vessels; general, when the diminished supply includes all the vessels ; partial, when the diminished supply is limited in area ; characterized by pallor, headache, vertigo, some loss of power, and, rarely, convulsions. Causes. Partial cerebral anaemia results from obstruction of a vessel, from embolism or thrombosis. General cerebral anaemia results from hemorrhages, wasting diseases, sudden shock, feeble car- diac action and general anaemia. Pathological Anatomy. The cerebral vessels contain less blood than normal; the brain is pale and milky in color, and on x 274 PRACTICE OF MEDICINE. transverse section there are no bloody points ; the ventricles and perivascular lymph spaces are well filled with fluid. In pai'tial anaemia the local conditions differ somewhat from the above. Symptoms. General: headache, relieved by the recumbent position ; vertigo, aggravated by exertion ; general pallor and anae- mia, with attacks oi fainting; when the general cerebral anaemia is sudden and decided, convulsions occur. Partial anemia ; sudden loss of power, of limited muscular area, gradually returning to the normal condition. Prognosis. Favorable in all cases save those the result ot severe and repeated hemorrhages. Treatment. Regulated nourish7nent, with stimulants. A certain number of hours daily in the recumbent position is of advantage. When a tendency to attacks or swooning exists, stimulants or even the cautious inhalation of amyl nitris are indicated. To improve the quantity or quality of the blood— R. Tinct. ferri chlor................................... H\,xv Acid, phosph. dil................................... r^v Liq. arsenici chloridi.............................. ffViij Syr. limonis......................................... n\xx Syr. zingiberis,............................q. s. ad ^ ij. M. Sig.—Every six hours, well diluted. Or— R. Extracti erythroxyli cocose fid................... f3ss Vini albi fort....................................... fsjss. M. Sig.—One hour after meals. CEREBRAL THROMBOSIS AND EMBOLISM. Synonyms. Partial cerebral anaemia; occlusion of cerebral vessels; cerebral apoplexy(?). Definition. The occlusion of a cerebral vessel, from the formation of a thrombus, or the presence of an embolus, thus causing anemia of some portion of the brain ; characterized by the gradual—when the result of thrombosis, and the sudden, when due to embolism— development of headache, vertigo, disorders of intelligence, with more or less complete insensibility and paralysis. Causes. Thrombosis, or the formation of a clot in the vessel— an ante-mortem coagulation—is almost always the result of chronic DISEASES OF THE NERVOUS SYSTEM. 275 endarteritis, together with a slowing and weakening of the blood cur- rent. Emboli usually results from an endocarditis—cardiac emboli; small particles of the exudation are carried into the circulation and are deposited in the brain. Emboli may also be derived from aortic aneurism, or syphiloma of the great vessels. Pathological Anatomy. The cerebral arteries may be ob- structed by emboli or thrombi; the cerebral veins and sinuses by thrombi only. The changes in the cerebral tissue are those of anaemia of the part or parts supplied by the occluded vessels. The subsequent changes depend upon the anatomy of the vessels. If the obstructed artery has anastomoses, the collateral circulation is soon established and the brain tissue assumes its normal condition. If, on the other hand, the occluded vessel be one of " Cohnheim's terminal arteries " —arteries without anastomoses—the blood in the whole extent of the occluded vessel coagulates, thus preventing the backward flow of blood from the surrounding capillaries and so obstructing collateral circulation, whence the anaemic tissue dies or undergoes necrobiosis, followed by yellowish-white softening ; or, if the vessel beyond the seat of the occlusion remains pervious, blood flows back through the capillaries from the nearest artery or vein ; the parts that a short time before were bloodless now become deeply engorged, the succeeding changes in the vessels permitting diapedesis of the red blood globules ; the tissues which are undergoing disintegration are colored by the red globules, causing the appearances entitled " red softening," which after some weeks becomes "yellow softening," finally changing to "white softening," when there is a milky, or rather creamy, fluid mixed with masses or particles of broken-down nerve elements. The vessel most commonly occluded is the left Sylvian artery, which sends branches to the second and third frontal convolutions, the anterior and superior portions of the three temporal convolutions, the island of Reil, the parietal convolutions, part of the external and all of the internal capsule, the lenticular nucleus, and most of the corpus striatum. Symptoms. Two distinct modes of onset; gradual, when the result of thrombosis; sudden or apoplectic, when due to embolism. Cerebral thro77ibosis. Most common in the aged. Persistent head- ache and vertigo, at one time severe and at another mild. Next, alterations of character; irritable, morose and desp07ident, with periods 276 PRACTICE OF MEDICINE. oi absent-mindedness, disorders of vision, and impairment of memory, speech becoming hesitating and mumbling. Impaired locomotion, the result of the vertigo, and of 7nuscular weakness and tre7nbling, followed sooner or later by he7iiiplegia, which may be preceded by sudden insensibility or occur gradually, the symptoms slowly pro- ceeding to senile dementia and death from exhaustion ; or rarely, the symptoms are not so grave, and partial or complete recovery occurs after the hemiplegia, from establishment of the " collateral circula- tion." Cerebral embolism. The symptoms are sudden, but either mild or grave in character. Mild variety ; sudden and severe vertigo, confusion of mind, mus- cular twilchings, usually one-sided, and vomiti/ig, followed by hemi- plegia, most frequently of the right side. After some weeks or months the paralysis usually disappears and recovery is complete. Grave or apoplectic variety. Sudden headache, vertigo, flushing or pallor of the face, or the patient may utter a sharp cry, fall to the ground with sudden unconsciousness and complete 7nuscular resolution, followed by death, or a gradual return of consciousness with hemi- plegia, which is generally right-sided, remaining for several weeks or months, or is persistent, the mind re7naining normal or enfeebled and the emotional nature highly excited and the reason and judgment clouded, continuing thus for years, or gradually developing into de- mentia, exhaustion and death. Duration. Thrombosis, essentially an affection of the elderly, has a chronic course. Months or years may be occupied with the various symptoms until the phenomena of senile dementia develop. Embolism is of sudden onset and may be followed by a rapid recovery. Diagnosis. Thrombosis is associated with changes in the vessels, the arcus senilis and other evidences of senile degeneration. Embolism may be mistaken for cerebral apoplexy, and while a positive differentiation cannot always be made, the chief points will be considered when discussing that affection. Prognosis. Thrombosis is a permanent and progressive con- dition in the majority of instances. Recovery is a rare termination. Embolism may be followed by a perfect recovery. Usually, how- ever, some evidences of the plugging remain permanently. Death may be the result within a day or two, from the plugging of a large DISEASES OF THE NERVOUS SYSTEM. vessel, the patient never emerging from the coma. In other cases the patient arouses from the coma, the hemiplegia with aphasia persisting, and the case pursues the usual course of localized cerebral softening. Treatment. Perfect rest for some time after the attack, a plain but nutritious diet, and attention to the various excreta. Prof. Bartholow " has had remarkable results from the following plan of treatment in thrombosis:" A77imonii carbonas, gr. x, with ammonii iodidi, gr. v, three times a day, continued for several months, " the object being dual—to increase the action of the heart and arteries and to effect a solution of thrombi forming by maintaining the alka- linity of the blood." In the aged, presenting indications of degeneration, much benefit results from the use of— R. Liquor potassii arsenitis................................... rtl.iij-v Syr. calcii lacto-phosphat................................ ^ j—ij. M. Sig.—After meals. It may be combined with oleum 7norrhue with decided advantage. For e77ibolis7ii, the immediate and persistent use of the following may dissolve the plug:— R. Ammonii carbonat......................................... gr. v Liquor ammonii acetatis.................................. f^j. M. Sig.—Three or four times daily. " In a month or two a very light galvanic current (from two cups) may be passed through the brain in both directions." (Bartholow.) CEREBRAL HEMORRHAGE. Synonym. Apoplexy. Definition. The sudden rupture of a cerebral vessel and escape of blood into the cerebral tissue, causing pressure and more or less destruction of the brain substance ; characterized by sudden uncon- sciousness, irregular, noisy respiration and complete muscular relax- ation. Causes. Rare under forty years of age. The principal cause is disease of the vessels—a periarteritis, resulting in miliary aneurisms, and especially if associated with cardiac hypertrophy; hereditary tendency; Bright's disease; syphilis; gout. More frequent in the spring and autumn. 278 PRACTICE OF MEDICINE. Pathological Anatomy. The most common locations of cere- bral hemorrhage are the corpus striatum and thalamus opticus ; less common the anterior and middle lobes and the cerebellum ; next in frequency the pons and medulla oblongata; and rarely on the con- vexity of the brain, termed meningeal hemorrhage. When the hemorrhage is large, the blood may break into the ven- tricles and pass by the iter from the third to the fourth ventricle. A recent clot is dark in color, and in consistency a soft, grumous mass, composed of coagulated blood and brain substance in varying proportions, at whose centre is the opening into the ruptured vessel. The clot excites inflammation around it, resulting in its being encysted, by the development of new connective tissue from the neuroglia, and then gradually absorbed, leaving a cicatrix, or the brain tissue around the clot softens and degenerates—localized softening. Symptoms. Two modes of onset, to wit: with and without prodromes or " warnings." Prodro/nes. Headache, vertigo, transient deafness or blindness, sensations of numbness of the extremities, with local palsies, together with the constant dread of an attack. The attack begins with vomiting, followed by either partial or com- plete insensibility ; respiration slow, irregular and noisy ; during the in- spiration the paralyzed cheek is drawn in, and puffed out in expiration ; pulse slow and full; //^//^uninfluenced by light, the face flushed, the eyes congested and the carotids throbbing ; the tei7iperature declines below the norm, a degree or two. The muscular system is profoundly relaxed, and the reflex 7nove- ments are abolished. The head and eyes deviate, in many cases, toward the affected side in the brain or from the paralyzed side. If the unconsciousness continues longer than twenty-four hours, death is the usual termination, preceded by pale face, irregular and rapid pulse and respiration, and rise of temperature. Reaction obtains in from a half to three hours, consciousness re- turning, reflex excitability reviving, associated with headache, confu- sion of mind, and more or less paralysis of motion and sensibility of one side of the body termed—hemiplegia. The electro-excitability of the paralyzed parts is preserved. Restoration may be delayed by inflammatory symptoms, the tem- perature rising to ioi°-io4° F., with tonic contractions (early rigidity) of the paralyzed muscles and severe neuralgic pains. DISEASES OF THE NERVOUS SYSTEM. 27!) Sequelae. Paralysis of the muscles of the face, tongue, body and extremities of one side, opposite to the location of the hemor- rhage, termed wiilateral paralysis or right or left hemiplegia. Paralysis of both sides of the body, due to simultaneous hemorrhage on both sides, termed bilateral he7niplegia. Paralysis of one side of the face and the extremities of the opposite side, due to hemorrhage into the pons varolii, termed alternating or crossed paralysis. Occasionally to7iic contractio/is occur in muscles long paralyzed, termed late rigidity, and is evidence of a secondary degeneration of the nerve fibres. Choreic movements in paralyzed muscles are termed post-he7ni- plegic chorea, due, according to Charcot, to changes in the motor centres. The 7/ientalpowers are always more or less permanently impaired, the patient irritable and emotional, and the same holds good concern- ing the 77ie77iory. Diagnosis. Insensibility fro77i drink differs from apoplexy in the following points, to wit: insensibility is not so complete, no drawing in and puffing out of one cheek with respiration, the pulse frequent instead of slow, the pupils influenced by light; upon raising both legs no difference is apparent on allowing them to drop ; the eyes and head are not turned to one side, and lastly, the condition is ameliorated on the inhalation of ammonia. Opium poisoning differs from apoplexy by the gradual approach of the coma, and that the patient can be momentarily aroused, and also by the absence of the heavy stertor of apoplexy. Uremia causes a coma that closely resembles apoplexy. A history of Bright's disease at once clears up the case ; again, uraemic. coma is always preceded by convulsions, and has a continued depressed tem- perature. Cerebral embolism cannot always be differentiated from apoplexy. We may suspect cerebral plugging, if the patient be young ; if he be laboring under acute, subacute or chronic valvular trouble; if, within brief periods, several incomplete attacks have occurred before a com- plete comatose condition obtains ; or, if hemiplegia results with pass- ing or slight unconsciousness; or, if the phenomena are sooner or later followed by cerebral softening, as embolism and thrombosis are the most common causes of softening. 280 PRACTICE OF MEDICINE. Syncope or a fainting-fit is of sudden onset, but being due to a failure of the circulation, the pulse is feeble, the face pale, the respi- ration quiet, and the duration of unconsciousness short, all the very opposite of an apoplectic attack. Prognosis. If the patient survive the immediate effects of a cerebral hemorrhage, he is always in danger of a new attack, since the causes of the original attack still remain. Another attack or two is the usual course, a fatal termination ultimately occurring. The hemiplegia is uncertain ; a partial recovery may occur within a few months, or it may continue for years. Treatment. If there are prodromal indications, the most prompt means of reducing the intra-cranial blood pressure is by venesection, followed by a brisk purgative ; if the patient be weak, however, leeches to the mastoid, and potassii bromidum, gr. xl-lx, may be substituted. For the attack, loosen clothing, elevate the head, remove constric- tions, place in a cool room, have perfect quiet, and at once venesec- tion, cold to head, 77iustard foot bath, and oleum tiglii, gtt. j-iij, glyce- rinum, gtt. xv, placed on back of tongue; if the pulse be full and strong, when consciousness is regained, either tinctura veratri viride or tinctura aconiti is indicated. If during the attack the face be pallid and the pulse irregular, the patient is prostrated by the shock and stimulants and digitalis are in- dicated, with, perhaps, leeches to the mastoid and an enema oi tere- binthina. For the secondary fever, either tinctura aconiti or tinctura veratri viride ; for the headache and delirium, camphore bromidum. For aiding the absorption of the clot, keep the secretions acting, a good diet and a course oi potassii iodidwn or hydrargyri chloridum corrosivum, alternated with— R. Liq. potassii arsenit................................... gtt. v Syr. calcii lacto-phosph............................. f^ ij. Three times a day. After two or three months a weak galvanic current applied directly to the brain, by placing an electrode on each mastoid process, pro- motes absorption. F'or the paralyzed'muscles; the faradic current applied by placing one electrode over or near the nerve innervating the muscle and the other over its belly, acts as a tonic, preventing wasting; it is assisted by hy- podermatic injections oi strychnine sulph., gx.fa, three times a week. DISEASES OF THE NERVOUS SYSTEM. 281 ACUTE MENINGITIS. Synonyms. Cerebral fever; arachnitis. Definition. An acute inflammation of the cerebral pia mater and arachnoid membranes; characterized by headache, chill, fever, deli- rium, and followed by symptoms of general collapse. Causes. Cerebral overwork ; prolonged wakefulness ; acute alco- holism; exposure to the sun; disease of the internal ear; erysipelas; secondary to diseases of serous membranes, and the continued and eruptive fevers. Most frequent in early adult life and in young chil- dren, and in males rather than females. Pathological Anatomy. The inflammatory changes may be limited either to the convexity or to the base of the brain. Intense hyperemia of both membranes, followed by a purulent and fibrinous exudation. The ventricles may be filled with fluid, com- pressing and flattening the convolutions. Symptoms. Vary according to the stages:— Prodromes; headache, vertigo, cerebral vomiting, more or less feverishness, continuing from a few hours to one or two days, when occurs the Stage of Invasion ; onset sudden, with chill, high fever, io3°-io4°, pulse 100-120, face flushed, with congested eyes, headache, ringing in the ears, photophobia, vertigo, the nausea aggravated, and projectile vomiting. Stage of Excitation; general sensibility of the body increased, sensitiveness to light, and acuteness of hearing, delirium furious, often resembling insanity, continual jerking of the limbs, oscillations of the eyeballs, twitching of the muscles of the face, followed by powerful contractions of the flexor muscles, even to the extent of opisthotonus, and in children convulsions. Duration, from one day to a week or two. Stage of Depression or Collapse; the patient gradually becomes more quiet; the delirium subsides, as well as the muscular agitation ; somnolence occurs, passing into co>7ia, at times temporary conscious- ness, coma soon following again; pulse irregular and slow, fever less; various palsies, to wit: strabismus, ptosis, pupils uninfluenced by light, mouth drawn to one side, urine and faeces involuntarily discharged. Death following, either by convulsions or by deepening coma. Diagnosis. Cerebrospinal fever closely resembles acute menin- gitis, the points of distinction between which are the first named 282 PRACTICE OF MEDICINE. occurring epidemically, associated with marked spinal symptoms and an eruption. The cerebral symptoms of rheumatism are differentiated from idio- pathic meningitis by the association of the joint trouble. Cerebral sy7nptoms of typhoid and typhus fever have a close resem- blance to idiopathic meningitis, and are only determined by a study of the clinical history. In acute urei7iia the face is turgid, with puffiness of the eyelids; in meningitis the face is pale and no oedema; uraemia has decided albuminuria; it is slight or absent in meningitis ; meningitis has chills followed by fever; uraemia has not. In delirium tremens the delirium is a busy one, the patient imagin- ing persons and animals around him, and is wild in his gestures and utterances ; the temperature is normal or subnormal, the skin wet and clammy. In meningitis the delirium is mild but incoherent, the sur- face is hot and dry, and there is severe vomiting and headache. Prognosis. Not very favorable. If recognized early and treated, a fair number of recoveries occur, but it usually leaves the patient subject to attacks of epilepsy or with a persistent headache. Treatment. Must be prompt and energetic from the onset. At once, active purgation by oleum tiglii, gtt. i],glycerinu77i, rt\,v, dropped on the tongue; and if the urinary secretion be scanty, dry cups ox digitalis poultices over the kidneys. In vigorous subjects a copious venesection or leeches applied behind the ears, to the temples, or the nuchal region, followed by the appli- cation of cold to the head, and that it may be thoroughly applied, the head should be shaven. Control the active circulation by aconitiwi in small doses, fre- quently repeated, combined with potassii bromidum, gr. xx-xl. The cerebral circulation may be markedly influenced by compression of the carotids. Ergota is of service in some cases. The apartment should be cool, the air pure, the patient's head elevated. The diet should be nutritious but easy of assimilation. The secretions must be carefully attended to, the catheter being frequently used in the stage of collapse. If the case show a disposition to linger, small doses of hydrargyri chloridu/n mite or potassii iodidum axe of benefit. Third stage: Free stimulatio7i, nutritious food, ferri iodidum and flying blisters. DISEASES OF THE NERVOUS SYSTEM. 2815 PACHYMENINGITIS. Synonyms. Meningitis ; haematoma of the dura mater. Definition. Inflammation of the dura mater ; when the external layer is primarily involved it is termed pachyi7ieningitis externa; when the internal layer is primarily involved it is termed pachy- meningitis interna. Causes. Pachymeningitis externa is a surgical malady, excited by fractures, penetrating wounds, and other injuries of the skull. Pachymeningitis interna is due to blows upon the head without injury to the skull. A predisposition may be created by chronic alcoholism, scurvy, Bright's disease and syphilis. Pathological Anatomy. Pachymeningitis interna. Hyper- aemia of the membrane, followed by an exudation which develops into a membranous new formation, containing a great number of vessels of considerable size but having very thin walls. Hemor- rhages from these new vessels are of frequent occurrence, which in- crease the size and thickness of the neo-membrane. The usual position of the neo-membrane or new formation is on the upper surface of the hemispheres, extending downward toward the occipital lobe. The changes in the adjacent portion of the brain are dependent on the size and thickness of the neo-membrane. Bartholow observed a case in which the " cyst" was half an inch in thickness at its thickest part, and it depressed the hemisphere corre- spondingly, the convolutions being flattened, the sulci almost oblit- erated, and the ventricle lessened one-half in size. Symptoms. Very obscure; principally those of cerebral pres- sure. Cases of persistent headache, vertigo, photophobia, anorexia, insomnia, gradual impairi7ient of intellect and loco77iotion, followed by apoplectic attacks andparalysis, in the aged, or in whom some one of the causes of the affection are present, inflammation of the dura mater may be suspected. Diagnosis. Always problematical, as its symptoms are masked and indefinite. Prognosis. Unfavorable. Death usually occurs within a few weeks after the onset. Treatment. Symptomatic, as there is no cure for the disease, although potassii iodidum has been recommended. 2*4 PRACTICE OF MEDICINE. TUBERCULAR MENINGITIS. Synonyms. Basilar meningitis; acute hydrocephalus. Definition. An inflammation of the membranes of the brain, more particularly the basal pia mater, attended with or due to the deposit of gray, miliary tubercle; characterized by gradual decline of the bodily and mental powers. Causes. Most frequently occurs in children between two and six years of age, although numerous cases are reported occurring be- tween the ages of twenty and thirty years; scrofulous diathesis; in- herited diathesis. The "gelatinous children of albuminous parents," as the phrase goes, possess a special susceptibility to tubercular meningitis. Pathological Anatomy. The deposition of tubercle usually occurs at the base of the brain. Depositions of grayish-white granules, of a translucent, somewhat gelatinous appearance—miliary tubercle, are distributed along the vessels of the pia mater, resulting in inflammation and the exudation of lymph, with the consequent thickening and opacity of the mem- branes. The cerebral tissue is not usually involved, although on section the lines indicative of blood vessels are very much increased in number. The ventricles are distended by a clear, or milky, or even bloody serum. Tubercular deposits occur in the lungs, intestines, and, at times, in other organs. The presence of the tubercles alone may give rise to no symptoms until the exudative products of the resultant inflammation develop. Symptoms. The advent is either gradual and insidious, or with convulsions, in which cases the after progress is rapid. Prodro7/ies: the child grows irritable, with loss of appetite, loss of flesh, swollen abdomen, constipation alternating with diarrhoea, irreg- ular attacks of feverishness, with attacks of grinding its teeth during sleep. Headache occurs, as shown by the child, even when at play, suddenly stopping and resting its head on its hand or on the floor. Duration of this stage is from one week to a month or two. Stage of excitation : the onset is rather sudden, with obstinate vomiting, severe headache, co7ivulsions, fever, io2°-io3° in the even- ing, falling to 990 in the morning, pulse soft and compressible, with irregular rhythm. On drawing the finger nail lightly over the surface DISEASES OF THE NERVOUS SYSTEM. 285 a red line results, " the cerebral stain "of Trousseau. The symptoms grow progressively worse with exaltation of the special and general senses : the least pinch or even touch causing exquisite pain ; spas- modic move7/ients of the 7nuscles, with contraction and rigidity, at times opisthotonus. Duration of this stage is about two weeks. Stage of depression: the result of the pressure of the exudation ; the pulse slow and compressible with irregular rhythm ; temperature de- pressed ; tendency to so7/inolence alternating with quiet delirium, mental stupor, continual movement of the fingers, as in picking up objects; convulsions from time to time, strabismus, oscillation of the eyeballs, followed by intervals of wakefulness, when the headache is excruciating, causing the peculiar, unearthly shrill cry or shriek, " the hydrocephalic cry," associated with contraction of the muscles of the face, as if suffering were experienced; finally collapse, occurring with the " Cheyne-Stokes " respiration, the coma deepening, followed by death, convulsions often ending the scene. Duration, from a day or two to two weeks. Diagnosis. Acute meningitis and tubercular meningitis have closely analogous symptoms during the stage of excitation, but the his- tory and clinical course of the two maladies determine the diagnosis. Prognosis. Unfavorable. Usual duration, three or four weeks after fully developed prodromes. If ushered in by convulsions the duration is shorter. Treatment. Most unsatisfactory. No means of retarding the disease. Treat symptoms as they develop. Blisters, leeches, active purgation, pustulating ointments, potassii iodidwn and hydrargyrum, are all useless. If the hereditary tendency be marked, nutritious food, oleum morrhue, iodum and quinina may somewhat delay the development of the affection. ACUTE HYDROCEPHALUS. Synonyms. Acquired hydrocephalus; serous apoplexy. Definition. Strictly speaking, hydrocephalus signifies water in the brain ; but it is here restricted to the presence of a serous fluid in the arachnoid spaces, in the pia mater, in the ventricles, and in the brain substance (oedema) ; characterized by the more or less sudden de- velopment of cerebral excitation, followed by depression and usually death. 286 PRACTICE OF MEDICINE. Causes. Most common between the ages of one and five, although it may occur at any age. " The predominance of the ner- vous system in the bodily conformation " is a strong predisposing cause. Among the exciting causes are unfavorable hygienic condi- tions, dentition, eruptive fevers, blows on the head, mechanical causes preventing the return of the blood from the vena Galeni and the right sinus, compression of the jugular vein, diseases of the right heart, and Bright's disease. Pathological Anatomy. The effusion may be limited to the ventricles, although there is usually considerable distention of the subarachnoid spaces and oedema of the pia mater and neighboring portions of the brain, whence results more or less softening, especially around the ventricles. The choroid plexus is hyperaemic and may be the seat of minute extravasations. Symptoms. There are three varieties of acute hydrocephalus with characteristic symptoms, to wit: comatose, convulsive and the ordinary. Comatose variety, known also as " serous apoplexy," begins abruptly with the phenomena of apoplexy, the result of the sudden effusion. The pressure is usually so great on the medulla oblongata that it ceases to functionate, death resulting in a few hours, rarely last- ing several days. Convulsive variety, the result of Bright's disease or a general dropsy, is ushered in with headache, nausea and vomiting, followed in a day or two with convulsions, passing into coma, which usually terminates fatally, although rarely a remission may precede death for a day or two. Ordinary variety, the most common in children, begins with fever- ishness, headache, vertigo, photophobia, restlessness, nocturnal deli- rium, insomnia, twitching and spasmodic contractions of the muscles and great hyperaesthesia of the skin. Such symptoms continue for several days, when convulsions occur, followed by death, or a con- tinuance of the symptoms, followed by rigidity, stupor and death. Prognosis. Unfavorable. Treatment. An attempt may be made to remove the fluid by diuretics and full doses oi potassii iodidum. DISEASES OF THE NERVOUS SYSTEM. 287 CONGENITAL HYDROCEPHALUS. Synonym. Chronic hydrocephalus (?). Definition. An excessive accumulation of the cerebro-spinal fluid—a cerebral dropsy—in the ventricles—internal hydrocephalus, or in the meshes of the pia mater—external hydrocephalus, or in both —mixed hydrocephalus ; characterized by enlargement of the head and more or less pronounced nervous phenomena. Causes. Imperfect development of the brain or its membranes. Occurs in the offspring of tubercular, scrofulous or syphilitic parents. Inflammatory changes in the ventricles and ependyma. Pathological Anatomy. Enlargement of the head is the chief external pathological condition, although there is no constant ratio between the size of the head and the amount of fluid, the quantity varying from an ounce to a pint or more. The liquid is transparent, of a straw color, containing a small amount of albumen and chloride of sodium. If the quantity of fluid be small the ventricles are simply distended, if the amount be large the optic thalami and corpus striatum are de- pressed and flattened, the roof of the ventricles thinned and the fora- men of Monro is greatly enlarged. The enlargement of the head may occur before birth and impede or prevent natural delivery, or the head may be normal at birth and increase after. As enlargement progresses the bones are so thinned as to be translucent, the fonta- nelles and sutures are widened, the lateral portions of the cranium pro- ject, the forehead bulges out over the eyes, and the orbital plates are depressed, forcing the eyes outward and downward, producing a variety of exophthalmus ; the head has an irregular, triangular shape, the base of the triangle being the top of the head. The scalp being stretched by the pressure within, becomes tense and thin and but scantily covered with hair, the veins which ramify in it are unusually prominent and large, and the entire head is elastic on pressure, from the amount of liquid beneath. Symptoms. The increased size of the head, with the emaciated condition of the child, who seemingly eats well, is what first attracts the attention. The head appears too heavy, the eyes have a promi- nent but downward direction, the face is devoid of expression, old and wrinkled, the voice feeble; the mental development is not in comparison with the age. When the period for standing or walking arrives the power is found wanting. The further history is but a con- 288 PRACTICE OF MEDICINE. tinuation and exaggeration of this, until convulsions occur, which sooner or later terminate fatally. The duration of congenital hydrocephalus is usually slow but pro- gressively worse. The majority terminate within the first year ; cases are recorded of ten and fifteen years' duration. Diagnosis. In rachitis the volume of the head is increased, due, in part, at least, to a deposit of calcareous matter on the exterior of the cranial bones. Rachitis may be mistaken for hydrocephalus in cases in which the amount of liquid is small. The differential diag- nosis is based on the shape of the head, round in rachitis, square or triangular or with prominences in hydrocephalus; with the persistent downward direction of the eyes and the elasticity of the head on pressure. Prognosis. Unfavorable. Arrest of progress and even cures are reported. Spontaneous cures are reported following the accidental discharge of the fluid. But such reports are exceptional. Treatment. The use of the finest aspirator needle to evacuate the fluid is fully justifiable, combined with the internal use of potassii iodidum, and gentle but firm compression of the cranium with adhe- sive strips. CEREBRAL ABSCESS. Synonym. Acute encephalitis. Definition. An acute suppurative inflammation of the brain structure, either localized or diffused, primary or secondary ; charac- terized by impairment of intellect, sensibility and motion. Causes. Primary cerebral abscess is exceedingly rare. Secondary cerebral abscesses result from injuries to the cerebral tis- sues, to wit: apoplexy, embolism, thrombosis, and injuries to the cranial bones. Pathological Anatomy. Abscess of the brain affects the left side more frequently than the right. They are usually encysted or in- closed in a limiting membrane. Abscess of the brain may be single or multiple, varying in size from an almond to an egg. It occupies a limited and well-defined region of the cerebral tissue, to wit: either corpora striata, optic thalami, gray matter of the cortex, the cerebellum, or the white matter of the hemispheres. " The initial stage at the site of the abscess is hyperaemia. Minute extravasations take place (capillary hemorrhages), giving to the in- DISEASES OF THE NERVOUS SYSTEM. 2S«1 flamed area a dark, reddish color, whence the term red softening. Migration of white corpuscles, diapedesis of some red corpuscles and exudation of serum holding albumen and fibre in solution, occur simul- taneously. The brain tissue, being soft and easily broken up, is rapidly disassociated and its elements disintegrated, and in a short time a soft, pultaceous, red mass results, which more and more as- sumes a purulent character, becoming first reddish-yellow, then yellow or greenish-yellow, ultimately almost white. The injury caused by an abscess is not limited to the portion of the brain inflamed, but the neighboring territory is in the condition of collateral hyperaemia and oedema " (Bartholow). Symptoms. A concise description of the symptoms of abscess of the brain is very difficult, on account of the wide variations depend- ent on its location, and also the difficulty of isolating it from the affections to which it is secondary. The onset varies according to the cause, although all cases are associated with headache, irritative fever, persistent and spreading paralysis, and convulsions. If following apoplexy, thrombosis, or emboli there occurs fever and delirium, the paralysis remaining and spreading with spasmodic con- tractions of the affected muscles. Occasionally cases run a chronic course, the onset rather insidious; dull, persistent headache, changed disposition, peevish, irritable, un- reliable, with decline of moral sensibility; easily fatigued by mental work ; inability to stand exertion ; memory impaired; vertigo ; dys- pepsia, soon followed by slight palsies, which progressively increase, becoming general, with involuntary discharges, death following from exhaustion. Diagnosis. A positive diagnosis is only possible by a close study of the clinical history, as the symptoms at times indicate meningitis, cerebral congestion, epilepsy or cerebral tumor. Prognosis. The usual termination is in death. The course de- pends upon the character and extent of the injury, varying from a few days to several months. Treatment. Palliative, unless the future shall justify the opera- tion of trephining, or of puncturing the brain, thus to favor the exit of pus. Y 290 PRACTICE OF MEDICINE. INTRA-CRANIAL TUMORS. Synonym. Cerebral tumors. Definition. Tumor of the brain is either a growth in the cerebral tissue, on the meninges, or in the vessels ; characterized by symptoms of pressure upon the brain structure. Causes. Injuries to the head ; syphilis ; changes in the vessels ; tubercle and cancer ; hereditary. Pathological Anatomy. The size of tumors vary, and may become as large as an orange before they will give rise to symptoms. Tumors of the brain are of various kinds, to wit: vascular tumors— aneurisms; parasitic tumors—cysticercus ; diathetic tmnors—tubercle or syphilis ; accidental tumors—fibroplastic. Whatever the character of growth, it produces irritation of the sur- rounding parts, and by pressure, destruction of the tissues, or it inter- feres with the arterial or venous flow. Symptoms. Those common to tumors in general are, headache, persistent and increasing in intensity, defects of vision, even blind- ness, defects of hearing, taste and of speech, the result of paresis of the vocal cords, vertigo, associated with nausea and V077iiti7ig; co7i- vulsions, epileptiform in character, usually limited to one side of the body, occurring at regular intervals, or confined to the eyeballs or one limb, with 710 loss of consciousness : palsies, beginning first as strabis- mus, ptosis and dilatation of the pupil, of the facial muscles, paraple- gia and general hemiplegia; defects of sensibility, to wit; sensations of numbness, and coldness in the limbs and body. Occasionally disturbances of equilibrium manifested by a tendency to go backward or turn to the right or left; intellectual faculties well preserved until late in the affection, when the memory becomes impaired or lost for certain articles, and finally a gradually advancing imbecility. Diagnosis. Rarely can a positive diagnosis be made. The fol- lowing points will aid : long-continued, persistent headache, without appreciable cause, epileptiform convulsions, unilateral, without loss of consciousness, difficulty of vision, hearing and speech, associated with nausea and vomiting, and local and general palsies. The location of the tumor may be determined by the more or less pronounced character of certain symptoms. The diagnosis of the character of the growth can only be deter- mined by a close study of the history. Prognosis. Unless of syphilitic origin, unfavorable. DISEASES OF THE NERVOUS SYSTEM. 291 Treatment. Unsatisfactory. Mostly symptomatic. As benefit occasionally follows the use of potassii iodidui/i, gr.xx, three times a day, or ext. ergotefld., Jss-j three times a day, continued until their physiological effects are produced, these remedies should be used in all cases, discontinuing them if no benefit follow. APHASIA. Definition. The inability to use spoken language or give vocal utterance to ideas. Amnesic aphasia, or loss of the memory of words by which ideas are expressed. Ataxic aphasia, the inability to combine the different parts of the vocal apparatus for vocal expression, although the memory of words still remains, so that the afflicted person can write his ideas intelli- gently. Agraphia, the inability to recognize and make the signs by which ideas are communicated in written language. Amnesic agraphia, the inability to combine the muscular apparatus —" writers' cramp." Paraphasia, the mental state in which the wrong words are used to express the idea. Paragraphia, the state in which wrong or meaningless written signs are used to express the idea. Pathological Anatomy. The distinction between aphasia and aphonia must be clearly determined. Aphasia is not the result of any one specific lesion, but occurs dur- ing the course of several, to wit: occlusion of certain cerebral vessels ; cerebral hemorrhage; cerebral abscess or softening; meningitis; tumors; mental or moral causes ; hysteria. It is now almost definitely determined that lesions of the left middle cerebral artery, island of Reil, third frontal convolution, and parts of the corpus striatum, are associated in the production of aphasia. The lesions are usually upon the left side of the brain, the aphasia being associated with right hemiplegia. Symptoms. The degree to which articulate language is im- paired varies, from the loss of a few words to complete inability to communicate ideas. The intellect does not suffer in proportion to the loss of words ; for, showing the individual an article, while he may 292 PRACTICE OF MEDICINE. miscall it, if you call it by name he will recognize it. This inability to convey thoughts is a source of great mental suffering, in some leading to a suicidal tendency. A strange clinical fact is the strong tendency to profanity shown by aphasic patients. Diagnosis. Aphonia, or loss of voice, should not be confounded with aphasia, or the inability to remember words. Paralysis of the tongue, or inability to move this organ, thereby interfering with articulate language, should not be confounded with aphasia, which, as a rule, is not associated with paralysis of the tongue. Prognosis. Controlled entirely by the cause. If the result of congestion of the brain or a syphilitic tumor, the prognosis is favor- able. If associated with hemiplegia the clot may undergo absorption, and recovery follow. If associated with softening of the brain, how- ever, the disease grows progressively worse. Treatment. Depends upon the cause, which must be energeti- cally treated, as the aphasia pursues a course parallel to the asso- ciated malady. Cases not associated with cerebral softening have regained the memory of words by a course of carefully conducted speech lessons. Cases of aphasia of sudden occurrence are strongly diagnostic of injury due to a spicula of bone if a history of a head wound, or from the pressure of a clot, and the operation of trephining will be of benefit. DISEASES OF THE SPINAL CORD. SPINAL HYPEREMIA. Definition. An abnormal fullness of the spinal vessels; active when arterial hyperaemia ; passive when venous hyperaemia; charac- terized by pain in the back, with more or less pronounced, but tem- porary, disorders of locomotion. Causes. Cold and exposure ; arrested menses ; arrest of habitual hemorrhoidal discharge; malaria; protracted erect posture; injuries to the back; certain spinal poisons, as strychnina, picrotoxinum, and alcoholic excesses. DISEASES OF THE SPINAL CORD. 293 Pathological Anatomy. Active. The post-mortem appear- ances are congestion of the meninges and cord, the same vessels supplying both, with numerous points of extravasation, due to the rupture of capillary vessels. The spinal fluid is increased in amount. Passive. A general bluish discoloration, owing to the abnormal fullness of the large anastomosing vessels ; the spinal fluid somewhat increased. Symptoms. Active. Dull pain in the back; persistent and increased by pressure, tenderness on motion; tingling sensations in the limbs and feet, and sometimes in the hands and arms. Increased reflexes, with disorders of 77iotility, and when the patient is in the recumbent position, jerking of the limbs. On attempting to walk it is accomplished with difficulty, from an inco/nplete loss of power. If the upper part of the cord be affected, dyspnea and palpitation occur. There often occur painful priapism and frequent nocturnal emissions. The above symptoms may be followed by a more or less pro- nounced temporary depression, the sensation diminished and the lower limbs feel benumbed and heavy, the movements weak. The electro-contractility is preserved, and in many cases even in- creased or exalted. Duration. From a few hours to several days ; if longer, myelitis may result. Diagnosis. Anemia causes more or less spinal irritability and tenderness; but the history, pallor and general weakness, unasso- ciated with defects of motility or sensibility, will prevent error. Spi/tal meningeal he7norrhage is more sudden in its onset, its vio- lence and its range of symptoms. Myelitis and spinal meningitis have symptoms in common with spinal congestion, which will be pointed out when discussing those affections. Prognosis. Favorable, recovery occurring in three or four days. If the symptoms show a tendency to linger, myelitis more or less pronounced will ensue. Treatment. Rest, but avoid lying on the back, cups or leeches along the spine, followed either by the iced or the hot douche, or hot sponges, with active purgation, to diminish the blood pressure. 294 PRACTICE OF MEDICINE. If the result of suddenly arrested perspiration, pilocarpus. If following suddenly arrested menses, aconitum. If associated with an active circulation, potassii bromidum orfluidumgelsemiiextractum, 1\ v, every four hours ; in all cases active purgation. For the passive form, treating the cause, ergota, digitalis, tonics and purgatives. SPINAL MENINGITIS. Synonym. Leptomeningitis spinalis. Definition. Inflammation of the arachnoid and pia mater mem- branes of the spinal cord, either acute, subacute or chronic ; char- acterized by pain in the back, rigidity of the muscles, disorders of motility and sensibility. Causes. Exposure to cold and dampness; injuries to the ver- tebrae or membranes ; rheumatism ; puerperal fever ; syphilis. Pathological Anatomy. Acute. Hyperaemia of the mem- branes, with swelling of the tissues, the result of serous infiltration followed by purulent and fibrinous exudations. The roots of the spinal nerves are covered with exudation, and are swollen and soft. The cord proper is more or less congested and cedematous. Chronic. Adhesions of the membranes, with more or less accu- mulation of fluid, resulting in atrophic degeneration of the cord from pressure. Symptoms. Although an inflammatory affection, yet its onset is usually subacute, the febrile reaction being moderate, with intense boring pain in the back, aggravated by motion, rigidity of the spine and a sense of constrictio7i around the body, " the girdle." Spasmodic co7itractions of the muscle enervated by the nerves originating at the seat of the lesion, with inability to straighten the limbs. If the lower part of the spinal membranes are the seat there occur retention of urine and constipation ; if upper part, dysphagia, dyspnea and feeble heart. The muscular contractions are excited or increased by motion, but uninfluenced by pressure. Reflex 7/iovei7ients are not abolished. The rigidity and spasmodic contraction of the muscles are followed by paralysis more or less complete, death following from paralysis of the muscles of respiration. If the inflammation extend to the medulla, the above symptoms are associated with disorders of speech, vomiting and delirium. DISEASES OF THE SPINAL CORD. 295 Electro-contractility lessened or absent, both as to motility and sen- sibility, in the affected parts. Chro7iicform succeeds to the acute or originates spontaneously, and presents the same form and order of symptoms—excitation and depression. Diagnosis. The points of importance are, deep, boring pain in the back, aggravated by motion but not by pressure, with spasmodic contraction of the muscles, followed by paralysis. Myelitis will be differentiated from spinal meningitis when discuss- ing that affection. Tetanus may be confounded with spinal meningitis. The points of distinction are: in the former occur early trismus with rhythmical spasms excited by irritation of the skin, such irritation not producing contractions in meningitis, while movement of the limb does; pro- gressively increasing and not associated with fever. Prognosis. Grave. Death is either sudden, from paralysis of the respiration or of the heart, or gradual, the result of exhaustion. Critical discharges, such as profuse perspiration, urinary flow or epistaxis occur and are followed by rapid recovery. Cases recover- ing may have more or less pronounced partial or complete paralysis. Treatment. Rest in bed, upon the side or face. Cups or leeches along the spine, followed by ice, the hot douche, hot sponges, or mus- tard. Active purgation. To reduce the amount of blood in the vessels of the cord, aco7iitu7n and ergota combined with an opitwi impression. When paralysis (depression) occurs, quinine sulphas, gr. iij, combined with ext. belladonne alcohol, gr. Y> three times a day, ox potassii iodidu7n, gr. xx-xxx, three times a day, with flying blisters along the spine. If the paralysis still persist, a hydrargyru/7t impression often benefits. For paralysis, the galva7iic current to the spine and nerve trunks, and the faradic current to the affected muscles, with the deep injec- tion of strych7ii7ia and the use of massage. PACHYMENINGITIS SPINALIS. Synonyms. Pachymeningitis spinalis interna; hypertrophic pachymeningitis; pseudo-membranous pachymeningitis. Definition. An inflammation of the spinal dura mater; charac- terized by violent pains in the head, neck, shoulders and arms, fol- lowed by paralysis of the upper extremities. 296 PRACTICE OF MEDICINE. Causes. Exposure to cold and damp ; alcoholism ; syphilis; gout; injuries. Pathological Anatomy. Hypertrophic pachy7neningitis is characterized by an exudation upon the inner surface of the dura mater, which gradually solidifies into a layer of compact connective tissue, which presses upon the spinal cord and nerves, producing a myelitis and an atrophic neuritis, resulting in muscular atrophy. The most frequent seat of this form of the affection is the cervical region, as first demonstrated by Charcot, whence the term cervical hypertrophic pachy7neningitis. In the pseudomembranous form a membranous exudation also occurs, in which large numbers of blood vessels develop and rupture, the hemorrhagic extravasation forming a cyst—haematoma—which causes pressure on the cord and nerves. Symptoms. The onset is slow and gradual, with irregular chills and feverishness, violent pains in the head, neck, shoulders and arms, continuous but subject to exacerbations, and associated with a pain- ful constriction of the upper thorax. These symptoms may continue off and on for several months, when the muscles oi the painful parts begin to atrophy, followed by spasmodic contractions and paralysis. The general health deteriorates with the progress of the muscular symptoms. The electro-contractility is lost. Prognosis. If early recognized and promptly treated, the hyper- trophic form may be cured. Treatment. Rest; nutritious diet; oleum 77iorrhue and the hypophosphites; large doses of potassii iodidum, and repeated but systematic counter-irritation. ACUTE MYELITIS. Definition. An inflammation affecting the substance of the spinal cord, which may be limited to the gray or white matter, and involve the whole or isolated portions of the cord. When the gray matter alone is inflamed, it is termed central myelitis ; when the white mat- ter and the meninges, it is termed cortical myelitis; it may be ascend- ing, descending or transverse in its extension. The disease is charac- terized by more or less sudden and complete loss of motion and sensation. DISEASES OF THE SPINAL CORD. 297 Causes. Following spinal meningitis ; exposure to cold and damp ; injuries to the vertebrae ; prolonged functional activity of the cord ; typhus fever; rheumatism ; syphilis; puerperal fever, or during the course of exanthemata ; arsenical or mercurial poisoning. Pathological Anatomy. Intense hyperaemia of the substance of the cord, with extravasations, giving the tissues a reddish-brown or chocolate tint, and also serous transudations, resulting in softening of the structure of the cord, the color changing to yellow and white, the nerve elements undergoing fatty degeneration, presenting the appearance and consistency of cream. The membranes also under- go more or less change. Symptoms. The severity of the symptoms depends upon the extent and location of the inflammation. The onset is usually sudden, with a chill, fever, 1030', frequentpulse, with alterations in sensibility and 7notility, to wit: pain in the back, aggravated by touch and by heat and cold, with sensations of formi- cation (" pins and needles "), the limb feeling as if asleep, or else complete anesthesia, associated with severe neuralgic pai7is. The distinction between anesthesia, insensibility to touch, and analgesia, insensibility to pain, must be clearly determined. A sensation of constriction around the body andlimbs, as if encircled by a tight cord, "the girdle pains;" rapidly developing paraplegia complete in a few hours, with involuntary discharges. The reflex functions are usually abolished, as seen by attempting to cause move- ment of the limbs by tickling the feet or by striking the patella ten- don ; rarely are they diminished, very rarely exaggerated. The tem- perature of the affected limbs is lowered three or four degrees. Sloughs and bedsores and muscular atrophy result if the anterior cornuae—the trophic centres—are affected. The above symptoms of loss of motio7i and sensibility are associ- ated with more or less pronounced vomiting, hepatic disorders, irreg- ularity 0/ the heart, dyspnoea, dysphagia, apnoea and painful pria- pisms. The urine is markedly alkaline in reaction. Among the late manifestations are shooting pains and spasmodic twitchings or contractions of one or all of the muscles of the paralyzed parts. The electro-contractility is abolished in the paralyzed parts. Diagnosis. Acute spinal meningitis is distinguished from acute myelitis by severe pains, increased by pressure, with muscular con- z -298 PRACTICE OF MEDICINE. tractions increased by motion, followed by paralysis much less pro- found than the paraplegia of myelitis; in spinal meningitis there exists cutaneous and muscular hyperaesthesia, which is absent in myelitis. Congestion of the spinal cord is characterized by the mild character and short duration of all the symptoms. Hemorrhage in the spinal canal is abrupt, with irritative symptoms, slight paralysis, preserved reflexes and electro-contractility. The principal diagnostic points of acute myelitis are the " girdle" around the limbs or body, rapid and complete paraplegia, lowered temperature in the affected parts, early and persistentsloughing (bed- sores) and alkaline urine. Prognosis. Varies according to the location of the lesion. If the paralysis is of the ascending variety, death occurs within a few days, from paralysis of the muscles of respiration. If the trophic centre is affected, there occur bedsores, intense pylonephritis and cystitis and changes in the joints ; death from ex- haustion in several weeks. Central 7nyelitis, or inflammation of the gray 7>iatter, is rapid in its progress, death occurring within a week or two. The morbid process may be arrested and the general health restored, but some spinal symptoms will persist. Treatment. Absolute rest is essential to even secure a palliation of the symptoms. Locally, considerable relief follows the use of hot-water bags or sponges dipped in hot water and applied along the spine every few hours. The remedies most strongly recommended are: digitalis, ergota, belladonna, bro7/iides, cimicifuga and quinina, although I have never observed a cure with any plan of medication, after it was fairly estab- lished, save those due to syphilis, by large doses oi potassii iodidum. INFANTILE SPINAL PARALYSIS. Synonyms. Poliomyelitis anterior acuta; essential paralysis of children. Definition. A rapidly developed inflammation of the anterior horns of the gray matter of the cord, occurring suddenly in children, at times in adults—acute spinal paralysis of adults ;—characterized by DISEASES OF THE SPINAL CORD. 299 mild fever, muscular tremors and twitchings, and paralysis of groups of muscles. Causes. Essentially a disease of early life—the second month to the third or fourth year. The fact of its having occurred in adults must be borne in mind. Cold and damp; dentition (?) ; injuries to the spine; developed during convalescence from the acute exanthe- mata. Pathological Anatomy. The early changes are: medullary hyperaemia, vascular exudation and inflammatory softening, although the naked eye may not recognize any changes. Microscopical exam- ination reveals inflammatory softening of the anterior horns of the gray matter. Among other constant lesions are atrophic degenera- tion of the multipolar ganglion cells and the anterior nerve roots. The changes noted as occurring in the cord are usually limited to the dorso-lumbar and cervical enlargements. As a direct result of the changes in the trophic ce7itre and the nerve degeneration of the muscular fibres supplied, there ensue changes in the bones and joints, leading to great deformities. Symptoms. The onset of the affection varies ; i,t is usually sud- den, with an attack of mild fever of a remittent type, of a few days' duration, on recovery from which it is noticed that the child is para- lyzed. Rarely the paralysis may be preceded by convulsions. The paralysis may affect both arms and both legs, the legs alone, or only one of the four extremities ; it may, but very rarely, be a hemiplegia. The bladder and rectum are not affected, nor can an- aesthesia or numbness be detected. The temperature of the paralyzed limb is low and the appearance cyanosed. After a few days there is a slight improvement in the paralyzed parts, although the muscles show a rapid wasting, which is progressive until all muscular tissue is gone. The reflex tnovei7ients are impaired or abolished. The electro-contractility by the faradic current is abolished in the paralyzed parts. With the galvanic or constant current the " reactions of degenera- tion " are developed. To fully understand the meaning of this term a knowledge of the normal electrical reactions is necessary. The normal formulae for the production of muscular contraction in the physiological state are as follows, the strength of the current being barely capable of causing fair contractions :— 300 PRACTICE OF MEDICINE. First. The most effective contractions are produced by the cathode (negative) pole on closing the circuit. Second. The second most effective are produced by the anode (posi- tive) pole on closing the circuit. Third. The next most effective is by the anode pole on opening the circuit. Fourth. Cathode pole contractions on opening circuit are rarely seen in the physiological state. The " reactions of degeneration " are shown by any reversal of the regular formulae, to wit: if the anodal closure shows stronger contrac- tions than cathodal closure ; still greater degeneration is shown if anodal opening contractions are stronger than either of the above; and almost complete degeneration is shown by the complete reversal of the normal formulae as shown by distinct cathodal opening contrac- tions. Diagnosis. Hemiplegia from acute cerebral affections in children can be distinguished from infantile paralysis by the disorders of in- telligence and the special senses, and the perseverance of the normal electro-contractility. Paralysis of myelitis occurs in older persons, and is associated with disturbances of the genito-urinary organs and bedsores. Pseudo muscular hypertrophy, with paralysis, begins gradually, becoming progressively worse with increase in the size of the limbs. Prognosis. Depends upon the treatment. If prompt and proper, recovery may be said to be the rule. Mild cases recover within a few days, others as many weeks, more severe cases a month or two. There is no danger to life. Treatment. The diagnosis during the initial fever is impossible, so that its treatment is symptomatic. On the appearance of the paralysis complete rest ; hot spinal douche, mild galvanism, and in- ternally, quinina, belladonna or ergota. With the improvement that follows the above measures, inter- nally, tinctura nucis vomice, rn^ j—iij t. d., or hypodermatic injections of strychnine sulphas, gr. fa to fa-§ twice a week, and faradism to the paralyzed muscles. DISEASES OF THE SPINAL CORD. 301 CHRONIC PROGRESSIVE BULBAR PARALYSIS. Synonyms. Glosso-labio-laryngeal paralysis ; bulbar paralysis. Definition. A progressive muscular paralysis of the laryngeal muscles, tongue, soft palate and lips. Causes. Obscure. Rare before the fortieth year. Among many others are named cold, rheumatism, gout, syphilis and injuries about the neck. Pathological Anatomy. " Degenerative atrophy of the gray nuclei in the floor of the fourth ventricle ; with atrophy and gray dis- coloration of the nerve roots from the medulla, especially of the facial and hypoglossal nerves." " Atrophy and disappearance of the motor ganglion cells is always to be noted. It may be the sole lesion." " The nerves going to the muscles exhibit sclerosis of the neuri- lemma, and the degenerative atrophy is found in the nerve roots coming from the bulb." Symptoms. The disease begins insidiously. There is first noticed some difficulty z« articulation, from want of precision in movements of the tongue, which increases until that organ is com- pletely paralyzed. The paralysis gradually invades the soft palate, pharyngeal muscles, causing difficulty in deglutition, the orbicularis oris, preventing closure of the lips, the laryngeal muscles interfering with articulation. When the disease is fully developed the condition of the patient is most pitiable, indeed; articulation is impaired or impossible, deglutition interfered with, the lips remaining apart, allow- ing the saliva to dribble from the mouth, and liquids to return through the nose if attempts are made to swallow them. The general health gradually suffers from insufficient nutrition and imperfect respiration. The "reactions of degeneration " are present. Diagnosis. It can hardly be confounded with any other malady. Prognosis. Unfavorable. The duration is from one to five years- Treatment. Entirely symptomatic. SPINAL SCLEROSIS. Synonym. Duchenne's disease. Definition. A myelitis ; an increase in the connective tissue of the spinal cord, with atrophy of the nerve structure proper. Varieties. I. Antero-lateral sclerosis ; II. Cerebrospinal sclero- sis; III. Posterior sclerosis or locomotor ataxia. 302 PRACTICE OF MEDICINE. Causes. Generally a hereditary neuropathic diathesis; syphilis; mineral poisons; shocks or injuries to the cord ; exposure to cold and wet; mostly occurring between the ages of thirty-five and fifty-five ; males more liable than females. Pathological Anatomy. The changes in the cord are gradual in their development and follow a longitudinal instead of a transverse direction. The form, consistence and color of the cord are altered, it being atrophied, indurated and of a grayish color. The changes are hyperplasia of the connective tissue, with granular degeneration, atrophy and disappearance of the proper nerve ele- ments. The nerve roots undergo the same fibroid change. The joints undergo remarkable atrophic degeneration. ANTERO-LATERAL SCLEROSIS. Symptoms. The chief symptom is paraplegia, or entire loss of motion in the lower extremities. Preceding the paralysis there occur jerking a7id twitclmig, with cra77tps and stiffness of the muscles of the affected parts. As the disease is progressing the gait is of a pecu- liar character, termed by Hammond "the waddle," the patient step- ping on the toes and showing a tendency to fall forward. There is a gradual and increasing feeling of heaviness and weakness in the affected limbs. Sensation is unaffected. Reflex phenomena are preserved, at times even exalted. As the morbid process extends upward, the superior extremities suffer in the same manner as those of the lower. Electro-contractility early impaired, and gradually declining until abolished. POSTERIOR SCLEROSIS, OR LOCOMOTOR ATAXIA. Symptoms. Gradual onset by sharp, darting, electric-like pains in the limbs, with loss of sensation in the feet, the patient being un- able to distinguish between hard and soft substances in walking, and, if the upper portion of the spinal cord be affected is unable to coordinate the muscles of the fingers sufficiently to button his clothing. Loss of coordination, the subject being unable to walk upon a straight line with his eyes closed, and with difficulty if his eyes are opened. Inability to preserve the erect position with the feet close DISEASES OF THE NERVES. 303 together. The sight impaired ; either double vision or inability to distinguish between different colors. Reflexes abolished, and " girdle " pains about the body and limbs. Inordinate stimulation of the geni- tal functions and frequent nocturnal emissions. Although the patient is unable to coordinate the muscles, their power is not lost, for, on being supported, he can kick or strike with his usual force. There is generally entire absence of cerebral phenomena. Diagnosis. The symptoms are so characteristic that with care an error in the diagnosis seems impossible. Chro7iic 7nyelitis is characterized by paralysis, and the course of the two affections is otherwise so different that error should not occur. Disease of the cerebellw7i presents symptoms of disordered co- ordination, but they are the result of vertigo, and associated with headache, nausea and vomiting. Prognosis. Sclerosis sooner or later terminates unfavorably. It may be retarded for years, but the patient is never able to walk with- out great difficulty. Treatment. Insist upon as complete rest as possible. Good nutritious diet, milk being the most desirable. Potassii iodidum, or hydrargyri chloridum corrosivui/i, in full doses, or aurii et sodii chloridum, gr. fa, three times a day, often remarkably retard the progress of the affection. The best results are obtained, however, from argenti nitras, gr. Y~Y> or oxidu7n,gx. %, three times a day, withholding it at intervals of a few weeks, to prevent discolor- ation of the skin (argyria). The severe and sharp pains require treatment, at first giving prefer- ence to any of the substitutes of opium, but finally opium itself will have to be resorted to. Galvanism to the spine and faradism to the affected limbs are beneficial. DISEASES OF THE NERVES. NEURITIS. Definition. An inflammation of the nerve trunks ; characterized by pain and paresis of the parts supplied by the affected nerve trunk. Causes. Wounds and injuries ; cold and damp. 304 PRACTICE OF MEDICINE. Pathological Anatomy. Hyperaemia, followed by exudation into the nerve, "which becomes softened and ultimately breaks down into a diffluent mass. Migration of white corpuscles takes place into the neurilemma. Recovery may occur before destruction of the nerve elements is produced, absorption of the exudation occurring, " It is important to note that when inflammation occurs in a nerve it may extend from the point first diseased upward (neuritis ascendens), or downward {7ieuritis descendens)." Symptoms. The onset may be accompanied with febrile re- action. The most decided symptom is pain along the course of the nerve trunk and its peripheral distribution, of a burning, tingling, tearing, i7itense character, increased by pressure or motion. If the affected nerve be a mixed one—sensory and motor—spasmodic con- tractions and 7nuscular cramps occur, followed by impaired motion, ter- minating in paresis of the muscles innervated by the affected trunk. If the inflammation proceeds to destruction of the nerve trunk, wast- ing and degeneration of the muscular tissue ensues. Various trophic changes also occur, such as cutaneous eruptions, and clubbing of the nails. The electro-contractility is impaired or lost. Diagnosis. Myalgia or muscular pain is not associated with paralysis, nor does the pain follow the course of a nerve trunk. Prognosis. Generally favorable, with proper treatment. Treatment. Repeated blistering along the course of the nerve, with full doses of potassii iodidum are usually successful. As the more acute symptoms subside the use oi galvanism or a feeble, slowly intexxxxoted faradic current restores the interrupted function. For the pain and muscular contractions, hypodermatic injections of morphina. NEURALGIA. Definition. A disease of the nervous system, manifesting itself by sudden pain of a sharp and darting character, mostly unilateral, following the course of the sensory nerves. Varieties. I. Neuralgia of the fifth 7ierve ; II. Cervico-occipital neuralgia; III. Cervico-brachial neuralgia; IV. Dorso-intercostal neuralgia; V. Lumbo-abdominal neuralgia; VI. Sciatica. Causes. Heredity ; anaemia; malaria ; syphilis; metallic poi- sons ; anxiety ; mental exertion ; exposure to cold and damp ; injuries to a nerve trunk. DISEASES OF THE NERVES. 305 Pathological Anatomy. The old axiom of neuralgia being "the cry of the nerves for pure blood" is perhaps only part of the truth. The changes in the nerve trunks or centres have not as yet been determined. A fair number of cases present the changes of neuritis. NEURALGIA OF THE FIFTH NERVE. Synonyms. Tic-douloureux ; Fothergill's disease. Symptoms. Paroxysmal pain, of a sharp, darting, stabbing character, most common at points along the course of the supra- and infra-orbital branches of the fifth nerve of the left side, attended with increased lachrymation. When of any duration nutritive changes are observed in the nervous distribution, to wit: edema along the course of the nerve, gray eyebrows and C07ivulsive twitches of the muscles, termed" tic douloureux," tenderness at the infra- and supra-orbital foramina, as well as along the course of the nerve distribution. CERVICO-OCCIPITAL NEURALGIA. Symptoms. Paroxysmal pain, of a sharp and lancinating, or deep, heavy, tensive character, along the course of the occipital nerve upon one or both sides, extending from the vertex and on the neck as far down as the clavicle, and upward and forward to the cheek. May be associated with hyperesthesia of the skin, and with crai7ips in the cervical muscles, and with attacks of herpes. CERVICO-BRACHIAL NEURALGIA. Symptoms. Paroxysi7ial pains, of a severe, boring, burning or tensive character, with sensations of 7iumbness and weakness of the arm, hand, shoulder, scapula and mamma, with tenderness along the cervical plexus. CEdema of the arm and other parts along the dis- tribution of the cervical plexus occur if the neuralgia be of long dura- tion, the result of nutritive changes, the limb at times becoming pale, the skin glossy, dry and harsh. DORSO-INTERCOSTAL NEURALGIA. Symptoms. Paroxysmal pain of a sharp and lancinating char- acter, along the fifth and sixth left intercostal spaces, often associated with the development of herpes, the so-called herpes zoster, or "shingles." Tenderness at the points where the nerves emerge from the inter- vertebral foramina at the sides of the chest and at points in front. 306 PRACTICE OF MEDICINE. LUMBO-ABDOMINAL NEURALGIA. Symptoms. Paroxysmal pai7i of a sharp and lancinating, at times heavy and dull character, following the course of the ileo-hypo- gastric nerve, ileo-inguinal and external spermatic nerve, supplying the integument of the hip, the inner side of thigh, the scrotum and labium. SCIATICA. Definition. Pain following the course of the sciatic nerve. The sacral plexus is made up of the fourth and fifth lumbar and the first two pairs of sacral nerves. Symptoms. Sciatica usually follows an attack of lumbago, the pain becoming fixed in the sciatic nerve ; at times it is a true neuritis. The pain is sharp, tearing, shooting or lancinating in character, in- creased upon motion, shooting along the course of the nerve into the hip, inner side of the thigh, half of the leg, ankle and heel, at one or all of these points, in paroxysms lasting from a few hours to twenty- four hours or longer. The tactile sensation in the foot and motility in the limbs are impaired, and if of long duration, wasting of the limb occurs. Diagnosis. Rheumatism, so-called, is the only condition likely to be confounded with neuralgia. The history of the attack, the character of the pain, with its local- ized spot of tenderness, should prevent such an error. Prognosis. If promptly and properly treated, unless the result of pressure of an exostosis, aneurism or other tumor, favorable. Treatment of Neuralgia. Rest; easily assimilated but nutri- tious diet; removal of the cause, if possible, If anaemic, ferrum and arsenicui7i. If rheumatic, alkalies. If syphilitic or the result of metallic poisons, potassii iodidum. If malarial, quinina. For an attack, 77iorphina and atropina, hypodermatically, afford the most prompt and ready relief. Success usually follows the use of the well-known " Gross (Prof. S. D.) neuralgic pill: "— R. Quininse sulphas......................................... gr. ij Morphinse sulphas ...................................... gr. fa Strychnine................................................ gr. 3^ Acidi arseniosi.......................................... gr. fa Extracti aconiti.......................................... gr. \. M. Ft. pil. No. 1. Sig.—One every one, two or three hours. DISEASES OF THE NERVES. 307 In sciatica, prompt relief follows the deep injection of chloroformum. Locally, blisters along the course of the nerve, or a lotion of chloral, camphora, morphina and chloroformum combined, in solution. Facial neuralgia is often wonderfully benefited by the internal administration of ext. gelsemii fld., gtt. iij-v, every three or four hours, until its physiological effects are produced. All forms of neu- ralgia are more or less benefited by— R. Quininae sulph.............. Ferri redact................, Acid arsenious.............. Aconitiae..................... In pill every four or five hours FACIAL PARALYSIS. Synonym. Bell's palsy. Definition. An acute paralysis of the seventh cranial or facial nerve, the great motor nerve of the muscles of the face—the nerve of expression. Causes. Exposure to a current of cold air against the side of the face—over the pes anseri/ius—is the most frequent cause. Also due to injury or disease of the middle ear. Syphilis. Symptoms. The facial nerve supplies the muscles of the face, the muscles of the external ear, also the stylo-hyoid, posterior belly of the digastric, the platysma, one muscle of the middle ear, the stapedius and one palate muscle, the levator palati; by means of the chorda tympani branch it controls the secretion of the parotid and submaxillary glands, and, possibly, the sense of taste. It also fur- nishes motor power to the azygos uvulae, the tensor tympani and the tensor palati muscles. The onset is usually sudden, with tingling of the lips and tongue, and upon looking in the mirror the patient is surprised by the per- fectly blank, motionless side of the face, the corner of the mouth depressed, the eyelids open, the face drawn toward the well side, and with inability to expectorate, whistle or swallow. Any or all the muscles innervated by the nerve may participate in the paresis. The electro-contractility is feeble or lost. The reflexes are abolished. Diagnosis. Paralysis of the muscles of the face occurs in hemi- gr- iij gr-j gr- fa gr- j fa- M. 308 PRACTICE OF MEDICINE. plegia; the points of differentiation are the presence of cerebral symptoms and the normal reflex excitability. Facial palsy with otorrhoea, imperfect hearing, obliquity of the uvula and loss of taste determine its origin within the aquaeductus Fallopii. It is the result of cold if the taste be normal and the uvula straight. If other nerves are also involved the origin is central. Prognosis. Favorable. Treatment. If the result of cold and damp, diaphoresis with pilocarpus, or diuresis with potassii iodidum, and blisters in front of ear, with galvanism of the affected muscles. CEREBRO-SPINAL NEUROSES. CHOREA. Synonyms. St. Vitus's dance; insanity of the muscles. Definitions. A functional (?) disorder of the nervous system ; characterized by irregular spasmodic movements of groups of muscles, with muscular weakness, more or less approaching paralysis of the affected parts. Causes. Essentially a disease of childhood ; hereditary; reflex from dentition, worms, masturbation or fright; probably the result of rheumatism in many cases. Pathological Anatomy. As yet there has been no constant anatomical lesion discovered, the theory of emboli having, however, many advocates. Symptoms. The onset is usually gradual, the child seemingly grimacing or jerking the arm or hand, as if in imitation, followed by decided, irregular jactations of the muscles of the face (histrionic spasm), of the eyelids (blepharospasm), eyeballs (nystagmus), and the shoulder, arm and hand, finally extending to the lower extremi- ties, interfering with 77iotility; in severe cases, inability of self-feeding or holding anything in the hands. The speech is often unintelligible, the tongue constantly moving in an irregular manner. The heart's action is tumultuous and irregular, associated with a soft, blowing, systolic murmur, most distinct at the base. The mus- CEREBRO-SPINAL NEUROSES. 309 cles are usually quiet during sleep, although this is not always the case. The mind is somewhat blunted, the temper irritable, the memory impaired. If the irregular muscular movements are con- fined to one side of the body it is termed hemi-chorea. Diagnosis. Chorea was confounded with epilepsy until the points of distinction were pointed out by Sydenham. Paralysis agita7is has general muscular tremor, beginning in one limb, gradually progressing, uninfluenced by treatment; a disease of the elderly. Post-hemiplegic chorea is the choreic movement of a paralyzed limb. Prognosis. The vast majority of cases recover, but relapses are very common. Treatment. Remove the cause, if possible. Easily assimilated diet. Many cases improve rapidly by confinement to bed in a dark- ened room. If the muscular movements interfere with sleep, mor- phina or chloral are indicated. Regulate the secretions. Arsenicum is the most reliable remedy yet introduced for the treat- ment of chorea. It should be pushed to its first physiological effects, then gradually reducing the dose until all symptoms disappear. The form of the remedy best adapted is liquor potassii arse7iilis, gtt. v, in- creased to x or even xv, three times a day*. Extractum cimicifuga fiuidum, ttlxx-^j, t. d., is serviceable, especially in cases following a rheumatic attack. Cases resisting the arsenicum treatment may suc- cumb to hyoscyamine, gr. fa-$-x\-§, three times daily. If anaemia be present, combine or alternate arsenicum Withfe7-rum. EPILEPSY. Definition. A chronic disease, of which the characteristic symp- toms are a sudden loss of consciousness, attended with more or less general convulsions. Causes. Heredity; rarely, worry, anxiety, depression or fright. Pressure from a tumor at the periphery, or thickening of the mem- branes of the brain, causing pressure; dyspepsia; syphilis ; uterine diseases. Pathological Anatomy. There are no constant anatomica lesions as yet, associated with epilepsy. Varieties. I. Epilepsia gravior, le grand mal; II. Epilepsia viilior, le petit mal. 310 PRACTICE OF MEDICINE. Symptoms. Le grand mal is preceded by a more or less pro- nounced and curious sensation, the so-called aura epileptica. The attack proper is sudden, the subject suddenly falling, with a peculiar cry, loss of consciousness, pallor of the face, the body assum- ing a position oi tetanic rigidity, succeeded after a few moments by more or less pronounced clonic convulsions, followed by coma of sev- eral hours' duration. The subject awakens with a confused or sheep- ish expression, with no knowledge of what has occurred, unless he has injured himself during the attack, either by the fall, or, what is very common, has bitten his tongue during the convulsions. Le petit mal is manifested either by attacks of vertigo, the con- sciousness being preserved, or by a passing absent-77iindedness, either form being associated with slight convulsive phenomena, followed by coma of short duration. The mental functions are not, as a rule, injured by attacks of epi- lepsy, unless they recur very frequently. Indeed, when at wide in- tervals the subject seems relieved by them, " the sudden, excessive and rapid discharge of gray matter of some part of the brain on the muscles," the so-called "electrical storm," having cleared the cere- bral atmosphere. Diagnosis. Ure77iic convulsions closely resemble an epileptic attack ; but the dropsy or general oedema and albuminous urine of the former should guard against error. Feigned epilepsy often misleads the most practical expert. Prognosis. The vast majority of cases will not recover under treatment, but have the frequency and severity of the attacks greatly ameliorated, but sooner or later returning with their former severity. Cases the result of the various reflex causes usually recover when the cause is removed. Treatment. To avert an impending attack, inhalations of aniyl nitris, gtt. iij-v, a few whiffs of chloroformum, or the hypodermatic injection of morphina. To prevent the return of attacks, remove the cause, if possible ; attention to the secretions, and the internal administration oi potassii bromidu77i in doses sufficient to abolish the faucial reflex and produce the symptoms of bromism, has great power in diminishing the severity and frequency of the attacks; better results are sometimes obtained by the combination of the various bromides. Cases in which the bromides are not serviceable are sometimes benefited by DISEASES OF THE BLOOD. 311 argenti nitras, belladomia, or cannabis indica. Weak and anaemic subjects usually do better with strychni7ia in full doses than with potassii bromidum. If a history of syphilis can be obtained, the com- bination oi potassii iodidum and potassii bromidiun will effect a cure. Whichever of the above remedies are beneficial in any particular case, the permanency of the relief can only be maintained by the continuation of the drug for at least two years after the last attack. Gowers highly recommends the following in cases complicated with cardiac dilatation :— R. Potassii bromid....................................... gr. xx Tinct. digital.......................................... TT1, x. M. Sig.—Three times a day. Another good combination is the following:— R. Potassii bromid....................................... gr. xv Sodiibromid.......................................... gr. xv Liq. potassii arsenit................................. rnjj Ext. conii fld......................................... TTLiij Aq. cinnamomi...................................... X) Inf. gentian comp............ad................... 3 ss. M. Sig.—Two hours after meals. Brown-Sequard's mixture for epilepsy is as follows :— R. Potassii iodidi........................................ 8 parts. Potassii bromidi. *................................... 8 " Ammonii bromidi.................................... 4 " Potassii bicarb........................................ 5 " Inf. columbo.........................................360 " M. Sig.—One teaspoonful before meals and three dessertspoonfuls on going to bed. Prof. Da Costa has used with success a bromide of nickel in cases that have withstood the other combinations of the bromides. DISEASES OF THE BLOOD. ANEMIA. Synonyms. Spanaemia; hydraemia. Definition. A deficiency of red corpuscles and albuminoid com- pounds—a poverty of the blood ; characterized by pallor and general weakness. 312 PRACTICE OF MEDICINE. Oligemia is a lessening in the amount of blood; Ischemia is a localized anaemia. Causes. Predisposing and exciting. Predisposing. Sex; the female, pregnancy and menopause; heredity. Exciting. Deficient food, air or sunshine ; excessive work ; mental worry; prolonged and frequent nocturnal emissions ; excessive nurs- ing ; chronic intestinal catarrh ; Bright's disease ; malaria. Pathological Anatomy. Post-mortem, the tissues are thin, shrunken and bloodless. If the anaemia has been of long duration, patches of fatty change are seen in the various organs. The blood has a brighter color, the result of diminution in the number of red corpuscles and the quantity of the haemoglobin; it is thinner than normal, and coagulates slowly and imperfectly, from diminution of the fibrino-plastic constituent. Symptoms. Pallor, gums, tongue, ear and conjunctiva pale. Muscular weakness, inability for exertion. Deficient appetite and impaired digestion, attacks of vomiting the result of anaemia of the medulla oblongata. Quickened respiration, irritable tei7iper, vertigo in the erect position, attacks of swooning, hysteria, and rarely epilepsy. h'ritable heart, with soft systolic basic 77iurmurs and attacks of hysteria. Nocturnal emissions in male and deficient menses in female. Maras77ius in children. More or less general edei7ia of the eyelids and ankles. Long continued, symptoms of fatty changes of various organs, or gastric ulcer result. Diagnosis. The symptoms of anaemia are so characteristic that an error is impossible ; the cause of it, however, may be hidden. Prognosis. Favorable if treated early. If protracted, results in more or less general symptoms of fatty degenerations or ulcer of the stomach. Treatment. Remove the cause. Easily assimilated, blood- producing diet. Fresh air, sunlight and exercise short of fatigue. Purgatives with stomachic tonics, to promote digestion. For the anaemia proper, ferrum in some form is the most valuable remedy, always remembering that it is not assimilated if the intestines and liver be torpid. The following alterative tonic, known as Smith's (Dr. A. H.), is frequently of value:— DISEASES OF THE BLOOD. 313 R. Hydrargyri chloridi corrosivum...................... gr. j—ij Liq. arsenici chloridi................................... f?j Tinct. ferri chloridi, Acidi hydrochlorici dil...............aa............... f-5'v Syrupi...................................................... f^5 iij Aqua..........................ad.......................... f^ vj. M. Sig.—One dessertspoonful in a wineglassful of water after each meal. CHLOROSIS. Synonym. Green sickness. Definition. A pronounced anaemia, occurring in girls about the age of puberty. Causes. Obscure; inherited; menstrual irregularities. Ham- mond maintains "that it is an affection of the nervous system, the blood changes being secondary." Pathological Anatomy. The blood is deficient in red cor- puscles, the volume of the fluid normal or nearly so. Rarely the mass of blood is increased. The body is well nourished and the sub- cutaneous fat well distributed. The organs are abnormally pale. The spleen, the lymphatics and the marrow of the bones are not affected in any manner. Symptoms. The condition is associated with disorders of men- struation. The young girl experiences a change of disposition, becom- ing 7norose and despondent, or rarely hysterical. " As respects the actual condition of the sexual organs, there are two forms of derangement which happen in chlorosis ; there are the amenorrheic form and the 7iie7iorrhagic form." After an attack of menorrhagia or after the failure of the flow to appear, the changes occur. The complexion changes, blondes becoming pallid, waxy and puffy, without oedema; bru7iettes becoming muddy and grayish in color, with bluish-black rings under the eyes. Weariness and fatigue upon the least exertion; the heart irritable, with shortness of breath. The appetite is vitiated, the digestion imperfect; attacks of gastralgia are frequent. A not infrequent complication is gastric ulcer. Phthisis develops in those having the slightest predisposition. Prognosis. As a rule, unfavorable, on account of the liability to grave complications. Those recovering are always liable to re- lapses. 2 A 314 PRACTICE OF MEDICINE. Treatment. A generous, nutritious diet; fresh air; moderate exercise; change of scene; cheerful surroundings. Ferrui7i and arsenicu77i are of the greatest utility. A good combination is— R. Ferri arseniatis.......................................... gr. fa—^ Ext. nucis vomicse...................................... gr-i~i- M. Ft. pil. No. I. Sig.—After meals. The following is Blaud's formula, so highly lauded by Niemeyer:— R . Pulv. ferri sulph., Potassii carbonat. purae...............aa............... § ss Tragacanthse............................................. q. s. M. Ft. pi. No. xcvj. Sig.—One to three or four pills three times daily. PROGRESSIVE PERNICIOUS ANEMIA. Synonyms. Anaematosis ; essential anaemia; anaemia of fatty heart. Definition. A pernicious, progressive form of anaemia, of un- known cause, resisting all treatment, and toward its termination associated with fever. Pathological Anatomy. The blood is scanty and pale, with diminished red corpuscles, albuminates and fibrin, showing a very feeble tendency to coagulate. There is no increase in the white corpuscles. The 77iarrow in adult bones becomes foetal, red and adenoid, and contains microcytes ; several other changes have occurred second- arily in the marrow. Secondary to the anaemia, the heart, larger arteries and certain capillary tracts exhibit circumscribed or diffused fatty degeneration. The liver, spleen, kidneys and stomach are decidedly anaemic, causing fatty changes in those organs. The skin may contain petechiae of a purplish or brownish tint, and internal hemorrhages are not in- frequent ; retinal hemorrhage is rarely wanting. There is not much emaciation, though the pallor is pronounced. Symptoms. It begins insidiously, with increasing languor and pallor, the muscular weakness compelling the patient to take his bed. Cardiac palpitation, dyspnea, attacks oi syncope, edema and swelling about the ankles, with petechial spots scattered irregularly over the surface. DISEASES OF THE BLOOD. 315 The appetite is wanting, and nausea and vomiting are occurrences, with marked dyspepsia and persistent diarrhea. As the disease pro- gresses a remittent form oi fever develops, the temperature frequently showing io2°-io4° F. Disorders of vision are the result of the reti7ial hemorrhage. The cardiac sounds are feeble and associated with soft basic or anaemic murmurs. Diagnosis. Progressive pernicious anaemia is distinguished from simple anaemia and chlorosis by the greater severity of the former. From leucocythemia by the normal-sized spleen and liver, and the absence of increase in the white corpuscles. Prognosis. Unfavorable. Treatment. Symptomatic. LEUCOCYTHEMIA. Synonyms. Leucaemia; white cell blood ; white blood ; anaemia splenica. Definition. A condition in which there is an enormous increase in the number of white blood corpuscles. It may assume either a splenic, a lymphatic, or a 7nyeloge7iic form, and is characterized by symptoms of pronounced anaemia. Causes. The real cause and nature of the affection is un- known. Pathological Anatomy. The spleen is increased in size, den- sity and firmness ; the lymphatic glands all over the body also en- large, but are soft to the touch, often fluctuating ; the 7narrow of the bones changes from its normal rose color to that of a greenish-yellow ; the liver also enlarges enormously. The blood is paler than normal, its specific gravity reduced from 1.055 to 1.040 or lower, and the white corpuscles increased in number and in size, the red corpuscles being lessened in number and size. Symptoms. The onset and early progress of the disease is identical with that of simple anaemia, accompanied by swelling of the abdomen and a feeling oi fullness and pain in the splenic region, due to enlargement of that organ. In the lymphatic variety, enlargement of the glands in the groin, neck and axillary region are associated with the great pallor. In the myelogenic variety, the bones, more particularly the ribs and 316 PRACTICE OF MEDICINE. sternum, are tender on pressure, the patient assuming a waxy appear- ance. In each variety the appetite is poor, the digestion feeble, the bowels loose, the patient easily fatigued, with cardiac palpitation, and dysp- noea, with oedema of the eyelids and ankles. The urine is scanty and of high specific gravity—i.020-1.030. Diagnosis. This should cause but little trouble if enlarged spleen, lymphatic glands and tender bones are associated with great pallor, and the characteristic appearance of the blood as demonstrated by a " puncture of the finger of the patient and receiving the blood on a piece of white linen or a lawn handkerchief, and placing by the side of it a similar stain of blood from a healthy subject. The full color of the latter contrasts strikingly with the stain of the former, which is hardly of a blood color, and translucent." Prognosis. No case of recovery has yet been recorded. The average duration is between two and three years. Treatment. Symptomatic. A combination of the following remedies with generous diet, fresh air, sunshine, pleasant surround- ings, oleum morrhue and the hypophosphites have at times seemed of temporary utility, to wit: quinina, arsenicum, ferruf7i and ergota. ADDISON'S DISEASE. Synonym. Melasma supra-renalis. Definition. " The bronzed-skin disease." Thus defined by Aver- beck : "A well-marked constitutional disease, exhibiting itself locally as a chronic inflammation of the supra-renal capsules, but in its essence consisting in a peculiar anaemic condition, always tending toward death, which is characterized by intense development of pig- ment in the cells of the rete malpighii and in the epithelium of the mucous membrane of the mouth." Causes. Uncertain. Tubercle, scrofula and syphilis have each been given as the cause. Pathological Anatomy. A low form of inflammation, termi- nating in degeneration of the supra-renal capsule. The blood is deficient in fibrin and red corpuscles, with a slight increase of the white corpuscles. Fatty degeneration of the heart and vessels has been observed in some cases. " The most striking change during life—the abnormal pigmenta- DISEASES OF THE BLOOD. 317 tion—is due to the deposition of granular pigment in the cells of the rete malpighii, in the papillary portion of the cutis, and even in the connective tissue corpuscles. No change occurs in the proper structure of the skin. Similar pigment deposits occur in the mucous membrane of the mouth, especially along the edges of the teeth." " The disease of the supra-renal capsules excites an irritation of the vaso-motor system—the trophic system—which leads to the pig- mentation." Symptoms. The onset of the disease is insidious, with a feeling of extreme languor, muscular fatigue, asthenia, indigestion, anorexia, dyspnea, cardiac palpitation, vertigo, melancholia and excessive drowsiness. The surface is first pale, then changes to a hue like that of melane/nia, changing to icteroid, finally resembling the color of a mulatto, and then to a lustreless bronze. These changes also occur on the mucous membrane of the lips, tongue, gums and mouth. Prognosis. An incurable disease. Duration, a year or two. Treatment. Symptomatic. HAEMOPHILIA. Synonyms. Hemorrhagic diathesis; "bleeder's disease." Definition. A congenital condition characterized by the habitual occurrence of hemorrhages. Cause. Hereditary. Symptoms. The bleedi7ig appears about the period of first den- tition, and consists of spontaneous hemorrhages from the mucous membrane of the nose, mouth, lungs, stomach, intestines, or genito- urinary passages, or in perfect cases, hemorrhages occur directly from the fingers, toes, lobes of the ears, back of the hands or arms, without any apparent change in the skin, and continue, in spite of the most powerful means, for days or weeks. Traumatic hemorrhages occur if an injury of any kind is sustained about the period of the develop- ment of the bleeding. Epistaxis is the most common form of all those named. As a result of the great loss of blood, the subject suffers from all the symptoms of profound anaemia. Diagnosis. It is impossible to confound the "bleeder's disease" with any other affection. 318 PRACTICE OF MEDICINE. Prognosis. Death is the usual termination within a few weeks from the time of its development, which may not be until adult life. Treatment. Entirely symptomatic. It is claimed that "potassii chloras—an ounce of a saturated solution three times a day—com- bined with tinctura ferri chloridi," will eradicate the constitutional tendency. SCORBUTUS. Synonym. Scurvy. Definition. A peculiar condition of malnutrition or anaemia, gradually developing upon a dietary deficient in fresh vegetable material; characterized by decided anaemia, debility, mental lethargy, petechiae and a swollen and spongy state of the gums, with a ten- dency to bleed upon the slightest irritation. Causes. The disease only occurs when fresh vegetable nutriment or some appropriate substitute has been for a time partially or com- pletely withheld. Pathological Anatomy. An undetermined derangement in the composition of the blood, with diminished proportion of the pot- ash salts. Spleen enlarged. The tissues are wasted and present extravasations, due to either one of or the combined presence of the following conditions, to wit: liquid condition of the blood, allowing it to escape from the vessels, alterations in the walls of the vessels, or, a vaso-motor paralysis. Symptoms. General weakness, lassitude, indisposition to either mental or physical exertion. The skin is dry, rough and of a muddy pallor, the face pale and bloated. Swelling and sponginess of the gums, with great tendency to bleed and an exceedingly offensive breath. Looseness of the teeth, hemorrhages from mucous surfaces, and extravasations of blood within and beneath the skin. The lips are pale, which is in striking contrast to the redness of the gums; the eyes are sunken and surrounded by a dark blue circle. Hemorrhages occur from the nostrils, mouth, bronchial tubes, intestinal canal and vagina. The skin is dry and rough, resem- bling that of a plucked fowl. CEdema of the face and ankles not infrequent. Depression of the spirits is characteristic. Palpitation and dyspnoea on exertion. Urine high colored, speedily becoming fetid. The patient usually longs for fresh vegetables and fruits. DISEASES OF THE BLOOD. 319 Complications. Dysentery. Scorbutic dysentery is a frequent complication. It may co-exist with typhoid and typhus fever. Prognosis. Favorable, if early and properly treated. Treatment. The chief indication is the assimilation of the ali- mentary principles needed for the healthy constitution of the blood and the invigoration of the system. The juice of lemons, oranges and other fruits. Antiscorbutic vege- tables, to wit: raw cabbage, cresses and raw potatoes, in conjunction with meats, milk and farinaceous food. Improve the appetite and digestion by the use of strychnina, quinina, mineral acids and bitter infusions. Potassii chloras, locally, will relieve the oral symptoms. PURPURA. Synonym. Hemorrhoea Petechialis. Definition. An acute disease, characterized by purplish discol- orations of the skin, the result of hemorrhages into the upper layers of the cutis and beneath the epidermis. Varieties. Purpura simplex ; purpura he77iorrhagica ; purpura urticans. Causes. Not properly understood. It may occur at any age, but is especially frequent in children and elderly people. Symptoms. Purpura simplex is the mildest form of the affection, and is characterized by the sudden appearance of small, bright red spots—a cutaneous hemorrhage—most commonly on the legs, asso- ciated with slight lassitude, mild febrile reaction, and aching pains in the limbs. The hue of the spots rapidly fades to a purplish color and slowly disappears. Relapses are common. Purpura hei7iorrhagica has in addition to the eruption of purpura simplex—the cutaneous hemorrhage—a flow of blood from the free surface of mucous membranes. The most common hemorrhage is epistaxis, slight or profuse. Other hemorrhages are hemalemesis, melena, hematuria, hemoptysis, menorrhagia, and also into the sub- stance of the mucous membranes of the palate, cheeks and gums. This variety is associated with great debility and depression, moderate fever and disorders of digestion. Marked anemia results from the hemorrhages. Purpura urticans is a combination of urticaria and purpura sim- 320 PRACTICE OF MEDICINE. plex. It is characterized by " rounded and reddish elevations of the cuticle, resembling wheals, but which are not accompanied, like the wheals of urticaria, by any sensation of itching or tingling." They are usually seated on the legs, thighs, breast and arms, and are inter- spersed with petechiae. They gradually form and subside within twenty-four or thirty-six hours. Relapses are frequent. This variety is also associated with malaise, moderate fever, and pains in the limbs. Prognosis. Purpura simplex and purpura urticans are favorable, but relapses are very frequent. Purpura hemorrhagica is always a grave disease, often proving fatal from exhaustion, or more rarely, cerebral or pulmonary hemorrhage. Recovery occurs frequently, under judicious treatment. Treatment. Rest and a concentrated nutritious diet, and the moderate use of stimulants, are used to combat the resulting anaemia. The internal use of oleum terebinthi7ie is one of the most reliable remedies for all forms of the disease. The following is an eligible formula:— R. 01. terebinthinse........................................ f.^ij 01. amygdalae express................................. f^j Tinct. opii deodorat................................... f/jss Mucil acacise.......................................... fSj Aq. lauro-cerasi..................ad................. f3nj. M. Sig.—One teaspoonful every three or four hours. Among the numerous remedies suggested, the most reliable have been acidum sulphuricum dilutum and tinctura ferri chloridi. Good results have followed acidum carbolicum, gtt. ij-iij every three hours, in cases seen by the author, and a particularly persistent case was cured by full doses of potassii iodidui7i. " If hemorrhages that are threatened come on with a strong pulse, flushed face, headache and excitement, digitalis, quinina, and ergota are the appropriate medicaments." (Bartholow.) Locally, to arrest bleeding, astringents and either hot or cold water or ice. DISEASES OF THE SKIN1. ",)'2l DISEASES OF THE SKIN. DISORDERS OF SECRETION. SEBORRHCEA. Synonyms. Acne sebacea; pityriasis ; tinea furfuracea; dan- druff. Definition. A disease of the sebaceous glands of the skin ; char- acterized by an excessive and abnormal secretion of sebaceous matter, forming upon the skin either an oily coating, or in crusts and scales. Varieties. Seborrhea oleosa ; seborrhea sicca. Causes. In newly-born infants an increased secretion of seba- ceous matter—the vernix caseosa—is a physiological process. The origin of the disease is for the most part illy understood, anaemia being a factor in many cases. Pathology. Seborrhoea is a functional derangement of the glands, unless it be allowed to become very chronic, when occur atrophy of the glands and follicles. Symptoms. The affection may occur upon any portion of the body, its most frequent seat being, however, the scalp (seborrhea capitis), and next in frequency the face (seborrhea faciei). Seborrhea oleosa; appears as an oily, greasy coating upon the skin, without hyperaemia, and not attended with itching. The secre- tion is of an oily character, the quantity at times being so great as to collect in minute drops of a clear, yellowish fluid upon the surface. The most common seat for this variety is the face—seborrhea faciei —and nose—seborrhea nasi. Seborrhea sicca; consists in the formation of dry, more or less greasy masses of scales or crusts oi a grayish, yellowish, or brownish- yellow color, having a strong tendency to adhere to the skin, and attended with decided itching. Occurring upon the scalp—seborrhea capitis—it is a frequent source of premature baldness. Diagnosis. Seborrhea capitis may be mistaken for dry eczema, but the former is always a dry disease, while in eczema moisture has occurred at some period of the affection. The scales in seborrhoea are very abundant and pale ; in eczema the scales are scanty and reddish, the parts infiltrated and thickened. 2 B 322 PRACTICE OF MEDICINE. Seborrhea sicca and psoriasis have many points of resemblance, whether occurring on the scalp or on the body. In seborrhoea the scales are minute or caked, grayish or yellowish in color, of an unctuous feel and usually uniformly diffused. In psoriasis the scales are very dry, abundant, thick, white, irregularly dispersed, with intervening healthy skin, and the surface beneath the scales is always reddish and inflamed. The clinical histories of the diseases are entirely different. Prognosis. If properly treated, favorable, although the affection is obstinate. Treatment. The secretions require attention. If anaemia be present, ferrum and arsenicum are indicated. The following formula of Sir Erasmus Wilson, and lauded by Hebra, is valuable :— R. Vini ferri...... ......................................... f^iss Syr. simpl.............................................. Liquor potassii arsenit...............aa............. % ij Aquae destil............................................ f^U- M. Sig.—Teaspoonful three times a day, with meals. Duhring recommends calcii sulphid., gr. fa-^, several times daily. Local measures are the most important in seborrhoea, For sebor- rhea capitis the following plan will usually be successful:— The scales are to be thoroughly moistened with either oleum olive, oleum morrhue, or adeps, to facilitate their removal; it is best ap- plied at night and the head covered with a flannel or other cap. As soon as the crusts are well soaked they should be removed by wash- ing with soap and warm water, or equal parts of soap and glycerine and water, or the following will be found valuable :— R. Saponis viridis (Hebra)............................ f.^iv Spts. vini rect......................................... t ^ ij. Solve et filtra. Sig.—As a soap-wash or shampoo. The scalp is to be thoroughly cleansed of either of the above by again washing with warm water and then dried by means of soft towels. Then should be applied some oily or fatty substance, depending upon the condition of the scalp. If much irritation, either vaseline or oleum amygdale expressum. If no irritation be present, a stimulating preparation will be found of great benefit. Either of the following may be used:— DISEASES OF THE SKIN. ;>o;> R. Tinct. cantharidis..................................... f^iij Tinct. capsici.......................................[ fziij 01. ricini.............................................. f^j: Alcoholis................ f'z;: c t ................................... *.-»y Spts. rosmanni........................................ f z; ^ —DUHRING. Or— R. Bismuthi subnitratis.................................. f-j Ung. hydrargyri ammon............................ ^ ij-iv Ung. aquae rosae...............ad.................... ^j. ]yj_ The above should be repeated every day or two, as the symptoms may require, until a cure be effected The seborrhoea of other portions of the body are to be treated upon the same general method. COMEDO. Synonyms. Acne punctata nigra ; black heads or worms. Definition. A disorder of the sebaceous glands ; characterized by retention in the excretory ducts of an inspissated secretion which is visible upon the surface as yellowish or whitish pin-point and pin- head sized elevations, containing in their centre blackish points. Causes. The true etiology is unknown. Among the causes as- signed are, anaemia, menstrual disorders, dyspepsia and constipation. Pathology. Comedo is an affection of the sebaceous glands and ducts, consisting of an accumulation of sebum and epithelial cells in the glands and follicles, dilating the ducts to such an extent as to pro- duce the point or elevation upon the surface. The obstructed gland may relieve itself, or it may continue distending the gland until a papule is formed. The duct sometimes contains small hairs, and also the microscopic mite—de7/iodex folliculorum—having a length of from Tfa to fa of an inch, and breadth of about zfa of an inch, which was at one time erroneously supposed to be the cause of the affec- tion. Symptoms. Essentially a chronic affection, observed for the most part on the face, neck, chest and back. Each single elevation or black-head or point is designated a comedo, or if a number, in the plural, as comedo7ies. Each comedo is small, varying from a pinpoint to a pin-head in size, having a brownish or blackish appearance, from the dust or dirt that has adhered to their unctuous extremity. If they form in 321 PRACTICE OF MEDICINE. great numbers upon the face they are disfiguring, giving the individ- ual the appearance of having had minute grains of powder im- planted in the skin. There are no evidences of inflammation unless acne be associated, but, on the contrary, the skin has a dirty, greasy, unwashed appearance. Diagnosis. There is no condition resembling comedo, so that its recognition is easy, unless complicated with acne ; but even then the inflammatory appearances of acne should prevent error. Prognosis. Favorable, although often remarkably obstinate. Treatment. Derangements of any of the functions of the body should be corrected, and strict attention given to the rules for pro- moting the general health. Local measures are usually sufficient to promote a cure of the affection. The parts affected should be thoroughly softened by bathing with soap and warm water, when the comedones are removed by friction with a Turkish towel, pressure between the thumb nails, the appli- cation of a watch key, or the instrument known as the "comedo extractor," and their reappearance prevented by an unguentum medi- cated, to meet the indications, with either sulphur, alkalies or hydrar- gyrum. Piffard's acne application I have found valuable :— R. Sulphur sublim., Alcoholis, Tinct. lavend. comp., Glycerini, Aquae camphorae...............aa....................... fi;j. M. Sig.—Apply freely, after removal of the comedones. MILIUM. Synonyms. Grutum ; tubercula miliaria or sebacea; acne punc- tata albida. Definition. An accumulation of sebum in the sebaceous glands which are minus their excretory ducts; characterized by the formation of small, roundish, whitish, sebaceous, non-inflammatory elevations, situated immediately beneath the epidermis. Cause. The origin of the affection is not understood. Pathology. The sebaceous gland is distended with the sebum, which is unable to escape owing to the obliteration of the duct, nor DISEASES OF THE SKIN. 325 can the contents be squeezed out, as no sign of aperture is to be found, the formation being completely enclosed. Rarely the retained secretion undergoes a metamorphosis into hard, calcareous, stone-like masses—sebaceous concretions or cutaneous calculi. Symptoms. Milia may occur upon any portion of the body; their usual seat, however, is upon the face, forehead, and about the eyes. They form gradually, are about the size of a millet seed, of a whitish, pearl or yellowish color, hard, and of a rounded shape, giv- ing the sensation to the touch of hard bodies embedded in the skin. They are not associated with inflammatory symptoms. Diagnosis. Milium and comedo are somewhat similar in appear- ance ; the differences are that in milium the sebaceous gland is dis- tended without an opening, while in comedo the duct of the gland is always patulous upon the surface. Milium usually exists singly, the skin looking normal; while comedo is more general, the surface having a soiled and greasy appearance. Prognosis. Favorable. Treatment. As a rule no treatment is needed, the number being few and their presence of-no consequence. If their removal be desirable, two modes suggest themselves; one, to open the cyst with a fine-bladed bistoury, and turning the contents out, destroying the remaining sack by the application of either tinctura iodi or acidum chromici; or, the cyst may be destroyed by electrolysis. If a tendency to recur is shown, the plan may be repeated. SEBACEOUS CYST. Synonyms. Wens; sebaceous tumor ; encysted tumor. Definition. A distention of the sebaceous gland and duct, with hypertrophy of the walls, which forms a thick, tough sack or cyst; characterized by the appearance of a firm or soft, more or less rounded tumor, having its seat in the skin or subcutaneous connective tissue. Cause. Unknown. Pathology. Hypertrophy of the gland and duct walls, the result of pressure from the accumulated contents, which consist of the altered products of the sebaceous secretion. Symptom. The development of wens is slow and insidious. The 32G PRACTICE OF MEDICINE. localities where they are more commonly developed are the scalp, face, back and scrotum. The tumors occur singly or in numbers, in size from a pea to a walnut, or larger, in shape either rounded, flattened or semiglobular; in consistency they are either hard or soft, and doughy; they are freely movable and painless. Diagnosis. Sebaceous cysts may be confounded with fatty tumors. Treatment. Excision and careful and thorough dissection of the cyst. HYPERIDROSIS. Synonyms. Hydrosis; ephidrosis; excessive sweating. Definition. A functional disorder of the sweat glands ; charac- terized by an increased flow of sweat. Causes. Often undetermined ; occasionally inherited; nervous derangements; malaria ; diseases of the heart and lungs. Pathology. A functional derangement of the sudoriparous glands, over which the vaso-motor system has control. The character of the secretion, chemically, does not differ from the normal. Symptoms. Universal general sweating, such as occurs during the course of pneumonia, rheumatism, tuberculosis, typhoid and other febrile maladies, can hardly be considered a distinct affection. Hyperidrosis may be acute or chronic, the amount slight or large, being constant or paroxysmal, the extent general or local, and it may or may not be symmetrical. Bromidrosis is the designation when the secretion has an offensive odor. Chromidrosis is the designation when the fluid poured forth is variously colored. Uridrosis is the designation when the excretion from the sweat glands contains the elements of the urine and particularly urea. Phosphoridrosis is the designation when the perspiration appears luminous in the dark. Local hyperidrosis occurs most commonly upon the palms, soles, axillae and genitalia. Hyperidrosis of the palms maybe so profuse that the fluid accumu- lates and keeps the parts constantly macerated, the wearing of gloves DISEASES OF THE SKIN. ;jl>7 being impossible, for as soon as the parts are wiped dry they are again bathed in the secretion. Hyperidrosis of the soles is a disagreeable and often distressing condition, as the socks and shoes become saturated, and thus keep the soles constantly bathed, allowing the macerated epidermis to peel off, leaving the more tender skin exposed, causing pain and distress when walking. The maceration of the epidermis, the secretion about the toes, together with the moisture of the socks and the soles of the shoes, promote the rapid development of the bacteria fetidum ; all these together produce a most disagreeable, disgusting and persistent odor, which is termed bro/7iidrosis pedum. Hyperidrosis of the genitalia attacks males more particularly, giving rise to a disagreeable, penetrating odor. The sweating may be limited to one side—unilateral hype/'i- drosis. Prognosis. The majority of cases are extremely intractable ; complete recovery is rare in a fair proportion, while some cases are easily relieved. Treatment. The general condition of the patient must receive proper attention. Local treatment is the most valuable, however, in this affection. The parts should be cleansed and immediately dried, and then dusted with some one of the numerous dusting powders. The follow- ing is a valuable powder :— R. Acidi salicylat....................................... gr. xx Zinci oleat................................... .......... !|j. M. Perhaps the very best local application is tinctura belladoivie, either diluted or full strength. In hyperidrosis of the palms and soles, the following are valuable, first washing the parts with a weak solution of acidum carbolicum:— R. Acidi salicylat........................................ gss Cretse praep............................................ ,^j Aluminis exsic....................................... ^j. M. et powder finely. SlG.—Apply to parts with puff ball. Or— R . Ungt. picis liquidae, Ungt. sulphuris..................aa.................. ,^j. Sig.—Spread on cloth and applied with bandage. (Wilson.) 328 PRACTICE OF MEDICINE. Or— R. Potassii permanganat................................ gr. ij Aquae destil.......................................... f^j. M. SlG.—Frequently applied. A saturated solution of acidum boracicum applied frequently to the hands and feet often proves curative. For obstinate cases, involving the palms or soles, the following plan of treatment, as suggested by Hebra, will be found of the great- est service. It is imperative that the various steps be closely followed: " The parts are to be cleansed with water and soap, and the follow- ing ointment applied on pieces of cloth cut to the size of the region. Lint smeared with the ointment is also to be placed between the toes or fingers, so that every portion of the skin may be covered with a layer of the ointment:— R. Emplast. diachyli.................................... ^ iv Olei olivae.............................................. f ^ iv. The plaster to be melted, and the oil added and stirred until a ho- mogeneous mass results. Sig.—To be used on cloths. " The cloths are to be changed every twelve hours, when the parts are not to be washed, but rubbed dry with lint and starch dusting powder, after which new dressings are again to be applied in the same manner. This proceeding is to be continued from one to two weeks. When the disease is upon the soles, the patient may walk about in loose shoes." After a week or ten days the ointment can be discontinued, but the dusting powder is to be continued for a con- siderable period. If relapses occur, the original treatment should again be instituted. SUDAMINA. Synonyms. Sudamen ; miliaria crystallina (Hebra). Definition. A non-inflammatory affection of the sweat glands; characterized by the rapid development of millet-seed-sized, translu- cent, whitish vesicles, in great numbers, upon any portion of the body. Cause. A high temperature, causing unusual activity of the sudoriparous glands. Pathology. The glands being excited beyond their capacity for normal excretion, the excessive fluid, instead of escaping upon the DISEASES OF THE SKIN. 32'.1 surface, from some cause collects between the layers of the epider- mis, in the form of minute, translucent, pin-point-sized vesicles. Symptoms. Each minute vesicle is distinct, but they exist in great numbers, very closely resembling drops of free sweat. They develop rapidly, never coalesce, become puriform or rupture. Fresh crops form from time to time. Their duration is transitory; the fluid is absorbed, the covering of each dries, forming a thin, delicate mem- brane, which disappears as a slight desquamation. Treatment. The treatment is that of the disease with which they occur. ANIDROSIS. Definition. A functional disorder of the sweat glands ; charac- terized by a diminished or insufficient secretion of sweat. Cause. The result of a congenital deficiency of the sweat glandular apparatus. Local anidrosis may result from injury to a nerve, during the course of chronic diseases of the skin, as ichthyosis, eczema, psoriasis, lepra and elephantiasis arabum. In rare cases an individual ceases to sweat entirely at times; in such cases the general health is impaired, and during the hot season much suffering may ensue. Treatment. Means to promote the activity of the skin and glands is the indication, such as the ingestion of large quantities of water, hot baths and steam baths, friction and the use of sudorifics, the most valuable of which is pilocarpus. HYPEREMIAS OF THE SKIN. ERYTHEMA SIMPLEX. Definition. An acute affection of the skin, in which occurs an abnormal quantity of blood in the dermal vessels ; characterized by discoloration, which disappears upon pressure and with more or less local increase of temperature. Varieties. Idiopathic erythema; symptomatic erythema. Causes. Idiopathic erythema; heat, cold, pressure, friction, or the contact of irritants, such as mustard, arnica and dyestuffs. Symptomatic erylhei7ia occurs most frequently in childhood, from diseases of the stomach and intestines; during the course of the vari- ous exanthemata. 330 PRACTICE OF MEDICINE. Symptoms. A more or less rapidly developed redness of the skin, varying in color from pink or light red to dark red, which dis- appears upon pressure, to rapidly return again. The extent and form of the congestion varies according to the cause, at times being as small as a coin and isolated, and again diffused over a large area. The temperature of the congested part is slightly above the normal. Slight itching and burning are, usually, associated with the dis- order. Diagnosis. Erythema resembles acute dermatitis in color, but the subjective symptoms of the latter are so decided that error cannot occur. Treatment. Controlled by the cause, which should be removed, and the local application of some one of the various dusting powders. ERYTHEMA INTERTRIGO. Definition. An acute congestion of the skin ; characterized by redness, heat, increased perspiration, and an abraded surface, with maceration of the epidermis. Causes. In the fleshy, from contact or friction of opposing sur- faces exposed to warmth—chafing. In children and infants contact of moist clothing; also disorders of digestion. Symptoms. Parts where the natural folds of the skin come in contact with one another, as the nates, perineum, groins, axillae and beneath the mammae, in the fleshy and in infants, become red, hot, painful, and have an increased flow of perspiration, which in turn softe7is the epidermis, giving rise to an acrid mucoid fluid. If not checked by the removal of the cause and the application of the dust- ing powders, inflammation—dermatitis—results. Treatment. The congested parts should be thoroughly washed with water and castile soap, or with bran-water, and carefully dried with a soft towel. The opposing folds of the skin are to be kept sepa- rated with lint or soft linen, the parts first covered with crete pre- parata, zinci oxidum, bismuthi subnitras, amylimi, lycopodinim or buckwheat flour. DISEASES OF THE SKIN. 331 INFLAMMATIONS OF THE SKIN. ECZEMA. Synonyms. Tetter; salt rheum ; scall. Definition. A non-contagious inflammation of the skin, charac- terized by any or all of the results of inflammation at once or in suc- cession, such as erythema, papules, vesicles or pustules, accompanied by more or less infiltration and itching, terminating in a serous dis- charge, with the formation of crusts, or in desquamation. Forms. Acute ; chronic. Varieties. Eczci7ia erythcmatoswn; eczema vesiculosui7i; eczema pustulosum; eczema papulosui7i; eczema rubrum; eczema squa77iosui7i; eczei7iafissum; eczema verrucosimi; eczema sclerosum. Cause. Eczema attacks persons in all spheres, the rich, the poor, the infant or the aged, and males or females. Many families, espe- cially those having the " catarrhal predisposition or peculiarity of con- stitution," seem more liable ; indeed, it appears probable that a pre- disposition to eczema may be transmitted from parent to child. Among the causes suggested are : dentition, improper food, gastro- intestinal disorders, intestinal parasites, deficient urinary secretion, the rheumatic and gouty diathesis, vaccination, prolonged contact of hot fomentations, heat and cold, and contact with the poison vine (rhus toxicodendron) and poison tree (rhus venenata). Pathology. Eczema is a catarrhal inflammation of the skin— a dermatitis with superficial serous exudation. There is first hyper- emia or congestion of the vessels of the skin—eczema erythematosum when uniformly distributed, eczema papulosum when the congestion is limited to distinct points. The hyperaemia is soon followed by a serous exudation. If the superficial exudation be profuse enough to form small drops, and if the epidermis possess sufficient resisting power not to giveaway immediately before it, vesicles form, producing the variety known as eczema vesiculosum ; if the vesicles contain a large admixture of young cells, so that the serum be turbid, yellow and purulent, the vesicles become pustules, termed eczema pustulosum ; if the serous exudation be not sufficient to either elevate or break through the epidermis, instead of either vesicles or pustules forming there occur dry scales, rising from the reddened skin—eczema squa- mosum. When the exudation is sufficient to detach the epidermis, thus exposing the red and moist corium, it is termed eczema rubrum. 332 PRACTICE OF MEDICINE. In chronic eczema the skin is subacutely inflamed; is very much thickened, hardened and infiltrated with cells which extend through- out the entire corium, even into the subcutaneous connective tissue. The papillae are enlarged and at times may be distinguished with the naked eye. Pigmentation may take place in the deep layers of the rete, and in the corium, especially about the vessels. Symptoms. Eczema is the most common of all cutaneous affec- tions, with symptoms varying in accordance with the particular vari- ety of the affection and its location, although the general character- istics of a catarrhal inflammation are present in all; these are redness, either limited or diffused, heat of the part affected, swelling, the result of the serous exudation, giving rise either to a discharge (weeping), with subsequent crusting, or to the deposition of plastic material. The most constant annoying and troublesome symptom is the itching, or at times bwning, which varies from that which is simply annoying to that which is almost unendurable. Eczema runs its course either as an acute affection, lasting a few weeks, not to return, or to return acutely at wide intervals, or, as is much more frequently the case, it assumes a chronic state, continuing with more or less variation for months, years or a lifetime. It may appear upon any portion of the body, or involve the whole integu- ment (eczema universale). The varieties are named in the order which the lesions assume at its commencement. Eczema Erythematosum. An erythema or redness of the surface, with a yellowish tinge. The size of the macule may be very small or quite extensive, with irregular outlines. There may be slight swelling of the patch, but no discharge occurs unless it be where two surfaces come into contact (eczema intertrigo), as about the genitalia. Cases without discharge are covered after a few days with a thin film of dry, exfoliating epidermis or scale [eczema squa77iosu77i). When a discharge (weeping) or moisture occurs, it is followed with more or less crusting. Inte7ise itching is a constant symptom. Eczema Vesiculosum. Begins with burning, pain, redness and swelling, followed by an immense number of 7ninute vesicles, either discrete or confluent, rapidly distending with a clear or yellowish fluid and attended with i7itense itching. Soon the vesicles rupture, the fluid rapidly diffusing over the surface and drying into yellowish, honey-like crusts. New crops of vesicles soon follow, or if subsequent DISEASES OF THE SKIN. 333 vesication do not occur, the fluid rapidly diffuses over the excoriated surface, which also, in turn, dries into large, yellowish crusts. After a variable time the various symptoms gradually subside. Itching is the most prominent subjective symptom, is intense, and gives rise to an irresistible desire to scratch. All portions of the body are liable to this variety of eczema, the most frequent location, however, being the face, and when occurring in children is commonly known as crusta lactea. Eczema Pustulosum, or Eczema Impetiginosum. This variety usually begins as vesicular eczema, the fluid rapidly changing to pus. After a short period, during which the pustules have in- creased in size, they burst and the escaped fluid forms thick, greenish- yellow crusts, which, in turn, rapidly dry and fall off, or crumble away. The location of this variety is most usually upon the scalp and face. It is stubborn to treatment. Itching is a prominent symptom. Eczema Papulosum, or Lichen Simplex. This variety of eczema appears in the form of small, rounded papules, the size of a pin-head, of bright red, or at times dark red color; they may be either discrete or confluent. In some cases all, while in others a greater or less number of the papules pass into vesicles and run much the same course as vesicular eczema. The itching is of the most intense char- acter, leading to severe scratching, by which the summits of the papules are torn, causing them to bleed, the blood forming dark red crusts. Eczema Rubrum, or Eczema Madidans. This is a variety only from a clinical standpoint. It may result from any of the fore- going varieties. The surface of the skin is inflamed and infiltrated, red, 7noist and weeping, the profuse serum rapidly drying into thick, yellowish, greenish or brownish crusts, the color depending upon the character of the fluid, which may be serum, pus or blood from the exposed and lacerated corium. The crusts adhere closely and firmly to the part, and, unless removed by mechanical means, may remain indefinitely, the disease pursuing its course beneath. Eczema rubrum, or madidans, " then, presents two appearances— as it occurs with its crust, and as it exists without this covering. In the one case the skin itself is altogether obscured by a dirty, yellow- ish or brownish crust; in the other the skin presents a bright or violaceous red, punctate, wounded surface, deprived in great part of 334 PRACTICE OF MEDICINE. its epidermis, and exuding a scanty or profuse, clear or opaque, syrupy, yellowish fluid. Sometimes this is streaked with blood." The itching and burning are severe. It may develop upon any por- tion of the body, but is most commonly seen upon the legs, par- ticularly in elderly people. Its course is chronic and increasing in severity. Eczema Squamosum. This is also a clinical variety. It re- sults from the erythematous, vesicular, pustular or papular varieties of the affection, but more particularly the first named. A typical case presents itself in the form of variously sized and shaped reddish patches, which are dry, or more or less scaly, the skin being more or less infiltrated or thickened. Its course is usually chronic. Eczema Fissum, or Rimosum. Another clinical variety. During the progress of the erythematous, vesicular or pustular varieties of eczema, cracks or fissures result when the lesion occurs upon regions subject to constant motion, such as between the fingers, toes and the various joints. At times the fissures are extensive and deep, and of a bright red color, showing the true skin, and intensely painful upon motion. Chapped hands are typical instances of fissured eczema. Eczema Sclerosum. This variety of eczema, occurring most commonly on the palms, soles and finger-tips, is characterized by hypertrophy of the papillae, showing itself as hard, thickened, infil- trated, localized patches, which are most apt to crack (eczema fissum). Eczema Verrucosum, or Papillomatosum, differs from the foregoing in that the thickened, infiltrated patch has a warty verru. cous appearance. Its course is chronic. Eczema Acutum et chronicum. The line which divides these two conditions is drawn by means of the clinical and patho- logical features. The course of eczema, in the majority of instances, is chronic. It may be said that so long as the general inflammatory symptoms are-high and the secondary changes slight, the affection is acute, and that when the process has settled itself into a definite line of action, continually repeating itself and accompanied by secondary changes, it is chronic. Diagnosis. The many varieties in which eczema manifests itself renders the diagnosis a matter of importance. The following charac- teristic features of eczema are of value in arriving at a diagnosis • DISEASES OF THE SKIN. 335 inflammation, swelling and edema, thickening from cell infiltration, redness, the discharge or moisture followed by crusting, on removal of which a moist surface is presented, and itching and burning. Erysipelas may be confounded with erythematous or vesicular eczema. The points of difference are the fever and other general disturbances, the deep-seated inflammation of the skin, rapidly spread- ing, with heat, swelling and oedema without moisture, giving the sur- face a deep red, shining and tense appearance, are characteristic of erysipelas and very different from eczema. Herpes and vesicular eczema bear some resemblance to each other; herpes zoster is distinguished by the neuralgic pains which are asso- ciated with it and are never associated with eczema. The other varie- ties of herpes occurring about the face and genitalia run their course in a few days, while eczema is of much longer duration and has a dis- charge followed by crusting. Seborrhea of the scalp and squamous eczema of the same region closely resemble each other. In eczema, however, the skin is more or less red, inflamed and thickened, and the scales larger, less abun- dant and less greasy and drier than seborrhoea. In eczema the scales are usually seated upon a circumscribed patch, while in seborrhoea, as a rule, they cover the scalp uniformly. Itching occurs with both dis- orders. The history of the two affections should be of material aid to render the diagnosis clear ; still, however, in many cases the difficulty is marked. Both are frequent affections. Psoriasis should never be confounded with atypical case of eczema, but chronic eczema, with infiltrated, inflammatory, scaly patches, fre- quently looks very much like psoriasis. Treatment. There is no specific. The indications are for the removal of the cause, where it can be ascertained, if it be possible, and attention to the general health. The diet should be of the most nutritious, but easily digestible character; fresh air and moderate exercise are also essential elements in the treatment, together with attention to the secretions. If the bowels be sluggish, much benefit follows the use of such laxative mineral spring waters as the Hathorn, or Hunyadi Janos, or a morning dose of 7nagnesii sulphas. For chil- dren, syrupus rhei, to which may be added 77iagnesia ; or what is per- haps more efficient, a small dose of hydrargyri chloridum 7nite. If the urinary secretion be small and the urine heavy, use should be made of full doses oi potassii acetas and large draughts of water. If 336 PRACTICE OF MEDICINE. either a rheumatic or gouty disposition exist, lithium salts, to which may be added vi7ium colchici sei7iinis. If a scrofulous tendency exist, use oleum 77iorrhue and syrupus ferri iodidi. If anaemia, ferrum, quinina, strychnina and the mineral acids are indicated. Locally : the most important means of treatment for all the varie- ties of eczema are with local remedies, suiting the appropriate ones for each particular case, as no one combination is applicable for all varieties. It may be stated, as a principle, that nothing irritant is ever to be applied to the surface in acute eczema, and that in the chronic form nothing can hardly be too stimulating. The too frequent wash- ing or general baths are to be avoided, as they have a tendency to macerate the already softened epidermis. For cleansing purposes, in the majority of instances, ordinary Castile soap is sufficient. Crusts and scales are nearly always present in eczema, and are to be removed before medicaments can be successfully applied. Their re- moval is to be secured by saturation with oily preparations, a starch or other mild poultice, or a saturated solution oi acidum boracicum. After their removal the parts are to be cleansed with Castile soap and water. For acute erythe77tatous or vesicular eczema, use but little, or what is better, no soap or water; instead, cover the parts with a dusting powder, such as— R. Pulv. camphorae.................................... ^j Zinci oleat............................................ "Z ij Pulv. amyli.......................................... Jj. M. SlG.—Dusting powder. For acute vesicular ecze7na, Dr. J. C. White recommends bathing the affected part with lotio nigra (hydrargyri chlor. mite, gr. viij, liquor calcis f^j), full strength, or diluted with equal parts of lime water, applied by means of a sponge or a piece of cloth, for ten or fifteen minutes at a time, and at intervals of a few hours or longer, the sediment being allowed to remain on the skin ; after which ung. zinci oxid. is to be gently rubbed over the part. As a rule, the itching and burning are relieved at once, and the affection often arrested. Good results follow the use of a saturated solution of acidum boracicii77i. There are cases which do better from the application of ointments, of which the following is valuable:— R. Zinci oleat., Olei olivae.................... aa.................... 31V. M. DISEASES OF THE SKIN. 337 Or, bismuth oleate, made according to the following formula of Dr. McCall Anderson:— R. Bismuthi oxidi..........................,........... z] Acidi oleici.......................................... ?j Cene albae........................................... ^iij Vaselini............................................. ?ix 01. rosae.............................................. TTLij. M, If the discharge be excessive, the following formula of Prof. Bar- tholow I have seen useful:— R. Plumbi acetat....................................... J ss Pulv. camphorae.................................... gr. xv 01. amygdal.......................................... f t^ij Cerat. flav............................................ gj. M. The late Dr. Frank Maury was partial to the following formula in vesicular eczema:— R. Hydrargyri chlor. mite........................... gr. xx Ung. zinci oxid. benz.............................. ^j. M. For eczei/ia papulosw/i the following lotions are particularly valuable:— R. Acid, carbolici...................................... J?j-|j Glycerini............................................. f3 iv Alcoholis.............................................f^iv-vj Aquae destil.................ad..................... Oj. M. —DUHRING. Or— R. Thymol............................................. gr. x-xx Alcoholis............................................f 5j Aquae destil......................................... fgj- M. After the disappearance of the more acute symptoms, more stimu- lating applications are indicated, among which are acidui7i carboli- cum, thymol, pix liquida or oleum cadinum. It is to be remembered, however, that the more chronic the affection and the less the inflam- matory symptoms, the more successful is tar in the treatment of eczema. Dr. Duhring considers the following one of the most elegant of the tarry ointments:— R. Oleicadini.........................................f.jjss Cerati simplicis..................................... oJ 01. amygdal. amar................................. g"-x- M- Ft. ungt. 2 C 338 PRACTICE OF MEDICINE. Or— R. Picis liquidae....................................... f.^j Glycerini............................................. f^j Alcoholis............................................. f,3 vj 01. amygdal. amar................................. gtt. xv. M. SlG.—To be rubbed firmly into the skin. The following is Dr. Bulkley's valuable " liquor picis alkalinus:"— R. Picis liquidae........................................ f3ij Potassae causticae................................... 3J Aquae destillatae.................................... f^v. M. The potassa to be dissolved in water and gradually added to the tar with rubbing in a mortar. Sig.—To be used diluted. A very elegant preparation of tar is the French mixture known as " Goudron de Guyot." For eczema rubrum, one of the most intractable varieties of the disease, especially the chronic eczema of the legs, the following mode of treatment, first suggested by Hebra, is the treatment par excellence. The accompanying instructions are to be adhered to. A lump of the sapo viridis (made originally of herring fat and potassa, and con- taining three per cent, of caustic potassa), the size of a small nut, is smeared upon a piece of wet flannel and applied to the affected part, and firmly rubbed until the soap has disappeared, when the flannel is to be dipped into warm water and again applied to the part and rubbed until an abundant lather forms, more water being added from time to time until the suds are most abundant, when the surface is thoroughly washed and freed from all the soap and carefully dried, after which the following (Hebra's diachylon) ointment, having been spread before the application of the soap, is to be applied. It is pre- pared as follows:— " Fifteen ounces of the best olive oil are added to two pounds of water, and heated to boiling in the water bath. Three ounces and six drachms of an equally good article of litharge (plumbi oxidum) are dusted over the fluid in ebullition, which is constantly stirred throughout, in order to prevent the formation of fatty acids. During the cooking, water is occasionally added as required. The stirring is to be continued until the ointment is quite cold." The ointment is spread upon strips of soft muslin and the affected part enveloped, care being exercised that neither folds nor wrinkles DISEASES OF THE SKIN, 339 occur, the whole being covered by a firm roller and the patient being able to go about as usual. The entire operation is to be repeated twice daily. A modification of the above ointment, technically known as " unguentum diachyli albi of Hebra," has been successful in my hands in a number of marked cases. The formula is :— R. Emplast. plumbi, Vaseline ..........................aa................. ^j 01. lavendulae........................................... q. s. M. Dissolve with heat and stir till cold. Sig.—Apply on strips, etc. Prof. Da Costa has used with success in eczema rubra, liquor arsenici et hydrargyri iodidi, rnij-v, t. d., and— R. Ung. plumbi subacet................................. $iv Acid, carbolici cryst................................... gr. iij Ungt. petrolei......................................... ^iv. M. SlG.—Apply freely on muslin strips. Eczema capitis is either erythematous, vesicular or pustular in character. If the first named, it at once tends to become chronic, settling into the variety known as eczema squai/tosum, often involving the entire scalp and accompanied with intense itching. The pustular variety is the more common form, occurring upon the scalp of chil- dren and young adults, existing as a few patches, or, what is more frequent, involving the entire scalp. The pustules soon rupture, the liquid drying into greenish-yellow crusts, which, if the affection be extensive, cover the whole scalp with a cap of crust. The hair be- comes matted and caked, the sebaceous secretion collects, and if the part be not cleansed the head becomes offensive. In severe cases of pustular eczema of the scalp, enlargement of the lymphatic glands of the back of the neck and of those behind the ear occur; they never suppurate. Pediculi are frequently associated with eczema capitis of children, either as a primary cause or a result of the matted condition of the hair constituting a favorable habitat for them. When present they call for active treatment. Eczema capitis may be confounded with psoriasis, seborrhoea syphilis, tinea favosa, and tinea tonsurans. Treat7nent. If the pustular variety, removal of the crusts is the first indication. This is accomplished by saturating the scalp either 340 PRACTICE OF MEDICINE. with oleum olive or oleum amygdale dulcis, and then washing with warm water and soap, or the use of a starch poultice; after their removal the application of the following ointment, used by Prof. Da Costa:— R. Hydrargyri chlor. mite.............................. gr. xx Acid, carbol. cryst...................................... gr- nj Ung. petrolei........................................... %'}. M. SlG.—Thoroughly applied. The late Prof. Ellerslie Wallace was fond of the following :— R. Sodii carb ............................................. gr. xxx Ung. petrolei............................................ %). M- Sig.—Apply thoroughly after removal of the crusts. In cases associated with pediculi, I have succeeded with the follow- ing, after removal of the crusts:— R. Hydrargyri ammoniat................................ gr. x-xx Adeps benzoat.......................................... ^j. M. Sig.—Thoroughly applied. For the squamous variety of the scalp, the following formula, recommended by Dr. Duhring, is excellent:— R. Picis liquidae...........................................f gj Glycerini................................................fgj Alcoholis.................................................f 3 vj 01. amygdalae amar................................... gtt. xv. M. Sig.—Diluted or full strength, rubbed thoroughly into scalp. Eczema faciei. In this location the affection may be either acute or chronic. In adults the erythematous variety is frequently encoun- tered in patches about the forehead and cheeks. Eczema of the face is more common in children, however, the varieties being the vesicu- lar and pustular. It is seen on the forehead, nose and upper lip, and is associated with severe itching. Treatment. The same as eczema capitis, or the following :— R. Zinci oleat.............................................. £j Ung. petrolei........................................... 3;j. M. Eczema labiorum. Eczema attacks the lips, either alone or in con- nection with other parts of the face. One or both lips may be affected. DISEASES OF THE SKIN. 341 The symptoms are: swelling, redness, heat, infiltration, slight scali- ness and fissures. The affection may be in the skin around the border of the mouth, or the vermilion and mucous membrane of the lips. The mouth may be contracted and the lips partly glued together by the exudation and crusts. Eczema labiorum may be confounded with herpes labialis and syphilis. Treatment. Very difficult and discomforting to the patient. Among the remedies at times successful are: argenti nitras, potassa nitras, acidw/i carbolicum, pix liquida, oleum ergota and collodium flexile. Eczema palpebrarum. A frequent occurrence in scrofulous chil- dren, showing itself along the edges of the eyelids. Pustules in- volve the hair follicles, followed by the usual crusting. The symp- toms are swelling, redness and itching, and unless the parts are frequently cleansed, the lids tend to glue together. Conjunctivitis frequently complicates the affection. Treatment. In mild cases success follows the use of zi7ici oleat. or glyceritum acidi tannici. In severe cases the plan recommended by McCall Anderson should be pursued. It consists in the extraction of the eyelashes and touching the edges of the lids with a solution of potassa in water, ten grains to the ounce. The edges should be care- fully dried and the lid everted, a very small quantity on a delicate brush being applied, immediately neutralizing the alkali with acidum aceticum or vinegar. Eczema barbe. Eczema of the beard is characterized by the for- mation of extensive pustules, with preference for about the hairs, drying as yellowish or greenish crusts, matting the hairs together and adhering to the parts. The affection may be confined to the hairy portions of the face, or extend to other regions of the face, be localized or general, acute or chronic. Eczema barbae in general features somewhat resembles both tinea sycosis and sycosis non-parasitica, but sycosis is an inflammation of the hair follicles only and is rarely associated with crusting, while crusting is abundant in eczema. Treatment. Must be energetic and decided. The crusts are to be removed by poultice or warm water and soap. Then the part is to be cautiously shaved ; although quite painful the first time, it is hardly so afterward, as it is to be repeated every two or three days. After 342 PRACTICE OF MEDICINE. shaving, if the attack be acute, the same plan of medication as recommended by Hebra for eczema rubrum is to be practiced, the application to be continuous both day and night, or only at night. If the attack be chronic, the following ointment should be applied after cleansing and shaving the beard :— R. Hydrargyri ammoniat...... Sulphur........................ Ung. petrolei................ SlG.—To be thoroughly applied In this variety of eczema I have seen marked benefit from the use of liquor arsenici et hydrargyri iodidi, TTLij-v, three or four times daily. Eczema aurium. Eczema of the ears may be either erythematous, vesicular or pustular. If the former, thickening results, with desqua- mation of flakes or large scales ; if either of the latter, crusts form, which may envelop the whole ear, the symptoms being swelling, red- ness and severe burning and itching, and if the process extend into the meatus, occlusion may result, causing temporary deafness. The most characteristic symptoms of erythematous eczema of the external auditory canal, besides the appearance of small flakes, is intense and persistent itching. Treat7nent. For acute vesicular or pustular eczema, removal of the crusts and the use of hydrargyri chloridi mile as an ointment of the strength of thirty grains to the ounce. If chronic, the use of pix liquida, as already suggested. For chronic erythematous eczema of the external auditory canal, the following formula has generally con- trolled this stubborn condition:— R . Hydrargyri flav. oxid Morphinae sulph....... Vaseline................ Sig.—Apply to the canal. Eczema genitalimn. This is a most distressing condition. In the male the scrotum and penis are involved alone or together, the former alone being the more common, and is complicated with eczema of the inner side of the thigh or thighs. The symptoms of eczema of the scrotum are, swelling, often oedema as well, moisture, crusts, and painful fissures, followed by extensive thickening and accompanied gr. xv-xxx 3ss-j gr- j-"j g"*-j 3'j- M- DISEASES OF THE SKIN. 343 by intense itching. In the female the affection attacks the labiae, and, rarely, the vagina and tnons veneris, and may extend to the surround- ing parts, especially to the perineum. The symptoms of eczema of the labia are, great swelling, oedema, redness, with great heat and a free discharge, forming crusts, which are apt to glue the opposing surfaces together. If the variety be the erythematous, in place of a discharge with crusts, the symptoms named are followed by slight scales. The itching is most violent and distressing. Treatment. The parts attacked should be kept constantly envel- oped in cloths wet with a saturated solution of acidu7n boracicimi until the more pronounced inflammatory symptoms subside, when should be applied ointments of zi7ici oleat. or hydrargyri chloridum mite. Persistent cases will often succumb to the plan of treatment suggested by Hebra for eczema rubrum. Ecze77ia a7ii. The anus may be attacked alone or associated with eczema of the perineum and genitalia. The symptoms are : redness, swelling, infiltration and thickening, with or without fluid exudation. Fissures of the anus are usually present, and add to the distress of the patient, the pain attending each stool. Persistent itching and burn- ing, worse after retiring, adds to the misery of the patient. Pruritus ani may be mistaken for eczema ani. In the former the itching is only associated with such symptoms of inflammation as result from the irritation of scratching, while in the latter inflammatory symptoms precede the itching. Treatment. The more acute symptoms are relieved by bathing the parts with a solution of acidum boracicum, after which a weak application of acidiwi carbolician, either as a lotion or ointment. The late Prof. S. D. Gross recommended the application of the following:— R. Zinci oxidi.......................................... ^vj Hydrargyri chlor. corrosiv........................ gr. j Glycerini............................................ 3vi- M- Sig.—Apply thoroughly to affected parts. Eczema intertrigo. Parts of the body that naturally come into con- tact with each other, as about the joints, the inner surfaces of the nates, in the groins and beneath the mammae, are frequently attacked with the erythematous eczema, which is frequently, but erroneously, termed erythema intertrigo or chafing. The symptoms are: redness, 344 PRACTICE OF MEDICINE. heat, and a moist, macerated surface, aggravated by movement of the affected parts. Treatment. The application of a solution of acidian boracicwn, or the use of dusting powders, such as, zinci oleat., a7nylmn or hydrar- gyri chloridwn mite. It is essential for successful treatment that the opposing surfaces be separated by means of lint or cloths. Eczema niammarum. The nipples, and more particularly those of primiparae, are at times the site of a vesicular eczema, with the forma- tion of crusts and fissures, and unless speedily relieved develops eczema rubrum. The pain on nursing becomes so severe that the mother is compelled to refuse the child. It must be borne in mind that eczema mammarum occurs in women who are not nursing and in single women. Treatme7it. Dr. Tilbury Fox advises the following plan:— " i. Great cleanliness and care in washing away any remnants of milk after each time that the child is put to the breast; and, if the nipple be tender and excoriated, use— " 2. A little liquor plumbi and calamine powder, as follows:— R. Liq. plumbi......................................... ^iss Pulv. calaminae praep.............................. ^iss Glycerini;............................................ gj Adepis.....................aa........................ ^j. M. " 3. I cover over the nipple with a lead nipple shield. This ex- cludes the air, keeps the part from being chafed, and I think the lead does good after the part has become less red and sore. I often use a little glyceral tannin, painted on night and morning. " The above application can always be removed with a little cold cream and a little warm water, sponging before the child goes to the breast." Eczema palmarum et plantarum. The features of the affection in both these regions are identical. The diagnosis is often obscured by the thickened state of the epidermis. The symptoms are: infiltra- tion, thickening, callosity, moisture followed by dryness, and Assur- ing, the last named frequently becoming so deep and painful that the patient is unable to use his hands, or, if on the soles, to walk. The affection is mostly chronic, affecting either of the parts alone, or all at one and the same time. Itching is a constant and annoy- ing symptom. DISEASES OF THE SKIN. 345 The diagnosis is to be made between eczema of these parts and psoriasis or syphilis. Treat7nent. The plan of Hebra for eczema rubrum will usually be successful for this variety. The following formula is also valuable :— R. Hydrargyri oleat. 5-15 per cent................... ^iv Olei cadini.............................................. 2 ss Cerat. simp............................................. '-iv. M. SlG.—Rub well into part morning and night, first macerating in hot water. Ecze7na unguium. The nails are seldom attacked alone, but in connection with eczema manuum. The symptoms are roughness, want of polish, unevenness and a punctate or honeycomb appear- ance similar to that seen in psoriasis of the nails. The nail becomes depressed, particularly at its root, thus interfering with its nutrition, resulting in loss of the appendage. Treatment. Internally arse7iicum is of the greatest value. Locally, the following:— R. Ung. picis liq......................................... ^iv Hydrargyri chlor. mite.............................. 3 ss Vaselini................................................. 5pv. M. SlG.—Apply thoroughly. URTICARIA. Synonyms. Hives; nettle-rash. Definition. An inflammation of the skin characterized by the development of wheals of a whitish, pinkish or reddish color, accom- panied by stinging, pricking and tingling sensations. Causes. Irritants and poisons produce an attack when brought in contact with the skin. Gastric, intestinal, hepatic, nephritic, ova- rian, uterine and cystic derangements are very frequent causes. Certain medicaments ; malaria ; nervous disorders ; associated with purpura and rheumatism ; pregnancy ; lactation ; menopause. Pathology. An acute inflammation of the papillary layer of the skin ; characterized by the rapid development of a " wheal "—a more or less firm elevation—consisting of a circumscribed' collection of a semi-fluid material, the result of a rapid exudation into the upper layers of the skin. The production of the wheal is the imme- diate result of a disturbance of the vaso-motor system, which is shown 2 D 346 Practice of medicine. by the interference of the circulation in the wheal, the blood being driven from its centre to its periphery, causing the whitish apex and red areola, so characteristic of the deyeloped wheal. Symptoms. An attack of " hives" is characterized by the sud- den development of wheals upon the cutaneous surface, which usually as suddenly disappear, their site being temporarily marked by a spot of redness or hyperaemia. With the appearance of the wheal occur distressing itching, burn- ing, tickling, crawling, pricking and sti7iging sensatio7is, to relieve which the patient still further irritates, tears or otherwise wounds the surface by scratching, whence are often developed deep-colored, flat, lenticular papules. Very frequently an attack of" hives " is associated with fever, head- ache and gastric disorder. The " wheals " may appear upon any portion of the body ; their size varies from that of a pea to that of a walnut or an egg—the "giant wheals ;" the number vary ing from a very few to being so numerous as to cover the whole surface of the body. The shape, size, color and number of the wheals that may occur in any given case have given rise to a number of names to designate the lesions. Thus, urticaria annularis occurs in rings ; urticaria figurata occurs in spirals; urticaria vesiculosa has a vesicular development on the summit of the wheal; urticaria bullosa, a bul- lous development at the summit; urticaria papulosa or lichen urti- catus, the wheal and a small papule are combined; urticaria luberosa, or giant wheals ; urticaria hemorrhagica or purpurata urticaria, a combination of urticaria and purpura; urticaria evanida, a rapid appearance and disappearance of the lesion ; urticaria perstans, slow disappearance; urticaria conferta, when the wheals are confluent; urticaria pigmentosa,-whexe the wheals are succeeded by pigmenta- tions of the site, the tints varying from dark-brown, greenish yellow, to a chocolate color; urticaria febrilis, when the wheals are associated with fever; urticaria ab ingestis, when associated with indigestion. Treatment. To prevent the recurrence of the disorder a thorough investigation of the cause must be made, and when found (not always possible) be removed. Attention should be directed to the state of general health, the diet and the secretions. The following remedies, alone or variously combined, are often of benefit: quinina, sodii salicylas, pilocarpus, atropina, ti7ictura bella- DISEASES OF THE SKIN. 347 donne, ami/iotiii chloridum, arse7iicum and potassii broi/iidum. The following pill is valuable in many cases :— R. Pulv. pilocarpus, Ext. guaiaci.....................aa..................... gr. iss Lithii benzoat.......................................... gr. iij. M. SlG.—Two to four each twenty-four hours. If there be atonic dyspepsia and constipation, the following com- bination is useful :— R. Magnesii sulphat...................................... ^j Ferri sulph at.......................................... gr-viij Sodii chloridi.......................................... £ss Acidi sulphurici dil................................... f i, ij Inf. cascarillae.....................ad................... f ^ iv. M. Sig.—Tablespoonful before breakfast, diluted. Local measures are of the greatest value, either as baths, lotions or dusting powders. The following are among the most serviceable: sponging with alcohol, bra7idy, whisky, vinegar and water, salt water, alkaline baths and acid baths. Duhring recommends the following :— R. Acidi carbolici......................................... sjiss Glycerini................................................ fzij Alcoholis............................................... f ,g viij Aq. amygdal. amar.................................... f^vnj- M. SlG.—Use as a lotion, two or three times daily. Bulkley suggests the following:— R. Chloralis, Camphorae.......................aa..................... fgj. Misce, and rub and incorporate with Pulveris amyli......................................... 3J_'J- Misce, and keep tightly corked in a wide-mouthed bottle. Sig.—Rub in with hand. A serviceable formula is the following :— R. Chloroformi............................................ f3J. Ung. zinci oxid....................................... 3'j- M. Sig.—Apply with hand. HERPES. Definition. An acute inflammation of the skin ; characterized by the development of one or more groups of vesicles, filled with a clear serum, occurring for the most part about the face (herpes facialis), and genitalia (herpes progenilalis). 348 PRACTICE OF MEDICINE. Causes. Herpes facialis; during the course of febrile and ner- vous disorders ; in connection with digestive disorders and colds. Herpes proge7iitalis; the origin is local, from uncleanliness or friction. Pathology. Hebra defines the various forms of herpes as " a series of acute cutaneous diseases of cyclical course, marked by an exudation which collects in drops under the epidermis and elevates it; forming vesicles which are never solitary, but always appear in groups.'' Symptoms. The appearance of the vesicles is usually preceded by a feeling of heat in the region, together with slight tumefaction or swelling. Rarely the herpetic attack is attended with malaise and pyrexia. The eruption usually appears in the form of a small cluster of pin- head to split-pea-sized vesicles, containing a clear fluid, becoming cloudy, afterward puriform and dries in small, yellowish or brownish crusts ; they are few in number and may coalesce. They disappear without leaving a scar. Herpes facialis; occur upon any portion of the face, but most frequently about the lips—herpes labialis. The alae of the nose, auricles and the mucous membrane of the mouth and tongue are frequent locations, in the latter appearing as excoriated patches from rupture of the vesicles. Herpes progenitalis; in the male the chief site is the prepuce {herpes preputialis). In the female they are comparatively rare ; but when occurring it is upon the labia majoraand minora and the skin about the vulva. This variety is preceded by burning, itching or neuralgic pains, accompanied with redness, congestion and more or less oedema. The lesion in these parts is likely to be mistaken for one form or other of venereal disease. Herpesgestationis; a rare affection of the skin occurring during pregnancy, consisting of erythema, papules, vesicles and bullae, attended with intense burning and itching. It may appear at any time of pregnancy up to the seventh month, and continues until some time after delivery. Treatment. Herpes facialis seldom calls for treatment, although in marked cases oi herpes labialis protection with liquor gutta-perche or collodiu77i flexile promotes desiccation. DISEASES OF THE SKIN. 340 Herpes progenitalis; cleanliness is all important. Coating the lesion with the medicaments mentioned above or washing with a saturated solution of acidum boracicum, and afterward dusting with hydrargyri chloridum 7/iite, are useful. The parts may be rendered less sensitive in frequently recurring cases by astringent lotions, as acidui7i tannicum or zinci sulphas. Circumcision, where required, may be practiced. HERPES ZOSTER. Synonyms. Zona ; shingles ; a girdle ; intercostal neuralgia. Definition. An acute, inflammatory disease; characterized by the development of groups of firm and distended vesicles situated upon inflamed bases and accompanied by more or less severe neuralgic pains. Causes. The eruption and consequent neuralgic pains are the immediate result of an inflammation of the ganglia or of the nerve trunks and branches—a neuritis—probably of the trophic fibres of the affected part; but the cause producing this condition is obscure. Among the many that have been suggested are: cold, injuries to nerves, anaemia, and the medicinal use of arsenicum. Pathology. An inflammation of either the ganglia, the nerve trunk or branches—probably the trophic system—causing the de- velopment of vesicles in the lower strata of the rete, with "the infil- tration of serum and inflammatory cells" of the papillae and corium. Symptoms. Begin with neuralgic pains, either of a burning or lightning-like character, with slight febrile phenomena, followed by the appearance of papulo-vesicles along the tract of pain; these soon become vesicles situated on bright red, highly-inflamed bases. The vesicles are about the size of pin heads or perhaps a little larger, usually discrete, although they frequently coalesce, forming irregular patches, coming in groups until the third to the fifth or even tenth day, when they gradually desiccate, and at the end of the second week nothing remains but a slight scar, which may also disappear after a time or rarely is permanent. When the eruption is at its height it is perfect in its anatomical formation, each vesicle being well-shaped and seated on a bright red, inflamed patch of skin, and distended with a translucent, yellowish fluid. 350 PRACTICE OF MEDICINE. The eruption is almost invariably confined to one side (unilateral) of the body, although,' in rare instances, it is seen upon both (bi- lateral) sides. It is usually found upon well-known nerve tracts. According to the region affected it is termed zoster capitis, zoster frontalis, zoster faciei, zoster ophthalt7iicus, zoster auricularis, zoster nuche, zoster brachialis, zoster pecloralis, zoster abdominalis, zoster femoralis. In the very young the eruption may develop and pursue its course without the neuralgic pains. Diagnosis. The characteristics of herpes zoster or shingles are usually so well marked that an error in diagnosis should not occur. The neuralgic pain preceding the eruption and its development in distinct groups upon inflamed bases following a nerve tract are so different from simple herpes of the face, or genitalia, or from the lesion of eczema. Prognosis. Favorable. The affection is self-limited, the dura- tion being about two weeks. It is said that " zoster of the orbital region may seriously involve the eye and prove fatal." Treatment. The affection being self-limited, it follows that remedies to cut it short are useless, although claims are made that " zinci phosphidum, gr. Yi every three hours, control the pain and abort the eruption." Prof. Bartholow " has seen excellent results in cases of shingles from galvanization of the affected intercostal nerves—the positive pole being placed over the point of emergence of the nerves, and the negative brushed over the terminal filaments in the skin." The general symptoms are to be treated as indicated. For the pain no remedy seems comparable with the hypodermatic use oi morphine sulph., gr. Y~Y> with atropine sulph., gr. fa^, near the lesion. Locally, relief follows coating the " shingles" with either collodium flexile or liquor gutta-perche, to which 7norphine sulph. may be added. MILIARIA. Synonyms. Lichen tropicus; miliaria rubra ; miliaria alba; prickly heat. Definition. An acute inflammation of the sweat glands; char- acterized by the development of discrete, whitish or reddish, pin-point DISEASES OF THE SKIN. 351 and millet-seed-sized papules, vesicles or vesico-papules, productive of pricking, tingling and burning sensations of a most aggravated character. Causes. Excessive heat, the result of excessive or tightly-fitting clothing, or a high external temperature. Most common in fleshy adults who perspire freely, and in children. Nervous prostration, severe dyspepsia and general debility seem to predispose to " prickly heat." Varieties. Miliaria papulosa ; 7niliaria vesiculosa. Pathology. The pathology of the two varieties is the same, both being inflammatory affections of the sweat glands; in the one papules, and in the other vesicles, develop about the orifices of the excretory ducts. In either variety occurs hyperaemia of the vascular plexus of the sweat gland, followed by slight exudation about the ducts, giving rise to the minute papule or vesicle, which remain until the cause has been modified or removed, when they are rapidly absorbed. Symptoms. Miliaria papulosa; known as lichen tropicus and "prickly heat," is of sudden onset, with the occurrence of numerous minute, acuminated, bright red papules, about the size of a pin head or millet-seed, and but slightly raised above the level of the skin. The papules are preceded by and accompanied with sweating (hy- peridrosis), and distressing tingling, pricking and bulling sensations. if the attack be severe, vesico-papules and vesicles are freely inter- spersed among the numerous papules- Miliaria vesiculosa; in this variety, instead of papules, immense numbers of vesicles develop, of the size of pin points and pin heads, of a whitish (miliaria alba) or yellowish-white color. The surface from which they arise is of a bright-red color, owing to each vesicle being surrounded by an areola (miliaria rubra). The vesicles are preceded and accompanied with sweating (hyperidrosis) and most distressing tingling, pricking and burning sensations. Either variety may attack all parts of the body, but the abdomen, chest, back, neck and arms are the regions usually invaded. Duration. This varies with the cause. It may appear, fully de- velop and disappear in a few hours. In those predisposed, it may continue more or less marked throughout the entire summer. Diagnosis. If the cause, nature and seat of the affection are taken into consideration, no error should occur. 352 PRACTICE OF MEDICINE. Eczema papulosum has a resemblance to " prickly heat," but the course of eczema is slow, and the papules are larger, more elevated, and firmer than those of miliaria papulosa. Eczema vesiculosum and miliaria vesiculosa are to be differentiated by the marked differences in the progress of each, the former slow, the latter rapid, the vesicles of the former rupturing spontaneously, those of the latter only when severely irritated. Sudamen is not an inflammatory affection, while miliaria is. Prognosis. The affection is often most rebellious in fleshy per- sons and children, and if neglected it passes into eczema or an erythematous intertrigo. Treatment. The patient should be kept as cool as possible, and undue perspiration avoided. The fears entertained by the laity, of danger from retrocession of the eruption, are groundless; the sooner it disappears the better for the comfort of the patient. The food should be light and unstimulating; wine, spirits and beer are to be avoided. The ingestion of water, lemonade, Apollinaris water, Vichy water, together with refrigerant diuretics, as potassii citras vel acetas, a cool apartment, and absolute rest will ordinarily insure speedy relief. Locally; sponging with alkaline lotions, liquor plumbi subacetatis dilutus, extractum grindelie fluidu77i well diluted, or cupri sulphas, in solution, gr. x, aque, f^j, or dusting powders, consisting of lycopo- dium, zinci oxidum and amylum, singly or combined. PEMPHIGUS. Synonym. Water blisters. Definition. An inflammatory disease of the skin, either acute or chronic, characterized by the development of a succession of rounded, irregular-shaped blebs or bullae, varying in size from a pea to an egg. Varieties. Pemphigus vulgaris; pemphigus foliaceus. Cause. Obscure. It is usually associated with a depressed state of the general system ; disorders of menstruation ; during pregnancy. Pathology. Hebra thus describes the appearance of the blebs: " Sometimes a circumscribed, light-red spot appears, perhaps of the size of a bean or large coin ; this is paler in the centre, and may even present a tinge of white, indicating the point at which the bleb is to DISEASES OF THE SKIN. 353 form, and from which it will spread outward over the surrounding skin, and, in fact, is at first a wheal, passing afterward into a bleb. In other cases the bleb is not preceded either by a red spot or by a wheal, but begins originally as a small collection of clear fluid be- neath the cuticle. Thus, hyperaemia of the skin may exist before exudation is poured out, or the latter may be formed before any con- gestion of the papillary layer is discoverable." The contents of the blebs or bullae are yellowish or colorless serum, of a neutral or alkaline reaction, the older the fluid the more alkaline it becomes. In the late stages of a bleb the fluid becomes puriform. In rare instances blood is contained in the bleb (pemphigus hemor- rhagicus). Symptoms. Pe77iphigus vulgaris; the onset is slow (pemphigus chronicus), without constitutional symptoms, or acutely (pe77iphigus acutus) preceded by febrile reaction. The lesions are the successive development of blebs, usually from half a dozen to a dozen, varying in size from a pea to an egg, oi a round or oval shape, their walls dis- tended with a colorless fluid, the color becoming yellowish or puri- form as they grow older. They develop abruptly from the sound skin, with a definite line of demarcation, unattended with symptoms of inflammation. A characteristic phenomena of the lesion is their successive appearance ; a crop no sooner disappears than another forms, throughout the course of the affection, each crop running its course in from three to six or ten days. With the appearance of the blebs occur itching and burning, usually of a mild character, although occasionally in a distressing degree (fiemphigus pruriginosus). Pe77iphigus malig7ius is characterized by the great size and number of the blebs, which coalesce, rupture and are succeeded by excoriated surfaces which occasionally take on ulcerative action, the patient's health being seriously impaired. Pemphigus foliaceus differs from pemphigus vulgaris in that the blebs, instead of being distended or tense, are flaccid and only par- tially filled with fluid, as they rupture before arriving at their state of full development. This variety also appears and disappears in crops. After rupture the fluid immediately dries into thin whitish flakes, which are detached in quantity, leaving a red, excoriated surface— the rete and corium. If the affection has continued for some time, the skin presents the appearance of a superficial scald. The course of this variety is essentially chronic. 354 PRACTICE OF MEDICINE. All portions of the body are liable to the lesion, as also the mucous membrane of the mouth and vagina. It is most common, how- ever, upon the limbs. Diagnosis. In a typical case no difficulty should be experienced in making a diagnosis. The mere presence of blebs, however, does not necessarily constitute pemphigus, for it must be remembered that they are at times developed in other diseases as well as by artificial means; the appearance of blebs in crops is a strong diagnostic point. Prognosis. The course of the affection is most uncertain, and relapses are frequent. In arriving at an opinion, the occurrence of fatal cases must not be forgotten. Treatment. Attention to the general health of the patient is of the greatest moment. A careful study of the cause should be made, and if determined, means for its removal are of the first importance. Two remedies, arsenicum and quinina, are of great value, the secret of success being the persistent use of the former; or if the lat- ter be used, the dose should be large. Local measures are also of importance. The blebs should be punctured and evacuated as soon as formed. The use of dusting powders of zinci oxidum, a7nylum, or violet-powder, or lotions of liquor plumbi subacetatis dilutum, are valuable. Hebra recommended the continuous bath. IMPETIGO. Definition. An acute inflammatory disease, characterized by the development of one or more discrete, rounded and elevated firm pustules, about the size of a pea, unattended by itching. Causes. Occurs for the most part between the ages of three and ten years, in the well nourished and healthy. It is not associated with eczema. It is not contagious. Pathology. The lesion is a well-formed, typical pustule, devel- oping abruptly from the surface, containing a whitish-yellow fluid, pus corpuscles, blood corpuscles, epithelial cells and cellular detritus. i The abscess or pustule is about the size of a pea, circumscribed and superficial. Symptoms. The affection manifests itself by the development of from one or two to a dozen or more distinct pustules, about the size DISEASES OF THE SKIN. 355 of a split pea, of a rounded shape, raised above the surface, with thick walls, of a yellowish or whitish color, surrounded by a distinct areola, which soon fades, are without a central depression or umbili- cation, and unattended with either itching or burning. The affection runs an acute course, usually lasting a couple of weeks. The pustules, after attaining their full size, remain stationary for a few days, when they disappear by absorption and desiccation, the crusts dropping off, displaying a reddish base, which soon dis- appears with pigmentation or scar. The pustules occur on all portions of the body, the most frequent locations being the face, hands, fingers, feet, toes and lower extremities. Diagnosis. Impetigo is unassociated with general symptoms, and its particular lesion—the pustule—is discrete, points of import- ance in the diagnosis. Eczema pustulosum is also a pustular affection, but the large num- ber, their disposition to coalesce, their location upon an inflammatory base, their rupture and subsequent crusting and itching, are diagnostic points. The diagnostic points from ecthyma will be pointed out when describing that affection. Prognosis. Favorable. Treatment. The pustules should be opened as soon as they mature, the contents removed by washing with tepid water and soap, and the floor covered with hydrargyri chloridum mite or zinci oleat. Coating the pustules with collodium flexile or liquor gutta-perche, if they are located where irritation be liable, is a valuable mode of treatment. ECTHYMA. Definition. An affection of the skin, characterized by the forma- tion of one or more large, isolated, flat pustules, situated upon an inflammatory base. Cause. It is most common among those who live in squalor and poverty, and in delicate and poorly-nourished children. Improper and insufficient diet, want of ventilation, excessive work, and un- cleanliness are all prominent causes. Pathology. The lesion is a typical pustular process, severe but superficial, and not extending beyond the papillary layer of the 356 PRACTICE OF MEDICINE. corium. The pustule is situated upon a firm and highly-inflamed base; the number varies from one to a dozen or more. Symptoms. The disease is characterized by the development of one or more round or oval, yet flat, pustules, about the size of a pea- bean, attended with moderate heat, burning and pain, and if the number be large, slight febrile reaction. The pustules are first yellowish in color, surrounded by a firm and sensitive bright-red areola, the pustule afterward becoming reddish from the admixture of blood, soon drying into flat crusts of a brownish color. The dura- tion of each pustule is between two and three weeks, new ones form- ing, until the cause is removed. The most prominent sites are the thighs, legs, shoulders, and back. Diagnosis. Ecthyma and eczema pustulosum have points of re- semblance, but a study of the clinical history of the latter should prevent error. Impetigo differs from ecthyma by the character of the pustule and crust. Prognosis. With care and removal of the cause, recovery is always prompt. Treatment. The general treatment of the patient is of the first importance. Nutritious and wholesome food, cleanliness, bathing, fresh air and regulated exercise should be advised, together with such tonics as ferrum, arsenicu77i, quinina, strychnina and 77iineral acids. Locally : remove the crusts by first soaking with oil or fat, or water dressings, and apply— R. Ungt. zinci oxid. benz.................................. 5ss Vaselini..................................................... £ ss Hydrargyri ammoniati.................................. J)j. M. Ft. ungt. —Duhring. Pustules showing a sluggish disposition to heal should be stimulated by touching with either arge/iti 7iitras or acidum carbolicum. FURUNCULUS. Synonyms. Furunculosis ; furuncle ; boil. Definition. An acute affection of the skin, characterized by the occurrence of one or more circumscribed cutaneous or subcutaneous abscesses (boils), which usually terminate by necrosis of the central DISEASES OF THE SKIN. 357 tissue, its subsequent expulsion in the form of pus or a core, and a resulting cicatrix. Cause. The result of a depraved condition of the system, in- duced by general debility, excessive fatigue, nervous depression, improper food and exercise, anaemia, diabetes, uraemia, or the result of local friction, pressure or contusions. Pathology. The process resulting in a "boil" has its origin in either a sebaceous gland, sweat gland, or a piliary follicle, and never begins in the meshes of the corium. " It begins as a small, roundish spot, which increases in size until certain dimensions are attained, when it undergoes suppurative change, resulting in the formation of a central point or core, composed of the tissue of the gland in which the furuncle originated, which, together with pus, is cast off. It shows no disposition to become diffuse, being always a circumscribed in- flammation. After the discharge of the core, a cavity of more or less depth remains, showing the tissues around it to be hard and infiltrated. After a few days or a week it fills up by granulation, leaving a cicatrix, which is often permanent. The central point or core, when thrown off, is composed of a whitish, tough, pultaceous mass of dead tissue, varying in size with the extent and depth of the inflammation." (Duhring.) Hydro-adenitis, as seen in the axillae, around the nipples and about the anus or perineum, differs from the ordinary "boil" merely in being deeper seated. Symptoms. "Boils" may occur singly, or more commonly in crops of two, three or more, another crop following their disappearance {furunculosis). The abscess begins as a small, rounded, imperfectly defined, isolated, reddish spot, oi a highly inflamed character, painful on pressure, its size gradually increasing, its central point presenting evidences of suppuration. It reaches its full development in about a week, when it consists of a slightly raised, rounded and pointed inflammatory swelling with a yellowish point in the centre—the " core." Abscesses with no central suppuration or core are called "blind boils." The size of a developed boil varies from a split pea to a walnut, the color deep red, with a yellow centre, and is surrounded by a slight areola. The pain of a boil is dull and throbbing, painful on pressure, and is usually worse at night. The constitutional symptoms are mild or severe, according to the number and size of the lesions. 358 PRACTICE OF MEDICINE. Any portion of the body may be attacked ; its preference, however, is for the face, neck, back, axillae, nipples, buttocks, anus, perineum and labiae. ' Diagnosis. The characteristics of furuncle are so marked that an error seems impossible. It may be, however, mistaken for carbuncle, the differences between which will be pointed out when discussing that affection. Prognosis. No danger results from occasional boils, but when occurring in crops they impair the general health and are rebellious to treatment Treatment. The treatment of a single boil is well expressed in the word "time ;" warm applications are said to hasten the stage of suppuration, and when reached an incision permits the expulsion of the " core," after which the cure soon results. If the lesion is located where friction or pressure is likely, protection by either covering with adhesive or soap-plaster, smoothly spread, is ample. When, however, successive crops of boils occur (furunculosis), the treatment should be both constitutional and local. The economy being below par, such tonics as arsenicum, qui7iina and ferrum are of value. Calcii sulphid., gr. fa~Y&, every two or three hours, is valuable in these cases. Locally, attempts to abort the process may well claim attention, among which are: crucial incisions, to relieve the tension of the central point, -will often abate the inflammation and prevent the gangrene; this little operation is rendered painless by the use of the ether spray. Acidum carbolicum, used in five per cent, solution, of which two to five drops injected into the apex of the boil is valuable. Painting the forming boil with argenti nitras or ti7ictura iodi., are also recom- mended. ANTHRAX. Synonyms. Carbunculus; carbuncle. Definition. An indurated, more or less circumscribed, dark red, painful, deep-seated inflammation of the skin and subcutaneous con- nective tissue, terminating in a slough and the subsequent production of a permanent cicatrix. Causes. Not positively determined. Perhaps, as in furuncle, impairment of the general health is the important factor. It is gen- erally noted to occur in middle and old age, and in men more DISEASES OF THE SKIN. 359 frequently than in women. A "specific" cause for anthrax is not an improbable discovery. Pathology. Although Billroth regards furuncle and carbuncle as differing only in degree, the explanation of Warren, of Boston, seems the more probable, he being the first to call the attention of histologists "to the existence of small columns of adipose tissue lead- ing from the panniculus adiposus up to the roots of the lanugo hairs, taking an oblique direction in a line with the erectores pilorum. The inflammation resulting in suppuration of the subcutaneous adi- pose tissue, must either form an abscess or become diffuse. In phlegmonous erysipelas the latter condition is observed. But when the inflammation is in the dermoid texture, the exudates infiltrate the skin and naturally follow the canals occupied by the ' columnae adi- posae.' The pressure thus exerted upon the whole dermoid tissue cannot fail to strangulate the circulation, and thus produce gangrene of the tissue, even if the exudate be not poisonous enough to destroy the cell by its presence. It can, by this explanation, be easily under- stood why this disease is apt to affect the skin on the nape of the neck and the back more than on other parts of the body. At this point the skin is dense, its fibrous element extending deep into the adipose layer, which is surrounded with strong bands; hence, the pus confined in such a place, seeking the easiest outlet, will travel along these miniature adipose canals, producing the peculiar appearance pathognomonic of carbuncle." Symptoms. Carbuncle is recognized by its peculiar form; com- mencing in the lower layers of the cutaneous tissue, it first resembles somewhat a phlegmon minus its bright redness. At first it is some- what rounded, with a strong tendency to the production of vesicles on its surface, soon, however, becoming firm, circular and flat, and raised above the surrounding parts, spreading through the subcutaneous tissue and skin, becoming at times enormously large, and having a dark red or violaceous color. As the disease progresses, the pressure results in the softening of the tissues, the skin becoming gangrenous, breaking down at numerous points, forming perforations, through which centres of suppuration appear in different stages of advance- ment, either as whitish, fibrous plugs, or as cavities, from which a yellowish, sanious fluid oozes, the surface of the anthrax having a cribriform appearance, perforated like a sieve. The entire mass ter- minates in a slough, which, on being detached, leaves a large, open, 360 PRACTICE OF MEDICINE. deep ulcer, with firm, everted edges, granulating slowly, a permanent cicatrix marking the site of the lesion. The development of the car- buncle is attended with severe pain of a deep throbbing and bur7ii7ig character. The constitutional sympto/ns vary with the size, number and severity of the disease; loss of appetite, coated tongue, general malaise, and moderate febrile reaction accompanies all cases, to which are added those of septicaemia in severe cases. The duration is from two to six weeks. Its favorite site is the back of the neck, shoulders, back and buttocks. It is usually single. Diagnosis. The disease is distinguished from furuncle by its great size, its flat form, its course, multiple points of suppuration, and the character of the slough. Also by the pain ; in furuncle, sensitive and painful to the touch, carbuncle not being particularly sensitive. Furuncles generally occur in numbers or in crops; carbuncle is almost always single. Prognosis. A guarded opinion should always be given, as death is not infrequent from anthrax, especially in elderly people with impaired health. The mortality, however, is not so great as the laity suppose. A great danger is septicaemia, from the action of the poison on the blood, or the result of secondary abscesses. Treatment. Constitutional and local measures are both of the greatest value. Nutritious diet, stimulants and full doses of such remedies as tinclura ferri chloridwn, qimiine sulphas, arse7iicum and ammonii carbo7ias are beneficial. Good results are reported from calcii sulphid., gr. Y every two hours. Locally; the crucial incision, so generally practiced in former years, is seldom performed now, the frequent occurrence of hemorrhages being too debilitating. The following are valuable plans :— Caustic potash, applied to the carbuncle before an opening occurs, until an eschar is fully formed; or, making several small punctures with a scalpel and inserting a small piece of caustic potash well into the diseased tissue; or, if openings have already occurred, insertion of the caustic stick into them, allowing it to remain until melted. By either of these methods I have seen the slough cast off more readily than in cases where the crucial incision was made or in those left to nature. Another method is, "a saturated solution of pure acidum carbolicum is injected through the several apertures in every direction into the DISEASES OF THE SKIN. yGl sloughing tissues, by the aid of an hypodermic syringe. The pain is severe but short lived." Prof. Agnew recommends painting collodiimi cum cantharide around the anthrax, in the form of a broad zone, the effect of the blister being to relieve the tension. Tinctura iodi. is also used for a similar purpose. Hebra advocates cloths wrung out in ice water, or ice bags, in the early stage, changing to warm fomentations as soon as suppuration has begun. Dr. Ashhurst has practiced with success the use of pressure by means of adhesive plaster applied in much the same manner as used for swelled testicle. The resulting ulcer, after expulsion of the slough, is to be treated on general principles. ACNE. Synonyms. Acne vulgaris; acne disseminata ; varus; stone- pock. Definition. An inflammation, usually chronic, of the sebaceous glands; characterized by the development of papules, tubercles or pustules, or by a combination of such lesions, usually in various stages of formation, occurring for the most part upon the face. Varieties. Acne papulosa ; ac7ie pustulosa ; acne artificialis. Cause. Not always understood, as the affection is frequently associated with apparently the most robust health. A frequent cause is puberty. Among the other causes observed are gastro-intestinal disorders, anaemia, chlorosis, uterine disorders, scrofula, and the use of large doses of the bromides and iodides. Acne may exist alone or be associated with comedo or seborrhoea. Pathology. An inflammation of the sebaceous gland structure and surrounding tissues. There first occurs retention of the sebaceous secretion, which is soon followed by hyperaemia and exudation about the glands and in the gland wall (acne papulosa), infiltration of the connective tissue (acne tubercula), followed by suppuration (acne pustulosa). If the inflammatory action be severe, destruction of the gland with a resulting cicatrix occurs. Symptoms. Ac7ie papulosa or acne pwutata. This variety of the affection is the earliest stage of the inflammatory action, and is usually of short duration, being soon followed by the development oi pus. It is characterized by the occurrence oi pin-head to pea-size, flat, more or less pointed papules, situated about the sebaceous follicles, 2E 362 PRACTICE OF MEDICINE. lightish in color, with a minute central black point, the opening of the sebaceous duct. Pustules are not infrequently observed scattered among the papules. The lesion is unaccompanied with either local or constitutional symptoms. While the forehead is the most frequent seat for this variety, they sometimes are seen elsewhere. Acne pustulosa. This is the fully developed affection. It is seen upon the face, neck, shoulders and back, as pin-head to pea-sized, rounded or acuminated pustules, seated upon an infiltrated, reddish base of superficial or deep inflammatory product (acne indurata). Scattered among the pustules may be seen numerous papules. There are no constitutional symptoms, nor is pain complained of unless the lesion be handled. Acne artificialis is rather a clinical variety, the result, usually, of large doses of the bromides or iodides, the lesion being identical with acne pustulosa. Diagnosis. The lesion is so characteristic, the course so chronic and the location so frequently upon the face, that an error seems impossible if care be exercised. The resemblance of the papular and pustular syphiloderms must not be mistaken for acne. Prognosis. Essentially a chronic affection, lasting for a number of years; but if persistent treatment be employed recovery will occur. Treatment. To successfully combat an attack of acne, both constitutional and local measures must be employed. Constitutional treatment. The successful treatment of a case of acne depends upon a knowledge of its cause and familiarity with the constitutional habits of the patient. Disorders of digestion and con- stipation should be corrected. If anaemia be present, fcrrui7i and arsenicum are indicated. Scrofula is an indication for oleum 77iorrhue and ferrum iodidum. Uterine disorders, if present, should receive proper attention. Calcii sulphid., gr. fa-}, every two or three hours, is valuable in many cases, as is hydrargyri chloridum corrosivwn, gr. i\$-fa, three times daily. A remedy highly spoken of by Dr. Bulkley is glycerinwn in tablespoonful doses, two or three times daily. Dr. Duhring recom- mends that it be given in combination with ferri et quinine citras. Prof. Bartholow " has seen excellent results from the use of syrupus hypophosphitum comp. in acne indurata." Local treatment. In acne of not very long duration I have seen DISEASES OF THE SKIN. 363 elegant results from the following plan: Just before retiring, the parts affected are to be thoroughly washed with water as hot as can possibly be borne, and after the water has partly dried the parts are to be thoroughly covered with sulphur sublimaium, applied by means of a powder puff ball, no rubbing or friction to. be employed, and on arising in the morning the sulphur is to be washed off with hot water and the face lightly mopped dry, or what is better, sulphur again applied, if the patient is willing to permit it, during the day. Dr. Hyde recommends that the contents of the papules and pustules be evacuated by means of a needle, rather encouraging slight bleeding, after which the parts are to be bathed with water as hot as can be tolerated; and while the part is still wet, it is thoroughly scrubbed with lotio sapo7iis viridis, then cleansed with water, carefully dried and anointed with a sulphur ointment. Prof. Bartholow suggested, in a case of ac7ie indurata seen with the author, the following successful plan. To dissolve the sebaceous matter— R. Liquor potassae........................................ fgj Aquae destil............................................. f^j. M. Sig.—Applied to the acne spots only. After which they were anointed with— R. Plumbi nitrat.......................................... gr. xv Ung.petrolei........................................... %)■ M. Sig.—Apply twice daily. Dr. Duhring recommends the- use of the following, after washing the parts with hot water:— R. Sulphuris praecip..................................... J5J Glycerini............................................... ^5?S Adipis benz............................................. 3J Ol. rosae................................................. g«. iij. M. Ft. ung. Sig.—To be thoroughly rubbed into the skin at night. ACNE ROSACEA. Synonyms. Gutta rosea; gutta rosacea. Definition. A chronic hyperaemia or inflammatory affection of the nose and cheeks; characterized by redness, hypertrophy of the skin and dilatation and enlargement of the blood vessels supplying 304 PRACTICE OF MEDICINE. the part, and the development of more or less acne. The nose and cheeks are the most frequent location. Cause. Not always determined. It occurs in young women about puberty who are anaemic, or suffer from a general debility, nervous irritability or prostration, dyspepsia or menstrual irregulari- ties. It often appears during the menopause. In young males the affection can often be traced to nervous or general debility, or dys- pepsia. The use of spirituous liquors is a frequent cause, as is constant exposure to the weather. It is frequently associated with seborrhoea. Pathology. There first occurs blood stasis in the vessels of the part, producing the undue redness first noticed. As a result of the stasis, sooner or later the capillaries are dilated and hypertrophied, and as a result of the interrupted circulation inflammation of the sebaceous gland (acne) results, with the development of papules and pustules. This constitutes the typical acne rosacea. The affection may proceed no further, remaining at this point for years, or, rarely, the pathology of this stage is exaggerated, the involved tissues all hypertrophying, and the connective tissue undergoing a true hyper- plasia, causing increased size and abnormal shape of the nose. Symptoms. The onset of the affection is slow and insidious, characterized at first by more or less diffused redness of the part, the color aggravated by water or cold air. If the nose be the part attacked, it is usually greasy (seborrhceic), and is apt to be cool or even cold. This condition may remain for years, but sooner or later the evidence of dilatation and hypertrophy of the capillaries is apparent by the more decided and permanent redness, and upon close exami- nation the enlarged minute cutaneous blood vessels are seen as deli- cate or coarse red lines, running superficially over the skin in an irregular and tortuous course. Soon are developed upon the hyper- aemic and hypertrophied skin papules (acne papulosa) and pustules (acne pustulosa), their number never, however, being very great. This constitutes true acne rosacea. The disease may remain in this state, or, rarely, the cutaneous tissues are greatly hypertrophied, the blood vessels enormously dilated, the glands enlarged and the connec- tive tissue undergoes hyperplasia, resulting in permanent, dark red, bulky formations, the shape of the nose being contorted into various irregular forms. Duhring reports a case in which the nose was the size of the patient's fist (rhinophyma). DISEASES OF THE SKIN. 365 The nose and cheeks are the usual location of the disease, although rarely it involves the forehead. Diagnosis. The characteristics of the disease are so marked, consisting of rosacea—the dilated and hypertrophic blood vessels— with papular and pustular acne superadded, that an error can hardly occur, if due care be exercised. Lupus vulgaris bears some resemblance to acne rosacea, as it is apt to develop about the face, and especially the nose; but the papules, tubercles and pustules of lupus vulgaris soon ulcerate, fol- lowed by crusts and cicatrices, which never occur in acne rosacea. Lupus erythematosus may be confounded with acne rosacea if it occur upon the end of the nose; but in the former the skin is harsh and covered with adherent whitish and yellowish scales connected with the openings of the sebaceous follicles, which is never the case in acne rosacea. Frostbite resembles the first stage of acne rosacea, but the history of the two conditions soon determines the diagnosis. Prognosis. Favorable, if treatment be instituted during the first stage. After hypertrophy has occurred but little can be accom- plished. Treatment. The cause is to be sought after and removed, and the general health- to be promoted. The use of all alcoholic drinks is to be interdicted and but small amounts of tea and coffee are to be allowed. In the first stage good results may be obtained from the following formula, known as " Kummerfeld's lotion : "— R. Sulphur praecipitat.................................. ^iv Pulv. camphorae..................................... grx Pulv. tragacanthae.................................. BJ Aquae calcis.......................................... f.5)J Aquae rosae.......................................... '.? 0- M. Sig.—Shake the bottle before using and apply every few hours. Or— R. Hydrargyri chlor. corrosiv........................ gr-ij Ung.petrolei.......................................... 3J- M- Sig.—Apply thoroughly. Or, the following, suggested by G. H. Fox— R. Chrysarobini.......................................... |ss Collodii............................................... 3 J- M- gIG _put a brush through the cork and paint lesion every evening. 366 PRACTICE OF MEDICINE. For the second stage stronger applications are usually required. The dilated capillaries should be incised with a sharp knife, in the hope that adhesive inflammation may close the calibre of the vessels, cold water compresses being used to control the bleeding, a few of the dilated vessels being thus treated every day or two, until all have been incised. Another plan is to paint the affected parts, once or twice a week, with a ten to twenty grain solution of potassa, following its application with an emollient poultice. Electrolysis has also been recommended. In the third stage the knife is the only effectual remedy. PSORIASIS. Synonyms. Lepra; alphos; psora; English leprosy. Definition. A chronic affection of the skin, characterized by reddish, more or less thickened and elevated, dry, inflammatory and somewhat wrinkled patches, variable as to size, shape and number, and covered with abundant whitish or grayish-colored, imbricated scales. It is not contagious. Cause. Not known. The source of the affection is, no doubt, limited to the skin itself, as no external or internal factors can produce it. It occurs in the robust and in the feeble, and in males and females. It usually first appears in early life and recurs at intervals, for years. Pathology. According to Dr. A. R. Robinson, of New York, " the disease is essentially a hyperplasia of the normal constituents of the Malpighian layer (mucous layer). The increase takes place chiefly in the interpapillary portion of the layer, the growth of which downward causes an apparent increase in the size of the papillae of the corium, which, however, on closer examination, are found not to be enlarged. In the later stages of the disease the more superficial blood vessels of the corium become dilated, a more or less consider- able emigration of white blood corpuscles takes place, and the imme- diate neighborhood of the vessels, together with the connective tissue of the corium, becomes the seat of a round-cell infiltration, which, with the effusion of serum, separates the connective-tissue bundles and fibres into an open mesh-work. During the period of disappear- ance of the disease there is a gradual return to the normal condition, until the hyperplasia, dilatation of the blood vessels, and cell infiltra- tion have completely disappeared. The hair in psoriasis is affected DISEASES OF THE SKIN. 367 from the beginning of the disease, hyperplasia of the external root sheath,- the structure corresponding to the Malpighian layer of the epidermis, taking place, with extension of the hyperplastic structure into the surrounding cutis. The sebaceous and sweat glands are not at any time affected." Symptoms. Psoriasis begins as small, reddish spots, of the size of a pin's head, which immediately become covered with scanty or abundant whitish ox grayish, imbricated scales. The spots gradually increase in diameter, forming patches of various sizes and shapes. If one of the scales be detached by means of the finger nail, it will be found to adhere quite firmly to the skin, and to be about the thick- ness of a card-board. If the reddish patch thus made bare be pinched up between the finger and thumb, and compared with a similar pinch of the healthy skin, its inflammatory thickening will be discerned. There is no watery discharge at any ti7ne. The skin between the patches is perfectly healthy. While the anatomical lesions are always identical, the eruption assumes such features, as to the size and shape of the patches, as to give rise to special names. Psoriasispwictata. The eruption occurs as small, rounded patches, about the size of a pin's head. This is a rare variety, as the lesion rapidly increases in size. Psoriasis guttata. The eruption occurs in the form and size of drops, and when covered with scales gives the skin the appearance of having been splashed with mortar. A quite frequent variety. Psoriasis mummularis. The eruption resembles variously-sized coins. This is frequently as large as the patches grow. Psoriasis circinala. The eruption about the size of the former variety, the centre clearing away, leaving the skin normal, although it may continue to enlarge at the periphery, after the manner of tinea circinata. Psoriasis gyrata. The eruption in wavy lines, of the width of about half an inch, resembling circles and semicircles. This variety is a continuation of the former, from the joining of the patches of psoriasis circinata. Psoriasis diffusa. The patches of eruption are large and of irregu- lar shape covering a considerable amount of surface. This variety occurs more frequently on the front of the leg and the outer aspect of the forearm. 368 PRACTICE OF MEDICINE. Psoriasispalmaris et plantaris. In these regions the eruption is characterized by larger, thicker and less lustreless scales, and- by the occurrence of deep and painful fissures, from which exudes either a serous or sanguineous fluid. Psoriasis unguium. In psoriasis of the nails they become thick- ened, opaque, grayish in color, deeply grooved transversely and often pitted, and in rare cases the nails are replaced by a scaly in- crustation. Any portion of the body is liable to be attacked with psoriasis. The only discomfort the patient suffers is the itching, which at times is very severe and distressing. Diagnosis. A typical case of psoriasis presents no difficulty in diagnosis. There are a few affections, however, which may be con- founding in irregular cases. Eczema squamosum occurring upon the legs closely resembles psoriasis, and if the former has been attended with a very small amount of moisture and the latter has been considerably irritated by scratching, the diagnosis will be very difficult. The papulo-squamous syphiloderm and psoriasis are frequently mistaken for each other, the diagnosis at times being extremely difficult. Tinea circinata and psoriasis circinata resemble each other, but the patches of the latter are less inflammatory, red and infiltrated, and the scales more abundant and larger than in the former. Tinea circinata is usually the result of contagion, and the scales contain a fungus. Seborrhoea of the scalp and psoriasis of the same region frequently are difficult of diagnosis. In the former the scalp is paler, the scales are finer, smaller, more generally diffused, of a grayish or yellowish color, and a greasy, sebaceous character. Psoriasis of the scalp is in patches, which are reddish and infiltrated, and there are almost always patches of the disease on other parts of the body. Prognosis. An attack can usually be removed, but it is always apt to return, so that a permanent cure can never be promised. Treatment. Constitutional and local measures are both needed in the majority of attacks of psoriasis. Constitutional treatment. Attention to the general health, removing all deleterious influences, such as dyspepsia, constipation, lithiasis, malaria, anaemia or catarrhs. DISEASES OF THE SKIN. 369 Among the most valuable remedies used in the treatment of psoriasis is arsenicum, given in full doses for a long period. It is to be borne in mind, however, that the drug is contraindicated in all acute and inflammatory cases. Chrysarobin, gr. }£, t. d., gradually increased, has been suggested, but of its utility I have had no experience. Phosphorus, acidum carbolicum and pix liquida have all been used with variable success. Local treati/ient. The character of the local measures should be controlled by the duration of the disease, its extent, location and obstinacy. The first step is the thorough removal of the scales. This may be accomplished by repeated washings with soft soap and water, by either plain or alkaline baths, medicated washes or caustic ointments. In the early stage, with highly inflammatory symptoms, soothing applications, such as water dressings or inunctions with oils, of which oleum olive rubbed over the patch several times each day, is very serviceable. For chronic cases nothing seems comparable with the following formula, suggested by Dr. G. H. Fox:— R. Chrysarobin............................................ gr. x-xx-^j Athens et alcoholis................ad............... q. s. Collodii................................................ |j. M. Sig.—Rub the chrysarobin with a little alcohol and ether and add to the collodion. If a camel's-hair pencil be placed through the cork, this may be painted over the affected patch after the removal of the scales, and after drying it will not stain the clothing. Care must be exercised that the strength be not too great, or a dermatitis may result. Other local remedies are: pix liquida, saponis viridis, creasotum, sulphur, calcium sulphuretum and acidui7i carbolicwn. HYPERTROPHIES OF THE SKIN. LENTIGO. Synonym. Freckles. Definition. A pigmentary deposit of the skin, characterized by irregularly-shaped, pin-head or pea-sized, yellowish, brownish or blackish spots, occurring for the most part about the face and back of the hands. 2 F 370 PRACTICE OF MEDICINE. Cause. In the majority of instances exposure to the sun is the exciting cause. Pathology. In anatomical structure freckles consist of a circum- scribed, increased amount of normal pigment, differing from chloasma only in the peculiar form and size of the deposit. Symptoms. The number of "freckles" varies from a very few to immense numbers. They occur as brownish or yellowish-brown, small, roundish, irregular spots, most commonly upon the face and hands. Rarely the number is very great, and they give to the skin an uncleanly appearance. They are apt to occur at all ages, but rarely before the third year. They are unattended with itching or other subjective symptoms. Prognosis. Usually favorable. Their course, when left to them- selves, is chronic, lasting for years or a lifetime. They ordinarily appear in the summer, fading away as cold weather approaches, to return the following summer. Treatment. The following application has been usually successful in my hands:— R. Hydrargyri chlor. corrosiv.......................... gr. iij Acid, hydrochlorici, dil.............................. f^j Alcoholis............................................... {"$, j Glycerini................................................ f.^ss Aquoa rosae.....................ad..................... f^iy- M. Sig.—Apply at bedtime, and remove with soap and water in the morning. CHLOASMA. Synonyms. Liver spots; moth. Definition. A pigmentary discoloration of the skin, characterized by variously sized and shaped, more or less defined, smooth patches, or of a discoloration, yellowish, brownish or blackish in color. Cause. The etiology of chloasma depends upon whether the pigmentation is idiopathic or symptomatic in its occurrence. Idiopathic chloasma results from the irritation of long-continued scratching, such as is practiced in severe eczema or pediculosis, the application of blisters and sinapisms, heat, the direct rays of the sun, and various medicinal and chemical substances, such as follows the prolonged use of argentum (argyria). Symptomatic chloasma occurs in connection with cancer, malaria, tuberculosis, disease of the supra-renal capsule (Addison's disease), DISEASES OF THE SKIN. 371 disease of the womb, pregnancy (chloasma uterinum), neurotic dis- turbances, anaemia and chlorosis. Pathology. The affection is an increased deposit of the normal pigment, having its seat in the mucous layer of the epidermis. The deposition of the pigment is the result of a nervous derangement, possibly of the trophic system. Symptoms. Chloasma is simply a discoloration of the skin, unattended with alteration of the surface. The patches vary in size and shape; they may be as minute as a coin or as large as the hand, or much larger, even to a universal discoloration of the entire surface, and they may be roundish or irregular in outline. The usual color is yellowish, brownish or muddy, or even blackish {melas77ia, 7nelanoder77ia). In Addison's Disease, of a typical character, "the coloration is brownish, with an olive-greenish or bronze tint, and is general, although, as a rule, especially pronounced upon regions having a disposition to normal increase of pigment, as the face, backs of the hands, axillae, areolae of the nipples, and the genital organs; the hair, also, may become darkened. It may, also, occur with or follow other pigmentary changes, as of the hair. Gaskoin reports a case, occurring in a woman aged forty-five, where the patch, situated on the cheek, near the nose, was intensely dark. It had existed nine years. The color of her hair had, fifteen years previously, changed from carroty- red to black." For additional symptoms, see page 316. In Argyria or discoloration of the skin resulting from the internal use of nitrate of silver, the color is a bluish, bluish-gray, slate, bronze or blackish, varying as to the shade. It occurs over the surface generally, but is more pronounced upon parts exposed, as the face and hands. Chloasma uterinum occurs most frequently between the ages of twenty-five and fifty, seldom after the menopause, caused, in the greater number of instances, by changes, physiological and patho- logical, which take place in connection with the uterus. It is seen in the married and single, although much commoner in the former. Pregnancy is the most frequent cause, although also associated with either dysmenorrhoea, chlorosis, anaemia or hysteria. It is seen in the mildest degree about the eyelids, especially during the menstrual epoch, as a duskiness or swarthiness of the complexion, 372 PRACTICE OF MEDICINE. either lasting a few days or being permanent. As usually encoun- tered, however, chloasma of this variety consists in the presence of one or several patches, appearing generally about the forehead or other parts of the face, upon the trunk, about the nipples and upon the abdomen. Rarely the entire face is covered with a discoloration, resembling a mask. Cases are recorded in which the pigmentary deposit was general, resembling Addison's disease. ' Diagnosis. Tinea versicolor and chloasma resemble each other in the color of the patches, but otherwise they have nothing in com- mon. Tinea versicolor occurs on the trunk, while chloasma occurs upon the face and about the nipples, and in cases the result of preg- nancy, about the umbilicus, except in those comparatively rare instances in which the discoloration is diffused. The patches of chloasma are smooth, those of tinea versicolor furfuraceous, as can readily be demonstrated by gently scraping the discoloration with the finger nail. Prognosis. Unless the result of Addison's disease, the pro- longed use of argentum, tuberculosis or cancer, favorable. Treatment. Chloasma, not the result of organic disease, or the use of argentum, is usually removed by either of the following formulae:— R. Hydrargyri chloridi corrosiv....................... gr. viiss Zincisulphat ........................................ jss Plumbi acetatis....................................... ^ ss Aquae................................................... f^lv. M. SlG.—Lotion. Apply morning and evening. —Hardy. Or— Or— R. Hydrargyri chloridi corrosiv...................... gr. vj Acidi acetici dil..................................... fgij Boracis................................................ p)ij Aquae rosae............................................ folv- M. Sig.—Lotion. Apply twice daily. —Bulkley. R. Hydrarg. ammoniat................................ ss Mistune amygdalae amar............................ 5 ^v- ^, Sig.—Apply thoroughly. —Bulkley. Or— R. Sulphur................................................. Z) Hydrarg. ammoniat.................................. gr. xx Ung. petrolei.......................................... f.lj- M- SlG.—Rub in well. Tinea favosa of non-hairy parts require the removal of the crusts and the application of either of the above formulae. TINEA CIRCINATA. Synonyms. Tinea trichophytina corporis; herpes circinatus; ringworm of the body. Definition. A contagious, parasitic affection of the skin, due to the trichophyton fungus; characterized by the development of one or more circular or irregularly-shaped, variously-sized, inflammatory, slightly vesicular or squamous patches, occurring upon the general surface of the body. Cause Ringworm of the body is caused by the presence of a vegetable'parasite discovered by Bazin, in 1854, termed the tricho- 382 PRACTICE OF MEDICINE. phyton, the same growth or fungus that produces tinea tonsurans and tinea sycosis. The affection is highly contagious, and is frequently communicated from one member of a family to another, although it has been determined that a certain unknown condition of the skin is requisite for its development. In children it is most frequently seen among the weakly and poorly nourished. In adults it is usually associated with a depreciation in the general health. Pathology. The fungus is seated between the strata of the epidermis, more particularly in the superior layers of the rete. The presence of this foreign body produces the subsequent phenomena— a superficial dermatitis, erythema, exudation, minute vesiculation and papulation, and, in the severe grades, tubercles and pustules. The desquamative symptoms are exfoliative—nature's efforts for relief. Symptoms. Tinea circinata varies greatly in the degree of its development, from the trivial complaint so often seen in children to the chronic, extensive and obstinate disease sometimes seen about the thighs in adults (tinea circinata cruris). The disease usually begins as a small, reddish, scaly, rounded or irregularly-shaped spot of papules, which, in a very few days, assumes a circular form (ringworm). It continues to increase in size, the papules often changing to vesicles. A characteristic of the eruption is its healing in the centre as it spreads on the periphery. Occasion- ally the circles or rings coalesce, forming serpiginous lesions. The usual size of a fully developed ringworm is about that of a silver quarter of a dollar. Chronic tinea circinata does not present the characteristic annular form, but "are usually in the form of single or multiple, disseminated, small, reddish, slightly scaly, ill-defined spots, on a level with or but slightly raised above the surrounding skin. Not infrequently they are the size of a small or large finger nail, and are irregularly shaped, and, as a rule, without line of demarcation." The "eczema marginatum" of Hebra is to be looked upon as a severe form of tinea circinata. Tinea circinata cruris, or ringworm of the thighs, a variety of the "eczema marginatum of Hebra," is usually complicated with true eczema, and is a very obstinate, chronic form of the affection ; it is accompanied by severe itching. Tinea trichophytina unguium is a rare variety. The nails become opaque, whitish, thickened and soft or brittle, especially along their DISEASES OF THE SKIN. 383 free border. The microscope is essential for a diagnosis. Its course is chronic and it is difficult to cure. Course. As commonly seen, ringworm is very amenable to treat- ment. Occasionally, however, it exhibits great obstinacy, showing itself repeatedly in the same region, in the form of relapses, or mani- festing itself from time to time in new localities. Diagnosis. Tinea circinata may be mistaken for squamous or other varieties of eczema, but the circular and often annular form, the well-defined margin, the slight desquamation and the course and history of ringworm should prevent error. Chronic ringworm is more difficult, however. Seborrhoea and psoriasis often assume a somewhat circular form, and then have a resemblace to ringworm; but a study of the clinical history should render the diagnosis easy. All doubtful points in diagnosis should be determined by the microscope. The examination can readily be made in the following manner: "A few of the scales may be scraped, with a blunt knife- blade, from the suspected patch and placed upon a glass slide con- taining a drop of liquor potassae, over which is laid a thin glass cover. The cover should be pressed down and the epidermic mass flattened out. Permitting the specimen to remain for a few minutes, it may be viewed with a power of from two hundred and fifty to five hundred diameters. The fungus will, in most cases, be detected here and there, having at first a faint outline, but becoming more distinct as the specimen stands." Prognosis. Favorable, as a rule, although the affection is rebel- lious to treatment in some instances and prone to relapses. Treatment. Local treatment is usually all that is required for the cure of tinea circinata. In the majority of instances the following plan will be successful. Washing the patch with soft soap and water and the application of one of the following ointments:— R. Cupri acetat........................................... gr. x Ung. aquae rosae....................................... ^j. M. SlG.—Keep in contact with the patch. Or— R. Hydrargyri ammoniat................................ gr. xx-xxx Ung. petrolei........................................... ^j. M. Sig.—Keep in contact with the patch. 384 PRACTICE OF MEDICINE. " In obstinate tinea circinata cruris the following, recommended by Tilbury Fox, may be employed :"— R. Creascrti.................................. Olei cadini.............................. Sulphuris sublimati.................... Potassii bicarb.......................... Adipis.................................... Sig.—Keep in contact with the affection TINEA TONSURANS. Synonyms. Tinea trichophytina capitis;' herpes tonsurans; ring- worm of the scalp. Definition. A contagious, parasitic affection of the scalp, due to the trichophyton fungus; characterized by the development of cir- cumscribed, vesicular or squamous, more or less bald patches, show- ing the hair to be diseased and usually broken off close to the scalp. Cause. The result of the presence and growth of the same fungus giving rise to tinea circinata—trichophyton. It is an affection of childhood, seldom being seen after puberty. It is highly contagious, and may be communicated from a case of ringworm of the body. Pathology. The parasite originally named "trichophyton ton- surans " invades the hair, hair follicles and epidermis of the scalp, the hair, however, suffering the most severely, becoming in a short time filled with the growth to such an extent, usually, as to cause its disintegration and destruction. The hair follicle, also, becomes dis- tended and prominently raised. The hair shaft is fractured just above the level of the scalp, and usually presents a jagged, bristly, stubble-like extremity. The epidermis of the scalp may either pre- sent the changes of minute vesicles and desquamation, or in severe cases, oedema and inflammatory symptoms with fluid exudation (tinea kerion). Symptoms. Ringworm of the scalp usually begins in the form of small circumscribed patches, which soon become the seat of small vesicles or pustules, which terminate in desquamation, or of furfur- aceous scales. The patches spread rapidly, soon reaching the size of a silver quarter to that of a silver dollar. They are circular in form, circumscribed, of a reddish, grayish or greenish-yellow color, covered with fine or coarse scales, with the hairs broken off close to the scalp. The epidermis of the scalp is more or less raised and the follicles are rnjcx 3»j 3j- M. DISEASES OF THE SKIN. 385 prominent, giving the characteristic appearance of the disease—the goose-skin or plucked-fowl appearance. As a result of the loss of hair, baldness, more or less complete, but temporary, exists. Itching, slight or severe, is a constant symptom. Ringworm of the face or body (tinea circinata) may complicate tinea tonsurans. Chronic ringworm of the scalp is the same condition in a more chronic form, having existed for six months to a year or two. Tinea kerion is a severe variety of tinea tonsurans, "characterized by oedema, inflammation, and the exudation of a viscid, glutinous, yellowish secretion from the opening of the hair follicles. When fully developed the patches are yellowish, reddish or purplish in color, and are more or less raised, cedematous and boggy. They are uneven and honeycomb-like (whence the name kerion), and studded with yellowish, suppurative points, or, later, with small cavities or foramina, the openings of the distended hair follicles deprived of their hairs, which discharge a mucoid, gummy, honey-like fluid." The patches are tender, painful and at times the seat of itching. The course of the affection is chronic. Diagnosis. The diagnosis is usually unattended with difficulty, if the characteristic circumscribed vesicular or scaly patches with stubby hair be present. Squamous eczema somewhat resembles tinea tonsurans, but the hairs are normal in eczema and firmly embedded in the follicles, whilst they are almost always stumpy in ringworm, and in those cases in which they are not broken off, if pulled, they easily fall out. Ring- worm is contagious, eczema is not. Alopecia areata presents the white, shiny, ivory-like, bald patch, devoid of scales or hair. Ringworm has the vesicular or scaly patch with broken-off hairs. In any case of doubt the microscope will readily determine the diagnosis, if " one or two of the short stumpy hairs should be placed upon a slide with a drop of liquor potasse and permitted to stand a few minutes, when, under a power of two hundred and fifty diameters the fungus, as well as the lesions of the hair, will be visible." Prognosis. Favorable, although obstinate in chronic cases. Relapses are of frequent occurrence. 2 G 386 PRACTICE OF MEDICINE. Treatment. Local measures are satisfactory in the majority of instances of tinea tonsurans. Mild cases should be treated by cutting the hair as close as possi- ble and thoroughly scrubbing the patches with sapo viridis and water and the application twice daily of a six per cent, solution of oleatwn hydrargyri, or either of the following:— R. Sodii borat ........................................... .^j Aceti destil............................................. 31J. M. Sig.—Apply thoroughly several times daily. Or— R. Acidi boracici........................................... gr. xv Sulphur, flos............................................ gr-xv Vaselini..................................................f^iss. M. Sig.—Apply morning and night. Or, use may be made of Morris' thymol solution, to wit:— R. Thymol.................................................. gss Chloroformi............................................. ^ij 01. olivae................................................ ijvj. M. A preparation very popular in London, known as Coster's paste, is used by painting the patches with a brush and allowing it to remain on until the crust is cast off, in the course of five or six days, when it may be reapplied. A few applications often suffice. Its formula is— R. Iodi...................................................... jjij Olei picis................................................ fij j. M. The iodine and oil of tar should be gradually and slowly mixed. Cases which resist these means are to be treated by removing the loose hairs about the edges of the patches, and the broken-off hairs over the surface, by means of small, broad-bladed, short foreceps, a few hairs only being seized at a time; a portion of the diseased hairs to be removed each day until the surface has been cleared. After each depilation, one of the above formulae are to be applied. TINEA SYCOSIS. Synonyms. Tinea trichophytina barbae; sycosis parasitica; bar- bers' itch ; ringworm of the beard. Definition. A contagious, parasitic affection of the hair, hair follicles and subcutaneous tissues of the hairy portion of the face and DISEASES OF THE SKIN. 387 neck in the adult male, due to the trichophyton fungus; character- ized by the development of tubercles and pustules. Cause. Tinea sycosis is the result of the presence and growth of the same vegetable parasite that causes tinea circinata and tinea ton- surans—trichophyton—which invades the hair follicle and hair. It is highly contagious, and is said to be acquired, in most cases, at the hands of the barber (?). It is not a very common affection. Like the other vegetable growths, it seems to require some peculiar, unknown condition of the skin for its development. It may develop from a case of tinea circinata or develop simultaneously with it. Pathology. The parasite finds its way into the hair follicles and attacks the root and shaft of the hair, causing inflammation, followed by more or less follicular suppuration and general infiltration of the surrounding tissues. The irritation caused by the presence of the fungus results in inflammation of the subcutaneous connective tissue and the well-known tubercular formations peculiar to the affection. They are firm, comparatively painless, and manifest but little dis- position to undergo change, remaining during the presence of the fungus and finally gradually disappearing without leaving a scar. Under the microscope the parasite is plainly discernible. Symptoms. Barbers' itch begins as an attack of tinea circinata —as one or more reddish, scaly patches. Soon the redness and des- quamation become more decided, attended with swelling and indura- tion. The hairs will also be dry, brittle, incline to break, and many of them are already loose. The process rapidly increases, the skin be- comes distinctly nodular and lumpy, and points of pustulation develop about the openings of the hair follicles. The subcutaneous connective tissue is also involved, giving rise to thick, firm masses of induration. The surface has a dark red or purplish color, and is studded with variously-sized tubercles and pustules. In some instances the num- ber of tubercles are in excess, whilst in others the pustules are more numerous, numbers of them discharging, and are succeeded by thick crusts, which are often so abundant as to simulate pustular eczema. The hairs are always diseased, and break off, either in the follicles or just above the level of the surface. Those not breaking drop out, leaving the region partly or wholly devoid of hair. The most frequent location attacked is the chin, neck and sub- maxillary region. One or, what is more common, both sides of the face are involved. 388 PRACTICE OF MEDICINE. Itching, burning and pain always accompany the affection, varying in intensity from moderate to very severe. The course of the affection is usually chronic. Relapses are fre- quent, unless most thoroughly eradicated. Diagnosis. Sycosis no7i-parasitica occasions difficulty of diag- nosis at times. The points of difference, however, are usually so marked that error should not occur. Sycosis non-parasitica is a chronic, inflammatory, non-contagious af- fection of the hair follicles, characterized by the development of papules and pustules, which are perforated with hairs, the hairs themselves being unaffected. The upper lip, cheeks and chin are the parts mostly involved. If of long duration, some inflammatory thickening results. In tinea sycosis or sycosis parasitica, the skin and subcutaneous connective tissue are extensively involved, as manifested by the in- duration and formation of the characteristic tubercles. The upper lip is rarely invaded, the hairs are diseased, broken off* or loose, and under the microscope reveal the parasite. Pustular eczema resembles tinea sycosis, with extensive pustulation and crusting. But in the former the hairs are not involved, nor are the characteristic tubercles present. Treatment. Local measures are sufficient for the cure of tinea sycosis. In the majority of instances the following procedure will effect a cure in three or four weeks. If crusts are present, and almost always some are, they are to be thoroughly saturated with inunctions of almond or olive oil, and removed by washing with soft soap and water. The part is then cleanly shaved, the first operation being more painful than subsequent ones. After shaving, the affected sur- face is bathed for ten minutes in water as hot as can be borne. All pustules are then opened with a fine needle, after which the parts are sponged freely for several minutes with a solution of sodii hyposul- phitis, gj, aque, f^j, after which the parts are again thoroughly washed with hot water, carefully dried and smeared with an un- guentum sulphur., containing 3 j-ij to the ounce. This procedure is preferably performed at night. The following morning the ointment is washed off with soap and water, the face bathed with the sodium solution, and dusted with any inert powder. This plan continued faithfully every night, omitting the shaving when the beard has not grown much, will usually be followed with success. Cases resisting the above means should, in addition to the above, DISEASES OF THE SKIN. 380 have the hairs depilated, the shaving performed every two or three days, thus allowing time for the hairs to grow sufficiently to depilate, the operation seldom being so painful as one would suppose. Shav- ing and depilation upon alternate days should be faithfully practiced until the new hairs show themselves to be healthy. In addition to the parasiticides mentioned, any of those recom- mended for the other vegetable parasitic diseases may be used. TINEA VERSICOLOR. Synonyms. Pityriasis versicolor ; liver-spots. Definition. A co7itagious, parasitic affection of the skin, due to the 7>iicrosporon furfur; characterized by the occurrence of variously sized, irregularly-shaped, dry, slightly furfuraceous, yellowish spots upon the chest or other portions of the body. Cause. Pityriasis versicolor is the result of the presence upon the surface of the skin of a vegetable fungus termed the microsporon fur- fur. It is a mildly contagious affection seen after puberty. It is said to occur most frequently in those suffering from wasting diseases, particularly phthisis pulmonalis. It is not connected with any affec- tion of the liver, as supposed by the laity. Pathology. The fungus permeates the horny layer of the epi- dermis, never the hair or nail, and gives rise to the irregular-shaped and sized maculae, of a yellowish or brownish color. As a rule, it gives rise to neither hyperaemia nor inflammatory symptoms. Symptoms. Tinea versicolor occurs in the form of irregular, roundish, circumscribed or reticulated maculae. The spots vary in size from that of a small silver coin to that of the hand. By coal- escing they often cover a greater portion of the chest, their most usual site. Upon close inspection the surface of the macule is seen to be covered with furfuraceous scales, and if the scales be not visible, scraping with the finger nail will demonstrate their presence. In color the spots vary from a delicate buff or fawn shade to a yellowish, deep brown, and, rarely, even blackish hue. At times mild itching accompanies the eruption. Diagnosis. The characteristics of the eruption are so distinct that errors in diagnosis can hardly occur. If any doubt exist, a few of the scales placed upon a glass slide, with a drop of liquor potasse, and covered with a thin glass cover and placed under a microscope 390 PRACTICE OF MEDICINE. with a power of from two hundred and fifty to five hundred diameters, the fungus is readily discerned. Prognosis. Favorable. Treatment. The parts should be cleansed with soap and water, and either of the following lotions applied :— R. Sodii sulphitis...................................... 3 iij Glycerini............................................. f.^ij Aquae........................ad..................... i%lw- M. Sig.—Apply frequently. Or— R. Hydrargyri chlorid. corrosiv................... gr. iv Alcoholis............................................. f.^vj Ammonii muriat.................................... £ss Aquae rosae.................ad..................... f^vj- M. Sig.—Apply frequently. —Tilbury Fox. SCABIES. Synonyms. The itch. Definition. A contagious, animal parasitic disease of the skin, due to the acarus or sarcoptes scabiei ; characterized by the formation of cuniculi (burrows), papules, vesicles and pustules, followed by ex- coriations, crusts and general cutaneous inflammation, and accom- panied with itching. Cause. Contagion. The only cause is the presence of the animal parasite, the acarus or sarcoptes scabiei. The affection occurs at all ages and in every walk of life. Pathology. Scabies is an inflammation of the skin with the development of papules, vesicles, pustules, excoriations and subse- quent crusting, the result of the ravages of the animal parasite, together with the irritation produced by the scratching of the patient. The parasite—acarus or sarcoptes scabiei—is a minute creature, barely visible to the naked eye as a yellowish-white, rounded body. The female is the most commonly met with, the males being said to take no part in causing the affection, and so are rarely seen. They are said to die in about a week after copulation with the female. The female finds her way by boring through the horny layer into the mucous layer of the epidermis, and, being impregnated, begins at once laying her eggs and at the same time making her burrow. A variable number of eggs are deposited, usually about a dozen, after DISEASES OF THE SKIN. 391 which she perishes in the skin. The ova hatch out in eight or ten days. Symptoms. Scabies being an artificial dermatitis or eczema, according to the amount of irritation produced by the presence of the parasite and the traumatism the result of the severe scratching of the patient. Immediately upon the arrival of the itch mite upon the skin it begins its work of burrowing, and very soon a burrow or cuniculus is formed, in which the eggs are deposited, and which also becomes the habitat of the female during the remainder of her life. The ova are hatched in about one week after their deposit, and they at once begin to care for themselves and to burrow, resulting in the formation of as many additional cuniculi as there are active female mites. It is the presence of these burrowing parasites that constitute the irritation resulting in the inflammation of the skin, characterized by the formation of minute papules, vesicles and pustules, with more or less inflammatory induration. Add to these the excoriations, scratch marks, fissures, torn vesicles, and pustules with yellow and bloody crusts, caused by the scratching, and a picture of the fully-developed disease is seen. The burrow, or cuniculus, as it is termed, is formed by the mite entering, and making its way beneath the horny layer of the epider- mis, which is raised, very much as a mole undermines the ground. It occurs as a slight linear elevation of the epidermis, varying from a half a line to four or five lines in length, and having an irregular or tortuous course. Its color is whitish or yellowish, speckled here and there with dark dots. At either end the cuniculus terminates as darkish points, the more prominent of which represent the parasite. The papules are the first inflammatory lesion, are numerous, and of small size, and may be the extent of the disease. The vesicles are the next stage, varying in size and number, having an inflamed base, sometimes presenting cuniculi upon their summits. The pustules represent the completion of the inflammatory action, their size and number varying with the severity of the irritation. The intense itching, which is worse at night, results in excoriations, torn papules, vesicles and pustules, followed by crustings, which after a time disguise the characteristic lesions. The regions of the body attacked are the hands, especially the sides of the fingers and the folds where they join the hands. After a time the wrists, penis and mammae, and around about and upon the nipples, are invaded. 392 PRACTICE OF MEDICINE. Persons predisposed to eczema have this affection developed in addition to the simple dermatitis, by the ravages of the itch mite. Diagnosis. A case of scabies seen before irritated by scratching presents no difficulty in diagnosis. The presence of the burrows always suffices for the diagnosis, but these are not always discover- able. The location of the eruption always points strongly to scabies. A history of contagion is of value. All doubt can be set at rest by the aid of the microscope. Prognosis. Always favorable, relapses only occurring when the treatment has been imperfectly carried out or where the individual has re-contracted the disease. Treatment. Local measures are alone required in the treatment of scabies. The strength of the parasiticides must be controlled by the severity of the inflammatory symptoms present. If eczema com- plicate scabies, it is to be treated as an ordinary attack after the death of the itch mites. Scabies always succumbs to the following plan. The patient is to be thoroughly washed with soft soap and water, followed by a warm bath, after which one of the following ointments is to be thoroughly rubbed into every portion of the body, special attention being devoted to the hands, fingers and other parts usually the seat of the disease. R. Styracis liquidis.................................... • PAGE Errhme, Ferrier's................... 182 Robinson's.................. 182 Erysipelas ........................... 42 ambulans .................... 43 of the brain................. 43 phlegmonous................ 43 Erythematous stomatitis........... 45 Erythema simplex.................. 329 Essential ancemia.................... 314 Eucalyptol in cystitis............... 130 EACIAL paralysis................. 307 ■*- Famine fever.................. 23 Favus.................................. 379 Febricula ............................. 13 Ferrier's errhine................... 182 Fever, bilious......................26, 52 bilious remittent............ 26 bilious typhoid............. 23 breakbone................... 44 catarrhal..................... 14 cerebral..................... 281 cerebro-spinal............... 21 congestive.................... 27 contagious................... 20 dandy......................... 44 enteric........................ 16 entero-mesenteric........... 16 ephemeral................... 13 epidemic cerebro-spinal... 21 famine........................ 23 gastric ......................16, 52 hay........................... 210 intermittent..............."... 24 irritative..................... 13 jail............................. 20 lung.......................... 218 malarial...................... 24 malignant intermittent..... 27 malignant remittent........■ 27 marsh......................... 26 Mediterranean.............. 31 nervous....................... 16 neuralgic..................... 44 pernicious.................... 27 relapsing..................... 23 remittent..................... 26 rheumatic.................... 138 rose........................... 210 sailors'........................ 31 PAGE Fever, scarlet........................ 33 ship........................... 20 simple, continued........... 13 spotted........................ 21 typhoid....................... 16 typho malarial.............. 26 typhus........................ 20 winter....................... 218 yellow........................ 31 Fevers................................. 12 continued.................... 13 eruptive..................... 23 essential...................... 13 general treatment of....... 13 periodical.................... 24 primary cause of............ 12 secondary.................... 13 Fish-skin disease.................... 377 Flesh-worm ......................... 159 Fluxes, vicarious.................... 70 Follicular stomatitis................ 46 Fothergill's disease................. 305 Freckles.............................. 369 Fremitus, bronchial................. 163 friction...................... 163 tussive........................ 163 vocal.......................... 163 Furuncle.............................. 356 Furunculus........................... 356 Furunculosis......................... 356 r^ALL stones....................... 101 ^ Gastralgia....................... 62 Gastric cancer........................ 58 carcinoma.................... 58 dilatation..................... 60 fever........................16, 52 hemorrhage.................. 61 ulcer.......................... 56 Gastritis, acute.....................54, 55 chronic...................... 55 subacute..................... 52 toxic.......................... 54 Gastrodynia.......................... 62 Gastrorrhagia........................ 61 Gastroscope, uses of................ 60 German measles..................... 38 Glossitis............................... 50 Glottis, oedema of................... 190 spasm of...................... 196 402 PAGE Glycosuria............................ 150 simple........................ 152 Goudron de Guyot.................. 338 Gout................................... 146 rheumatic.................... 144 Gravel................................. 126 Green sickness...................... 313 Gripes................................. 67 Gross' neuralgic pill............... 306 Grutum................................ 324 Gutta rosea........................... 363 rosacea....................... 363 TJiEMATEMESIS............... 61 H Haematoma of the dura mater.......................... 283 Haemophilia^........................ 317 Haemoptysis.......................... 214 Heart, anaemia of fatty............ 314 dilatation of................. 259 fatty degeneration of...... 261 hypertrophy of.............. 257 neuralgia of................. 271 palpitation of................ 270 physical examination of... 245 valvular diseases of........ 263 Heartburn............................ 64 Hemiplegia........................... 278 Hemorrhage, bronchial............ 214 cerebral..................... 277 gastric........................ 61 renal.......................... 128 solution for.................. 31 Hemorrhagic diathesis............. 317 Hemorrhoea petechialis. .......... 319 Hepatic cancer...................... 108 Hepatitis, acute.................... 104 interstitial.................... 106 parenchymatous............ 104 suppurative.................. 104 Herpes............................... 347 circinatus.................... 381 facialis....................... 348 gestationis .................. 348 labialis........................ 348 praeputialis.................. 348 progenitalis ................. 348 tonsurans..................... 384 zoster......................... 349 Hives...... ........................... 345 PAGE Hooping cough...................... 212 Hydraemia............................ 311 Hydro-adenitis....................... 357 Hydrocephalus, acquired......... 285 acute.......................... 285 chronic....................... 287 congenital.................... 287 Hydropericardium.................. 251 Hydropneumothorax............... 243 Hydrosis.............................. 326 Hydrothorax......................... 242 Hyperaemia, cerebral............... 272 spinal......................... 292 Hyperaemias of the skin........... 329 Hyperidrosis......................... 326 local........................... 326 unilateral.................... 327 Hypertrophies of the skin........ 369 Hypertrophy, cardiac............... 257 ICHTHYOSIS..................... 377 *■ Icterus........................... 99 Ileo-colitis............................ 72 Impetigo ............................. 354 Incubation........................... 10 Indigestion........................... 65 acute.......................... 52 intestinal..................... 65 Inflammations of the skin......... 331 Influenza.............................. 14 Inspection.......................162, 245 Intermittent fever................... 24 Intestinal colic....................... 67 dyspepsia.................... 65 obstruction................... 88 parasites..................... 91 stricture ..................... 88 torpor......................... 68 Intestines, diseases of............... 65 irrigation of.................. 100 Introduction.......................... 9 Invagination ...................... 88 Ipecacuanha in dysentery......... 85 Ischaemia............................. 312 Itch.................................... 390 barbers' ..................... 386 JAIL fever........................... 20 Jaundice, catarrhal............ 99 malignant ................... 105 INDEX. 403 PAGE T/IDNEYS, amyloid.............. 122 *■*■ congestion of................ 115 contracted................... 120 diseases of................... 109 gouty.......................... 120 lardaceous .................. 122 sclerosis of................... 120 small red..................... 120 waxy.......................... 122 Kummerfeld's lotion................ 365 T ARYNGISMUS stridulus...... 196 *-* Laryngitis, acute catarrhal.. 188 croupous..................... 192 cedematous.................. 190 spasmodic................... 191 Law of parallelism................. 139 Lentigo............................... 369 Lepra................................. 366 Leptomeningitis spinalis.......... 294 Leucaemia........................... 315 Leucocythemia ..................... 315 Lichen, simplex..................... 333 tropicus....................... 350 Liquor picis alkalinus............. 338 Lithaemia............................. 149 Lithiasis.............................. 149 Liver, abscess of..................... 104 albuminous................. 107 amyloid ..................... 107 atrophic...................... 103 cirrhosis of.................. 106 congestion ................. 102 diseases of................... 102 gin-drinkers'................ 106 hob-nailed................... 106 hypertrophic sclerosis of.. 106 lardaceous .................. 107 nutmeg....................... 103 sclerosis of.................. 106 scrofulous.................... 107 spots.....................370, 389 torpid........................ 102 waxy.......................... 107 yellow atrophy of.......... 105 Locomotor ataxia.................... 301 Lotio nigra.......................... 33° Lousiness ........................... 392 Lumbago............................. J42 Lumbo-abdominal neuralgia...... 306 PAGE Lumbodynia ........................ 143 Lungs, cirrhosis of.................. 233 congestion of................ 216 gangrene of...............'.. 220 hyperaemia of............... 216 cedema of.................... 217 Lysis.................................. 11 Yf ALIGNANT intermittent fe- i'-l ver.......................... 27 remittent..................... 27 Mal, le grand...................... 310 Mal, le petit.......................... 310 Marsh fever.......................... 26 Measles............................... 36 black.......................... 37 . false .......................... 38 French....................... 38 German ..................... 38 Mediterranean fever................ 31 Melasma, supra-renalis............ 316 Melituria ............................. 150 Membranous enteritis.............. 74 Meningitis, acute.................... 281 basilar........................ 284 spinal......................... 294 tubercular.................... 284 Mensuration......................... 163 Metastasis............................ II Miliaria ............... .............. 350 alba........................... 350 papulosa..................... 351 rubra.......................... 350 vesiculosa.................... 351 Milium................................ 324 Mixture, Bartholow's cholera.... 77 Basham's iron............... 117 DaCosta's muscular cramps..................... 77 Hartshorne's cholera...... 77 Hope's camphor............ 74 Keating's pertussis spray. 214 Pepper's asthma............ 210 Squibb's diarrhoea......... 71 Morbid anatomy..................... 11 Morbilli............................... 36 Morphina in acute uraemia........ 126 in cardiac dilatation...... 260 Morris' thymol solution........... 386 Moth.................................. 370 404 INDEX. PAGE Mouth, catarrh of.................. 45 diseases of................... 45 white......................... 49 Mucus, test for............,......... m Muguet................................ 49 Mumps.............................. 131 Murmurs, aortic..................... 265 endocardial.................. 246 exocardial.................... 247 mitral......................... 264 pericardial................... 247 pulmonic .................... 266 see-saw....................... 267 tricuspid..................... 265 Muscles, insanity of................. 308 Myelitis, acute....................... 296 Myocarditis........................... 256 1VTASAL acute catarrh............ 179 ^ chronic catarrh.............. 182 Nephritis, acute desquamative... 116 catarrhal.................... 115 chronic parenchymatous.. 118 interstitial ................... 120 parenchymatous............ 116 peri........................... 124 pyelo......................... 123 suppurative ................. 123 tubal ......................116, 118 Nephrolithiasis..................... 126 Nephrosis-pyelo..................... 124 Nervous fever ...................... 16 Nettle-rash........................... 345 Neuralgia............................ 304 cervico-brachial ............ 305 cervico-occipital ........... 305 dorso intercostal........... 305 intercostal.................... 349 lumbo-abdominal........... 306 of the fifth nerve........... 305 of the heart.................. 271 sciatic........................ 306 Neuralgic fever...................... 44 Neuritis .............................. 303 Neuroses, cerebro-spinal.......... 308 Nickel, use of, in epilepsy......... 311 Nystagmus........................... 308 ABSTRUCTION, aortic........ 267 ^ intestinal.................... 88 PAGE Obstruction, mitral.................. 266 pulmonic .................... 268 pyloric ....................... 60 tricuspid..................... 268 Occlusion of cerebral vessels.... 274 0'idium.albicans..................... 49 Ointment, diachylon, Hebra's... 338 Oligaemia.............................. 312 Oxyuris vermicularis............... 93 Ozaena ................................ 183 PACHYMENINGITIS..:...... 283 *■ spinalis...................... 295 Pains, the girdle.................... 297 Palpation........................162, 245 Palsy, Bell's......................... 307 Paragraphia......................... 291 Paralysis.............................. 279 bilateral..................... 279 bulbar........................ 301 cardiac...................... 134 chronic progressive bulbar 301 diphtheritic.................. 134 essential, of infants........ 298 facial.......................... 307 glosso-labio laryngeal..... 301 infantile spinal.............. 298 of the tongue............... 292 pharyngeal .................. 134 unilateral..................... 279 Paraphasia .......................... 291 Parasitic diseases of the skin..... 379 Parotitis.............................. 131 m etastatic.................... 131 Paste, Coster's ..................... 386 Pathological anatomy.............. 11 Pathology............................. 9 Pediculosis........................... 392 caP"is........................ 393 corporis ..................... 393 pubis......................... 394 Pemphigus........................... 352 foliaceus.................... 352 malignus..................... 353 pruriginosus................ 353 vulgaris ..................... 352 Percussion ............ ........164, 165 auscultatory................. 168 immediate.................... 164 INDEX. 405 Percussion, mediate................. 164 objects of..................... 165 respiratory.................. 168 Pericarditis, acute.................. 250 chronic....................... 252 dry...............,............ 250 Pericardium, adherent............. 251 effusion of................... 260 hydro-........................ 253 Peri-nephritis ....................... 124 Periodical fevers................... 24 Periproctitis.......................... 88 Peritoneal dropsy................... 97 Peritonitis............................. 94 Perityphlitis.......................... 87 Pertussis............................... 212 Pharyngeal paralysis............... 134 Pharyngitis, acute catarrhal...... 184 erysipelatous................ 185 phlegmonous............... 186 Phosphates, test for................. n 1 Phosphoridrosis..................... 326 Phthiriasis............................ 392 Phthisis.............................. 226 acute.....................228, 235 caseous...................... 227 catarrhal..................... 227 chronic....................... 228 fibroid........................ 233 florida....................... 228 incipient..................... 230 pneumonic.................. 227 pulmonalis.................. 226 subacute..................... 228 tubercular.................... 230 Physical diagnosis.................. 161 signs.......................... II Piffard's acne solution.............. 324 Pill, Bartholow's gout.............. 148 Blaud's....................... 3J4 DaCosta's, hemorrhage... 216 Gross'neuralgic ........... 306 Loomis' gout............... 148 Niemeyer's.................. 232 Pilocarpus for spreading erysipe- las................................... 44 Pitting, to prevent................. 41 Pityriasis............ ................. 3|f versicolor.................... 3°9 Pleurisy............................... 239 PAGE Pleuritis............................... 239 chronic....................... 240 dry............................ 239 Pleurodynia.......................... 143 Pleuro-pneumonia.................. 218 Pneumonia, bilious.................. 221 catarrhal..................... 223 chronic catarrhal........... 227 chronic interstitial......... 233 croupous..................... 218 lobar.......................... 218 lobular........................ 223 typhoid...................... 221 Pneumonitis.......................... 218 Pneumothorax....................... 243 Podagra............................... 146 Poliomyelitis anterior acuta....... 298 Polyuria.............................. 153 Poultice, pilocarpus................ 143 spice.......................... 80 Predisposition........................ 9 acquired...................... 10 Prickly heat.......................... 352 Proctitis............................... 87 Proctitis, peri-........................ 88 Prodromes........................... 10 Prognosis................ ............ 11 Psoriasis............................... 366 circinata...................... 367 diffusa........................ 367 guttata........................ 367 gyrata........................ 367 mummularis................. 367 of the tongue............... 52 palmaris..................... 368 plantaris..................... 368 punctata..................... 367 unguium..................... 368 Pulse, Corrigan..................... 264 receding..................... 264 water-hammer.............. 264 Purpura.............................. 319 hemorrhagica............... 319 simplex...................... 319 urticans...................... 319 Pus, test for.......................... 113 Pyelitis................................ 123 Pyelo-nephritis...................... 123 nephrosis..................... 124 Pyloric obstruction.................. 60 406 INDEX. PAGE Pyloric stenosis...................... 60 Pyrosis................................. 64 OUININA in trichinosis......... 160 , Quinsy.......................... 186 malignant.................... 132 DALES.............................. 174 ^ bronchial.................... 174 cavernous.................... 176 dry............................ 176 laryngeal..................... 175 moist.......................... 175 pleural........................ 176 tracheal...................... 175 vesicular..................... 176 Reactions of degeneration........, 299 Rectitis................................ 87 Rectum, catarrh of.................. 87 washing out the............ 85 Regurgitation, aortic.....,......... 264 mitral........................ 263 pulmonic..................... 266 tricuspid..................... 265 Renal cyst............................ 124 Respiration, Cheyne-Stokes...... 262 oscillating................... 262 Rheumatic gout..................... 144 Rheumatism, acute articular..... 138 gonorrhceal.................. 145 hyperpyrexia of............ 138 inflammatory............... 138 muscular.................... 142 Rheumatoid arthritis............... 144 Rhinitis, acute....................... 179 chronic....................... 182 Ringworm,honeycombed......... 379 ofthebody.................. 381 of the scalp.................. 384 of the beard................. 386 Robinson's errhine.................. 182 Rotheln............................... 38 Round worms........................ 93 Rubeola................................ 36 CAILORS' fever.................. 31 ^ Saline fluids in cholera...... 158 Salt rheum........................... 331 Sand, renal........................... 127 Sapo viridis......................... 338 PAGE Scabies................................ 39° Scall.................................. 331 Scarlatina ............................ 33 mixture, Smith's............ 35 Scarlet fever.......................... 33 Sciatica................................ 306 Sclerosis, antero-lateral ........... 302 cerebro-spinal.............. 301 hepatic hypertrophic...... 106 posterior.................... 302 spinal........................ 301 Scorbutus............................. 318 Scurvy................................. 318 Sebaceous cyst....................... 325 Seborrhoea........................... 321 capitis........................ 321 falciei........................ 321 oleosa........................ 321 sicca........................... 321 Secondary processes.............. n Shingles............................. 349 Ship fever............................ 20 Sickness, green...................... 313 Sign, Corrigan's..................... 59 Signs, physical, association of.... 179 Silver nitrate in phlegmonous erysipelas.......................... 44 Smallpox............................. 38 Smith's, Dr. A. H., tonic......... 312 Solution, Dobell's.................. 184 Sore throat, acute..............184, 188 Sounds, in disease, chest.......... 171 in health, chest............. 169 normal cardiac.............. 245 Spanaemia............................ 311 Spasm, histrionic.................... 308 Splenification........................ 216 Spotted fever........................ 21 Sprue.................................. 49 St. Anthony's fire................... 42 Stomach, cancer of................. 58 diseases of................... 52 neuralgia of.................. 62 remorse of................... 64 spasm of..................... 62 washing out the............ 60 Stomatitis, catarrhal................ 45 croupous..................... 46 diphtheritic................. 47 erythematous............... 45 INDEX. 407 PAGE Stomatitis, follicular............... 46 simple........................ 45 ulcerative................... 47 vesicular....................... 46 Stonepock............................ 361 Stones, chalk........................ 147 St. Vitus's dance................... 308 Stools, chopped spinach........... 79 Storm, electrical..................... 310 Succussion........................... 178 Sudamen.............................. 328 Sudamina............................ 328 Sugar, test for...................113, 114 Summer complaint.................. 80 Sweating, excessive................ 326 Sycosis parasitica.................... 386 Symptoms............................. 10 Syncope............................... 280 "TAENIA saginata.................. 91 1 Taenia solium.................. 91 Tapeworm, armed................. 91 unarmed..................... 91 Test for albumen.................... 112 bile............................ 113 bile pigment................. 113 blood......................... 112 chlorides..................... m mucus........................ m phosphates.................. m pus............................ 113 sugar.....................114, 115 urates......................... no urea.......................... no Tetter................................. 331 Throat, acute sore..............184, 188 putrid sore,.................. 132 Thrombosis, cerebral............. 274 Thrush................................ 49 Thymol solution, Morris'......... 386 Tic-douloureux..................... 305 Tincture, Warburg's............... 29 Tinea circinata..................... 381 favosa........................ 379 furfuracea.................... 321 kerion....................... 3^5 sycosis........................ 3^6 tonsurans..................... 3^4 versicolor..................... 3^9 Tinkling, metallic.................. 177 PAGE Tone, bandbox,of Bamberger__ 209 Tongue, strawberry................. 34 Tonic, Dr. A. H. Smith's.......... 312 Sir Erasmus Wilson's..... 322 Tonsillitis, acute..................... 186 catarrhal..................... 184 Tormi na............................... 67 Torticollis........................142, 143 Treatment............................ n abortive..................... 12 expectant.................... 12 preventive.................. 12 restorative.................. 12 specific for typhoid fever.. 18 Tremens, delirium.................. 282 Trichinae............................ 159 spiralis........................ 159 Trichinosis........................... 159 Tuberculosis......................... 230 acute miliary............... 235 Tumors, intra-cranial............... 290 Turpeth mineral in croup......... 195 Tyloma................................ 373 Tympanites, chronic............... 98 Typhlitis............................. 85 Typho-malarial fever............... 26 Typhus icterode..................... 31 TTLCER, duodenal............... 57 ^ gastric....................... 56 perforating.................. 56 Ulcerative stomatitis............... 47 Ulcerative gingivitis................ 47 Uraemia, acute....................... 124 morphina in................. 126 Uraemic coma........................ 124 convulsions................. 124 Urates, test for....................... no Urea, test for......................... no Uricacid diathesis.............. ... 149 test for........................ ill Uridrosis.............................. 326 Urine.................................. 109 hysterical..................... 208 normal color................ 109 normal constituents........ no normal quantity........... 109 reaction...................... 109 Urticaria.............................. 345 408 INDEX. PAGE yACCINATION................. 41 ' Vaccinia.................,..... 41 Valvular diseases of the heart.... 268 diagnosis of.................. 268 Valvulitis............................. 254 Varicella.............................. 42 Variola................................ 38 Varus.................................. 361 Verruca............................... 375 Vertigo, stomachic.................. 52 Vesicular stomatitis................. 46 Vomit, black......................... 31 coffee-ground............... 31 WADDLE, the.................... 302 PAGE Warburg's tincture................. 29 Wart................................... 375 venereal..................... 376 Water blisters........................ 352 colored, in rheumatism.... 140 Wens................................. 325 Wheals................................ 346 White mouth....................... 49 Whooping cough.................... 212 Wilson's, Erasmus, tonic......... 322 Worms, round....................... 93 seat............................ 93 VERODERMA................... 377 CATALOGUE No. 7. OCTOBER, 1887 A CATALOGUE OF Books for Students. CONTENTS. PAGES PAGES The Quiz-Compends, 2, 3, 4, S Pathology and Histology, . 11 Anatomy, 6 Physical Diagnosis, . 11 Chemistry, . 6 Physiology, . . n Children's Diseases, 7 Practice of Medicine, . . 12 Dentistry, 8 Prescription Books, . 12 Dictionaries, 8 Skin Diseases, • n Eye Diseases, 8 Surgery, . n Electricity, . 9 Throat, • J4 Gynaecology, 10 Urine and Urinary Organs, 14 Hygiene, Q Venereal Diseases, *4 Medical Jurisprudence, P Medical Briefs. A Neiu Miscellaneous, 10 Series, i"i Obstetrics. . 10 New Manuals, 16 PUBLISHED BY P. BLAKISTON, SON & CO., Medical Booksellers, Importers and Publishers. LARGE STOCK OF ALL STUDENTS' BOOKS, AT THE LOWEST PRICES. 1012 Walnut Street, Philadelphia. *#* For sale by all Booksellers, or any book will be sent by mail, postpaid, upon receipt of price. Catalogues of books on all branches of Medicine, Dentistry, Pharmacy, etc., supplied upon application. PQUIZ-COMPENDS? A MEW SERIES OF COMPENDS FOR STUDENTS. For Use in the Quiz Class and when Preparing for Examinations. Price of Each, Bound in Cloth, $1.00. Interleaved, $1.25. Based on the most popular text-books, and on the lec- tures of prominent professors, they form a most complete, practical and exhaustive set of manuals, containing infor- mation nowhere else collected in such a condensed, practical shape. Thoroughly up to the times in every respect, containing many new prescriptions and formulae, and over two hundred and thirty illustrations, many of which have been drawn and engraved specially for this series. The authors have had large experience as quiz- masters and attaches of colleges, with exceptional oppor- tunities for noting the most recent advances and methods. The arrangement of the subjects, illustrations, types, etc., are all of the most improved form, and the size of the books is such that they may be easily carried in the pocket. 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Interleaved for Notes, $1.25. 4 THE T QUIZ-COMPENDS ?. No. 5. OBSTETRICS. Third Edition. A Compend of Obstetrics. For Physicians and Students. By Henry G. Landis, m.d., Professor of Obstetrics and Diseases of Women, in Starling Medical College, Columbus. Third Revised Ed. New Illustrations. " We have no doubt that many students will find in it a most valuable aid in preparing for examination."—The American Jour- nal of Obstetrics. " It is complete, accurate and scientific. The very best book of its kind I have seen."—J. S. Knox, M.D., Lecturer on Obstetrics, Rush Medical College, Chicago. No. 6. MATERIA MEDICA, THERAPEU- TICS AND PRESCRIPTION WRITING. Fourth Edition. A Compend on Materia Medica, Therapeutics and Prescription Writing, with especial reference to the Physiological Actions of Drugs. By Saml. O. L. Potter, m.a., m.d., Professor of Practice, Cooper Medical College, San Francisco, Late Surgeon U. S. Army. " I have examined the little volume carefully, and find it just such a book as I require in my private Quiz, and shall certainly re- commend it to my classes. Your Compends are all popular here in Washington."—John E. Brackett, M.D., Professor of Materia Medica and Therapeutics, Howard Medical College, Washington. " Part of a series of small but valuable text-books. . . . While the work is, owing to its therapeutic contents, more useful to the medical student, the pharmaceutical student may derive much use- ful information from it."—N. Y. Pharmaceutical Record. No. 7. CHEMISTRY. Revised Ed. A Compend of Chemistry. By G. MASON Ward, m.d., Demonstrator of Chemistry in Jefferson Medical Col- lege, Philadelphia. Including Table of Elements and various Analytical Tables. No. 8. DISEASES OP THE EYE AND REFRACTION. Compend on Diseases of the Eye and Refraction, in- cluding Treatment and Surgery. By L. 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With Lithographic Plates and Numerous Illus- trations. Sixth Edition. 8vo. Cloth, 6.00 Heath's Practical Anatomy. Sixth London Edition. 24 Col- ored Plates, and nearly 300 other Illustrations. Cloth, 5.00 CHEMISTRY. Bartley's Medical Chemistry. A text-book prepared specially for Medical, Pharmaceutical and Dental Students. With 40 Illustrations, Plate of Absorption Spectra and Glossary of Chemi- cal Terms. Cloth, 2.50 *** This book has been written especially for students and phy- sicians. It is practical and concise, dealing only with those parts of chemistry pertaining to medicine; no time being wasted in long descriptions of substances and theories of interest only to the advanced chemical student. Bloxam's Chemistry, Inorganic and Organic, with Experiments. Fifth Edition, nearly 300 Illustrations. Cloth, 3.75 ; Leather, 4.75 Richter's Inorganic Chemistry. A text-book for Students. Second American, from Fourth German Edition. Translated by Prof. Edgar F. Smith, ph.d. 89 Wood Engravings and Colored Plate of Spectra. Cloth, 2.00 Richter's Organic Chemistry, or Chemistry of the Carbon Compounds. Translated by Prof. Edgar F. Smith, ph.d. Illustrated. Cloth, 3.00; Leather, 3.50 Watt's (Fowne's) Chemistry. 13th Edition. 2 Volumes. Volume 1, Inorganic, 2.25; Volume 2, Organic, 2.25 *** These volumes are based on Fowne's Chemistry, being, in fact, the 13th edition of Fowne's, etc. 4E9~ See pages 2 to 5 for list of ? Quiz- Compends ? STUDENTS' TEXT-BOOKS AND MANUALS. Chemistry :— Continued. Trimble. Practical and Analytical Chemistry. A Course in Chemical Analysis, by Henry Trimble, Prof, of Analytical Chem- istry in the Phila. College of Pharmacy. Illustrated. Second Edition. 8vo. Cloth, 1.50 Wolff's Applied Medical Chemistry. By Lawrence Wolff, m.d., Demonstrator of Chemistry in Jefferson Medical College, Philadelphia. Cloth, 1.50 CHILDREN. Goodhart and Starr. The Diseases of Children. A Manual for Students and Physicians. By J. F. Goodhart, m.d., Physi- cian to the Evelina Hospital for Children; Assistant Physician to Guy's Hospital, London. American Edition, Revised and Edited by Louis Starr, m.d., Clinical Professor of Diseases of Children in the Hospital of the University of Pennsylvania; Physician to the Children's Hospital, Philadelphia. Containing many new Prescriptions, a List of over 50 Formulae, conforming to the U. S. Pharmacopoeia, and Directions for making Arti- ficial Human Milk, for the Artificial Digestion of Milk, etc. Just Ready. Demi-Octavo. 738 Pages. Cloth, 3.00; Leather, 3.50 The New York Medical Record says :—"As it is said of some men, so it might be said of some books, that they are ' born to greatness.' This new volume has, we believe, a mission, particu- larly in the hands of the younger members of the profession. In these days of prolixity in medical literature, it is refreshing to meet with an author who knows both what to say, and when he has said it. 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Price of Each Book, $1.00. No. i. POST-MORTEM EXAMINATIONS. With Especial Reference to Medico-Legal Practice. By Prof. Rudolph Virchow, of Berlin Charite Hos- pital, author of Cellular Pathology; Translated by T. P. Smith, m.d., Member of the Royal College of Sur- geons of England. 2d American, from the 4th German Edition. With new Plates. Illustrated by Four Lith- ographs. " We are informed in precise and exact terms how a post-mortem examination should be made, both with regard to the plan to be pursued, and the manner of making the several cuts into the various organs and tissues. The method of recording the results of the investigation is clearly indicated by the addition of the detailed account of the examination of four cases; and the value of the ob- jective evidence is accurately stated in the form of the inferences drawn concerning the manner and cause of death."—American Journal of Medical Sciences. No. 2. MANUAL OF VENEREAL DISEASES. A Concise Description of those Affections and of their Treatment, including a list of Sixty-seven Prescrip- tions for Vapor Bath, Gargles, Injections, Lotions, Mixtures, Ointments, Paste, Pills, Powders, Solutions and Suppositories. By Berkeley Hill, m.d., Pro fessor of Clinical Surgery in University College; Sur- geon to University College and Lock Hospitals; and Arthur Cooper, m.d., formerly House Surgeon, Lock Hospital, London. 4th Edition, Revised and Enlarged. " I have examined it with care, and find it to be a practical and useful compendium of knowledge on the subjects discussed, well adapted to the use of medical students and those physicians in general practice who have occasional need to consult a work of this kind."—James Neven Hyde, m.d. , Professor ofSkin and Venereal Diseases, Rush Medical College, Chicago. No. 3. MEDICAL ELECTRICITY. A Com- pend of Electricity and its Medical and Surgical Uses. By Chas. F. Mason, m.d., Ass't Surg. U. S. Army'; with an introduction by Charles H. May, m.d., Instructor in Ophthalmology, New York Polyclinic. Illustrated. Just Ready. OTHER VOLUMES IN PREPARATION. Price of Each Book, bound in Cloth, $1.00. The latest, cheapest, most compact and practical series of text- books published. May be used by students of any College. A New Series of Manuals FOR Medical Students. Price of each' Book, Cloth, $3.00 ; Leather, $3.50. PRACTICAL SURGERY. By Wm. J. Walsham, m.d., Asst. Surg, to, and Dem. of Surgery in, St. Bartholomew's Hospital. 256 Illustrations. DISEASES OF WOMEN. By Dr. F. Winckel, Prof. Royal University of Munich. The Translation Edited by Theophi- lus Parvin, m.d., Prof, of Obstetrics and Dis. of Women and Children, Jefferson Medical College, Phila. 117 Engravings. PHYSIOLOGY. By Gerald F. Yeo, m.d. Prof, of Physiology King's College, London. 2d Edition, revised. 301 Illus. MATERIA MEDICA, PHARMACY AND THERAPEU- TICS, including the Physiological Action of Drugs, Special Thera., Official and Extemporaneous Phar., with Tables, For- mula;, Notes on Temperature, Clinical Thermometer, Poisons, Urinary Exam, and Patent Meds. Over 600 prescriptions and formulae. By S. O. L. Potter, m.d., Prof, of Practice of Medi- cine, Cooper Coll., San Francisco, late A. A. Surg. U. S. A. MIDWIFERY. By A. L. Galabin, m.d., Lecturer on Midwifery and Dis. of Women, Guy's Hospital, London. 227 Illustrations. CHILDREN. By J. F. Goodhart, m.d., Phys. to the Evelina Hospital for Children, London. Amer. Ed. Edited by Louis Starr, m.d., Clin. Prof, of Dis. of Children in the Hospital of the Univ. of Penn.; Phys. to the Children's Hospital, Phila. 50 Formulas, and Directions for preparing Artificial Human Milk, for the Artificial Digestion of Milk, etc. PRACTICAL THERAPEUTICS, With an Index of Diseases. By Ed. John Waring, m.d. 4th Edition. Rewritten and Revised. Edited by D. W. 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