NATIONAL LIBRARY OF MEDICINE NLfl DDDflSfiSM a ARMY MEDICAL LIBRARY WASHINGTON Founded 1836 Section. Number Fobm 113c, W. D.. S. G. O. > r o 3—10543 (Revised June 13. 1936) ;:V NLM000858548 HUGHES' COMPEND OF PRACTICE. PHYSICIANS' EDITION. 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 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}£ x $7/i 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, undated and monthly. Prices range from 75 cents to $3. Complete circular will be sent you upon application. P. Blakiston, Son & Co., Medical Publishers and Booksellers, 1012 Walnut Street, Philadelphia. A COMPEND PRACTICE OF MEDICINE. DAN'L- E. HUGHES, M. D., ».-■« LATE DEMONSTRATOR OF CLINICAL MEDICINE IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA; FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, ETC. PHYSICIANS' EDITIOrl ' THOROUGHLY REVISED AND ENLARGED. BASED ON THE FOURTH REVISION OF THE QUIZ-COMPEND EDITION, Y COMPLETE SECTION ON SKIN DISEASES. PHILADELPHIA : P. BLAKISTON, SON & CO., No. 1012 Walnut Street. 1889. W 6 Copyright, 1889, by P. Blakiston, Son & Co. PRESS OF WM. F. FtLl * CO., 1220 24 SANSOM ST., PHILA. TO HIS ESTEEMED FRIEND AND TEACHER, J. M. DA COSTA, M.D., Professor of the Practice of Medicine in the Jefferson Medical College, THIS WORK IS RESPECTFULLY DEDICATED BY THE AUTHOR. PREFACE TO THE PHYSICIANS' EDITION. The favor with which the "Compends of the Practice of Medicine," as published in the Quiz-Compend series, have been received, together with the knowledge that many practitioners have made use of them, suggested the advisability of preparing an edition especially for Physi- cians. To that end the Compends have been thoroughly revised and enlarged, by the incorporation of the more recent improvements in practice and the addition of a very complete section upon Diseases of the Skin, which, with the addition of a complete index, and its publi- cation in one volume, renders it much more convenient for reference. The exceptional character of the advantages afforded the Author for clinical work, as Demonstrator of Clinical Medicine in the Jeffer- son Medical College, and also as Assistant-in-charge of the Medical Dispensary of the College Hospital for a number of years, together with his system of notes employed in the Quiz-room during the past five years, have formed the basis of this Compend, which may there- fore be regarded as a full set of notes upon the Practice of Medicine. Free reference has been made to the latest writings and teachings of Professors Da Costa, Bartholow, Pepper, Flint, Loomis, Reynolds, Duhring, Fred. T. Roberts and others, to whom acknowledgment is here made. DANIEL E. HUGHES. PREFACE TO FOURTH EDITION. The rapid sale of the previous editions of this book has encouraged the author to make a very complete revision for the fourth edition. This has necessitated the rewriting of many sections and a slight enlargement of the work, so as to include all new methods and dis- coveries in Diagnosis, Pathology and Treatment. Every effort has been made to keep it as compact as is compatible with clearness, and to make it a thorough guide to the practice of medicine. D. E. H. CONTENTS. PAGE INTRODUCTION,................................ 9 FEVERS,..................................... I4 . . . 16 Continued,.......................... Periodical,........................... Eruptive,.............................. DISEASES OF THE MOUTH,......................... S2 DISEASES OF THE STOMACH,....................... & DISEASES OF THE INTESTINAL CANAL,.................. 72 INTESTINAL PARASITES,........................... 98 DISEASES OF THE PERITONEUM,......................T°2 DISEASES OF THE BILIARY PASSAGES...................io7 DISEASES OF THE LIVER,.........................."° DISEASES OF THE KIDNEYS,........................Il8 ACUTE GENERAL DISEASES,.........................'43 DISEASES OF THE RESPIRATORY SYSTEM,................i74 DISEASES OF THE NASAL PASSAGES,...................'93 DISEASES OF THE PHARYNX,........................i&8 DISEASES OF THE LARYNX,.........................203 DISEASES OF THE BRONCHIAL TUBES,..................216 DISEASES OF THE LUNGS,..........................238 DISEASES OF THE PLEURA,.........................261 DISEASES OF THE CIRCULATORY SYSTEM,................268 DISEASES OF THE NERVOUS SYSTEM,...................297 DISEASES OF THE SPINAL CORD,......................33' CEREBRO-SPINAL NEUROSES.........................34^ DISEASES OF THE NERVES,.........................357 DISEASES OF THE BLOOD,..........................362 DISEASES OF THE SKIN,..........................-37' INDEX,.....................................449 viii NEW EDITIONS. BLAKISTON'S ? QUIZ-COMPENDS ? For the Use of Students and Physicians. Price of each, Cloth, $1.00. Interleaved for taking Notes, $1.25. flQT* These Compends are based on the most popular text-books, and the lectures of prominent professors. The Authors have had large experience as Quiz-Masters and attaches of colleges, and are well acquainted with the wants of students. They can be used by students of any college. SPECIAL NOTICE. These Compends may be obtained through any Book- seller, Wholesale Druggist or Dental Depot, or upon receipt of the price, we will send postpaid. In ordering, always specify " Blakiston's ? Quiz-Compends ? " LIST OF VOLUMES. No. i. HUMAN ANATOMY. Based on " Gray." Fourth Revised and En- larged Edition. Including Visceral Anatomy, formerly published separately. 117 Illustrations. By S. O. L. Potter, m.d., Prof, of the Practice of Medicine, Cooper Medical College, San Francisco, late A. A. Surg. U. S. Army. Index. No. 2. PRACTICE OF MEDICINE. Parti. Third Edition. Revised and Enlarged. By Dan'l E. Hughes, m.d., Demonstrator of Clinical Medicine, Jefferson College, Philadelphia. No. 3. PRACTICE OF MEDICINE. Part II. Third Edition. Revised and Enlarged. Same author as No. 2. No. 4. PHYSIOLOGY. Fourth Edition, with Illustrations and a table of Physio- logical Constants. Enlarged and Revised. By A. P. Brubaker, m.d., Professor of Physiology and General Pathology in the Pennsylvania College of Dental Sur- gery ; Demonstrator of Physiology, Jefferson Medical College, Philad'a. Index. No. 5. OBSTETRICS. Fourth Edition. Enlarged. By Henry G. Landis, m.d., Professor of Obstetrics and Diseases of Women and Children, Starling Medical College, Columbus, Ohio. Illustrated. Index. No. 6. MATERIA MEDICA, THERAPEUTICS AND PRESCRIP- TION WRITING. Fifth Revised Edition. By S. O. L. POTTER, M.D., Prof. of Practice, Cooper Med. Coll., San Francisco; late A. A. Surgeon, U. S. Army. No. 7. GYNAECOLOGY. A Compend of Diseases of Women. By Henry Morris, m.d., Demonstrator of Obstetrics, Jefferson Medical College, Philad'a. No. 8. DISEASES OF THE EYE, AND REFRACTION, Second Edition, including Treatment and Surgery. By L. Webster Fox, m.d., Chief Clinical Assistant, Ophthalmological Department, Jefferson Medical College Hospital, and George M. Gould, m.d. With 39 Formulae and 71 Illustrations. Index. No. 9. SURGERY. Third Edition. Enlarged. By Orville Horwitz, b.s., m.d., Demonstrator of Anatomy, Jefferson College, Chief of the Out-Patient Sur- gical Department, Jefferson College Hospital, late Resident Physician Pennsyl- vania Hospital, Philadelphia. With Formulae and 90 Illustrations. Index. No. 10. CHEMISTRY. Inorganic and Organic. A new book prepared espe- cially for Medical and Dental Students. By Henry Leffmann, M.d., Professor of Chemistry in Pennsylvania College of Dental Surgery, and in the Woman's Medical College, Philadelphia. Index. No. n. PHARMACY. Second Edition. Based upon Prof. Remington's Text- book of Pharmacy. By F. E. Stewart, M.D., PH.g., Quiz Master in Pharmacy and Chemistry, Philadelphia College of Pharmacy; Lecturer at the^Medico- Chirurgical College, and Woman's Medical College, Philadelphia. NEW EDITIONS. These books were originally prepared with great care, but with each new edition revisions and additions have been made, sections rewritten and rearranged, and the books greatly improved. They have become the standard compends, because both the authors and the publishers have done all that time, trouble, experience and outlay could accomplish towards making them perfect. B®~ Send for our special descriptive circular of the ? Quiz-Compends? Price of each, Cloth, $1.00. Interleaved for Taking Notes, $1.25. BLAKISTON'S ? QUIZ-COMPENDS ? The following recommendations, which are but a few of those we have received, show the high value set upon these books by Medical Journals and Teachers :— From The Cincinnati Lancet and Clinic. " For the student desiring to review the lectures upon any subject, they are convenient, brief and much more legible than notes taken in the Lecture room."' From The Canadian Practitioner, Toronto. " Nos. 6 and 9 are excellent little compilations from the standard authorities on the subjects, and, owing to their very convenient shape and size, constitute admirable vade mecums and remembrancers for students." From James M. French, M. D., late Assistant to Chair 0/ Practice, now Lecturer on Morbid Anatomy and Pathology, Medical College of Ohio, Cincinnati. " With carefully prepared compends like these, it seems to me, the student could entirely do away with the customary taking of notes, which I hold is, at the best, of very doubtful ad- vantage. Let the student modify the opinions of the author to agree with those of his instructor, or underline the parts which agree while the lecture is fresh in his memory, and he will find it more profitable than writing during a lecture." From The Medical Register, Philadelphia. " They undoubtedly satisfy a demand of the student, and we can understand how they can be a practical aid to him immediately prior to his examination, and a useful adjunct to his quiz exercises." From The, Dental Cosmos, Philadelphia. " These are good books of their class, well arranged and well condensed, the essentials of each subject appearing to have been kept well in view." From The College and Clinical Record, Philadelphia. " These little books may be commended if we can judge of the series by this (Potter"s Anatomy) specimen volume." * * * "An excellent and popular series." From The Canada Lancet. " Some are utterly opposed to all compends, as tending to superficiality and cramming; and while this remains true to some extent, yet the fact remains, that much may be gleaned" from small and convenient pocket companions, such as the compends before us." * * * "Very well adapted for the purpose intended." From The Southern Clinic. " We know of no series of books issued by any house that so fully meets our approval as these ? Quiz-Compends? They are well arranged, full and concise, and are really the best line of text-books that could be found for either student or practitioner." *** A complete circular of these books will be sent, free, upon applica- tion. They are for sale by all booksellers. Purchasers should be careful to get latest editions, and should specify, in ordering, " Blakiston's Com- pends." Each Book is Bound in Dark Brown Cloth. Price $1.00; Interleaved, I1.25. COMPEND OF THE PRACTICE OF MEDICINE. INTRODUCTION. The Principles of Medicine constitute what may be termed Medical Science. The Practice of Medicine is the exercise of medical art, and embraces all that pertains to the knowledge of, prevention and cure of, the diseases which the physician is called upon to treat. Disease may be defined as a deviation or alteration in the func- tions, properties or structure of some tissue or organ, whereby its office is no longer performed in accordance with the natural standard: Organic disease, when associated with an organic change in the af- fected part; Functional disease, when the phenomena are indepen- dent of any apparent structural lesion. The study of disease, whether organic or functional in character, is termed Pathology. Pathology explains the origin, causes, clinical history and nature of the various morbid conditions to which the economy is liable. The study of individual diseases constitutes Special Pathology; while the study of the morbid conditions common to a greater or less number of diseases, constitutes General Pathology. Nomenclature, or the naming of diseases, is a subdivision of gen- eral pathology. The value of nomenclature as applied to disease is i 9 10 PRACTICE OF MEDICINE. that the name chosen shall express the morbid condition involved, as well as its location. If the morbid condition be an inflammation, the suffix His is added to the anatomical name of the part affected; thus, if the disease be an inflammation of the peritoneum, it is named peritonitis. If the morbid condition is catarrhal, such as a transudation or flux, the liquid escaping upon a mucous surface, the suffix rhcea is used; thus, a catarrhal inflammation of the intestinal tract is termed diar- rhoea and enterorhoea. If the morbid condition be a flow of blood or hemorrhage from a mucous surface, the suffix rhagia is used ; thus, a hemorrhage from the small intestines is termed enterorhagia. If the morbid condition be pain without inflammation, the suffix algia is used. The various forms of neuralgias being an example ; thus, neuralgia of the stomach is termed gastralgia. If the morbid condition be in the blood, the suffix cemia is used. Thus, Ancemia is impoverishment of the blood ; Urcemia, the morbid accumulation of urea in the blood; Septiccemia, putrid infection of the blood; Pycemia, purulent infection of the blood. If the morbid condition is in the urine, the ending uria is used to indicate it. A'lbumi7i.uria, when albumin in the urine ; Hcematuria, when blood in the urine ; Oxaluria, when oxalates occur in the urine. If the morbid condition be a dropsical affection, the prefix hydro is added to the part affected. Thus, a dropsical accumulation in the peritoneum is termed hydro-peritoneum. If the morbid condition be that of air in an unnatural part, the prefix pneumo to the name of the part is used, as in pneumopericar- dium. If the morbid condition be an inflammation of the membrane investing the part inflamed, the prefix peri is made use of. Thus, for an inflammation of the investing membrane of the kidney the term is perinephritis. Inflammation of the connective tissue surrounding an organ is designated by the prefix para. Thus, parametritis for inflammation of the connective tissue about the womb. A termination in oma signifies a tumor, as in sarcoma or carcinoma. The suffix pathy is used to designate a morbid condition of a part, without indicating its particular character, an example being the use of the term encephalopathy. INTRODUCTION. 11 Morbid Anatomy is the study of the changes in the tissues and fluids of the body appreciable to the naked eye or with the aid of the microscope. Histology is the study of the minute anatomy of the tissues and fluids of the body with the microscope. Pathogenesis is the study of the origin and development of pathological processes. Lesions are appreciable anatomical changes. Etiology is that subdivision of general pathology which treats of the causes of disease. The knowledge of the cause of any morbid action is of value in the prevention, management and removal of disease. The Causes of disease may be divided into internal, external, ordinary, specific, primary, secondary, predisposing and exciting. Examples of internal or intrinsic causes are those having their origin in the mind, such as prolonged mental application, intense or long-continued emotional excitement, long-continued mental de- pression and the possession of and concentration upon a predominant idea. Other examples are the accumulation of certain products in the blood, such as urea, uric or lactic acid. External or extrinsic causes are such as infectious miasms, viruses, poisons, wounds and injuries. An ordinary cause is one to which all are more or less exposed; to wit, atmospherical changes. Specific or special causes are those producing a distinct and spe- cific disease, such as the special cause of typhoid fever, yellow fever, smallpox and cholera. A contagious disease is one due to a special cause, whose causative agent is a specific poison that, introduced into the body of another, will give rise to the same disease. An infectious disease is also due to a special cause that under certain conditions is capable of unlimited increase or multiplication. An infectious disease may or may not be contagious. An example of a primary cause is any external traumatic cause. A secondary cause is well seen in the secondary pericarditis result- ing from an accumulation of urea in the blood. The retention of the urea in the blood being due to a diseased kidney. A predisposition to disease is a special liability or susceptibility to its occurrence, and may be either inherited or acquired. 12 PRACTICE OF MEDICINE. Inherited or constitutional predisposition to certain diseases is also termed Diathesis; an example is in the offspring of phthisical pa- rents, who are said to be of a phthisical diathesis. Acquired predisposition is such as arises from— I. Habits, to wit: Strain upon the nervous system resulting in nervous diseases. II. Age, to wit: Children are very liable to catarrhal disorders. Young adults, to fevers and perverted sexual disorders. Middle age, to heart, kidney and digestive disorders and cancer. Old age, to degeneration of the heart and vessels. III. Occupation, to wit: Miners, weavers and cutlers, lung dis- eases. IV. Sex, to wit: Women, emotional nervous diseases. Men, as more exposed, rheumatism and pneumonia. V. Race, to wit: Negro, phthisis and scrofula; exempt from malaria. Exciting causes are those giving rise to morbid conditions in those already predisposed to certain diseases, but lacking the action which determines their occurrence; to wit: Persons predisposed to acute rheumatism, on being exposed to certain atmospheric changes have an attack; fear has produced chorea; anger has caused jaundice; worry has produced cardiac troubles. The Clinical History of disease includes all the symptoms and signs which may occur from the period of incubation until its final termination. Symptoms and Signs are such alterations in the healthy func- tions as give evidence of the existence of a diseased condition or per- verted function, and may be either objective or subjective. Objective, when evident to the senses of the observer, such as redness or swell- ing. Subjective, when felt by the patient, such as pain or numbness. The Period of Incubation is that interval between the entrance of the poison into the system and its manifestation, and seldom pre- sents recognizable symptoms. The Prodromes are the earliest recognizable symptoms ; as the rigors or chills during the invasion of fever, and the various aura pre- ceding" an epileptic fit. An acute disease is one in which the invasion is sudden and rapid, and as a rule severe ; when the symptoms develop less rapidly and INTRODUCTION. 13 are less intense the disease is said to be sub-acute; when gradual or slow in development, duration and intensity the disease is said to be chronic. It must be borne in mind, however, that there may be disturbed action in every intermediate degree between these extremes. Pathognomonic is the term applied to such symptoms as belong to one particular disease, and are therefore characteristic of it, to wit: the rusty sputum of pneumonia. Physical signs are, strictly speaking, objective symptoms. The Termination of a diseased action may occur in one of three ways, to wit: Cure, Secondary Processes, or in Death. Cure may occur by— I. Lysis, or slow return to health. II. Crisis, abrupt termination, usually with a critical discharge, III. Metastasis, or changing from one location to another. Secondary processes is when the diseased action is substituted by a new morbid process, to wit: Rheumatism followed by endocarditis ; apoplexy by cerebral softening. By Death is meant a complete cessation of tissue change occurring by I. Asthenia, or an ever increasing debility, to wit: phthisis, cancer, Bright's disease. II. Ancemia, or insufficient quantity or quality of blood. III. Apncea, or non-aeration of blood, to wit: acute lung dis- eases, or croup. IV. Coma, death beginning at the brain, to wit: uraemia, narcotic poisoning, cerebral hemorrhage. Diagnosis of disease, or the discrimination of diseases, implies a complete, exact and comprehensive knowledge of the case under consideration, as regards the origin, seat, extent and nature of all its morbid conditions. A direct diagnosis is made when the morbid condition is revealed by a combination of clinical phenomena, or some one or more pathognomonic symptoms. A differential diagnosis is the result when the diseases resembling each other are called to mind and eliminated from each other. A diagnosis by exclusion is by proving the absence of all diseases which might give rise to the symptoms observed, except one, the pres- ence of which is not actually indicated by any positive symptoms. Prognosis of disease is the ability or knowledge to foretell the 14 PRACTICE OF MEDICINE. most probable result of the condition present, and involves an amount of tact or knowledge only acquired by prolonged clinical experience. Treatment. The ultimate and most important object of the study of medicine, from a practical point of view, is to learn how to cure, relieve, ox prevent disease, and it must be borne in mind that this does not consist solely in the administration of drugs, but requires strict and faithful attention to diet and hygiene. When the object is to prevent disease, such as smallpox by vaccina- tion, it is called Prophylactic or Preventive treatment. When disease is to be broken up, although already begun, such as aborting the chill of malaria, it is called the Abortive treatment. When the disease is allowed to run its natural course without attempting its removal, but being constantly on the alert for obstacles to its successful issue, such as the generally adopted plan of treating continued fevers, it is called Expectant treatment. When the disease is incurable, and removal of marked suffering is the cause, it is called Palliative treatment. When marked weakness and prostration are to be overcome, it is called Restorative treatment. FEVERS. Fever is a condition in which there are present the phenomena of rise of temperature, quickened circulation, marked tissue change and disordered secretion. The primary cause of the fever phenomena is a disorder of the sympathetic nervous system giving rise to disturbances of the vaso- motor filaments. Rise of temperature is the preeminent feature of all fevers, and can only be positively determined by the use of the clinical ther- mometer. The term feverishness is used when the temperature ranges from 990 to 100° Fahr.; slight fever \i ioo° or ioi°; moderate, 1020 or 1030; high if 1040 or 1050; and intense if it exceed the latter. Quickened circulation is the rule in fevers, the frequency usually maintaining a fair ratio with the increase of the temperature. A rise of one degree Fahr. is usually attended with an increase of eight to ten beats of the pulse per minute. FEVERS. 15 The following table gives a fair comparison between temperature and pulse :— A temperature of 980 F. corresponds to a pulse of 60 99° F. ioo0 F. 1010 F. 1020 F. 103° F. 1040 F. 1050 F. 1060 F. 70 80 90 100 no 120 130 140 The tissue waste is marked in proportion to the severity and dura- tion of the febrile phenomena, being slight or nil in febricula, and excessive in typhoid fever. The disordered secretions are manifested by the deficiency in the salivary, gastric, intestinal and nephritic secretions, the tongue being furred, the mouth clammy, and there occurring anorexia, thirst, con- stipation, and scanty, high-colored, acid urine. An Idiopathic or Essential fever is one in which no local affec- tion causes the fever phenomena, although lesions may arise during its progress. A Symptomatic or Secondary fever is one dependent upon an acute inflammation. GENERAL TREATMENT OF FEVERS. 1. Reduce the temperature. The cold bath or cold pack will do this most decidedly, but entails much labor and is not altogether free from danger, and so its use is advised only in severe cases. Cool sponging is of decided advantage. Qicinina, in gr. xx doses repeated, is usually reliable. Antipyrine, gr. xx repeated and antifebrin gr. x-xv repeated, are also recommended. 2. Lessen the circulation. If the pulse be full, strong and rapid, use aconitum. If the circulation be weak, stimulants with digitalis or caffeina, are indicated. 3. Attend to the secretions. Remove the waste of the tissues by diuretics, diaphoretics, and, if particularly indicated, laxatives. It is better for every fever that the skin should be moist, than that it should be harsh and dry. It is better that the urine should be abundant, than that it should be scanty and thick with tissue waste. Watch the 16 PRACTICE OF MEDICINE. stools that you may judge whether the food, be it solid or liquid, is be- ing digested. The free use of water is beneficial in promoting the various secretions. 4. Nourish the patient. " Don't starve a fever." Administer milk, beef-tea, and other light nutritious food, in small quantities, but at frequent intervals. 5. Watch the nursing. Much of the success in the management of fever patients can be attributed to good sensible nursing. Through it are secured the five important essentials of every sick room ; to wit: cleanliness, cheerfulness, regularity, ventilation and light. CONTINUED FEVERS. All continued fevers are characterized by a steady progress of the febrile movement, without either a too decided rise or fall in the tem- perature to modify the impression of a continuous action. SIMPLE CONTINUED FEVER. Synonyms. Irritative fever; febricula ; ephemeral fever; synocha. Definition. A continued fever, of short duration, mild in charac- ter, not the result of a specific poison, rarely fatal, but when death does occur, presenting no characteristic lesion. Causes. Fatigue, mental and physical; exposure to the sun, great heat or cold; excesses in eating and drinking ; excitement and violent emotion. Most common in childhood. It is not a miasmatic fever, neither is it contagious. Symptoms. Onset sudden with an abrupt feeling of lassitude, followed by a decided chill or chilliness, a sudden and rapid rise of temperature, quick tense pulse, headache, dry skin, great thirst, coated tongue, costive bowels, and scanty high-colored uri7ie. Cases due to errors in diet are accompanied by nausea and vomiting. Attacks occurring during childhood, due to excitement, fright or the emotions, may be associated with convulsions. The temperature may within an hour or two reach 1030 F., or more, when slight delirium may occur. The affection has no constant or characteristic eruption. Duration. From twenty-four hours to six or seven days. Termination. Usually within a few hours, to a day or two, the temperature rapidly falls to the norm, an instance of crisis; or it may continue for several days gradually falling to the norm (lysis). Herpes FEVERS. 17 about the lips and nostrils are often observed at the close of an attack. Convalescence is rapid. Diagnosis. Unless the fever can be attributed to some one of the causes that give rise to it, a doubt as to its character may exist for the first twenty-four hours, after which time it can hardly be mistaken for any other disease. The following is a familiar instance of this affection. A child, apparently in the best of health, is at play, or, may be at school, suddenly complains of nausea and may vomit, the skin becoming hot, dry and flushed or soon covered with an erythematous rash, the pulse is quick and tense, there is headache, pains in the limb?, and great fretfulness or nervousness. The axillary tempera. ture may reach io2°-io4° F. The whole aspect is most alarming, when a laxative is administered, the surface sponged with a tepid lotion, sleep follows during which there may be free perspiration, and the following day the child is and continues perfectly well. Prognosis. Recovery, without sequelae, the rule. Treatment. Very little medicine. Rest in bed. A full dose of hydrargyri chloridum mite, or an enema, sponging the surface with cold or tepid water, and the administration of saline diaphoretics and diuretics. If there is great arterial excitement aconitum may be added. Light liquid diet is most agreeable. Cases in which the nervous symptoms are prominent do well on Fothergill's "fever mix- ture of the future," to wit:— R. Acid, hydrobrom.,...........fzss-j Syr. simplicis,.............fg ss-j Aquse,................f 3 ij—iij. M. SiG.—Every four hours. Quinina* sulphas in tonic doses during convalescence. CATARRHAL FEVER. Synonyms. Influenza; epidemic catarrhal fever; contagious catarrh. Definition. A continued fever, occurring generally as an epi- demic; due to a specific cause ; characterized by a catarrhal inflam- mation of the respiratory organs, and sometimes of the digestive ; always accompanied by nervous phenomena and a debility out of proportion to the intensity of the fever and the catarrhal processes. During the prevalence of an epidemic animals suffer more than man. Causes. A specific vegetable germ, uninfluenced by soil, climate 18 PRACTICE OF MEDICINE. or atmospheric changes. It is not contagious. One attack does not give immunity from another attack, but rather predisposes to it. Symptoms. The clinical history of this disease presents the greatest variations as regards intensity, from the most trifling indis- position in one, to an illness of the gravest kind, terminating in death, in another. The onset is sudden, with a chill followed by fever, the temperature reaching ioi° to 1030, a quick, compressible pulse, and severe shooting pains in the eyes, frontal sinuses, joints and muscles. The chill and fever are rapidly followed by chilliness along the spine, pain in the throat, hoarseness, deafness, coryza, sneezing, injected, zvatery eye, and a dry, irritative, laryngeal cough, sometimes becoming bronchial. The tongue is furred, there is anorexia, epigastric distress, nausea, vomiting, and oftentimes diarrhoea. In some epidemics the digestive symptoms are the most prominent, when dysentery may occur. The above symptoms are always associated with decided weakness and debility altogether out of proportion to the intensity of the fever and the catarrhal phenomena. Delirium is rare, but marked hebetude and cutaneous hyperesthesia are common. Duration. Four to seven days, with protracted convalescence. Relapses frequently occur. Complications. Lobar or catarrhal pneumonia frequently occur, which adds to the gravity of the attack. The cough may outlast the disease several weeks. Diagnosis. Isolated cases may be mistaken for a " bad cold." But when epidemic, the sudden onset, marked general catarrh and decided prostration should prevent error. Prognosis. Recovery is the rule when it occurs in the healthy and vigorous. Grave when the very young, very old, or those suffer- ing from organic disease, such as Bright's disease, fatty heart, or em- physema, are attacked. Treatment. No specific. Support the system and treat indica- tions. All measures, of whatever kind, that tend to depress the gen- eral nervous system, or the functional activity of the respiration, and especially the heart-power, are to be avoided. The catarrh, pains and cough are at least ameliorated by the following :— R . Pulvis ipecacuanhse et opii,.......gr. v Potassii nitrat.,............gr. v. Every three hours. FEVERS. 19 Or— R. Quininse sulph.,...........grs. ij-iv Morphinse sulph.,...........gr. _i Aquae lauro-cerasi,..........zj. M. Sig.—Every four hours. . The frequent inhalation of tincture benzoin comp., ss-j, in aqua: bul., Oj, relieves the naso-pharyngeal and bronchial catarrh. If the bronchial symptoms become troublesome, use— R. Ammonii muriat.,.....t.....grs. x Spts. frumenti,...........fzss Mist, glycyrrh. comp.,.........'^iss. M. p. r. n. Should Pneumonia occur, treat as an ordinary case, but never de- press. During convalescence administer strychnine sulph., gr. ^ four times daily. TYPHOID FEVER. Synonyms. Enteric fever ; gastric fever; nervous fever; entero- mesenteric fever ; abdominal typhus ; autumnal fever. Definition. An acute, self-limited, febrile affection, due to a special poison; characterized by insidious prodromes ; epistaxis ; dull headache followed by stupor and delirium ; red tongue, becoming dry, brown and cracked; abdominal tenderness, early diarrhoea and tympany ; a peculiar eruption upon the abdomen ; rapid prostration and slow convalescence; a constant lesion of Peyer's patches, the mesenteric glands and of the spleen. Causes. Predisposing and exciting. The chief predisposing causes are Age, to wit, young adults, be- tween eighteen and twenty-five years; rare after forty years. I have seen well-marked cases with typical symptoms at eighteen months and at five years of age; and Season, to wit, a dry and hot autumn. The exciting cause is a special typhoid germ, the bacillus typhosus. The poison usually results from the decomposition of the typhoid stools and the suptinn, although it has been claimed that the disorder may be generated under certain undetermined circumstances, de novo, from ordinary filth and decomposition. The atmosphere is never impregnated with the fever germ. The poison gains its entrance into the system by means of infected water, 20 PRACTICE OF MEDICINE. milk, ice, meat or other food. The germ is easily destroyed by thor- ough disinfection of the stools and sputum with heat, mercuric bichlo- ride or acidum carbolicum, but it is to be borne in mind that extreme cold will not destroy the typhoid germ. Pathological Anatomy. The specific anatomical lesions of typhoid fever are invariably present, and are so characteristic that an examination of the body after death will in any case make known the nature of the disease, even had the symptoms been unknown. These lesions consist in changes in the Peyerian patches and solitary glands, which may be divided into well-defined stages, as follows :— First Stage. Swelling from infiltration and excessive proliferation of their cellular elements; the surrounding mucous membrane is also infiltrated with cells. The Peyer's patches are thickened, hard- ened and elevated above the mucous membrane. The number of patches and glands involved is from three or four up to nearly the entire number. The above changes have been noted as early as the second day. Second Stage. Softening, sloughing and ulceration of the solitary and agminate glands constitutes this stage. Either of the processes going on in different glands at the same time. Not all the patches necessarily slough; in a certain number of them the morbid changes are arrested before softening. This stage constitutes the anatomical change of the second and third week. Fourth Stage. Cicatrization, or in rare cases perforation. The ulcer gradually diminishes in size, the surface becoming covered with a delicate layer of granulations, which is soon transformed into con- nective tissue and covered with epithelium, the resulting scar being slightly depressed. The gland-structure is never regenerated. The Mesenteric glands become infiltrated, enlarged and softened, but seldom ulcerate. The Spleen also enlarges and softens. There is besides, parenchy- matous degeneration ox granular changes in all the tissues of the body. Symptoms. Stage of Prodromes.—The onset is insidious, with a feeling of general malaise, vertigo, headache, disordered digestion, disturbed sleep, epistaxis, depression, and muscular weakness, fol- lowed by a chill or chilliness, the patient being unable to designate the day when the symptoms began. In rare instances the disease begins abruptly with a chill, followed by high fever; this is particu- larly the case in malarial districts. FEVERS. 21 First Week, dates from onset of the fever, when are present increas- ing temperature, frequent pulse, coated tongue, nausea, diarrhea, headache^ and upon the seventh day a few reddish spots resembling flea bites appear upon the abdomen, chest or back. Second Week, the foregoing symptoms are exaggerated ; fever con- tinuous, frequent and compressible pulse, tympanitic, tender abdomen, gurgling in the right iliac fosse, nocturnal delirium, severe and con- stant headache, often stupor, a short cough with distinct bronchial rales on auscultation, irregular muscular contractions [subsultus tendinum), sordes upon the teeth and lips, the diarrhea continuing. During this stage deafness develops, often increasing until complete, continu- ing into convalesence. Disturbances of vision are frequent in pro- nounced cases. Third Week. Fever changes from continuous to remittent; the evening exacerbations continue as high as the preceding week, and all the symptoms remain about the same until near the end of the week, when a marked amelioration begins. Fourth Week. The fever decidedly remits; almost normal in morning, the pulse becoming less frequent and more full, the tongue gradually becoming clean, the abdomen lessens in size, the diarrhoea ceases, the patient passing into a slow convalesence, greatly ema- ciated, which condition may continue for several weeks. Analysis of Symptoms. The temperature record of typhoid fever is a characteristic one. The fever on the morning of the first day may be stated at 98.50 F., evening 100.50 ; second morning 99.50, evening 101.50; third morning 100.50, evening 102.50 ; fourth morning 101.50, evening 103.50; fifth evening 104.50. From that time until end of the second week, the evening temperature ranges between 1030 and 1050, the morning temperature being a degree or more lower. Diarrhea is the principal intestinal symptom ; if absent, the lesion is slight. The stools are at first dark, but early in the second week they become fluid, offensive, ochre-yellow in color, resembling "pea soup," and may be streaked with blood. They number from three to fifteen in the twenty-four hours. Constipation occurs more frequently than is supposed. I have seen fifty cases with constipation within the past five years. Eruption is almost constant. Consists of from five to twenty small, rose-colored spots on the abdomen, chest or back, sometimes on the 22 PRACTICE OF MEDICINE. limbs, appearing in crops, lasting about five days, disappearing on pressure and at death. Returnifig with relapses. Eruption day from the seventh to the ninth. Rarely spots of a delicate blue tint—the " taches bleuatres" of French authors—are observed. Nervous symptoms are, pronounced headache, early and severe, dullness of intellect soon following, passing into drowsiness and stupor, with great prostration. Deafness pronounced. Sight impaired, in grave cases double vision. Delirium low and muttering, generally pleasant in character ; always present in marked cases. Coma vigil is a grave symptom, the patient lying perfectly quiet with eyes open, taking no heed to his surroundings. Muscular sympto7ns are developed late in the second or early in the third week, and consist of irregular contractions or subsultus ten- dinum, and are the result of great debility. The reverse of muscular contractions, to wit, perfectly motionless in bed, attempting no mus- cular effort of any kind, is a grave sign. Convalescence shows great debility, great anaemia and great nerv- ousness, often very protracted. It is during convalescence that great irritability of the heart, profuse night sweats and insomnia occur, and in woman loss of the hair. Complications. Lntestinal hetnorrhage is the most frequent and at times the most critical of any of the complications of typhoid fever. The hemorrhage may occur any time between the fourteenth and twentieth day ; a sudden decline of the temperature to the norm or below frequently precedes the passage of blood by stool. The hemorrhage is due to the erosion of a vessel during the ulcerative action. Perforation makes the case almost hopeless. Peritonitis without perforation adds to the gravity, but not necessarily fatal. Lobar pneu- monia, hypostatic congestion and bronchitis are frequent occurrences. Albuminuria may occur, as may phlegmasia dolens. Relapses are common. The symptoms all return abruptly; the duration is half the time of the original attack ; occur at the end of the fourth or beginning of the fifth week. Not so fatal as generally supposed. Abortive typhoid fever are cases of mild character, having many of the typical symptoms, running its course in about two week?. The so-called walking cases are often of this character. FEVERS. Diagnosis. An error that is constantly being made is that of confounding typhoid fever with the typhoid (depressing) symptoms or condition developing during the course of many acute diseases. The absence of the characteristic diarrhea, the peculiar eruption, and the typical temperature record, should prevent the error. Enteritis has intestinal disorders alone. Peritonitis, abdominal symptoms only, with constipation. Acute miliary tuberculosis often mistaken for typhoid fever, an error difficult to prevent at times. Meningitis lacks the intestinal symptoms and fever record. The so-called typho-malarial or malario-typhoid fever has many symptoms in common, but lacks the diarrhoea, eruption and tempera- ture record. Prognosis. A positive prognosis cannot be made. Favorable indications are constipation, slight diarrhoea, low temperature and moderate delirium. Unfavorable symptoms are obstinate and severe diarrhoea, early high temperature, marked nervous symptoms with coma vigil or stupor, albuminuria and repeated intestinal hemor- rhages. The prognosis is always more favorable in winter than in summer. The mortality in typhoid fever in private practice is about one death in twenty; in hospital practice it varies from one death in five to ten cases. Treatment. No specific. Chiefly symptomatic and expectant, with intelligent nursing, pure air, quiet sick chamber, and disinfecting the urine and the stools, with a nutritious liquid diet at intervals of every two or three hours. A word of caution, however, as to the quantity of food administered. The amount should be small, as the digestive capacity of the patient is greatly lessened by the febrile phenomena. Much harm results in typhoid fever from stuffing the patient. The following remedies have advocates, claiming that they modify the course of the disease; to wit: Hydrargyrum, iodum, acidum car- bolicum, mineral acids, argentum nilras, and ergota. A mild case of the disease will do well with acidum hydrochlori- cum dilutum, tt^x-xx, well diluted, every four hours, alternated with quinine sulphas, gr. ij. Cases with high temperature and costive bowels are sometimes wonderfully benefited by the following:— 24 PRACTICE OF MEDICINE. R . Hydrargyri chlor. mite,..........gr. % Pulv. ipecacuanha?,............gr. \ Pulv. opii,...............gr- \- Repeated every three or four hours, and qitinime sulphas, gr. ij, every four hours. The present so-called " specific treatment" of this disease consists in the administration every second evening, until four doses are taken, of hydrargyri chlor. mite, gr. vij-x, which seemingly lessens the frequency of the stools in the later stages of the attack, although slightly increasing them at the time. Also administering from the beginning of the attack— R. Tinct. iodi.,...............3 ij Acid, carbol. liq.,.............3J. M SiG.—One, two or three drops in ice water, every two or three hours, after food. To reduce the temperature, use either the cold bath, cold pack, and cold sponging, with quinine sulph., gr. xv-xx, repeated within an hour, or antipyrine, gr. xx, repeated pro re nata. Diarrhea should not be checked unless it exceeds three stools in twenty-four hours, when may be used— R . Bismuth subnit.,.............gr. xx Acid, carbol.,..............gtt. j Tinct. opii deodorat.,...........gtt. x-xv Mucil. acacise,.............^j Aquae,.................giij. M. SiG.—Every three or four hours. Or— R. Cupri sulph.,..............gr. y% Extracti opii,..............gr- X- ^. SiG.—In pill, every four hours. For Tympanites ; cold compresses or turpentine stupes to the abdo- men, or R. ol. terebinthine, gtt. x, morphine sulph., gr. ^, in emul- sion, every third hour, or tinct. nucis vomicis, gtt. x, p. r. n. Tympany with constipation is relieved by the use of olei terebinthine, gtt. x, olei ricini, gtt. xv, in emulsion every three or four hours. For Thirst; cooling drinks, in moderation, or pellets of ice slowly dissolved in the mouth. Headache; cold to the head, mustard to the neck, and foot baths ; if these fail to relieve, morphina or atrophia hypodermically. Delirium ; if from debility, increase the stimulants; other causes, use morphina. FEVERS. 25 Restlessness and coma vigil; chloral alone or with potassii bro- midum, or morphina. Debility ; food every two or three hours ; do not permit sleep to interfere with nourishment. Stimulants are indicated early ; the best guide being the heart's action ; an average amount would be % vj spts. vini gallici, per diem, or chloroformi, rnjj-v every hour or two, well diluted, or moschus, gr. x, repeated p. r. n. The bladder should be examined at each visit. Intestinal hemorrhage; at once morphina, gr. %, hypodermically, and ext. ergote fid., fsjj, repeated p. r n., or MonselTs solution, gtt. ij-iv, every two hours, or acidum tannicum,gx. ij-v, with pulv. opii el ipecacuanha, gr. iij every hour. Perforation and peritonitis ; at once morphina sulphas, gr. y^, hypo- dermically, followed with extractum opii, gr. j every hour, hot appli- cation to the abdomen and bold stimulation. TYPHUS FEVER. Synonyms. Contagious fever; ship fever ; jail fever. Definition. An acute febrile, epide?nic disease; highly contagious, and characterized by sudden invasion, profound depression of the vital powers, sickening odor, and a peculiar petechial eruption ; favorable cases terminating by crisis about the fourteenth day. No lesion. Cause. A special infecting germ, the character of which is un- known, but which is influenced by filth and overcrowding. Rarely seen in the United States. Pathology. No constant lesion. Blood dark and thin, with les- sened fibrin ; tissues dark, soft and flabby. Symptoms. Begins abruptly; f^z7/followed by violent fever; temperature within a few days reaching 104° to 1050 F.; a frequent, bounding pulse, soon becoming compressible ; severe headache, fol- lowed 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 case passes into a rapid convalesence. Complications. Pneumonia and swollen parotid glands are common. Diagnosis. From typhoid fever, the age, season, onset of the disease, character of the eruption, and the intestinal symptoms. 2 26 PRACTICE OF MEDICINE. Measles begin milder, with coryza and cough, and seldom have 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 fever is distinctly conta- gious, isolation is imperative, with immediate removal and disinfec- tion of the patient's excreta. All cases are benefited by small doses of the mineral acids alternat- ing with quinine sulphas. For high temperature, cold pack, cold bath, cold sponging, full doses of quinina or antipyrine. 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 constipation, 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 head- ache, vomiting, painful contractions of the muscles of the back of the neck, retraction of the head, hyperaesthesia, disorders of the special senses, delirium, stupor, coma, 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. Bad hygiene seems to favor the development of this affection, but can hardly be considered its cause. The disease seems to have a predilection for the young. Occurs- most frequently in the winter months. Not contagious. Pathological Anatomy. The extent of lesion present in a FEVERS. 27 given case depends upon the duration of the illness. In cases rapidly fatal, it is probable that the subject is overwhelmed by the poison ere the characteristic anatomical changes have time to develop. The changes in this disease are twofold, to wit: those due to the direct action of the infecting poison upon the blood, producing the group of symptoms constituting the fever; and those giving rise to the local inflammation, viz : Hyperemia of the membranes of the brain and spinal cord, followed by an exudation of lymph and an effusion of serum, resulting in pressure on the brain and cord. The inflammatory changes are more marked in the membranes at the base of the brain than elsewhere. 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 abruptly with a chill, excruciating head- ache, persistent nausea, vo7niting, vertigo, and an overwhelming sense of weakness. Within a few hours the muscles of the back 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. There is great restlessness, and the surface of the body becomes highly sensitive {hyperesthesia). Cramps in the mus- cles of the legs and elsewhere, and spasmodic twitchings of the lips and eyelids come and go, and finally co7ivulsions or delirium occur. Intolerance of light, and in some cases amaurosis, more or less deaf- ness, loss of sense of smell and taste soon following. The te7nperature 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, ox ameliorates and passes into a protracted conva- lescence. The Fulmina7it For77t. 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. Sequelae. Result from thickening of either the cerebral or spinal membranes; persistent headache, blindness or deafness, partial or complete ; epilepsy, or different forms of spinal palsies. Complications. Pneumonia; typhoid fever; pleuritis; intes- tinal catarrh, in infants. 28 PRACTICE OF MEDICINE. Diagnosis. Typhoid fever begins slowly, has a charactensti: temperature record, without so intense headache, muscular rigidity, vomiting, early delirium, ending in coma. Typhus fever has higher fever, is of longer duration, and has a peculiar measly eruption, is not attended with muscular rigidity and retraction, hyperaesthesia, 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. biflammation 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. There is no abortive plan of treatment for cerebro- spinal fever, nor can the antiphlogistic treatment of the inflammatory symptoms be advised. Like the infectious diseases in general, sus- taining measures are indicated in all but the most sthenic cases. Nutritious and easily assimilated food, such as milk, eggs, meat- juice and broths, should be given at regular intervals night and day. If food cannot be taken by the mouth, nutritious enemata should be substituted. The drug that holds the highest place in the treatment of this dis- ease is opium. The hypodermic use of morphina, gr. % to % every two or three hours; or extractum opii, gr. j every hour until stage of effusion in adults, when qui7iina in tonic doses, and potassii iodidum are indi- cated. Prof. DaCosta alternates potassii bromidum with opium, especially in children. Locally, warmth to the surface, with hot sponging along the spinal column and to the nape of the neck. The cautious use of cold com- presses to the head for headache may be useful in some cases. For scquele, potassii iodidui7i, a course of hydrargyrum, oleum morrhue, and flying blisters along the spinal column. FEVERS. 29 RELAPSING FEVER. Synonyms. Famine fever ; bilious typhoid fever. Definition. An epidemic, co/itagious, 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, vo77iiting, and lanci- nating pains in limbs and muscles, marked in the calf of leg; seco7id day, feeling o{ 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. Re77iittent 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. Expecia7it. Act on secretions ; nourish patient and meet urgent symptoms. For fever, antipyretic doses of quinina which, however, has no power to prevent the relapses; for pain, hypoder- mic injections of morphi7ia ; for nausea and vomiting, acidimi carboli- cum ox cerii oxalas; during remission, ferrum and quinina in tonic doses. 30 PRACTICE OF MEDICINE. 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; swamp fever. Definition. A paroxys77ial fever, the phenomena observing a regular succession ; characterized by a cold, a hot and a sweating stage, followed by an interval of complete inter/nission or apyrexia, varying in length, according to the variety of the attack. Cause. Malaria. Bacillus Malaria ? The period of incubation varies from a few days to weeks, months or even years, an auxiliary condition such as exposure to cold, over- exertion, excesses in eating and drinking, or great excitement often being necessary to give efficiency to the special cause. Either sex and all ages are susceptible to the poison. Pathological Anatomy. Blood dark, from the formation of pigment (Melanemia). 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, pre- sents irregularity of the characteristic phenomena. Symptoms. Each paroxysm has three stages, the cold, hot and sweating. Cold stage begins with pi-odromes, 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 ie77iperature, 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 thiist, dry, flushed, swollen skin FEVERS. 31 scanty urine and other phenomena of pyrexia, continuing from one to eight or ten hours. Sweating stage begins gradually, first appearing on the forehead, then spreading over the entire surface; the fever lesse7is, the tempera- ture rapidly falling to 99° or 980, pulse less full, headache lessens, and a general feeling of comfort exists, sleep often following; duration of the sweating from one to four hours, when the inter77iissio7i occurs, the patient apparently well, except for 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 sec- ondary 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 hypodermic injection of either 77iorphine sulph., gr. yi~xX, or pilocarpine hydrochloras, gr. y%, or chloroformi spts., f3J, by the stomach. Hot stage, cool drinks and cold sponging. Sweati7ig stage, when excessive, sponging with alumen and hot water. Interi7iission ; at once a brisk purgative, followed by ci7ichona in some form, the most efficient being quinina 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 re- < place 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, Quininas sulph.,......aa......gr. xlviij Acidi arsenio-i,........... gr. j 01. pip. nigr.,.............gtt. xv. M. Ft. pil. No. xxiv. Sig.—One pill after meals, continued for one month, at least. 32 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 7iineteenth to the twenty-first days. REMITTENT FEVER. Synonyms. Bilious fever; bilious remittent fever; marsh fever; typho-malarial fever ? Definition. A paroxys7nal 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 i° to 2°, coated, dry tongue, oppression at the epigastrium, slight head- ache, and pains throughout the body. Hot stage ; persistent vomiting, furred tongue, full pulse, rising to ioo or 120, flushed face, injected eye, violent headache, pains in limbs and loins, hurried respiration, the tenipe7-ature rising to 1040 F., or 1060. The bowels costive, stools tarry and offensive, and the surface becoming yellow. Deliriwn occurs when the temperature is very high. Sweating stage ; after six to twenty-four hours, the above symptoms abate, and slight sweating occurs ; the pulse, headache and vomiting subside, and the tentperature falls to ioo0 F., or 990. This is the re7nissio7i. After some two to eight or twelve hours, the symptoms of the hot stage return, generally minus 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 re7nit, and instead, becomes continuous, the symptoms resembling, if they are not identical with, the typhoid state, whence the term typho-77ialarial fever, or malario-typhoid fever. FEVERS. 33 Sequelae. The i/ialarial cachexia results when the poison has not been eliminated from the system. 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 inter7nission 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 apparently 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 such an 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 thchypo- dermic method or in a suppository. During the hot stage, cool spong- ing, 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,............^ ij Liq. ammon. acetat.,...........'jij. M. Every two hours. Purgation 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 3 34 PRACTICE OF MEDICINE. be of the intermittent or remittent form ; characterized by intense co7igestion 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 re77iittent fever; again, the first paroxys7n is rarely per- nicious, but appears as the ordinary malarial attack. The gastro-e7iteric variety has as distinctive features, intense 7iausea and vo77iiting, purging of thin discharges mixed with blood, te7iesi7ius, bur7ii7ig 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 C07na, slow, full pulse, the surface e'xthex flushed or livid. Cases may either resemble apoplexy—comatose variety, or acute meningitis— delirious variety. Duration same as the other forms. Hei/torrhagic 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: 7iausea, vo77iiting, 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 107° F. The attack begins with a chill, which is soon followed by fever of variable dura- FEVERS. 35 tion, when the body becomes cold, the axillary temperature falling to 900, 88° or even 850 F., a cold sweat covers the surface, the tongue is white, 77ioist 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 inte7ise thirst. The 77iind 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 he7iiorrhagic 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, an epidemic preva- lence, are the chief points of distinction. The cerebral variety may be mistaken for cerebral apoplexy, 77ie7i- 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 epidemic prevalence of the latter should be of material aid in determining the diagnosis. Prognosis. In all varieties the result is unfavorable, unless it can be controlled prior to the second paroxysm. Cases in which an inter77tission occurs are better controlled than where a remission follows. The mortality is one in eight from all plans 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 hypodermic injec- tion of morphina, gr. }£, at once. After reaction, quini7ie sulph., not less than gr. xl, repeated p. r. n.; administer by stomach, rectum, or better still, by hypodermic injection. Dr. Bartholow pronounces the fol- lowing one of the best formulae for the hypodermic use of quinina :— R. Quininse disulph.,.............gr. 1 Acid, sulph. dil.,.............rt^c Aquae font.,...............§j Acid, carbol. liq.,.............rt\v. M. The following formula, known as " Warburg's Tincture," has dur- ing the last few years gained considerable reputation in the various forms of malarial fevers :— 36 PRACTICE OF MEDICINE. R. Rad. rhei, P. aloe soc. and Rad. angelica officinalis, . . . . . . aa......f, iv Rad. helenii, Crocus Hispan., Sem. foeni- culi, and Cretne preparat., , . aa . . . o'J Rad. gentian, Rad. zedoar, P. cubeb, G. myrrh, G. camphor, and Boletus Lari- cis,.......aa........5 J Confect. damocratis,*.........3™ Quininse sulph.,..........3 1XXX1J Spt. vini rect.,............ Oxx Aquae purse,.............Oxij. Macerate in a water bath twelve hours, express and filter. Each half ounce contains quininae 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 a7n7>ionii 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 Confectio damocratis .•— Cinnamon...................................... xiv Gm. Myrrh......................................... xj Gm. White agaric, Spikenard, Ginger, Spanish saffron, Treacle, Mustard seed, Frankincense, and Chian turpentine..................aa................ x Gm. Camel's hay, Costus 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 mont, 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 arabic, 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. 37 For the algid variety warmth to the surface, hypodermic use of morphina and the free use of a77i7nonii carbonas and alcoholic stimu- lants. For the hemorrhagic variety, purgatives, 7iwrphina hypodermic- ally, and either acid, sulph. dil., acid, gallic, Mo7iselTs solution, or terebinthina, for the hemorrhages. The following is highly spoken of for hemorrhages :— R . Ext. ergote fid.,............g ss Acid, sulph. dil..............f ^ jss Acid, gallic,.............i^j Syr. zingib.,..............fgiij Aquae, q. s.,.......ad......fo»j- M. Sig. — Dessertspoonful every 4 hours, well diluted. After the paroxysms are controlled, a long course o( ferrum, 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 re7nission, 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 ; sto7/iach, 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 to 1060 F., high pulse, 38 PRACTICE OF MEDICINE. 90-100 beats, brillia7it eye, flushed countenance, coated tongue, irri- tability of the stomach, and severe neuralgic pains in the head, limbs, epigastrium, back and large joints. The patients are restless, anx- ious, with a feeling of general prostration. In severe attacks delirium is frequent. Albumin in the urine, and a peculiar and characteristic odor is emitted from the patient. Duration of the first stage from thirty-six hours to three or four days. Second stage, the remission, when the temperature declines to ioo0 or 101° F., and all the distressing symptoms abate or subside and, with some critical evacuation, convalescence occurs, or, more com- monly, after from a few hours to one to four days, the Third stage, the stage of collapse, or the period of secondary fever, 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 vo7nit and hei7iorrhages from other parts, feeble pulse, cold surface, irregular respiration, and death from ex- haustion, the mind remaining clear until the end. The above symptoms represent a sthenic case; other varieties are the algid, hei7iorrhagic 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 albumin 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 7nenthe pip., every two hours, alternated with liquor calcis and milk, each an ounce, or— R . Hydrargyri chlor. mite,..........gr. JL Morphinae sulph.,.............gr. f Every two hours until nausea controlled. FEVERS. 39 For the black vomit and hemorrhages, either liquor ferri subsul- phatis ox plumbi acetas. The pains, restlessness or delirium are best controlled by the hypodermic 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. Highly contagious, the contagion residing chiefly in the desqua- mated epidermis. Klebs' micrococci, the " monas scarlatinosum," may prove to be the poison. Incubatio7i short, one to seven days. Varieties. Scarlatina simplex, scarlatina anginosa and scarlati7ia maligna. Symptoms. A mild case is a very trival affection, but in its severest form there are few diseases more malignant. Onset sudden with a decided chill and vomiting (in infants, con- vulsions), pain in throat followed by high fever, soon reaching 1050; a rapid pulse, no to 140 being common. At the end of twenty-four hours a bright scarlet rash appears on the neck and chest, spreading 40 PRACTICE OF MEDICINE. over the entire body within a few hours; the eruption is not raised, there is no intervening healthy skin, and scattered irregularly are points of a darker hue. With the appearance of the eruption occurs burning heat of surface, bumi7ig in the throat and difficulty in deglu- tition, the throat on inspection presenting the appearance of a catar- rhal inflammation. Tongue at first furred, later, red, with prominent papillae—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 the addition of great inflamma- tion and swelling of the pharynx, 7iose, palate, to7isils and neighbor- ing glands, the swollen glands pressing upon the surrounding parts, causing difficulty of breathing a7id of deglutition. Scarlatina 7naligna are cases with decided nervous phenomena, to wit: convulsions, delirium and 7nuscular twitching, the temperature reaching 1070 to lio°, the pulse rapid, feeble and irregular, the erup- tion delayed, of a purplish color, and in patches. Sequelae. Chronic sore throat; conjunctivitis; otorrhcea; chronic diarrhoea; subacute rheumatism; chorea; endocarditis; pleuritis; acute Bright's disease and 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 in the bones. Diphtheria; gradual invasion, great prostration, and no eruption, but the frequent complication of scarlatina and diphtheria must be remembered. 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 FEVERS. 41 can be positive of the result. Mortality ranges from ten to twenty-five per cent. 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, isolation, 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 tinctura bella- donne, gtt. j-x, according to age. For scarlatina anginosa, internal use of ti7tctura ferri chloridi and potassii chloratis, and stii7iulants. Externally, ice or cold compresses, unless they cause chilliness; if so, heat. Astringent gargles and small pellets of ice dissolved in the mouth are of use. The throat and nasal cavities are kept clean and the breathing relieved by the use of Dobell's solution used with a hand atomizer every hour. Dr. J. L. Smith warmly lauds the following mixture for cases with decided throat symptoms: R. Acid boracic,.............£ss Potass, chlor.,.............gij Tinct. ferri chlor.,...........f^ij Glycerins, Syrupi,........aa.......f f, j . Aquae,................f ^ ij. M. SiG.—One tablespoonful every two hours, to a child of five years. For scarlati7ia 77ialigna, in addition to ferru77i 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 or 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 42 PRACTICE OF MEDICINE. 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. For the headache, disturbance of vision and coi7ia, the result of uraemia, free purgation and diaphoresis with pilocarpus are to be employed. Prof. Da Costa advocates the administration of ammo7iii 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, thy7nol or acidum boricu7>i; an eligible way of administering acidum carbolicum is the syr. ammonia phenatis (Declat), f^ss-f^j, four to six times daily. 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, phary7igeal and laryngeal catarrh ; on the evening of the second day a decided re/7iission takes place in the fever, the catarrh FEVERS. 43 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 remaining clear and 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 tonsillitis, lobar and catarrhal pneui/ionia. Sequelae. In those of stru.77ious diathesis, scrofula or phthisis may develop. Diagnosis. A typical case begins gradually, with chilliness, nasal catarrh, watery eye, and fever, which decline before the erup- tion, rising afterward, the eruption crescentic in shape, and of a crim- son color. Scarlet fever; absence of catarrh, and earlier appearance and dif- ferent character of the eruption with high 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, sim- ply regulating the diet and bowels, and cool sponging; the indica- tions are to render the patient as comfortable as possible, the disease pursuing a favorable course without therapeutical interference. If the febrile reaction is high the following soon controls it:— R. Tinct. aconiti rad.,............Hlss-J Spts. setheris nitrosi............ffi_,x-xv Liquor, potassii citrat., .... ad.....fgj. M. Every two hours. For the pruritus of the eruption, the local use of oils and fats. For catarrhal syi7iptoms, inunction of the nose, neck and chest with cam- phorated oil and small doses of pulv. ipecac et opii, at bedtime ; if the catarrh extends to the bronchial mucous membrane, expectorants. 44 PRACTICE OF MEDICINE. During convalescence, for the strumous, protect from exposure, and administer oleum morrhue with syr. ferri iodidi. For black 77ieasles, bold stimulation, with ferrum and quinina. 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. Bicubation from one to three weeks. Symptoms. Onset sudden, with 7nild fever, suffused eyes, with little or no coryza, sore throat, and enlargeme7it 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 showing no ill effects from the attack. Diagnosis. From scarlet fever, by absence of 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 cresentic shape. Prognosis. Most favorable. Treatment. Mild laxatives and restricted diet. If 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 FEVERS. 45 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- 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 mildness 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, vo77iiting, and agonizing pains in the back, shooting down the limbs ; fever, in short time rising to 1030 or 104° F.; full, strong and rapid pulse, ranging from 100 to 130; the face red, eyes injected, intense headache and sleeplessness; delirium and convulsions 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 U77ibilicated; 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 seventeenth 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 co7ivalesce7ice is established. 46 PRACTICE OF MEDICINE. Confluent smallpox differs from the discrete in the greater severity of all the symptoms and the marked prostration of the patient, the eruptio7i appearing during the second day, the pustules coalescing into large patches, causing great distortion of the features. Maligna7it smallpox is characterized by the greater intensity and the irregularity of the symptoms, death resulting before the character- istic eruption appears, by convulsions or coma. In these cases hem- orrhages are frequent and petechias 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 seco7idary fever. Complications. During the course of the secondary fever there is a great tendency to grave inflammations, such as 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, such as chill, vomiting, pains in back and legs, high fever and pulse, all declining on third day, when the erup- tion 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.; C07ifluent, fifty per cent.; malignant, all perish; xxndex five years and over forty years, fifty per cent. die. Treatment. No specific; the disease will run its course under any plan of medication, although cases seem to do better if acidum carbolicum, thymol or the sulphites are used. For the initial fever and the fullpulse, relief follows the use of— R . Tinct. aconit. rad., Spts. aether, nitrosi, Liq. ammonii acetat Aquae,...... Every hour or two. Antipyrine should be serviceable in this stage, not only for the fever, but to relieve the pains. If headache and backache are intense, hypodermic injections of 7norphi7ia, or an ice bag to the head and along the spine. g«- j-ij f3'J f Z iss. M. FEVERS. 47 For sleeplessness and restlessness or early delirium full doses of potassii bro77iidum, or chloral. For secondary fever the best remedy is quinina, gr. v, every three 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.............fVjj Aquae................f 3 jj. 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 being 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 carbolicu77i employed. The disease being contagious, isolalio7i, ventilation, cleanliness and disinfection are imperative. To prevent pitting keep patient in a dark room, 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. amy li, 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 infa7icy and at puberty ; and it is safer to have it again performed if special exposure be liable to occur. 48 PRACTICE OF MEDICINE. In practicing 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 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 brow7i 7nahogany 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. Ecze7natous 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 eruption, 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/^7/torrhage fro77i 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. Lee, internally and applied in bladders over the epigastrium and along the spine. Hypodermic injections of 7norphina quiet the patient's fear, and at the same time have a constringing effect upon the vessels. Extrac- DISEASES OF THE STOMACH. 69 turn ergota fiuidum or ergotin hypodermically after the patient is quieted, or liquor ferri subsulphaiis, gtt. j-v, well diluted by stomach. Cases resulting from congestion of the liver or spleen are benefited by sali7ie purgatives. 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, and symptoms of collapse. Causes. The affection belongs to the group of neuralgisa. 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 at the praecordium, there is sev'ere griping pain in the stomach, usually extending to the back, with a feeling offaintness, a shrunken countenance, cold hands and feet, and an intermittent pulse. The pain becomes so excessive that the patient cries out. The epigastrium is either puffed out, like a ball, or retracted, with tension of the abdominal walls. There is often pul- sation in the epigastrium. External pressure is well borne, and not unfrequently 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 or longer; 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." 70 PRACTICE OF MEDICINE. Besides such severe attacks, we often see painful sensations in the epigastriu77i, of various degrees of intensity, with passing faintness or sinking at the " pit of the stomach." Diagnosis. From 77iyalgia of the abdo7ninal 77iuscles, by the pain of gastralgia being more acute and lancinating, accompanied by nausea and vomiting and the absence of tenderness on pressure. From i7itercostal 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 vomiting. From gastric ca7icer, by the age, character of the vomited matter, constancy of the pain, the cachexia, emaciation and the tmnor. 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 paroxys7n,. hypodermic injections of mor- phina, gr. r^-J, or the stomachic administration of the " compound of anodynes," the so-called chlorodyne, in doses of ttlx-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 i7iterval, regulated diet and one or more of the following remedies: qui7iina, arsenicu77i, bismuth, ferritin, 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 and the presence of sympathetic nervous symptoms. Causes. Imperfect mastication ; bolting of food; eating large quantities of food; same diet long continued; depressed nervous system, from worry and fatigue; sedentary habits or occupations. It is often inherited. DISEASES OF THE STOMACH. 71 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 vo77iiting of portions of partly digested food or acrid fluid—water brash or pyrosis. Pai7i 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 7/iemory, headache and absent mental vigor, with flashes of heat, followed by more or less perspiration. Palpitation of the heart with irregularity in rhythm. Varieties of Dyspepsia.—I. Nervous dyspepsia, atonic form, seen in active business or busy professional men, especially those of thin, spare build of nervous temperament, who eat meals rapidly and hurry off to their business. These cases present all the marked ner- vous phenomena. II. Flatulent dyspepsia, seen in hysterical indi- viduals, and showing immense development of gas throughout abdomen, and nervous symptoms. III. Acid dyspepsia, water- brash. Seen when the diet is coarse. Acidity of the gastro-intestinal canal and of the urine. IV. Irritative dyspepsia. Vomiting a* prominent symptom. In these cases the tongue is small, red and pointed. 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 eati7ig, 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' sti77iu- lants with the 7neals. Aid digestio7i with pepsinum, with or without acidwn hydrochlori- cu7n dilutum. Stii7iulate sto7nachicperistalsis with nux vo77iica, gentian or ci7ichona. For acidity, alkalies at time of acidity. For flatulency, carbo ani7tialis purificatus, gr. x-xx, or one or more of the carminatives, with tinctura nucis vomica before meals. Yox pyrosis, bis7nuth and pulvis aro7/iaticus, in large doses. 72 PRACTICE OF MEDICINE. For vomiting, sodii bro77iidum in small doses, or acidwn carbolicwn, gr. \-\, three or four times daily. For constipation, resina podophyllwn, at bedtime. For ana7nia, massa ferri carbonatis ox ferri lactas. 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 some hours after meals and nervous perturbation, 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; malaria. 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, borboryg>7ii, 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. Ty77ipanites and borborygitti are marked, the result of gaseous accumulations which have resulted DISEASES OF THE INTESTINAL CANAL. 73 from the decomposition of the intestinal contents. Dyspnea, the result of pressure against 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 drea7ns, headache, vertigo, buzzing in the ears, musce volitantes, deficient mental application, cardiac irritability, nu77ibness 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. Aneniia and emaciation result if the attack be protracted. Diagnosis. With our present knowledge it is usually impossible to designate forms of intestinal indigestion due to defects in the quantity or quality of either the pancreatic, biliary or intestinal secretions. Acute intestinal indigestion differs from gastric indigestion in the time of development 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 i7idigestion 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 indigested 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, such as beef, eggs and milk. 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 liquorpancre- 6 74 PRACTICE OF MEDICINE. aticus, f^j-iv, of the extractwn pancreatis, gr. ij—vj, with sodii bicar- bonatis, gr. v-x, two or three hours after meals. For constipation, bitter waters, such as Friedrichshall, Pullna, or Hunyadi Janos, or resina podophyllwn, 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 ; rheumatism ; 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 \n changing his position and in compressing the abdomen; his surface maybe 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, DISEASES OF THE INTESTINAL CANAL. 75 shooting to loins and thigh, with retraction of the testicle of the affected side, strangury and bloody urine. 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. Lnfia7)H7tatory disorders of the abdoi7ien 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 hypodermic injection of morphina, gr. l/e-lA 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 masse hydrargy- rum, gr. v-x, or hydrargyri chloridum 77iite, gr. yi every half hour until four or five grains are taken, followed by a mild saline cathartic. 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, 7norphi7ia, for the pain ; oleu77i ricini or 7nag7iesii sulphas, ^j, every hour for the constipation, and potassi iodidum, gr. v-x, after meals, 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 or less 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. 76 PRACTICE OF MEDICINE. Or in other cases the bowels may be relieved once a day, but the stool is small and hard, causing great pain. 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 symptoms of dyspepsia, headache, mental torpor, vertigo, palpi- tation on exertion, 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 hearty co-operation of the patient. First, the patient must have a regular hour each day for going to stool, and must remain a sufficient ti7ne to permit a thorough evacua- tion of the bowels. Seco7id, 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. yl Ext. belladonna? alco.,..........Sr- H 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. Resinse podophyl., Ext. physostig., Ext. belladonnae alco., Aloine,..........aa . . . pt i/. In pill, every night, or second or third night. R. Ext. cascarae sagradse, fid..........rnxxx Glycerini................' r^x Syr. sarsaparillse,...........yn XXi Hour after meals, or once a day as indicated. Success often follows an enema of glycerini ^j-iv, or a suppository of glycerinum. Electricity to the abdomen is worthy a trial; one pole over ab- domen the other at anus ; using either galvanism or faradism. DISEASES OF THE INTESTINAL CANAL. 77 DIARRHOEA. Synonyms. Enterorrhcea; 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. Causes. Those acting locally, such as indigestion, indigestible food, i77ipure food and water, irritating 77iatters or secretions poured into the bowels, or entozoa, cause the flux by a direct irritation of the mucous surface. Attacks of diarrhoea due to constitutional derangement may be secondary to such diseases as tuberculosis, pyemia, albuminuria, typhoid fever, or disturbances of the functions of other organs, giving rise to vicarious fluxes. Atmospheric changes as well as a sudden mental shock will predis- pose to an attack of diarrhoea. Forms. Acute and chronic. Symptoms. Acute diarrhoea presents itself in several varieties, the result of its particular 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 fecule7it character, are of brown fluid, containing faeces, often offensive, the color be- coming lighter after four or five evacuations. Constitutional symp- toms 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 offood, which passes through the intestines more or less unaltered. The stools are 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 increased peristalsis of 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. 78 PRACTICE OF MEDICINE. ' 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 is the result of some cachexia. The symptoms, as far as the stools axe 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, colic, ei7iaciation and anemia. The appetite is at times capricious, again impaired. Prognosis. Favorable \n 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- catio7i 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,..............g1"- tV Pulv. rhei,...............gr. y£-% 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 tanni7i; or the following modification of " Squibb's diarrhoea mixture:"— R . Tinct. opii deodorat.,..........f,~ viss Tinct. camphorae,............f5 j Tinct. capsici,.............f 3 v Chloroformi purae,...........f^iiss Sots, vini gallici,............f.^j Alcoholis,........ad......f'^iv- M. Sic.—One teaspoonful, p. r. n. For children— R. Bismuth,...............gr. iij-v Cretae praep.,..............gr. v. M. Every two hours. In adults, an opium suppository often checks a flux that is uninflu- enced by opium internally. DISEASES OF THE INTESTINAL CANAL. 79 For the bilious form— R. Hydrargyri chlor. mitis,.........gr. y% Sodii bicarb.,..............gr. ij Pulv. opii,...............gr. yl. 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. Chronic diarrhea. Bisi7iuth, gr. xxx-xl, in milk, every four hours ; Hopes ca7/iphor mixture, every four hours ; cupri sulphas, gr. -^y, ext. opii, gr. ■£%, every four hours; argenti nitras, gr. yi, 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,.............f^j 01. amygdal. express.,..........f^ss Tinct. opii, ..............f g ij Mucil. acaciae,.............f 3 v Aq. lauro-cerasi,............f Jss. M. SiG.—f^j 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. Pathological Anatomy. There first ensues hyperemia of the mucous membrane and intestinal glands, manifested by redness, swelling and ede7na; 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 hyperasmia, 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. 80 PRACTICE OF MEDICINE. 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 and paroxysmal in character, situated above the umbilicus, localized tenderness and loose evacuations. Nausea and voi7titing often occur. The stools contain but little fecal matter, are yellow or greenish-yellow in 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, which is 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- served. Treatment. Rest the bowels by a restricted diet, such as 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~^ Camphorae, ..............gr. iij. M. In pill, every three hours. Or— R. Tinct. opii deodorat.,..........gtt. x Liq. potassii citrat,...........-r\\ ;\j. Every four hours. The strength and the frequency of administration of either of these formulae must be governed by the severity of the attack. DISEASES OF THE INTESTINAL CANAL. 81 For children— R. Tinct. opii deodorat,...... .... gtt. j Bismuth, subnit.,............gr. v Mist, cretae,..............f^j. M. Every four hours, for a child of one year. If the case shows the least tendency to linger, the acid treatment should be substituted for the above, the best of which is " Hope's Camphor Mixture," the formula being— R. Acidi nitrosi,..............fgj Tinct. opii,...............gtt. xl Aquae camphorae,............fjjviij. M. The dose ranging from fgj to f^ij, according to the age. Acidum sulphuricui7i dilutum may be substituted for the acidum nitrosum in the above formula. Locally, poultices, warm fomentations, or ung. belladonne or oleum ca/nphorate, 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 subjects 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 rootlets 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, continuing for half an hour, an hour or longer, and after a longer or shorter inter- val occurring again ; these phenomena continue for a day or two, when 7 82 PRACTICE OF MEDICINE. looseness of the bowels, with distressing pain and tenesi7ius occur, the stools containing mucus, with or without blood, and shreds of membrane or cylindrical casts of the bowel. Great relief is then experienced, although a feeling of rawness or soreness persists for a day or two. 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 hypodermic 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, before meals, or hydrargyri chloridui7i corrosivum, gr. ^, three times a day, 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 membrane. 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. DISEASES OF THE INTESTINAL CANAL. 83 Pathological Anatomy. Cases in which death has occurred within a few hours present no pathological changes. Generally, however, the gastro-intestinal mucous membrane is con- gested and denuded of epithelium ; the Solitary and Peyerian 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 tnatter 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 partake of the "rice-water" character. The patient is rapidly ema- ciated and reduced in strength, the body shrinks, the surface cold and covered with a cla7nmy 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 co7nma bacilli of Koch are proven to be always in the true cholera stools. Irritant poisons, such as tartar emetic, elaterium, or other sub- stances, 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. 84 PRACTICE OF MEDICINE. Treatment. At once, regardless of the cause, a hypodermic injection of morphina sulph., gr. yi-yi, and atropina sulph., gr.^, to be repeated in half an hour if no improvement; for patients who object to the hypodermic 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 78, and if much depression, small doses of brandy ox 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- V(> Glycerini,...............gtt- xx Aquae,.........ad.......f 3 iv. M. Every hour or two. Dr. Hartshorne strongly recommends— R. Spts. ammon. aromat.,..........f^J Magnes. optim , ............f 3J Aq. menth. pip.,.............fgiv- M. SiG.— ^j every twenty minutes. If the case is seen early, and if the diarrhoea is copious, he adds tinct. opii camph., f 3 iv, to the mixture. The closer the case approaches the true cholera type, the more severe are the muscular cra77ips, and their treatment is indicated. Prof. Da Costa suggests— R. Chloral,................3Jv Cosmoline,...............3J- To be rubbed over the affected muscles. Dr. Bartholow suggests— R. Chloral,................3 iij Morphinae sulph.,............gr. iv Aquae,.................f^j. M. SiG.— Twenty minims, hypodermically, 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. DISEASES OF THE INTESTINAL CANAL. 85 ENTEROCOLITIS. 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 becomes chronic ; characterized by moderate fever, nausea, vomiting, diarrhoea, swollen abdomen, pain 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 follicles 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 of 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 have 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 membrane 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 for7n ; may develop slowly, with restlessness and fretfulness, or suddenly with feverishness, loss of appetite, thirst, nausea, moderate vo7niting, 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, gree7iish, acid, mixed with 86 PRACTICE OF MEDICINE. 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 symptoms ; 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 tender, 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 mis- taken 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 great importance. Any one of the following formulae may be used with advantage :— R. Calcii carbon, precip............zj Tinct. opii camph.,...........f 5 ss Tinct. lavendulae comp.,.........fzij Syr. gallae aromat.,...........f i iss Syr. acaciae,..............f'^j_ M. SiG.—Teaspoonful, repeated every hour or two. Or- R. Tinct. opii camph.,...........f3n'j Tinct. catechu comp.,.........f z iv Misturae cretae,.............f'z ix. M SiG.—One or two teaspoonfuls, every hour or two. DISEASES OF THE INTESTINAL CANAL. 67 Or— R . Bismuth subnit.,.............5 iv Pulv. acaciae, Sacc. alb.,.......aa.......q. s. Syr. gallae aromat.,...........f^j Spts. vini gallici,............f 3 ij Aquae,.........ad.......f^i'j- ^ SiG.—One or two teaspoonfuls, every two hours. Or— R . Pulv. ipecac,..............gr. *{ Bismuth subnit.,.............gr. v Cretae praep.,..............gr. iij. M. Sic.—After each stool. Many cases do well with pulvis kino comp., others with minute doses, frequently repeated, of acidum lacticutn. 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 formulae :— R. Acidi carbolici,.............gr. TV-| Tincturae iodi, .............gtt. j-ij Aquae menthae,.............3J. M. SiG.—Every three or four hours. Or— R . Tinct. calumbae,.............f 3 iij Liq. ferri nitratis,............rnjcxvij Sjrupi 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. 88 PRACTICE OF MEDICINE. Cause. Age ; bad hygiene, or as it is now entitled, " civic mala- ria ; " continuous high temperature ; improper food; dentition; con- stitu'ional as in the feeble, delicate, nervous or irritable. 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 77iatter 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, soaking 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 V077iiti7ig, 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 abdoi7icn 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 DISEASES OF THE INTESTINAL CANAL. 89 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. Treatment. The first indication is to arrest the vomiting and purging, for'which use— R. Bismuth subnit.,.............gr. v-x Mucil. acaciae,.............3 ss Acidi carbolici,.............gr. TVj—^ Tinct. opii deodorat.,..........gtt. j Mist, crctae,..............3iss. M. Every two hours for a child between one and two years. Or— R. Hydrargyri chlor. mit,..........gr. ^ 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^ ij Morphinae acetat,............^r. ij Spts. vini gallici,............f^ ij. M. Et adde 3J to Aquas calcis, Aquae 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. Yox 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 sy7npto7ns become aggravated, small dose of potassii bromidwn, ox valerian, which "reduces the reflex excitability, motility and sensibility," is indicated. 90 PRACTICE OF MEDICINE. 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- terized by fever, tormina, tenesmus and frequent, small, mucous and bloody stools. It occurs either in the sporadic, ende77iic or epide7nic form. Causes. Sporadic and ende7nic dysentery is caused most com- monly by atmospheric changes, such as hot days with cool nights; also from malarial attacks, and rarely from errors in diet. Epide77tic dysentery prevails in armies, jails and tenement houses, propagated by decomposition of dysenteric stools, and the unfavor- able hygienic surroundings. // 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 develop, 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 DISEASES OF THE INTESTINAL CANAL. 91 to expel it, or tenes77ius, 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 tor77iina, 7iausea and vomiting may 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 fiiem- brane, even casts of the bowel, together with more or less gangrenous mucous membrane; nausea, vomiting, and great prostration, cold skin, feeble pulse and ei7iaciation 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. Catarrhalfori7i 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 yet bland 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 Plumbi acetat.,.............g^r. ij Pulv. ipecac,..............gr. j. M. Every two hours; 92 PRACTICE OF MEDICINE. Or— R. Pulv. ipecac et opii,...........gr-x Bismuth subnit.,.............gr. xx. M. Every two hours. If the case is seen early the very best prescription possible is— R. Matjnesii sulph...............3 J Acid, sulph. dil.,............"lv Tinct. opii deodorat.,..........^^ Aquae menth.,...........■ • 3'J- M- Every two or three hours, until faeces appear in the stools, when small doses of opium and quinina may be used. Lpecacuanha 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 chloridu7n corrosivmi, gr. y^j, 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- X 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. Lingering or chronic cases are benefited by one or any of the fol- lowing remedies: Terebinthina, acidum carbolicwn, argentum nitras, cupri sulphas or zinci oxidu7n. DISEASES OF THE INTESTINAL CANAL. 93 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 77iechanical, from the lodgment of seeds or hardened faeces. 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 promi7ience 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 axe greater, there are ii/ipaction of feces and no 77iovei7ients. There are decided fever, restlessness, and also nausea and vomiting. The vomited 77iat- ters, 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 for7n 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 for77i 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 for77i 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 ophmi influence, to be maintained until convalescence is well pronounced. 94 PRACTICE OF MEDICINE. In severe cases, begin an opium influence at once, by hypodermic injections of 77iorphina guarded with atropi7ia, 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 77iagnesii sulphas in drachm doses, every two hours. If suppuration develop, laparoto77iy with strict antiseptic precautions is the indication. Locally. Leeches over the caecum followed by hot fomentations or ice bags, or cold compresses. PERITYPHLITIS. Synonyms. Perityphlitic abscess ; suppurative appendicitis; peri- caecal 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- ys77is 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, feverishness, 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 discharge 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 tinclura iodi; if suppuration is evident, hasten by poul- DISEASES OF THE INTESTINAL CANAL. 95 tices, and follow by evacuation of the pus with the aspirator or a free opening, conjoined with the use of opium and quinina. If the disease is not rapidly controlled, a laparotomy with strict antiseptic precautions is indicated. 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. Symptoms. Uneasy sensations and burni7ig in the rectum, with a constant desire for stool, or te7ies7/ius, often so severe as to cause a prolapse of the tnucous membra7ie. The stools may be either hard- ened faces 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 fistulas. Complications. Periproctitis ; peritonitis ; hepatic abscesses. Diagnosis. In tnales, the disease cannot be confounded with any other affection, save, perhaps, hemorrhoids. In females, dis- placements of the uterus may somewhat simulate the symptoms of proctitis, 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 77iagnesia 77iixture mentioned for dysentery is the most suitable remedy; after which emollient e7ie- mata, with opimn, are indicated. Lrrigation of the bowel with warm 96 PRACTICE OF MEDICINE. water once or twice daily assists in the liquefaction of the hardened faeces. Either enemata or suppositories of glycerinum should answer in certain cases. Cases other than those due to constipation, emollient enemata and opiu77i, one of the best being— R. 01. olivae,................I ij Tinct. opii deodorat.,..........rr^xv. M. 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 ; ileus. Definition. A sudden or gradual closure of the intestinal canal; 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 :— DISEASES OF THE INTESTINAL CANAL. 97 Constipation, with more or less severe colicky pains, not relieved by either purgatives or injections ; feeling of weight and soreness, with distentio7i of the abdomen and nausea and vomiting; the symptoms all grow more pronounced, the pain becoming viole7it, tenderness in limited areas, the vo77iiting becoming stercoraceous, the abdomen hard and tense, the eyes sunke7i, 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 there is a 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. Intestinal obstruction may be mistaken for intestinal colic, hernia, enteritis, peritonitis, hepatic or renal colic. Prognosis. Always grave, but guided by the cause. Impacted faces favorable. Invagination less favorable, but recoveries occur; the longer the symptoms continue, the more favorable the outlook. Strangulations unfavorable, but many recoveries recorded. Strict- ures, due to cancer, cicatrized ulcers and the like, are the most unfavorable. Treatment. Stop all forms of purgatives as soon as the diagno- sis of obstruction is determined. Opium is indicated in all forms with pain, and is best administered in the form of 7iiorphina, combined with small doses of atropina, hypodermically. The author has seen the most brilliant results follow the plan of washing out the stomach as suggested by Kiissmaul, and with full doses of atropina hypodermically, for its action on intestinal peristal- sis, and with electricity, one pole over abdomen, the other in rectum. Cases resulting from i7npacted faeces are rapidly cured by the above plan combined with irrigation of the lower bowels with tepid soap- suds. If invagi7iation, raising the buttocks and lowering the chest, and repeated injectio7is of wari7ied oil, axe recommended. Distention of the bowel by pumping air through long rectal tubes, or disengaging carbonic acid gas in the bowel, by first injecting a 8 98 PRACTICE OF MEDICINE. solution of sodii bicarbo7ias, and follow this with a solution of acidum tartaricum, 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. Laparoto77iy is no doubt the operation of the future, when our means of diagnosticating the location of the trouble is more exact. The nutrition of the patient is best attained by injections of either peptonized foods or defibrinated blood, or both. INTESTINAL PARASITES. TAPEWORMS. Varieties. Tania solium; Tania saginata; Bothriocephalus talus. Causes. The Tania 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 Ta/iia 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 embryo 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 fiat segments or joints. The head, or scolex, measures about ^ 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- INTESTINAL PARASITES. 99 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 ttVo of an inch in diameter. 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 y\, of an inch and has four strong and prominent suckers, but no hooklets,—whence the term "unarmed tapeworm ; " the neck is short and thick and the segme7its are larger, stronger and thicker than those of the T. solium. The Bothrioaphalus latus is the largest of the three Cestoda, the length ranging from fifteen to sixty feet, the head oval, measuring about y^ 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, ei7iaciation, 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: exlractu77i granati rad. cort. fluidu77i, f3ss-ij, or a decoctum granati rad. cort. (gij bark of root, aquae Oj), wineglassful every hour until all is taken, as suggested by Prof. Bartholow; or oleoresina aspidii, 3ss doses repeated, or oleum pepo express., 3J-iv, followed by oleum ricini. Creosota has been successful in a number of cases. Several cures are reported from glycerinum f3ij-,lj, repeated p. r. n. A much pleasanter remedy is pelletierine, the active constituent of 100 PRACTICE OF MEDICINE. granatum, used in the form of the tannate, gr. x-xx, or Tanrefs solu- tion of pelletieri7ie. Cases which resist these means are often cured by the following :— R. Chloroform i, Ext. aspidii fid.,.....aa.....■ ^3J Emul. olei ricini, . . . . (B. Ph.).....giij. 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. ROUND WORMS. Varieties. Ascaris lumbricoides ; Oxyuris vennicularis. Causes. The ascaris lu77ibricoides 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 vennicularis 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 wonn, 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 ver/nicularis, thread or seat wonn, 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- INTESTINAL PARASITES. 101 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 intestinal 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 ven7iicularis, or seat wori7i, produces intense itchi7ig 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 lu77ibricoides are readily removed by the following " worm powder " :— R . Santonini................gr. ^-j-ij Hydrargyri chlor. mite,.........gr. ^/j-ij. M. Ft. chart. SiG.—At bedtime, followed by a dose of oleum ricini before breakfast. For the oxyuris vennicularis the above sa7itoninum powder, with the use of ene7nata of quassia, alumen, sodii chloridui7i, 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. 102 PRACTICE OF MEDICINE. 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, tenderness, tympanites, vomiting and prostration. It may be limited to a part—local, or 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; vermiform appendix or inflammation of this part or the surrounding parts ; inflammation of the pelvic viscera •; septicaemia or pyaemia ; erysipelas ; hernia. Many surgeons doubt that peritonitis is ever an idiopathic disease, but that rarely it does so occur is certain. 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 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. Pus develops if the absorption is not prompt or if any cachexia be present. 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 character, and encysted by the agglutinated membrane. DISEASES OF THE PERITONEUM. 103 Symptoms. Acute fonn; 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 abdome7i is disle7ided and rigid, from constipation, effusion and meteorisiti; 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 ii7ipaired appetite, and nausea and vomiting axe almost constant, as is hiccough. It is a clinical fact that a sub-normal temperature is of frequent occurrence in acute peritonitis. 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. If pus forms, symptoms of hectic develop. 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 intense7iess and hardness; colicky pains during diges- tion, rapid emaciatio7i and failure of strength. Usually, the lower portions of the abdomen give a dull note on percussion, from the presence of fluid, or scattered points of dullness, showing the presence of encysted fluid. Diagnosis. The question of diagnosis in this disease is of great importance, as it so frequently, if not always, is associated with the diseases and accidents of the abdomen. 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. Rheu7natis77i of the abdominal 7nuscles 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. 104 PRACTICE OF MEDICINE. 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. Ldiopathic 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 fonn : 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. The profession are divided between two plans of treatment of peri- tonitis, one side-favoring opium and the other party as strongly urging saline purgatives and laparotomy. Prof. DaCosta says opiimi and quinina are the remedies indicated at the onset of the disease, to wit: at once hypodermic of 77iorphina, gr- xA-lA, maintaining the effect by hourly doses of either morphi7ia 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. yi-yi, 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. While the opium treatment places the patient as well as the bowels "in splints" and relieves the pain, it is urged by the advocates of saline purgatives, however, that instead of locking up the bowels, the use of salines puts the bowels into active peristaltic action, thereby the peritoneal cavity is drained of the products of inflammation and the inflamed surfaces are relieved of all engorgement by a thorough depletion of the vessels in the intestinal walls, the pulse and temper- DISEASES OF THE PERITONEUM. 105 ature are improved, the pain is lessened as quickly as by opium, and the formation of adhesions and bands is prevented. Should the active symptoms continue under either plan of treatment, laparotomy with thorough antisepsis is indicated. The decline of the vital powers must be averted by regulated nutri- tioti and free sti77iulaiio7i. Locally, an ointment of belladonna and hydrargyrwn are of advan- tage. During co7ivalescence, perfect quiet, nourishing diet, moderate stim- ulation, scattered flying blisters, and the following— R . Potassii iorlidi,.............gr. v-x Ferri pyrophos., . . ..........gr. ij Tinctura lavandulae comp.,........Tl\xv Aquae destillatae,.....ad.......3 ij. M. Every six hours, should constitute the treatment, with tonic doses of quinina. Peritonitis from perforation, absolute quiet, hypodermic injections of morphina, ice locally, and stimulants per mouth, rectum, or hypo- dermically, and laparotomy. Chro7iic peritonitis ; locally tinctura iodi, and internally opium, for pain ; potassii iodidwn as an absorbent, with nourishing diet, olemn morrhua 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 mechani- cal obst7-uciion of the portal system, from cirrhosis of the liver, tumors, diseases of the heart or lungs. Pathological Anatomy. The quantity of fluid in the perito- neal 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 9 106 PRACTICE OF MEDICINE. points to cancer as a cause. The peritoneum becomes cloudy, sodden, and thickened, from long contact with the fluid. Symptoms. The onset is insidious, and considerable swelling of the abdo7nen occurs before the disease attracts attention. Co7istipa- tion, from pressure of the fluid on the sigmoid flexure. Scanty urine, from pressure on the renal vessels. Embarrassed respiration and car- diac actioti, from pressure on the diaphragm upward. The umbilicus is forced outward. Physical sig7is; 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 tu77iors 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 fcetal 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 unfavorable, for while the dropsy may be removed, it as rapidly returns. DISEASES OF THE BILIARY PASSAGES. 107 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. jalapse comp.,...........3J-ij In water, an hour before breakfast; And—R . Potassii acetat.,.............gr. x-xx-xl Tinct. scillae,.............. 3SS Infus. digitalis,.............f^iss. M. Every six hours. Or instead use the following :— R . Hydrargyri chlor. mite,.........gr- iij Ext. opii,...............gr- A M. Et ft. pil. SiG.—One every three or four hours. If these fail, as they certainly will after a time, the embarrassed respiration and cardiac action will call for tapping, which may be done with the trocar, 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- 108 PRACTICE OF MEDICINE. 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, ii7ipaired appetite, nausea, with, perhaps, vomiting and looseness of the bowels and slight feverishness, 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 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 wan/i bath, to which potassii carbo7ias, §j, may be added, morning and night. For diuresis, potassii bitartras lemonade, every four hours. Yox purgation, either sodii py7-ophos., 3J-ij, every four hours, well diluted, ammonii murias, gr. xv-xx, every five hours, well diluted DISEASES OF THE BILIARY PASSAGES. 109 magnesii sulphas, gr. xx, every couple of hours, or hydrargyri chloridi mite, gr. %, every hour until free purgation. 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 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 article of diet. For convalescence— R. Acid, nitro-hydrochlorici dil.,......gr. v-x Elix. taraxaci comp.,.........3J-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 cholesterine, 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 110 PRACTICE OF MEDICINE. shoulder; the abdominal muscles are crai7iped and tender; there is nausea and vo7niting, 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 perit07iitis follow, the calculi discharging by the intestine, stomach, or through the abdominal walls. Diagnosis. The malady should not be mistaken if severe pain, diverging from the hepatic region, and nausea and vomiting are 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, hypodermic injections of morphina, Sr- V^-yi-y^y combined with atropi7ia, gr. T|o, and warm fomenta- tions over the hepatic region, are indicated. Prof. Bartholow strongly urges the following prophylactic treat- ment: Carefully regulated diet, abstinence from all fatty and sac- charine substances, daily exercise, stoppage of all excesses, and the long use of sodii phosphas, 3J, before meals, well diluted, to which may be added, if gastro-intestinal catarrh be present, sodii arsenias, gr. 2V). or aurii et sodii chloridum, gr. ^, 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 arterial; passive when venous. The condition is charac- DISEASES OF THE LIVER. Ill terized by torpidity of the digestive and mental functions, and slight jaundice. Causes. Active congestion; heat, atmospherical or artificial ; habitual constipation; malaria; excess in eating and drinking; alco- holic or malt liquor. In females, an arrested menstrual epoch may give rise to an attack. 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- rhosis, but the " atrophic liver " is smooth, while the " cirrhotic liver " is nodulated. Symptoms. Active congestion; following cause, rapidly pro- duced malaise, aching of limbs, evening feverishness, headache, depression of spirits, yellowish tongue, disgust for food, nausea, and, may be, vomiting, constipation, scanty, high-colored urine, with a feeling of fullness, weight, and soreness in the hepatic region, with dull pain extending to the right shoulder, and slight jaundice, the eye yellow, and the co7nplexion muddy. Duration about a week. Passive congestion; onset gradual, with a feeling of weight and fullness in the hepatic region, slight jaundice, and symptoms of gas- trointestinal catarrh. On percussion the hepatic dullness is increased in all directions. Diagnosis. Acute congestion is continually confounded with catarrhal jaundice; the latter begins with marked gastro-intestinal symptoms and distinct jaundice; in the former these are less marked. Obstructive congestio7i 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. 112 PRACTICE OF MEDICINE. 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, or small doses of hydrargyri chloridi 7nite, with sodii bicarbonas repeated several times, followed with saline, followed by R. Acidi nitro-hydrochlorici dil.,.......rTLviiss Elix. taraxaci comp.,..........31J.J Before meals, and a milk diet. Attacks due to 77ialaria ; the above purgative followed by quinina 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, 3j-ij, three or four times daily, well diluted. 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 thi 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. In persons who seem to have a predisposition to attacks of con- gestion of the liver upon the slightest exposure to any of the various exciting causes, the habits and diet must be regulated, to which must be added a course of alkaline waters and regulated exercise. 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. DISEASES OF THE LIVER. 113 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. Hyperasmia, 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 systei7i, melancholia, slight jamidice, constipation, the stools light col- ored, and if of long duration, typhoid syi7iptoms. Locally, if the abscess is near the suxface, prominence of the hepatic region, throbbing, 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. 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. Sympto7natic, and when pus is present, the use of the aspirator to remove it, and sustaining treatment, to wit: quinina, ferrum, alcohol, and oleu7n morrhua. 114 PRACTICE OF MEDICINE. 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 albumin. 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. Lcteric period; jaundice deepens, pulse slow, headache increases, and great and obstinate sleeplessness. Toxa/7iic period ; fever, rapid pulse, more complete jaundice, pain, nausea, vomiting of blackish, grwnous 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." DISEASES OF THE LIVER. H5 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 gaslro-i'7itestinal catarrh, with attacks of jaundice, in a drinking man, are suspicious. Symptoms of the second stage are, abdominal dropsy, enlargement of the superficial abdominal veins, dyspepsia, localized peritoneal pain, hemorrhages from the st07nach or intestines, muddy or slightly jaundiced skin and decided emaciation; the enormously distended abdomen with thin legs are characteristic of sclerosis of the liver. 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 116 PRACTICE OF MEDICINE. 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 ap- pearance 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. ^Vt^ three times a day; hydrargyri chloridum mite, gr. f^, three times a day; aurii et sodii chloridum, gr. -£$, after meals; sodiiphosphas, 3ss-j, after meals ; potassii iodidum, after meals. The diet must be regulated, 77iilk 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 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. DISEASES OF THE LIVER. H7 The amyloid change involves the spleen, kidney, intestines, and their 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 albumin, 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. Prof. DaCosta recommends ammonii murias gr. x-xx three times daily, for several weeks, then change for same length of time to syrupus ferri iodidum, beginning with rrr.x gradually increased to f^j after meals, then to the former again, and so on, for months. Symptomatic, with prolonged use of ferrum, syr. calcii lacto-phosphas and oleum 7/iorrhua. 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 of the new growth. The branches of the hepatic artery enlarge and permeate the growth, while the branches of the portal vein are compressed and atrophied, thereby blocking up the portal cir- culation. 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 118 PRACTICE OF MEDICINE. a history of dyspepsia, flatulency and constipation. The uneasiness, weight and pain, increased by pressure, are noticed ; jaundice, ascites, occasional intestinal hemorrhages, emaciation, feebleness, anamia, 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 non7tal 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 1.008 to 1.020; it is low 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, anunonium,potassium, calciui7i 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. DISEASES OF THE KIDNEYS. 119 I. Quantitative test for urea, by hypobro- mite of sodium(Davy's Method). II. Tests for urates and uric acid by nitric acid. III. Quantitative test for uric acid by nitric acid. Fill a graduated glass tube one-third full of 77iercury, and add one-half drachm of the 24 hours' urine; then fill the tube evenly full with a saturated solution of hypobro77iite of sodium, and close it immediately with the thumb; invert the tube and place its open end beneath a sat. sol. of chloride 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 calculated. 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 firsb 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.) 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 I on a weighed filter, wash it thoroughly, and dry at 2120 F. The increased weight repre- j sents the uric acid in part excreted, approxi- L mately. 120 PRACTICE OF MEDICINE. IV. Test for the earthy and alkaline phosphates by the magnesian fluid. V. Test for the chlo- rides by nitrate of sil- ver. VI. Test for mucus by acetic acid and li- quor iodi comp. VII. Test for albu- Heatox liquor potassa increases the cloud- iness caused by earthy calcium and magne- sium 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 puras, liquor ammoniae, each one part; aquae destil., 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 (i 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 so- dium 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., when threads and bands of 77iucin are made visible. The addition of nitric acid dis- [ solves them. Slightly acidulate the urine, if necessary, by addition of nitric or acetic acid, and boil; this causes a white deposit of coagulated albumin, which is not dissolved by nitric acid, unless the acid is in excess. Nitric acid causes a white deposit of coagulated albumin, which is dissolved if a DISEASES OF THE KIDNEYS. 121 min by heat and nitric - acid. X. Test for blood by heat and caustic pot- ash (Heller's). VIII. Quantitative test for albu77iin. Ap- proximately.] IX. Test for blood by heat and nitric acid. XI. Test for pus by liquor potassa. 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 albumin 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., yi-yi, etc. Heat or nitric acid causes deposit of albu- min, with the coloring matter changed to a 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, and after standing, forms a coagulum of blood at the bottom of the vessel. Caution. Heat or nitric acid causes co- agulation of the albumin 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. 10 122 PRACTICE OF MEDICINE. 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 by liquor potassa and heat (Moore's). XV. Test for sugar by subnitrate of bis- muth, liquor potassa and heat. 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 3 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 po- tassa. (Caution. This may give a white, flaky precipitate of the earthy phosphates, which should be removed by filtering.) Now boil; this causes, at first, a yellow-brownish color, becoming darker if much sugar is present, due to glucic, and finally to melassic 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. Albumin must be absent. DISEASES OF THE KIDNEYS. 123 XVI. Test for sugar by a solution of cupric sulphate, liquor po- tassa and heat (Trom- mer's). XVII. Quantitative test for sugar by Pavy's solution, to wit:— R. Cupric sulphate, gr. 320 Neutral potassic taitrate, . . gr. 640 Caustic potash, gr. 1280 Distilled water, f g 20 Keep corked. XVIII. Quantitative test for sugar by fer- mentation and the specific gravity. 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 hydraled cupric suboxide, occurring at once, denotes the presence of sugar. Caution. Albumin must be absent. 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. 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 7ninims of the copper solution. 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 in the one contain- ing the yeast, the difference in the specific gravity of the two specimens expresses the number of grains in each ounce of the urine. Approximately. 124 PRACTICE OF MEDICINE. 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 congestio7i; characterized by pain, frequent desire for urination, the amount of urine scanty, high-colored, occasionally containing albumin 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 albumin ; there is, as a rule, no pain during the act of urination. The constitu- tional symptoms are headache, slight nausea, vomiting and a general feeling of discomfort. If the condition persist, infla77ii7iation of the kidney results. Passive; the kidney changes are marked by the lung or heart trouble, until dropsy, scanty, high-colored, albuminous urine is observed. 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; infusum digitalis is pre-eminently the remedy for congestion of the kidneys; if great irritability of the bladder, camphora, gr. ij-iv, every four hours, DISEASES OF THE KIDNEYS. 125 combined with morphina sulph., gr. Tz~k, or the hypodermic injec- tion of morphina, gr. -fa. The treatment of the passive form resolves itself into the treatment of the cause. 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 ex- posure ; scarlatina; persistent use of irritants, to wit: turpentine and cantharides. Blows and injuries of the back have caused this affection. 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 ; frequent desire to urinate; diarrhoea; skin harsh and dry; pulse quick, tense and full. Soon dropsy appears, the eyelids and face become puffy and swollen, followed 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. Albumin is present in large quantities, and the microscope reveals casts of the uriniferous tubules, blood corpuscles, uric acid, urates and oxalate crystals and epithelium. Duration from one to four weeks. Complications. Pericarditis, pleuritis, pneumonitis, peritonitis, 126 PRACTICE OF MEDICINE. or acute ura7nia, 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. Albu7ninuria may be confounded, on account of the presence of albumin 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. Uramic 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 kid- neys by dry or wet cups, and poultices of digitalis. For the dropsy, purgation by pulv. jalapa co7np., 3J, in water, be- fore breakfast, or elateriu77i, gr. \. Diaphoresis by warm baths, or extractum pilocarpifiuidum, tr^ x- xxx, every three or four hours, or vinum ipecacuanha, gtt. j-ij, every half hour. Diuresis, by— R. Potass, acetas,..............gr. x-xx Infus. digital., .............f 3 ij Infus. juniperi,.............f 3 ij. 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 albumin disappears and health is restored. The following is the formula of Basham's mix- ture :— R. Liq. ammon. acetat Acid acetic, . . Tinct. ferri chlor., Alcoholis, . . . Syrup,..... Aquae,..... Sig.—Dose, f3J-f Jj. fgvj 3»J f ^v f|iv f^iv. M. DISEASES OF THE KIDNEYS. 127 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 urai7iia. Causes. Occasionally follows the acute form ; syphilis ; chronic malaria ; chronic alcoholism; chronic mercurialism ; lead poisoning ; protracted suppuration ; some undetermined nervous condition. 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, although in many cases the dropsy is a late symptom, the patient becoming pale, debili- tated and suffering from cardiac palpitation, increasing dyspnea, and vomiting, all gradually developing without apparent cause; also headache, vertigo and defective vision. The urine is scanty, high- colored, albu77tinous, 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 normal amount of the urine as the disease progresses must not be forgotten, when the specific gravity is low, 1.010-1.015, and the quan- tity of albumin is increased. Irritable bladder is a very constant symptom 128 PRACTICE OF MEDICINE. Ana7nia is pronounced, from the large waste of albumin. 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, occurs in a greater or less degree in all pronounced cases. Uramic symptoms occur, and especially uramic asth7na (renal asthma). Complications. Pneumonitis, pleuritis, pericarditis, peritonitis, meningitis, and cardiac hypertrophy. Prognosis. Not unfavorable, unless urine persistently contains a large number of fatty tube casts and oil globules. Relapses are frequent, but many complete (?) recoveries are recorded. I have seen four apparent recoveries, one after twelve months' duration, another after two years' duration, and still another after five years' duration, no return showing itself after two years. 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 7nilkdiet, 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, for which administer the following :— R . Hydrargyri chlor. mite, Pulv. scillae, Pulv. digital.,.......aa..... gr. j. M. Etft. pil. SiG.—Three times daily for a few days. Diuresis should be promoted, if the secretion is small, by digitalis, DISEASES OF THE KIDNEYS. 129 caffein or arbutin internally, and dry cups and poultices over the loins. Iron is preeminently the drug for this variety of Bright's disease, the tinctura ferri chloridum the best form for administration. The ana77iia is to be treated by oleum morrhua, arse7iicum and ferrmn, an excellent formula for the latter being— R. Strychninae sulph.,...........gr. yl Tinct. ferri chloridi,...........f g ss Acidi acetici purse,...........f^iss Curacoae alba,.............f ?j Liq. ammonii acetat.,.....ad . . . . f]§yj. M. SiG.—Tablespoonful every five hours, followed by a glass of cold water. Another good formula is— R . Hydrargyri chlor. corrosiv.,........gr. j Aurii et sodii chloridi,..........gr. j Ferri per hydrogen,...........gr. xxiv. M. Ft. pil. xxiv. SiG.—A pill after meals. To check the waste of albumin, a difficult matter, the following remedies have been used with more or less success : ergota, quinina, acidum gallicum, acidum benzoicum, tinctura ca7itharidis, potassii, iodidui7i, and, lastly, the Russian remedy, blatta orientalis (cock- roach). For dropsy, purgatives, such as pulvis jalapa compositus, hydra- gogue cathartics and alkaline mineral waters; act on skin with vapor baths, or pilocarpus 7/iuriat. gr. yi, repeated if not much cardiac depression, or combining pulvis ipecacuanha et opii gr. iij with potassii nitras gr. iij-v every two or three hours. If there be great distention 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 iodidu77i with oleum 7iiorrhua. 130 PRACTICE OF MEDICINE. 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 tissue of the kidney, chronic in its progress, resulting in an induration or hardening, with contraction of the organ ; characterized by frequent passing of large amounts of pale, albuminous urine, of low specific gravity, disorders of the gastro-intestinal and nervous systems, 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; long-continued worry, anxiety or grief; alterations in the renal gan- glionic 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 glo7neruli 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. 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 "ga7iglionic 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 degene- ration. Symptoms. Onset insidious, and often marked alterations in the kidneys, heart and vessels have occurred before the disease is recognized. There are no characteristic early symptoms in the DISEASES OF THE KIDNEYS. 131 majority of cases, the disease being apparently latent, until some spe- cial outbreak cause a more thorough examination of patient, when he is found to have an interstitial nephritis. Any of the following symptoms may first attract attention, to wit: frequent 7nicturition, increased amount of urine, of a pale color, containing a small amount of albumin, which may be absent for days, occasional epithelial cells and hyaline casts. No dropsy, but a little puffiness and oedema of the conjunctiva—the Bright's eye. Dis- orders of vision. Forcible cardiac action with high arterial tension. And any of the following symptoms, the result of uremia: Persistent dyspepsia, occasional vomiting, regardless of food ; headache, vertigo and stupor, or drowsiness; violent itching of the skin ; tremors, con- vulsions, 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 ; cardiac hypertrophy. Diagnosis. Differs from parenchyi7iatous nephritis in the fol- lowing : large quantity of urine, clear, of low specific gravity, small amount of albumin, 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. ^, aurii et sodii chloridwn, gr. ■£$, ferri iodidum and arsenicum. For uremia, if patient is conscious, purgatives, diaphoretics and diuretics. If unconscious, morphina hypodermically or chloroform inhalations. AMYLOID KIDNEY. Synonyms. Chronic Bright's disease; waxy kidney; lardaceous kidney. Definition. A peculiar infiltration into, or a degeneration of, 132 PRACTICE OF MEDICINE. the structure of the kidney, from the deposit of an albuminoid mate- rial, having a superficial resemblance to starch granules. Similar 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 violet 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 albmnin 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. Diagnosis. Differs from parenchymatous 7iephritis 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 DISEASES OF THE KIDNEYS. 133 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 ferri iodidum, alternating with ammonii murias and olew/i morrhua. If caused by syphilis, a thorough course of potassii iodidum, ferri iodidum and hydrargyri corrosivum chloridum, with oleum 7norrhue. 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 ; if 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; abuse of certain drugs; rheumatism; sequelae of infectious diseases. 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 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. 134 PRACTICE OF MEDICINE. Begins by chilliness, feverishness, lumbar pains following the course of the ureters, frequent micturition, the urine 77iilky 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 albumin, no more than is due to the pus. Cases of pyelitis due to renal calculi frequently show hemorrhages ; the bloody urine after some extra exertion. 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 we77iic symptoms are frequent. Diagnosis. From cystitis, by history, lumbar pains and acidity of purulent urine, the urine in cystitis being always alkaline. A microscopical examination of the urine will aid the diagnosis very much. 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 or 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. Da Costa strongly recommends pix liquida ; other remedies are oleum santali, copaiba, eucalyptol, terebinthina and cubeba. I have seen excellent results from a prolonged course of the Buffalo Lithia Springs water or the Rockbridge Alum Springs water of Virginia. For renal hemorrhage, alumen, gr. xx, repeated p. r. n., is suc- cessful. If abscess results, aspiration, quinina and stimulants. Extirpation of the diseased kidney has been followed with fair health. DISEASES OF THE KIDNEYS. 135 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 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, di7iiness of vision, dilated, slug- gish pupils, drowsiness, vertigo, deafness, dusky countenance, nausea, V07niting, 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 ure7nic stertor is a sharp, hissing sound, while 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 136 PRACTICE OF MEDICINE. pallor of the face, the countenance being dusky in uraemic con- vulsions. 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. 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 hypodermic injections of 77iorphina, gx .yi-yi-yi, repeated, if required, every two hours. He says, " the most uniform effect of morphine so administered is, first, to arrest muscular spasms ; second, to establish profuse diaphoresis ; third, to facilitate the action of cathartics 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- dermic use of pilocarpi7ie hydrochloras, gr. ^^-yi-%, provided no counter-indication to its use exists, or frequent doses of caffeina. The convulsive phenomena are rapidly controlled by inhalations of chloroformwn, or the internal or rectal administration of chloral. Diuresis should be promoted by infusum digitalis, and dry or wet cupping, and poultices over the loins. Catharsis is best produced by elalerium, gr, jj-yi. For warding off attacks of uraemia, good results follow the use of acidum be7izoicu7n, acidwn nitricwn dilutwn, or acidum hydro- chloricui7i dilulu/n in small, frequently repeated doses. 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. DISEASES OF THE KIDNEYS. 137 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. 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 pai7i 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, ure/nic sy7nptoms 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 138 PRACTICE OF MEDICINE. 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 hypodermic injection of i/iorphina and atropina, and a warm bath or a suppository 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., f3ss-j. For renal hemorrhage, Prof. Bartholow reports success with R. Extracti ergotse fluidi, Tincturse kramerise,.....aa.....^ij. M. Sig.— 3J every two or more hours. I have always successfully controlled renal hemorrhages with twenty-grain doses of alumen, repeated p. r. n. 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; DISEASES OF THE KIDNEYS. 139 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. 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 urine 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 micturi- tion, 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 cor- puscles, extremely regular both in contents and in shape, may be detected. Although the quantity of urine voided by the patient is small, yet 140 PRACTICE OF MEDICINE. 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 vai'iety is, as a rule, good, being controlled by the cause. The chro7iic 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......3 ij Infusi buchu, vel Infusi uvse ursse,............f 5 vj. M, Sig.—Tablespoonful every 2 hours, well diluted. Or— R. Liquor, potassse,............f g iij Mucil. acaciae,.......ad.....f ? viij. M. Sig.—Tablespoonful every 4 hours, well diluted. For the pain and tenes7nus relief is afforded by a suppository of extractum opii and exiractum belladonne, repeated as needed. The vesical tenesmus is often benefited by extractwn 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, or a good preparation of tar, or extractum grindelie fluidum, Ti\/xx-f3J, DISEASES OF THE KIDNEYS. 141 three or four times daily, and washing out the bladder with, the fol- lowing mixture, has been of decided benefit in the hands of the author:— R. Sodii borat.,..............?j Glycerini,...............f H\\ Aquae,............ . ! . ! f'gij. 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. MOVABLE KIDNEY. Synonym. Floating kidney ; wandering kidney ; ectopia renis. Definition. A condition of the kidney, either congenital or acquired, in which the tissues around about the organ are so lax and the renal vessels so elongated as to permit the kidney to be moved in certain directions, causing a movable tumor in the abdomen. Causes. The kidney is normally held in position by the layer of peritoneum which is attached to the anterior surface of its adipose capsule. In movable kidney, the adipose tissue in which the normal kidney is imbedded partly or wholly disappears. The renal vessels are in many cases abnormally long. Relaxation of the abdominal walls from pregnancy or other causes. The use of tight corsets or girdles about the waist; violence ; increased weight of the organ from disease; the pressure of tumors growing in the neighborhood of the kidney ; the traction of hernias. The condition may be congenital or acquired, more frequently the latter. It is far more frequent in women than in men. Symptoms. Floating kidney may and often does exist without any noticeable symptoms, the condition being unknown until acci- dentally discovered by the physician while making a physical exam- ination of the abdomen. As a rule, however, patients experience a heavy, dragging pain in the abdomen, aggravated when walking or standing. There are also present gastro-intestinal symptoms, more or less constant, with melan- cholia aggravated by the mental anxiety the presence of a iwnor in the abdomen causes the patient, in spite of the assurances of the physician, that it is not a cancer. 142 PRACTICE OF MEDICINE. At times, from some unknown or unrecognized cause, the movable kidney swells and becomes very sensitive to the touch, and migrates a considerable distance from its normal position. Such an occurrence aggravates all the former symptoms mentioned. This condition has been ascribed to a twisting of the ureter and consequent retention of the urine in the pelvis of the kidney, or to a localized peritonitis or to a partial strangulation of the kidney from compression or twisting of its blood vessels. Hysterical symptoms are frequently observed in women suffering from wandering kidney. Diagnosis. The dislocation of the kidney is to be recollected in determining the nature of obscure tumors within the abdomen. The late Prof. Austin Flint based the recognition of this variety of abdominal tumor on the following diagnostic points : " It is situated in the hypochondriac region. It has the size and shape of the normal kidney, and this may be determinable by palpation, which is most advantageously employed by placing one hand over the lumbar region and the other in front on the abdominal walls, and then making coun- ter-pressure from one hand to the other. It is generally movable, and in some cases the organ can be restored to its proper situation." Other tumors are to be excluded by the absence of their diagnostic characters. Prognosis. It is a rare occurrence to have a fatal termination from movable kidney per se. Treatment. Symptomatic. It is said that some of the inconve- nience and sometimes suffering attending movable kidney may be lessened by means of an abdominal bandage, belt or supporter. If attacks of pain and swelling occur, the patient should be placed in bed, hot applications over the abdomen, the use of opiates and attempts at replacing the organ. Extirpation of a movable kidney has been successfully performed a number of times. Nephroraphy, an operation for fixation of the kidney by means of sutures, has been devised. ACUTE GENERAL DISEASES. 143 ACUTE GENERAL DISEASES. PAROTIDITIS. Synonym. Mumps. Definition. An acute specific infectious inflammation of one or both parotid and other salivary glands and the surrounding connect- ive tissue, with a very strong tendency to migrate into the mammae or testes; characterized by pain, swelling and disordered function of the glands. Causes. A specific poison. Contagious. Occurs in epidemics, although isolated 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 adja- cent 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 parotiditis occurs secondary to severe blood poisoning, as in pyaemia, typhoid or typhus fevers or diphtheria. The usual termi- nation of secondary parotiditis is by suppuration and destruction of gland structure. Symptoms. The onset is rather sudden, by 77ialaise, chill, fever, ioi°-io3° E., 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 and other salivary glands, 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 deaf- ness occurs. The swelling and other glandular symptoms subside about the 144 PRACTICE OF MEDICINE. 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 mamma, ovaries, or 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 77ietastasis. It is claimed that the involvement of other organs during the course of mumps is not an example of metastasis, but is a true transfer of the disease. 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, rr^x-xxx repeated has been used with varying success as a specific. Locally, either cold or warmth to the affected gland, whichever is most agreeable, or equal parts of unguentwn belladonna et hydrargyrwn. If the swelling shows a tendency to linger, use small blisters over the part and administer potassii iodidwn, if suppuration occur, evacuate pus, apply poultices and administer quinina. If orchitis occur, the use of the belladonna and mercurial ointment and the internal use of potassii iodidu7n. DIPHTHERIA. Synonyms. Putrid sore throat; malignant ulcerous sore throat; malignant quinsy; membranous angina. Definition. An acute, specific, constitutional disease, both epi- dei7iic 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. AH conditions of bad hygiene increase its virulence and diffusion, although the chief cause of its spread is contagion. ACUTE GENERAL DISEASES. 145 The poison exists in the exudation and secretions of the fauces and in the breath, and floats in the atmosphere at a considerable distance 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 catarrhalioxxn, 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- tion makes its appearance. The deposit may commence from One or several points, such as 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 speedily 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 7iasal 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. 12 146 PRACTICE OF MEDICINE. 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 sore7iess 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. 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 co7npressible. The urine is scanty, high colored and contains albutnin. 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 exuda- tion, the false membrane, are expectorated, with particles of the ulcer- ated tissues, having an offensive odor, which is transmitted to the breath. The ly7nphatic 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 coi7iplete loss of voice, croupy cough and obstructive dyspnea, which often become urgent, the breathing being noisy and slridulous, 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 ACUTE GENERAL DISEASES. 147 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, 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- 148 PRACTICE OF MEDICINE. 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, great swelling of the cervical glands, large amount of albumin, 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 should be resorted to in all cases. The diet should be of the most nutritious character from the onset, with such articles 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 being a suitable formula;— R. Milk,.................{%) Spts. frumenti,.............f3'v Egg,.................One. M. Sig.—Little salt added, beaten up and warmed. Stimulants should 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 vinigallici or spiritus frumenti, every two or three hours ; an adult from two to four drachms every three hours. Ferrwn 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,...............f3ss Syr. zingib.,.......ad......f3J-'J- M. Sig.—In water every three hours, for a child of two or three years. ACUTE GENERAL DISEASES. 149 The efficacy of the above is greatly enhanced, in the author's expe- rience, by the addition to each dose of tinctura belladomia, 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. Hydrarg. chlor. corros., gr. s^-zj, repeated every second or third hour, also acts well in many cases, combined as follows:— R. Hydrargyri chlorid. corrosiv.,.......gr. ^ Tinct. ferri chlorid.,...........rr^v-x Glycerini,...............n\x Aquae,........ad........3J. 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 disinfecta7it be added, its value is enhanced. Prof. Bartholow " has seen excellent results from the frequent application of a solution of acidu7/i 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 5j Aquae destil.,..............f 3 iij. M. Or— , R. Potass, chloras,.............3 iv Acid, carbol.,..............gr. ij-iv Tinct. myrrh,..............^j Inf. cinchona?,.............^ij. M. Or— R. Ext. pancreatis,.............3j Sodii bicarb.,..............3 iij. Sig,—Add 3J to aquae 3yj, 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 150 PRACTICE OF MEDICINE. 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, or intubation of the larynx, which have succeeded in many desperate cases. For nasal diphtheria, the same general trerffeient, and syringing the nose every two or three hours with a weak solution potassii chloras, or acidum carbolicum, or the following :— R. Sodii suiphit.,..............3 iij Glycerini,...............f 3 ij Aquae,.................f ^ iv. M. For the paralysis, strychnina and ferrum internally, or strychnina hypodermically, with the galvanic or faradic 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- ACUTE GENERAL DISEASES. 151 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 ox 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 io8°to no° (the hyperpyrexia), the pulse seldom exceeding 95, great thirst, profuse acid sweats, scanty, high colored, acid urine, at times showing traces of albumin, 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 7niliaria rubra, red papule and 7niliaria alba, the result of irritation at the orifices of the perspiratory glands, from the excessive sweating. The local phenomena are pain, tenderness, increased heat, swelling and redness of one or more joints; if but one joint, it is termed monoarthritis, if more than one, polyarthritis. Pain is aggravated by 77iotion 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 152 PRACTICE OF MEDICINE. disease, but cases running a subacute course may be mistaken for acute rheumatoid arthritis, gonorrhceal 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. Pya7nia is usually manifested at a single joint at the time, and is followe'd 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 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. Wannth is as imperative, for which purpose the patient should be kept in blankets—no sheets—and wear woolen garments. The diet should 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.,..........f3iss Spts. aetheris nitrosi,...........rr^xx Syr. simplicis,.............Tt^xv. Every three hours, well diluted. Or— R. Sodii salicyl.,..............3ij Sodii bicarb...............3 iv Aq. menth. pip., ............f ^ij Aq. destillat,..............f'gij. M. Sig.—One tablespoonful every three or four hours. Omit the soda as soon as urine becomes alkaline. If benefit follows, the evidence is quickly afforded in the relief ofpain ACUTE GENERAL DISEASES. 153 and the decline of the temperature and swelling. If, therefore, after three or four days' use of the salicylates or acidum salicylicum, as above recommended, signs of improvement are wanting, the treat- ment had better be changed for the alkaline treatment, which consists in the administration of an ounce and a half of the alkaline carbon- ates, either alone or with a vegetable acid, each twenty-four hours until the urine becomes neutral or alkaline, when the quantity is reduced to an amount sufficient to maintain alkaline urine, to wit:— R. Potassii bicarbonatis,...........31J Acid, tartaric,.............gr. xxx. Dissolved in a glass of water and drank effervescing, every three hours. Or— R. Potass, bicarb.,.............3 ij Succi limonis,.............f 3 iv Aquae cinnamomi,.....ad.....f3ss- M. SiG.—In water, every three hours. After the more acute symptoms are passed, change either of the above for tinct. ferri chlor., gtt. xx every four hours, well diluted, or full doses of Basham's mixture. Pale, feeble and anaemic patients, or attacks following scarlatina, are most favorably influenced with— R. Tinct. ferri chlor.,............gtt. xx-xxx Syr. limonis,..............gtt. xx Aquas,........ad........f 3 j. M. SiG.—Every four hours, in glass of water. Or— R. Acid, salicylici,.............Bv'*j Ferri pyrophos., . ...........■ B*v Sodii phosphat.,.............3 iij Aquae font, ..............fgij. M. Sig.—Dessertspoonful every three or four hours. Prof. DaCosta reports a lessened proportion of cardiac complica- tions with ammonii broi7iidum, gr. xv-xx, every four hours. Subacute attacks and lingering cases are favorably influenced by R. Lithii salicylatis,............gr. xv-xx Syr. zingiberis,............f.3J Aq. lauro-cerasi,............fgj. M. Every four hours. 14 154 PRACTICE OF MEDICINE. Good results follow, in a fair number of cases, salol, gr. v-x, every four hours, also from antipyrine, gr. xv, every three or four hours. Whichever plan, acidum salicylicum, salicylates, alkaline or ferrum, is adopted, quinina, gr. xij-xx, per day, should also be used. Pain and restlessness should be controlled by opium in some form, in full doses, or atropina, gr. g^, hypodermically. For the hyperpyrexia, quinina, gr. xxx-lx repeated p. r. n., with the cold bath or 7vetpack. Locally, the affected joints should be wrapped in cotton-wool or flannel, saturated with a solution of tinctura opii, one part, and liq. plumb, subacetat. dil., two parts, or— R . Sodii bicarbonatis,............3 ij Tinct. opii,...............f o ss Aquae bul.,...............Oij. M. Dr. Bartholow finds the application of blisters an effective method. He says, " I have small blisters, the size of a silver dollar, placed around the joint, leaving an interval between for succeeding applica- tions. It is by no means so painful and disagreeable as it appears at first sight. The blisters remarkably relieve the pain, bring about a more alkaline condition of the blood, and render the urine less acid, or bring it to neutral, or even to alkaline." The complications are to be treated according to their character. MUSCULAR RHEUMATISM. Synonyms. According to location, to wit: cephalodynia; lum- bago ; torticollis; pleurodynia. Definition. An affection of the voluntary muscles, inflammatory in character, either acute or chronic ; characterized by pain, tender- ness, and stiffness of the affected muscles. It is never complicated with cardiac disease. Cause. A disease of adult life. One attack predisposes to another. Almost always due to cold and damp, or direct draught of cold air. Gout increases the tendency to attacks. Pathological Anatomy. The true nature of muscular rheuma- tism is not yet determined. Virchow suggests a "hyperaemia of, and scanty serous exudation between, the muscular striae, and in chronic cases inflammatory proliferation of the connective tissue." ACUTE GENERAL DISEASES. 155 Symptoms. The first attack is generally acute. Onset rather sudden, with pain in the affected muscles, with slight tenderness, and considerable stiffness, and difficulty of movement, by which also the pain is increased. The suffering may be severe and constant, or only on motion. Spasm of the affected muscles may occur. Objective symptoms are wanting, except it is evident that the patient keeps the affected muscles as quiet as possible. Fever is absent. The pain may pre- vent sleep. Duration, acute form, about one week. Chronic returns frequently, and finally becomes constant and aggravated when the weather is damp. Varieties. It may affect any or all of the voluntary muscles, but its most frequent and important varieties are:— I. Cephalodynia. Situated in the occipitofrontal muscle. Distin- guished from neuralgia of the trifacial, or occipital nerve, by pain on both sides of the head, excited or aggravated by movements of the muscle, and by absence of disseminated points of tenderness. The muscles of the eye may be affected, and movements of that organ excite pain. If the temporal and masseter muscles are at- tacked, mastication excites pain. 2. Torticollis. Wry neck, or stiff neck. Situated in the sterno- mastoid muscles. Generally limited to one side of the neck, toward which side the head is twisted, great pain being excited on attempt- ing to turn to the opposite side. Rheumatism of the muscles of the back of the neck, cervicodynia, may be mistaken for occipital neu- ralgia, 3. Pleurodynia. Situated in the thoracic muscles, and may be mistaken for pleuritis, or intercostal neuralgia, from which it is differ- entiated by the absence of the diagnostic features of each. Pain is excited by forced breathing, coughing and sneezing. 4. Lwnbodynia or lu77ibago. Situated in the mass of muscles and fasciae which occupy the lumbar region. Most common variety. Usually affects both sides. It may set in rapidly and become very severe. Motion of any kind aggravates the pain, often becoming very sharp or stabbing in character. It is sometimes complicated with acute sciatica, when the suffering is agonizing. Diagnosis. The different varieties may be mistaken for any of the following ailments, to wit: trifacial, occipital or intercostal neu- 156 PRACTICE OF MEDICINE. ralgia, pains of progressive muscular atrophy, syphilis, metallic poi- sons, or painful affections of the loins, arising from calculi or gravel in the kidney. A careful examination of the history is usually sufficient to arrive at a correct diagnosis. Prognosis. Difficult to eradicate, and in chronic cases to amelio- rate ; but is not dangerous to life. Death never results. Treatment. Rest is the first indication. This is accomplished in pleurodynia by firmly strapping the affected side with broad strips of plaster, extending from mid-spine to mid-sternum. The local application to the affected muscles of hot poultices, made of two-thirds pilocarpus leaves, and one-third flaxseed meal, changing them every two hours, is, in the opinion of the author, the most rapidly successful treatment in acute cases. Internally, sodii salicylal., gr. xv-xx, every two or three hours, is a most valuable remedy. Prof. Bartholow declares that lit hit bromidu7n is almost a specific in muscular rheumatism. For the pain, and consequent-sleeplessness, use— R . Pulv. ipecac et opii,...........gr. x Potass, nitras,..............gr. v-x. M. Sig.—In powder, morning and night. Or, hypodermically, at the seat of pain, 77iorphina, gr. yi-%, and atropina, gr. g1^, p. r. n. The following liniment is valuable in many cases:— R. Quininae sulph.,.............gr. xl 01. gaultheriae,.............f Jj j Lin. saponis co.,.............f^'ij- M. SiG.—Thoroughly applied several times a day. In attacks where the disease is limited to a few muscles, the follow- ing liniment is valuable :— R .* Chloral hydrat., Camphorae,....... . . aa.....^ss M. et adde Lanoline,................gj. M. SiG.—Apply locally. Chronic cases: Rest, flannel worn next to the skin, stimulating and anodyne liniment, mild galvanism, dry heat, as ironing over the ACUTE GENERAL DISEASES. 157 affected part with a common flat-iron, a piece of paper, or towel, being placed next to the skin. Internally, potassii iodidui7i, ammonii murias, sulphur, guaiacum or arsenicum variously combined. RHEUMATOID ARTHRITIS. Synonyms. Arthritis deformans; rheumatic gout. Definition. An inflammation of the joints, accompanied with but slight fever, without suppuration, progressive in character, causing nearly symmetrical enlargement and deformity of various articula- tions. Causes. More common in females than in males, and in the weak and anaemic. Among the causes are bad hygiene, exposure, prolonged lactation, frequent pregnancies, menopause, grief, tuber- cular diathesis, and following attacks of articular rheumatism. Pathological Anatomy. It is not rheumatism, as the blood contains no lactic acid. It is not gout, as uric acid is not found in the blood nor urate of sodium in the joints. At first rheumatoid arthritis is attended with hyperaemia of the affected synovial membrane and increase of the synovial fluid. Soon the capsular ligament becomes irregularly thickened, the synovial fluid decreasing. If the process continue, the internal ligament is destroyed, thus allowing dislocations to occur. The inter-articular fibro-cartilages ulcerate and disappear, as do the cartilages covering the ends of the bones, the ends of the bones becoming smooth and eburnated, and often greatly enlarged. Symptoms. Either acute or chronic, the latter most common. Acute form involves several joints at the same time, and is attended with slight pyrexia. Chronic form slowly involves one joint, which seemingly soon recovers, and is attacked again, and may never recover, but grows progressively worse. The joint slowly enlarges, is painful, movement exciting neuralgic pains along the limb. Soon the articulation becomes rigid or slightly movable after prolonged attempts. Redness and tenderness are wanting. Crepitation is distinct after ulceration has destroyed the cartilage. 158 PRACTICE OF MEDICINE. The hands are first involved, the disease spreading symmetrically from articulation to articulation, until in severe cases every joint is deformed. Diagnosis. Chronic articular rheui7iatis/n is often confounded with rheumatoid arthritis ; but the former lacks the marked structural changes and the progressive involvement of joint after joint. Gout differs from rheumatoid arthritis by the presence of deposits of urate of sodium in the joints, the ears, tips of fingers and the bursae over the olecranon process of the elbow, the presence of uric acid in the blood, and the decided history of acute paroxysms. Gonorrheal rheumatis7n, so-called, has symptoms akin to rheu- matoid arthritis, but the history of urethral suppuration clears up the diagnosis. Paralysis agitans, when pronounced, might be confounded with rheumatoid arthritis, if the examination were limited to the joints, but the whole history, such as the tremor, the gait, etc., should pre- vent error. Prognosis. If early treatment be instituted, the disease may be held in abeyance for several years. After pronounced structural changes have begun, the malady is incurable, although it may remain stationary for a long time. Treatment. If treatment be instituted before serious structural lesions have occurred, the author has seen benefit in many cases by the following treatment: Oleum 7norrhua carefully and thoroughly rubbed into the affected joints, three times a day, with the internal use of lithii citras effervescentes 3J, three times a day, and the follow- ing tonic mixture:— R . Massae ferri carbonat,..........gr. v Liquor, potass, arsenit............X\v Vini xerici,...............3J Aqure,.................3J. M. After meals, well diluted, Sodii salicylicum is recommended early in the disease. Complete recoveries are reported from the long-continued admin- istration in small doses of liquor potassii arsenitis. Attention to diet and hygiene are also necessary. When structural changes have destroyed portions of the joint, palliative treatment is the only indication. ACUTE GENERAL DISEASES. 159 GOUT. Synonyms. Podagra, gout in the foot; chiragra, the hand ; gonagra, the knee. Definition. A constitutional disease, usually inherited; charac- terized by the sudden occurrence of a paroxysm of severe pain and swelling in one of the smaller joints—the great toe usually—with the presence of uric acid in the blood, and the deposit of the urate of sodium in the structure of the joint. Causes. Predisposing; inherited; male more than female— women after menopause. Exciting. Malt liquor and wine drinking, whether male or female; large consumption of animal food; lead poisoning; winter season. When inherited tendency, may begin early in life; when acquired tendency, after thirty-five years. The pathological cause consists in the presence of an excess of uric acid in the blood, in the form of urate of sodium. Pathological Anatomy. Gout is characterized by the deposit of urate of sodium from the blood into the structure of joints and tissues that are not very vascular. The deposit is associated with signs of inflammation, to wit: hyperaemia, redness of the surface, with swelling and effusion in and around the affected joint. The surfaces of the joint are incrusted with chalk-like masses, consisting of urates, which become greater with each attack, finally causing great deformity. The deposit usually begins in the metatarso-phalangeal joint of the great toe, but other and many joints are soon affected. The deposits may also be found in the knuckles, eyelids, and car- tilages of the ear. " Crystals of urate of soda are deposited in the tubules and intra- tubular tissues " of the kidneys—" gouty kidney "—and may be seen by the naked eye, the kidneys becoming small, granular and fibrous. Hypertrophy of the left ventricle and of the arteries, ending in atheromatous changes, are results of gout. Symptoms. Acute gout is rare in the United States. It occurs in paroxysms; one year's interval between the first and second attack ; six months usually between the second and third, after which it may occur at any time. Prodromes usually precede the paroxysm for several days, to wit: acid dyspepsia, constipation, headache and lassitude. 160 PRACTICE OF MEDICINE. The paroxysm begins suddenly, between midnight and 2 A. M., with acute pain in the ball of the great toe, which becomes red, hot, swollen, and so sensitive that the slightest touch cannot be borne. The veins are filled, the foot, ankle and leg swollen, and the limb the seat of sudden spasmodic contractions, which increase the suffer- ing ; slight relief is afforded by elevating the limb. Associated with the local symptoms are, chill, fever, quickened pulse, thirst, coated tongue, constipation, and scanty, acid, high-colored urine, which de- posits, on cooling, a heavy brick-dust sediment. Towards daylight the symptoms ameliorate, to return again at sun- down, the severity gradually lessening, until the fourth or fifth day, when convalescence is established, the patient, as a rule, feeling better than before the attack. Chronic Gout. . Either the result of acute attacks or with a greater number of joints being attacked. The paroxys7ns occur at any time, but develop slowly, with less pronounced local and general symptoms. Deposits are noticed, the joints becoming hard, knobby, and often distorted. The deposits or chalk-stones (urate of sodium) occur about the joints, tendons and bursae, and helix of the ear. Diagnosis. An error cannot occur if the history of the case can be obtained, to wit: hereditary tendency, age, sex (females rare, until menopause), mode of living, character of symptoms and presence of the characteristic deposits. Prognosis. Acute gout rarely fatal; is prone to return, but much depending upon the mode of living. Chronic gout decidedly shortens life. The most serious signs are those indicating advanced renal disease, with non-elimination of uric acid. Gout influences unfavorably the prognosis from acute diseases or injuries. Treatment. For the acute paroxysi7is at once, vinum colchici radicis, gtt. xv-xx-xxx, every two hours, well diluted, either alone or in combination with a potassa salt, or sodii salicylas, gr. xx, every three or four hours, well diluted, or Prof. Bartholow's pill, R. Colchicinae..... Ext. colocynth. comp Quininae sulph., . . Every two or three hours, gr- its gr. ss gr. iij. I ACUTE GENERAL DISEASES. 161 Or the following, recommended by Loomis :— R. Pulv. ipecac,..............gr. j Ext. colchici acet.,............gr. j Hydrargyri chlor. mite,..........gr. j Ext. aloes aq............t . . gr. j Ext. nucis vomicae,............gr. X- ^- Ft. pil. No. I. SiG.—Every three hours. For the pain, hypodermic injection of 77iorphina, and wrapping the inflamed joint in cotton wool saturated with liq. plumb, sub-acetat. dil. and tinctura opii. The diet must be restricted to liquid food. For chronic gout, regulated diet, free action on the secretions, and lithii citras effervescentes, 3j, three or four times a day, well diluted with water; and perhaps a course of quinina, ferrum and arseni- CU771. To prevent paroxysm, keep secretions acting, by the free use of pure water or a good alkaline water, especially the Saratoga Vichy. The diet is of the greatest importance, and should consist chiefly of vegetables and fruit, excepting tomatoes and strawberries ; fresh meat may be used once a day, as may oysters, fish and soups. Alco- holic and malt liquors are contraindicated, as are tea and coffee; skimmed milk should replace all the above. No eggs or dishes containing eggs, no pastry, hot bread or cakes, no sweetmeats, spices or condiments. Systematic exercise, especially walking, is of great advantage. Cold bathing, with caution, while the vapor or Turkish bath are of benefit. Changing from a cold to a warm climate in winter, and the use of flannel under-clothing, are strongly recommended. LTTTLLMIA. Synonyms. Lithiasis; uric acid diathesis; half gout. Definition. A condition in which the fluids of the body are satu- rated with nitrogenized waste, in the form of lit hie or uric acid; char- acterized by marked dyspepsia, various nervous phenomena, muscular and articular pains, bronchial catarrh, all or any of these associated with scanty, high-colored, acid urine. 162 PRACTICE OF MEDICINE. Causes. High living, with little exercise; imperfect digestion of nitrogenized food; impaired elimination of uric acid. Symptoms. Those of dyspepsia associated with irregular bowels, scanty, high-colored, acid urine, sp. gr. 1.024-1.028, containing neither sugar nor albumin, but showing an increased proportion of urates. Also, depressed spirits, impaired me77iory, loss of interest in occupa- tion, sleepless nights, attacks of vertigo, neuralgic pains in the head, and a constant dread of apoplexy or cerebral disease. Also, pains in the joints, neuralgic in character. If the condition be allowed to continue, the following organic changes may result, to wit: fatty heart; fibroid kidney; enlarged liver, or changes in the cerebral vessels. Diagnosis. From gout, by the absence of acute paroxysms and resulting changes in the joints, Prognosis. If properly recognized and treated, complete recovery will result, although it is a disorder of long duration. If not properly treated, develops some one of the organic diseases mentioned. Treatment. Regulate diet, using fresh meat once daily, poultry, game (plainly cooked), fresh fish, oysters, occasionally eggs, lettuce, spinach, celery, cold slaw and tomatoes; avoid all stimulants, tea and coffee, using milk, skimmed milk or milk and cream. Act freely on all the secretions. Systematic exercise. Avoid tonics, bromides, chloral and opium. Long course of alkaline waters. Good results follow lithii citras, gr. xx, t. d., sodii phosph., gr. xxx, ter die, or acidui7i benzoicum,gx. x, t. d., all well diluted with water. The author strongly urges the use of acidum nitricu77i dilutum, gtt. x, in half a glass of water, four times a day, with the occasional use of pilule rhei composita at bedtime. DIABETES MELLITUS. Synonyms. Glycosuria; melituria. Definition. A chronic affection characterized by the constan presence of grape sugar in the urine, an excessive urinary discharge, and the progressive loss of flesh and strength. Causes. Most common in males. Occurs at all ages, but most frequently between twenty-five and fifty years. It is often hereditary. ACUTE GENERAL DISEASES. 163 Disorders of the nervous, hepatic and renal systems. Excessive use of farinaceous food and malt liquors. Sexual excesses. The exact pathology of diabetes mellitus differs in different cases, and in the present state of our knowledge no exclusive view can be adopted. Still, there are reasons for believing that, in a large pro- portion of cases, the nervous system is primarily at fault, though the character of the lesions may differ. Pathological Anatomy. None peculiar to diabetes are yet recognized. Hyperaemia and hypertrophy of the liver and kidneys are gener- ally present, the result of increased functional activity. The changes in the lungs peculiar to phthisis are often found in very chronic cases. The changes in the nervous system are not fully determined. Symptoms. Clinically cases differ greatly in their course and severity; one class presenting slight symptoms and a chronic course; another class having marked local and constitutional symptoms and an acute course. The symptoms of a typical case may be arranged under the following heads:— Urinary Organs a7id Urine. Micturition more frequent and the urine increased in quantity. Pain over the region of the kidneys. The quantity of urine may amount to 4, 8, 12, 20 or 30 pints in twenty-four hours. It is usually pale, clear and watery, having a sweetish taste and odor, the specific gravity ranging from 1.025 t0 1.050. It ferments rapidly if kept in a warm place. It yields grape sugar to the usual tests, the amount present varying from an ounce to two pounds in the twenty-four hours. The urea and uric acid are increased. Albumen may be present. The increased passage of a large quantity of saccharine urine causes a constant itching, burning and uneasy sensation at the prepuce, along the urethra, and at the neck of the bladder; in females, itching and eczema of the vulva are common ; in children, incontinence of urine is frequent. Digestive Organs. An almost constant symptom is thirst, with a dry and parched condition of the mouth. At times the appetite is excessive, again absent. The breath may have a sweetish odor, the tongue irritable, red and often cracked. Dyspeptic sympto/ns are common, and occasionally vomiting. The bowels are constipated, the stools pale and dry. At times diarrhoea may occur. 164 PRACTICE OF MEDICINE. The patient complains of feeling very weak, languid, and of sore- ness and pain in the limbs, there is more or less emaciation, a harsh, dry skin, the countenance distressed and worn. The mind is often greatly altered; depression of spirits, decline in firmness of character and moral tone, with irritability, are present. Sexual inclination and power are diminished. Defects of vision are present. The blood and various secretions contain sugar. Complications. Pulmonary phthisis ; Bright's disease; defects of vision from atrophy of the retina or the formation of a soft cataract; boils and carbuncles, and chronic skin affections, such as psoriasis and eczema. Course. The clinical history varies in different cases. In the majority of instances the course is chronic, lasting for years, the symptoms beginning insidiously, and becoming progressively worse, with, at times, decided remissions. Occasionally the disease runs an acute course, death occurring within four or five weeks. Termination. The majority of cases ultimately prove fatal, the symptoms markedly changing, the urine and sugar diminishing in quantity, the occurrence of albuminuria, disgust for food and drink, and the development of hectic fever or colliquative diarrhoea. The fatal result usually arises from gradual exhaustion, from blood poisoning, leading to stupor, ending in co7nplete coi7ia, or occasionally to deliriu77i or co7ivulsions, or from complications. Rarely, death occurs suddenly, from ura7nic convulsions or uramic coma. Diagnosis. Diabetes mellitus only exists when grape sugar is permanently present in the urine. " It is not the quantity, but the persistence of sugar which constitutes diabetes." When are present grape sugar in the urine, with more or less increase in the urinary flow, it can be mistaken for no other affection. From Bright's diseases, by the absence of dropsy, and of tube casts in the urine; the amount of albumin in the urine is never so great or constant in diabetes mellitus as in Bright's diseases. From Diabetes Insipidus, by the absence of sugar in the blood and urine, and the larger quantity of urine voided in polyuria. Simple glycosuria differs from diabetic glycosuria in that the amount of sugar in the urine is not constant—at one time being present, at another absent—the amount of urine voided is never in excess of ACUTE GENERAL DISEASES. 165 health; simple glycosuria is a disease of the aged ; diabetic glycosuria usually appears under fifty years. Simple glycosuria often results from the inhalation of chloroform, the use of chloral, in the insane, from excitement, or the result of injuries to the head. Prognosis. Most unfavorable as regards a cure, it being fairly questionable if complete recovery has ever occurred in a typical case. Still, decided amelioration may take place in the symptoms, and the progress of the malady be greatly retarded. The younger the patient, the more rapid the fatal termination. Treatment. Impress upon patients the importance of a strictly regulated diet. Prohibit or restrict the consumption of such articles as contain sugar or starch, especially ordinary bread or flour, sugar, honey, potatoes, peas, beans, rice, arrowroot, cracked wheat, oat meal, turnips, beets, corn and carrots ; prunes, grapes, figs, bananas, pears, apples, and liquors of all kinds whether distilled or fermented. The main diet should be of animal food, including meat, poultry, game and fish. A moderate amount of fluids should be allowed, and in a majority of cases milk will prove beneficial, although, theoretically, contra- indicated. Tea, coffee and cocoa, without sugar, may be allowed in moderation, glycerin or saccharin being used as a substitute for the sugar. Regulated exercise is of importance. The patient should wear flan- nel, and have two or three warm baths every week, or an occasional Turkish bath. Therapeutical Treat7nent. It is difficult to estimate justly the action of any drug in this disease, for, as is so well known, a proper modi- fication of the diet will alone produce the most marked improvement. Opium exercises an influence over the excretion of sugar, but the effect is not maintained in all cases. Pavy strongly urges the use of codeia in doses of gr. yi-W), three times a day. The use of morphina hydrochloras, gr. j daily, or pulvis opii, gr. iij-v daily, or codeina, gr. v-x-xv daily, I have seen of some value. Prof. DaCosta suggests the use of ergota, which has decreased the urinary discharge and the quantity of sugar in a number of cases. Prof. Bartholow has met with an apparent cure by ammonii carbonas. The author has met with decided partial success with uranii nitras, gr. j-iij, three times a day, the cases not yet being under observation a sufficient length of time to pronounce them cured, although in two the urine has been 166 PRACTICE OF MEDICINE. diminished from three quarts per day to normal, the quantity of sugar from nine ounces to less than half an ounce, in the twenty-four hours. Liquor bro7nidum arsenitis, xc\, iij-v three times a day often gives good results. Dickinson remarks that "strychni7ia is, of all remedies, the most constantly useful." Potassii bro7nidu7/i, 3j during the twenty-four hours is strongly urged. The following remedies are recommended by different ob- servers, to wit: pepsinum, liquor potassii arsenitis, iodum, potassii iodidu7n, sodium salicylas, acidum lacticu77i, glycerinum, quinina and ti7ictura camiabis indica. The evidence in favor of the majority of these drugs is far from satisfactory. Symptomatic treatment is mostly called for. For emaciation and anaemia, ferrwn and oleum morrhua; for sleeplessness and restless- ness, morphina, potassii bromidui7i, chloral, or hyoscyamia. For boils and carbuncles calcii sulphide. Duchenne suggests the following solution for the excessive thirst of diabetic patients :— R. Potassii phosphat., .... two parts Aquae..........seventy-five parts. Sig.—One teaspoonful twice or thrice daily, in wine or hop tea. The dyspepsia and lung symptoms must be managed on general principles. The constant galvanic current'has been productive of good results. A change of scene and air is beneficial. Surgical operation should on no account be undertaken on diabetic patients. DIABETES INSIPIDUS. Synonyms. Polyuria; polydipsia. Definition. An affection characterized by the habitual discharge of a very large quantity of pale, watery urine, free from albumin and sugar. Causes. Occasionally hereditary, or diabetes mellitus may have existed in the parent; more common in children or young adults; men are more liable than women; injuries and diseases of the nerv- ous system; exposure to cold; drinking freely of cold water; fatigue ; prolonged debility; malaria; syphilis. The probable immediate cause of the excessive flow of urine con- sists in dilatation of the renal vessels, the result of paralysis of their ACUTE GENERAL DISEASES. 167 muscular coat, caused by derangement of innervation, as the con- dition can be induced experimentally by irritating a spot in the fourth ventricle, or by section of portions of the sympathetic nerve. Symptoms.—The affection is characterized by great thirst, with an increased flow of pale, watery, slightly acid urine, the amount varying from one to five or six gallons in the twenty-four hours. The specific gravity ranges from 1.001-1.007. Sugar and albu>7iin are absent. Urea and the other solids are increased. The appetite is voracious, the bowels are obstinately constipated, and the skin is dry and harsh! The large flow of urine is usually preceded by various nervous phenomena as nervousness, irritability, inability to conce/itrate the mind, vivid imagination, failure of memory, and headache. Unless the affection is soon arrested great loss of flesh and strength result. Diagnosis. It differs from diabetes mellitus by the absence of grape sugar in the urine. From paroxysmal diuresis, by the absence of the increased urine permanently. From interstitial nephritis, by the greater amount of urinary dis- charge and the absence of albumin, oedema, etc. Prognosis. Rather unfavorable as to a radical cure, unless caused by syphilis. Death rarely is due to the diabetes, but to some inter- current malady that the patient has been unable to withstand, on account of the weakness produced by the diabetes. Treatment. If due to syphilis,potassii iodidum and hydrargyrum are of real benefit. Prof. Da Costa has had success with ergota in the form of the fluid extract or the aqueous extract. Pilocarpus has been used with success. Prof. Bartholow recommends galvanis7n in cases not cured by potassii iodidum, placing " one electrode to the neck below the occiput, the other to the hypochondriac regions in turn." Valerian and potassii bromidu>7i have been used. The author has effected a cure in three cases, where other remedies had failed, by the use, internally, of— R. Strychninae sulph.,.............gr. JL Acid, hydrochlor. dil.,...........rt\,x Aquae lauro-cerasi, ..... •z\\. M Well diluted. The obstinate constipation is best overcome by pilula cathartica co77iposite, one at bedtime. 168 PRACTICE OF MEDICINE. CHOLERA. Synonyms. Epidemic cholera; Asiatic cholera; malignant cholera; spasmodic cholera. Definition. An acute, specific, infectious disease, epidemic in the majority of, although endemic in other, localities ; characterized by the transudation of serum into the stomach and intestinal canal and violent purging of a peculiar, rice-water-like fluid, the persistent vomiting of a similar material, severe muscular cramps, and a condi- tion of prostration, followed by collapse and death, or of a reaction from the collapse and the development of the typhoid state {cholera typhoid). Causes. A specific poison, probably the "comma bacillus" of Koch. Cholera is but feebly contagious, in the usual acceptation of that word, but it is unquestionably infectious. The evidence seems conclusive that the cholera stools axe the main, if not the only, channel of infection, and that the great cause of the propagation of cholera is the contamination with the stools of the water used for drinking purposes. Milk may also be the vehicle by which it spreads. Little, if any, danger exists from being in the pres- ence of the affected, although the emanations from the cholera excreta in the atmosphere may generate the disease if swallowed or inhaled. The dead bodies of cholera subjects apparently possess slight infec- tive property, "the bacteria of decomposition" probably destroying the cholera germs. One attack does not afford protection against another. The period of incubation is short, under a week, usually. Pathological Anatomy. This is, as yet, far from satisfactory. The morbid appearances in the majority of cases of death from chol- era may be thus summarized : The temperature generally rises after death, the body remaining warm for a considerable time. Rigor mortis rapidly ensues, the muscular contractions being often so pow- erful as to displace and distort the limbs. The skin is mottled and the body greatly shrunken. The blood is darker in color, thick, viscid, feebly coagulable, and slightly acid. The arteries are quite empty of blood, the veins, on the other hand, are distended. The organs are, as a rule, pale and shrunken. The stomach and intestinal mucous membranes are congested, and present evidence of extravasations and ecchymoses, or are bleached ACUTE GENERAL DISEASES. 169 and pale. The stomach and intestines usually contain a quantity of whey-like material, having an alkaline reaction, as well as quantities of cast-off epithelium and the peculiar bacillus. It is thought by many that the stripping-off of the epithelium is a post-mortem phe- nomena. The Peyer's, solitary and Brunner's glands are usually enlarged and prominent, and occasionally evidences of ulceration are apparent in the solitary glands, and sections placed under the microscope show the " comma bacillus." The villi of the mucous membrane, as well as the epithelium of the small intestines, are stripped off, leaving the basement membrane, for the most part, exposed. The liver is more or less advanced in fatty degeneration, presenting a somewhat mottled, yellowish discoloration. The kidneys are congested, the epithelium of the tubules granular and detached from the basement membrane, blocking up the tubes. Prof. Bartholow observed, in all of his autopsies, "considerable hyperaemia and dila- tation of the vessels of the medulla oblongata. The constancy of this lesion would seem to indicate a relationship between congestion of the medulla and the cramps." Symptoms. In accordance with the law of epidemic infectious diseases, the onset, course and character of the symptoms vary in different cases and at different periods in the same epidemic. The disease may either set in suddenly in a patient previously in good health, or it may follow an attack of rather severe and persistent diarrhoea, with pain, nausea, vomiting a7id depression. Such cases are termed Cholerine, the stools of which are infectious. In a typical case there are three stages : first, diarrhoea; second, prostration ; third, collapse, or, in favorable cases, reaction. First Stage. Begins with chilliness, excessive thirst, coated tongue, unpleasant taste in the mouth, slight abdominal pain, and three or four copious, watery, yet fecal stools during the day, and a decided feeling of weakness, the stools rapidly becoming whey-like, easily voided, but with force, and only slight pain. Second Stage. The stools rapidly increase in number, are voided with a rushing force, and consist of many quarts of grayish, or whitish, rice-water-like fluid, accompanied with forcible vo77iiting, first of the contents of the stomach, mixed with more or less bilious matter, afterward of the peculiar rice-water-like material; thirst becomes most intense, increasing or diminishing with the variations in the 15 170 PRACTICE OF MEDICINE. number of the vomiting and stools; severe 77iuscular cramps soon fol- low, most severe in the calves, although occurring in all parts of the body. Third Stage. The stools, vomiting and cramps continue. The ap- pearance of the patient becomes frightful; the eyes are sunken and surrounded by blackened rings, the nose pinched and pointed, the cheeks hollow, and the lips blue (facies cholerica) ; the surface cold and moistened with a sticky perspiration ; the skin of the hands and fingers have the sodden appearance of the " washerwoman who has washed all day," and if picked up in folds, the fold but slowly dis- appears. The temperature rapidly falls, the pulse becomes small and compressible, barely perceptible at the wrist, and the heart beats are scarcely recognizable. The voice is weak, husky and sepulchral (vox cholerica), the tongue is like ice, the breath is cold and icy, the urine markedly diminished and albuminous. The mind is not cloudy, but most patients are apathetic and indifferent to their danger. This, the algid stage of cholera, or cholera asphyxia, usually terminates in death in from three to twelve, twenty-four or forty-eight hours, but reaction may be established. Stage of Reaction. The temperature of the body rises, the pulse gradually becomes fuller and stronger, the countenance becomes brighter, the stools less frequent and more fecal, the vomiting de- creases, the thirst lessens, the urine increases in amount, but.con- tinues albuminous, the patient entering a slow convalescence, or typhoid symptoms develop, the so-called cholera typhoid, which pro- longs the recovery for several weeks. Convalescence is often prolonged and complicated by the develop- ment of severe bed sores, boils, bronchitis, pneumonia or parotitis. Sequelae. Suppuration of the parotid gland; painful tetanic con- traction of the flexor muscles of the limbs; abscesses or ulcers of the limbs; profuse sweats; roseola, erythema, urticaria, and rarely vesicular eruptions. Diagnosis. The epidemic character, and rapid spreading, and great mortality of the affection prevents its being mistaken for any other disease, although isolated cases are often confounded with cholerine or with cholera morbus, the points of distinction being few, unless the "comma bacillus" only be found in the stools of true cholera. ACUTE GENERAL DISEASES. 171 Prognosis. Very unfavorable, the mortality ranging from twenty to eighty per cent. The last epidemic in this country was much milder than former ones. The prognosis is controlled by the general condition of the patient, the age, habits and the development of the algid stage; the prognosis being more favorable in those cases which develop gradually than in those in which it reaches its acme at a single bound; the very young or very old, those addicted to the various excesses and surrounded by unfavorable hygienic conditions, are more apt to perish than are others. Treatment. The success depends, to a great extent, upon its prompt and early treatment, for experience amply attests that the arrest of the disease in the diarrhceal stage is comparatively easy, and that in the stage of collapse its cure by any means whatever is altogether an exceptional occurrence; therefore, during the prevalence of cholera the mildest cases of diarrhoea ought to receive prompt treatment, for many cases have their beginning as a mild diarrhoea. It must not be overlooked that intelligent nursing and regimen are equally as important as medical treatment. First Stage. The remedy of all others is opium in some form, to which may be added, with benefit, plumbi acetas, in doses of gr. iij-v, repeated p. r. n., or acidu77i sulphuricum dilutum combined with tinctura opii deodorata, and at the same time applying mustard over the abdomen. Water and food should be used with great caution, but ice is indicated in unlimited amounts, and at times iced dry chai/ipagne. The patient must be kept quiet, in bed. Ziemssen says : " Calomel has the first place of all drugs which have been recommended in the prodromal stage. Begin with two or three doses of gr. vij, followed with small doses—gr. }(—every two hours." Second Stage. The opiian treatment should be continued, together with the free use of stii7iulants. For the distressing vomiting, ice, iced champagne, acidum carbolicwn or acidu77i hydrocyanicui7i may sometimes give relief. Locally either continue the mustard application to the abdomen or the constant use of rubber bags filled with boiling water, or cold cloths. For the crai7ips, hot water in bottles, hot irons or bricks applied over painful parts, or an ointment of chloroform or chloral, chloroform or ether inhalations, or the use of the following hypodermic solu- tion, strongly recommended by Prof. Bartholow:— 172 PRACTICE OF MEDICINE. R. Chloral,................3 iij Morphinae sulph.,............gr. iv Aq. lauro-cerasi,............f(^j. M. SiG.—Fifteen to thirty minims each injection. For the collapse, heat to the surface and the free use of stimulants, or spiritus fru77ienti, or spiritus vini gallici, hypodermically, also the hot, and, in some cases, the cold bath has been of advantage ; the intravenous injection of saline fluids was unusually successful during the 1884 epidemic in France, and as the 7nodus operandi becomes more perfect, its success will be the more marked. If reaction occur, treat indications as they arise, and use tonics, such asferrum, quinina and arse7iicum. All the discharges from the patient should be thoroughly disinfected as soon as voided, and the stools and vomited material buried. TRICHINOSIS. Synonyms. Trichinae ; Trichina spiralis ; " flesh-worm disease." Definition. A typhoid condition, the result of the entrance of a parasite—the Trichina spiralis—into the intestinal canal, and their subsequent migration into the muscular structure: characterized by severe gastro-intestinal irritation, severe muscular soreness, and a low typhoid condition. Cause. The Trichina spiralis are introduced into the human body by eating the infected hog's flesh, either raw or but imperfectly cooked. Description. The parasite is found in two forms, to wit: intes- tinal trichina, which is sexually mature, and 7nuscle trichina, which is sexually immature. The intestinal trichina is a small, hair-like worm, the male meas- uring y\ of an inch, and the female y% of an inch in length ; the head is smaller than the rest of the body ; the tail of the male has a bi-lobed prominence, between the divisions of which the anal opening is placed, and from which a single spiculum can be protruded; the female has a blunt, rounded tail, the reproductive outlet being situated toward the anterior part of the body; the ova are very small, containing embryos being produced viviparously at the rate of at least one hundred each week after the entrance of the female into the intestinal canal. ACUTE GENERAL DISEASES. 173 The 7nuscle trichina develops its sexual apparatus after it has entered the intestinal canal of the host. The viable embryos discharged from the female are in a state of motion, and at once migrate from the intestines to the muscular structure of the individual, and here set up inflammatory action, they becoming surrounded by a capsule or shell in which they are coiled. After a time, in the muscle, the trichina undergoes a further change; lime salts being deposited in and about the capsule and in the parasite itself, when minute specks of lime are seen distributed throughout the muscular structure. The development of the parasite from the period of impregnation up to the time of sexual maturity is, under favorable conditions, less than three weeks. Within two days from the ingestion of the infected pork occurs the maturation of the muscle larvae; in six days more the birth of embryos occur, and in about two weeks the migrating progeny have arrived at their habitat, the muscular structure. Symptoms. These depend upon the number of parasites in the infected food. According to Dr. Sutton, of Indiana, a piece of pork the size of a cubic inch contained eighty thousand trichinae. There are three stages described, to wit: the intestinal, the migration, and the encapsulation. Intestinal stage, a gastro-intestinal inflammation, with nausea, vom- iting, and a watery diarrhea, the severity depending upon the num- ber of the parasites ingested. Migration stage, a typhoid-like fever, rapid, feeble pulse, profuse sweats, intense thirst, dry tongue and lips, and red, swollen face, with soreness and tenderness of the 77iuscular structure, increased by any muscular act. As a rule the mind is clear but decidedly apathetic. Encapsulation Stage. If the number of parasites ingested have been few, recovery may occur in this stage, but if the number have been large, the gastro-enteritis, fever and muscular phenomena are severe, the patient is in a critical condition, between twenty and fifty per cent, succumbing. Diagnosis. Unless the physician has some intimation of the cause, cases are readily mistaken for either ordinary ileo-colitis or typhoid fever. Prognosis. Depends upon the number of trichina in the pork eaten. Mortality between twenty and fifty per cent. Treatment. The preventive treatment consists in eating no pork 174 PRACTICE OF MEDICINE. that has not been so prepared as to kill any trichinae that might exist. If the parasites have been recently taken, within the first four or five days, emetics and purgatives to remove them from the stomach and intestinal canal are indicated. After thorough action from these, at- tempts may be made to destroy such of the parasites as have escaped the action of the emetic or purgative. For this purpose much is said in favor of glycerini, one part, aqua, two parts ; or a trial can be made of acidum carbolicum and tinct. iodi, as suggested by Prof. Bartholow. Quinina gave the best results in the cases seen by Dr. Sutton. After 77iigration has begun the powers of life should be sustained by nourishing food, stimulants and tonics. DISEASES OF THE RESPIRATORY SYSTEM. PHYSICAL DIAGNOSIS. Physical Diagnosis is the art of discriminating disease by means of the eye, the ear and the touch. The signs thus ascertained are connected With changes or altera- tions in the form, density, or condition of the structures -within, and are known as physical signs. " Physical signs are, the7i, the exponents of physical conditions, and of nothing 77iore." The methods employed in the physical exploration of the chest, are:—I, Inspection; II, Palpation; III, Mensuration; IV, Percussion; V, Auscultation ; VI, Succussion. Percussion and auscultation, dealing with sounds, are of the greatest value clinically. For the purposes of physical exploration, the chest is mapped off into regions or divisions, as follows :— ANTERIORLY. First:—Supra-clavicular, Lying above the upper edge of the clavicle, usually about an inch in extent, DISEASES OF THE RESPIRATORY SYSTEM. 175 Second:—Clavicular, Corresponding to the inner two-thirds of the clavicle. Third :—Infra-clavicular, From the clavicle to the lower border of the third rib. Fourth :—Mammary, Between the third and sixth ribs. Fifth :—Infra-mammary, Downward from the sixth rib. LATERALLY. First:—Axillary, That portion above the sixth rib. Second : —Infra-axillary, That portion below the sixth rib. POSTERIORLY. First:—Supra-scapular, That portion above the scapula. Second:—Scapular, That portion covered by the scapula. Third:—Inter-scapular, That portion between the scapulae. Fourth:—Infra-scapular, That portion below the angle of the scapula. INSPECTION. Inspection signifies " the act of looking." Views of the chest should be taken from the sides and behind as well as from the front; for which purpose a good light should be obtained, and the patient be placed in as easy and comfortable a position as is possible. Inspection reveals the fonn, size, color, and 7>iovements of the chest, as well as the condition of the superficial parts. In health the sides of the chest are for the most part sy77imetrical'in form, size, color and movements, both sides rising equally during the act of inspiration, and falling equally during the act of expiration. During the act of inspiration the intercostal spaces in the lower two- thirds of the chest become more hollow, as also do the supra-clavicular fossae. Inspiration is almost entirely the result of muscular action ; expira- tion, on the other hand, is chiefly due to the elasticity of the lungs and chest walls, aided somewhat in forced respiration by muscular action. The movement of inspiration by inspection is of longer duration than that of expiration, and the pause between the acts but momentary. The respirato/y 7nove7nent is visible over the whole thorax, although in males and in children it is most distinct at the lower portion (inferior costal breathing), while in the female it is most distinct at the upper portion of the chest {superior costal breathing). 176 PRACTICE OF MEDICINE. PALPATION. By palpation is meant the application of the palmar surfaces of the hands and fingers to the chest, by which means we appreciate impressions which are capable of being conveyed by the sense of touch. The objects of palpation are :— First:—To give more accurate information regarding what is revealed by inspection. Second:—To locate spots of soreness, the density and condition of tumors, if any be present, the state of the chest walls, the frequency of the breathing, and the action of the heart. Third:—To determine the existence and character of the various kinds of frei7iitus (vibrations). By fremitus is understood certain tactile impressions or vibrations conveyed to the surface of the chest, which are classed and produced as follows :— First:— Vocalfrei7iitus, produced by the act of speaking or crying. Second:— Tussive fremitus, produced by the act of coughing ; of value especially when the voice is very weak. Third:—Bronchial fremitus, produced by the passage of air through mucus, blood, or pus, in the bronchial tubes, during the act of respiration. Fourth :—Friction fremitus, produced by the rubbing together of the roughened surfaces of the pleurae. When the normal chest vibrates lightly, it is termed the normal vocalfre7tiitus. The vocal fre77iitus is more distinct upon the right side toward the apex. It the lung be consolidated (denser), the vibration is greater and more easily distinguished,—the vocal fremitus is increased. In feeble persons, or when any cause interferes with the transmission of the vibrations, the vocal fremitus is di7ninished or absent. MENSURATION. Mensuration, or measurement of the chest, is of little practical importance, and hence seldom performed. The only measurement likely to be required is the circular or circutnferential, in different DISEASES OF THE RESPIRATORY SYSTEM. 177 parts of the chest, which is performed with either an ordinary gradu- ated tape measure or a double tape measure, made by uniting two tapes in such a manner that they start in opposite directions from the same point at the mid-spinal li7ie. The tapes drawn around each side until they meet at the mid-sternal line, on a line immediately- above the nipple, or on the level of the sixth rib near its attachment to the cartilage—the sixth costo-sternal joint—the patient first being directed to effect a complete expiration, the number of inches noted, and then to take a deep inspiration, the increase in inches noted, the difference between the two giving a rough estimate of the capacity of the lungs. In right-handed persons the right side is usually one-half to three- fourths of an inch larger than the left; if larger than this it is usually the result of some abnormal condition. In well-developed men the chest measures at the upper part about thirty-three to thirty-five inches during expiration, and is increased fully three inches upon inspiration. PERCUSSION. Percussion, or " The act of striking," to ascertain the composi- tion of structures, affords signs and information of great value in diagnosis. * There are two methods employed, immediate and 7nediate. Immediate, or direct percussion, is performed by striking the thorax directly with the points of the fingers or the palmar surface of the hand. This method of percussion has been generally abandoned, as it does not enable the physician to distinguish, with sufficient correct- ness, between the various shades of difference in the pitch or quality of percussion sounds. Mediate, or indirect percussion, may be practiced in three different ways, to wit:— First:—With the finger of one hand interposed between the body percussed and the percussing finger. Second:—With the finger acting as a pleximeter and the percussion hammer. Third:—With the percussion hammer and the pleximeter. The first of these modes affords the most correct and ready infor- mation regarding the resistance of the parts percussed. The skillful 16 178 PRACTICE OF MEDICINE. use of the fingers is more difficult to acquire than that of the plexi- meter and hammer ; but if the examiner has acquired sufficient skill in its performance, an absolutely accurate result may be obtained. " He who is skilled in digital percussion will be able to percuss equally well with the hammer, the inverse of which does not always hold good." In addition to being proficient in the technical 77iodus. ope- randi, it is necessary to possess a sensitive ear, educated to distinguish between the various shades of the sounds. When the fingers are employed, it is a matter of choice whether one or more fingers are used as the pleximeter. Usually the last phalanx of the first or second fingers of the left hand are used, the other fingers being raised from the chest, so as not to interfere with the sound vibratio7is; they should be applied firmly and eve7ily to the surface, thus preventing the slipping of the soft parts, and also to determine the resistance of the chest walls when the blow is given. The rounded ends of the first and second fingers of the right hand are used as a hammer, striking the pleximeter fingers in such a manner that the nails shall not touch the skin of the underlying fingers. The force employed varies in different regions, but usually, for the chest, should be only of moderate degree. Forcible percussion is of use only when the sound of deep-seated organs is desired. The stroke should be made perpendicularly to the surface and not slanting, as is too often done. The whole movement should proceed only from the wrist-joint, and ought not to be too rapid or unequal, or of great force, the fingers being rapidly withdrawn, so as not to interfere with the vibrations. The objects of percussion are to elicit certain sounds, and the amount of resistance or elasticity of the organs percussed. The main sounds elicited by percussion are the dull, clear and tympanitic. Familiarity with the intensity, character and pitch of each of these sounds is essential. When percussing the healthy chest, the sound obtained is termed the normal pulmonary resonance. It is of variable intensity, depend- ing upon the force of the stroke employed and the amount of adipose and muscular tissues covering the thorax, and the tension of the chest walls. There is no exact standard of the normal pulmonary or vesicular resonance, but if the two sides of the chest are compared, the normal standard of each person is obtained. DISEASES OF THE RESPIRATORY SYSTEM. 179 The character is termed pulmonary or clear, as characteristic of the healthy chest wall. The pitch is always relatively low. The sounds elicited by percussing a healthy chest are not, however, alike over all its parts. Anteriorly, the portion of lung above the clavicle yields a sound which becomes somewhat tympanitic as the trachea is approached. Over the clavicle the sound is clear and pulmonary at the centre of the bone, but at the scapular extremity it is duller, and towards the sternum it becomes somewhat tympanitic. At the infra-clavicular regio7i the resonance is clear and distinct, but little resistance being offered to the percussing finger, and the sound elicited may be taken as the type of the pulmonary resonance. In this region, however, a slight disparity exists between the two sides; on the right side the sound is less clear, shorter and of a higher pitch than on the left side. In the mammary region of the right side the resonance of the lung is not so clear, the sound being modified by the size of the mamma and the upper border of the liver. On the left side the heart deadens the sound from the fourth to the sixth rib, and in a transverse direction, from the sternum to the left nipple. This dull sound in the left mammary region is lessened in extent during full inspi- ration, and *in emphysema, when the lung more completely covers the heart. In the infra-mammary region on the right side the percussion note is dull, except during the act of complete inspiration, when the liver is displaced downward by the inflated lung. In the left infra-ma7n- i7iary region the sound consists of a mixture of the dull sound of the heart and spleen and of the clear sound of the lung, together with the tympanitic sound of the stomach. Over the upper part of the sternum—above the third rib—the sound is slightly tympanitic. Below the third rib, over the sternum, the sound is dull, due to the presence of the heart and liver. The position exercises some influence on the results of percussion. More accurate results are obtained when the patient is standing or sitting than when recumbent. While the front of the chest is per- cussed, the arms should hang loosely by the sides; the hands may be clasped across the top of the head during the percussion of the axillary region; during the examination of the back the head must be bent forward and the arms tightly crossed in front. 180 PRACTICE OF MEDICINE. On the posterior surface of the chest the sound also varies according to the part percussed. Over the scapula the sound is duller than between these bones or below their inferior angles. Over the infra-scapular region a clear sound is obtained as far as the lower border of the tenth rib on the right side, where the dullness of the liver begins. On the left side, below the angle of the scapula, the percussion sound is tympanitic if the intestines are distended, or it may be slightly dull if the spleen be enlarged. In the axillary region the sound is clear and distinct on each side. In the infra-axillary region of the right side the sound is duller, owing to the presence of the liver; at the correspondiug situation on the left side, the sound is clear or tympanitic, from the distention of the stomach, and at the ninth or tenth rib of the left axillary region dullness and the sense of resistance mark the location of the spleen. The sounds obtained by percussion of the unhealthy or abnormal chest are as follows :— First:—Hyper-resonance or an increase of the normal pulmonary resonance is due to the relative increase in the proportion of air to the solid tissues of the lung, providing the tension of the chest walls be not altered, occurring in emphysema of the lungs, atrophy of the lungs, or consolidation of the opposite lung. Second:—Dullness or an absence of resonance due to the relative increase of solid tissues in proportion to the amount of air, as seen in the different stages of phthisis, in pneumonia, or pleurisy. The pitch is increased or heightened in proportion to the diminution of the amount of the air and the increase of the solids. If there be entire want of resonance the percussion note is said to be flat; if there is a slight decrease in the resonance of the part the note is said to be impaired. The sense of resistance is greater, the more marked the consolida- tion of the lungs and the greater the tension of the chest walls. Third:—Ty77ipanitic, or the drum-like percussion note, is a non- vesicular sound having the character elicited by percussing over the normal intestines; wherever heard it indicates the presence of air in conditions similar to that of the intestines, to wit: inclosed in walls which are yielding, but neither tense nor very thick. When elicited over the chest it may be due to the transmitted DISEASES OF THE RESPIRATORY SYSTEM. 181 sound of the distended stomach or colon. It is obtained over the chest in pneumothorax, in moderate pleural effusions above the level of the liquid, over the seat of cavities in the pulmonary tissues, and in oedema of the lungs. The tympanitic percussion note differs from the normal pulmonary resonance in being more ringing in character and of a higher pitch. The amphoric or metallic sound is in reality a concentrated tym- panitic sound of high pitch, and denotes a large cavity with firm, elastic walls. The cracked-pot or cracked-metal sound is another variety of the tympanitic sound. The condition most commonly occasioning this sound is a cavity in the lung tissue, communicating with a bronchial tube. It requires for its development a strong, quick blow of the percussing finger, with the patient's mouth open. RESPIRATORY PERCUSSION. The percussion sound will vary greatly with the respiratory move- ments. If a full inspiration be taken and percussion performed, then a full expiration taken and percussion performed, and then the chest percussed during the normal respiration, slight changes in the char- acter and pitch of the note are obtained, which otherwise would escape detection. Prof. DaCosta has designated this method, respira- tory percussion. AUSCULTATORY PERCUSSION. This method consists in listening with a stethoscope applied to the thorax, to the sounds elicited by percussion. " It is a serviceable means of determining with accuracy the boundaries of various organs, as those of the lungs or heart, or of the liver or spleen, and yields particularly exact results when carried out with the double stetho- scope." AUSCULTATION. Auscultation, or listening to the sounds produced within the chest during the act of respiration, coughing, or speaking, furnishes the most reliable means of studying the condition of the lungs, and is, therefore, the most valuable method of discriminating between the various conditions which may affect the organs of respiration. Auscultation is either immediate or mediate. 182 PRACTICE OF MEDICINE. It is i7ni7iediate when the ear is applied directly to the chest, which may be either denuded or thinly covered. It is mediate when the sounds are conducted to the ear by means of a tubular instrument, termed a stethoscope. For ordinary purposes, immediate, or direct auscultation is suffi- cient, but when it is desirable to analyze circumscribed sounds, as in diseases of the heart, or where the patient objects to this method, on the score of delicacy, or the auscultator objects, on account of the un- cleanliness of the person examined, the stethoscope is to be preferred. Moreover, there are certain parts of the chest which can only be ex- plored satisfactorily by the aid of a stethoscope, and moreover, this instrument has the additional advantage of intensifying the sound. In auscultation, the following rules, formulated by Prof. DaCosta, should be observed :— " i. Place yourself and your patient in a position which is the least constrained and permits of the most accurate application of the ear or stethoscope to the surface. Above all, avoid stooping, or having the head too low." " 2. Let the chest be bare, or what is better, covered only with a towel or a thin shirt." " 3. If a stethoscope be employed, apply closely to the surface, but abstain from pressing with it. This may be obviated by steadying the instrument, immediately above its expanded extremity, between the thumb and the index finger." "4. Examine repeatedly the different portions of the chest, and compare them with one another while the patient is breathing quietly. Making him cough, or draw a full breath, is, at times, of service ; especially the former, when he does not know how to breathe." SOUNDS IN HEALTH. If the ear be applied over the lary7ix or trachea of a healthy per- son, a sound is heard with both the act of inspiration and expiration. Its intensity is variable, its pitch high, and its quality tubular (to wit: a current of air passing through a tube—the larynx or trachea). The duration of the sound during inspiration being somewhat longer than during expiration. A short pause follows the act of expiration. This sound is termed the normal laryngeal respiration, and is identical in character, duration and pitch with an important morbid sound, termed bronchial respiration. DISEASES OF THE RESPIRATORY SYSTEM. 183 The sound heard by placing the ear over the lung tissue is differ- ent; it is produced in the very finest bronchial tubes and air cells by their expansion and contraction, and is termed the normal vesicular murmur. The inspiratory portion of the sound is of variable intensity, its pitch is low, its quality soft and breezy, designated vesicular; its duration is during the entire act of inspiration. The expiratory portion of the sound is not always perceptible ; it is of feeble intensity, very low pitch, its character soft and blowing, and its duration much less than the act of expiration. It is to be remembered, however, that the vesicular murmer will be found to vary in the different regions on the same side, and in corre- sponding regions on the two sides of the chest. These variations within the range of health are especially important, and should be memorized. Infra-clavicular Region.—The vesicular murmur in this region on either side is much more distinct than over any other part of the chest. On the left side the inspiratory sound is of greater intensity, of lower pitch, and more distinctly vesicular in quality than that heard upon the right side. On the right side the expiratory sound is nearly or quite the same in length as the inspiratory sound, and is higher in pitch and more tubular in quality than the expiratory sound upon the left side. Supra-scapular Region.—Owing to the small number of air vesicles and the large number of bronchial tubes, and-their nearness to the surface, the respiratory murmur has an intense, high-pitched, tubular and expiratory quality. Scapular Region.—Compared with the infra-clavicular region, the respiratory murmur heard over the scapulae on either side is more feeble, and the vesicular quality less marked. Inter-scapular Region.—The murmur in this region differs from the normal laryngeal breathing only in intensity and duration. Infra-scapular Region.—The murmur in this region very closely resembles that heard in the left infra-clavicular region. Mam77iary and Infra-i7ia7n7nary Regions.—The murmur in these regions differs from that heard in the infra-clavicular region, in being of less intensity. Axillary and Infra-axillary Regions.—The respiratory sound in 184 PRACTICE OF MEDICINE. the axillary regions it as intense as in any portion of the chest. In the infra-axillary regions the intensity is less and the pitch lower. VOICE IN HEALTH. If the ear be applied over the larynx or trachea of a healthy per- son, and he be directed to count " twenty-one, twenty-two, twenty- three," in a uniform tone and with moderate force, there is perceived a strong resonance, with a sensation of concussion or shock, and a sense of vibration, thrill or fremitus, the voice seeming to be concen- trated and near the ear. Often the articulated words are distinctly transmitted (laryngophony). The sounds thus heard are termed the normal lary7igeal resonance. If the ear or stethoscope be applied over the third rib anteriorly, on either side of the chest of a healthy person, and he be directed to count "twenty-one, twenty-two, twenty-three," in a uniform tone, with moderate force, a confused, distant hum is perceived, of variable in- tensity, accompanied with more or less vibration, thrill or fremitus, most distinct in adults, but notably weaker in women than in men. This sound is termed the normal vocal resonance. If the ear or stethoscope be applied over the third rib anteriorly, of a healthy person, and he be directed to whisper, in a uniform man- ner, the words " twenty-one, twenty-two, twenty-three," there is heard a sound corresponding closely in character to the sound of expiration over the same region during the act of forced respiration ; or, in other words, a feeble, low-pitched, blowing sound. This sound is termed the normal bronchial whisper, and is pro- duced by the air in the bronchial tubes during the act of expiration. SOUNDS IN DISEASE. The vesicular murmur may undergo, in disease, changes in its in- te7isity, its rhythm, and in its character. The intensity of the respiratory murmur may be :— I. Exaggerated or increased. 2. Diminished ox feeble. 3. Absent or suppressed. Exaggerated respiration differs from the normal vesicular respiration only in an increase in the intensity of the respiratory sounds. When general over one lung, it will usually indicate deficient action of other parts. In this manner an effusion compressing one DISEASES OF THE RESPIRATORY SYSTEM. 185 lung, one-sided deposits, obstruction of the bronchial tubes by secre- tion, or inflammation of the lung structure, necessitate a supple- mentary respiration in a healthy portion of the same lung or the lung upon the opposite side. From its resemblance to the loud, strong, quick respiration of young children, it has been termed puerile respiration. Exaggerated respiration is, therefore, to be regarded as indirect evidence of disease in some portion of the pulmonary tissue. Diminished respiration, called also senile respiration, as being characteristic of old age, is characterized by diminished intensity and duration of the sound. In the large majority of instances the inspi- ration suffers the greatest, the expiratory sound not diminishing in the same proportion. In asthma, emphysema, diseases of the larynx and bronchial tubes, pleuritic pain, rheumatism or paralysis of the chest walls, or in thickening of the pleural membrane, we observe super- ficial or diminished respiration. When one side of the chest is partially filled with fluid, we may hear a deep-seated, but feeble breath sound. Absent or suppressed respiration occurs whenever the action of the lung is suspended; this may be from external pressure, as when the lung is compressed by the presence of fluid or air in the pleural cavity, or when complete obstruction of the bronchial tubes prevents the air from either entering or escaping from the lungs. The rhythm of the respiratory murmur may be— i. Interrupted or jerky. 2. The interval between inspiration and expiration prolonged. 3. Expiratio7i prolonged. In health the inspiratory and expiratory sounds are even and continuous, with a short interval between each act; this may be altered in disease, and both sounds, especially the inspiratory, have an interrupted or jerky character, termed "cog-wheel respiration." This jerky breathing is noted in some spasmodic affections of the air tubes, in hysteria, the earliest stages of pleurisy, pleurodynia, and the early stages of pulmonary phthisis. It is most frequently associated with phthisis, due probably to the adhering to the walls of the finer bronchial tubes of tough mucus, which obstructs the free entrance and exit of the air; it is usually most notable under the clavicles. The interval between inspiration and expiration may 186 PRACTICE OF MEDICINE. be prolonged, instead of these two sounds closely succeeding one another. When this occurs the inspiratory sound may be shortened, or the expiratory sound may be delayed in its commencement. If the inspiratory sound is shortened, it is the result of consolidation of the lungs; if the expiratory sound is delayed, it is the result of lessened elasticity of the lung structure, and is most commonly associated with emphysema. Prolonged expiration denotes that the air is obstructed in its exit from the lungs. It may be the result of diminished elasticity, the result of emphysema, or from the deposit of tubercles, which impair the contractile power of the lungs. If the former, it is asso- ciated with clearness on percussion ; if the latter, however, with impaired resonance on percussion. When prolonged expiration is detected at the apex of the lung, and is associated with impairment of the normal pulmonary resonance, it is for the most part the result of a tubercular deposit. The quality of the respiratory murmur may be I. Harsh, termed vesiculobronchial respiration. 2. Bronchial. 3. Cavernous. 4. Amphoric. Harsh respiration, or, as it is termed by Prof. DaCosta, vesiculo- bronchial respiration, is that variety in which both the inspiratory and expiratory sounds have lost their natural softness. It generally indi- cates more or less consolidation of lung tissue. In normal vesicular respiration the sounds produced by the air expanding the air cells and finer bronchial tubes obscures the sound produced by the passage of air through the larger bronchial tubes, the healthy lung being an imperfect conductor of sound, so that as soon as any portion of the lung becomes consolidated the vesicular element of the respiratory sound is diminished, the bronchial element becoming prominent. Harsh respiration is, then, a union of the vesicular and bronchial sounds, being a vesicular sound mixed with some of the qualities of a bronchial sound, the expiration being prolonged and tubular in character. It is present when the bronchial mucous membrane is swollen, as in the earlier stages of bronchitis, also in the earlier stages of phthisis and pneumonia. Bronchial respiration is characterized by an entire absence of all the vesicular quality. Inspiration is of high pitch and tubular in DISEASES OF THE RESPIRATORY SYSTEM. 187 character; expiration still higher in pitch, of greater intensity, pro- longed and tubular in quality; the two sounds being separated by a brief interval. The bronchial respiration encountered in disease closely resembles that heard in health over the larynx or trachea. Whenever bronchial respiration is present where, in health, the normal vesicular murmur should be heard, it indicates consolidation of the lung structure. Cavernous respiration is a variety of the bronchial respiration, at least so far as the quality of the sound is concerned. It is essen- tially a blowing sound, yet not always heard during both the act of inspiration and expiration, being often only perceptible in the one, and in the other mixed with gurgling sounds, Its pitch is lower than that of ordinary bronchial respiration, and its character is hollow. For its production there must be a cavity of considerable size in the lung substance, not filled with fluid, near the surface of the chest walls, communicating with a bronchial tube. It is met with most commonly in the last stages of pulmonary consumption, although hollow spaces of any kind, from abscess or dilatation of the bronchial tubes, occasion it. Amphoric respiration is a blowing respiration, having a musical or metallic quality. It is a variety of bronchial respiration produced in a large cavity with firm walls, permitting the reflection of the sound. An imitation of this sound, though only an imperfect one, is produced by blowing over the mouth of an empty bottle. The amphoric character is present with both the act of inspiration and expiration. Amphoric or metallic respiration is indicative of a large cavity, not common in phthisis, but much oftener heard at the upper part of a lung compressed by fluid and air, as in pneumo-hydrothorax. RALES. Rales, or, as they are termed, adventitious sounds, because they have no analogue in the healthy state, cannot be considered as modifications of the normal respiration. Grouped according to the anatomical situation in which they are produced, we have :— I. Laryngeal a7id tracheal rales. 2. Bronchial rales. 188 PRACTICE OF MEDICINE. 3. Vesicular rales. 4. Cavernous rales. 5. Pleural rales. Rales may be divided into two groups, according to their character, to wit: dry and 7noist, and may be audible either during the act of inspiration or expiration, or during both. Dry rales, for the most part, are produced by the vibration of thick fluids which the air cannot break up, and which, therefore, temporarily lessens the calibre of the bronchial tubes. When this narrowing exists in the smaller bronchial tubes the resulting sound is high-pitched, or the rale is said to be sibilant or whistling ; when the narrowing exists in the larger bronchial tubes, the rale is low-pitched, more musical in character, or sonorous. Dry rales are particularly prone to be dislodged by coughing, and when they are uninfluenced by the acts of breathing or coughing, they do not depend upon the presence of secretions, but upon the narrowing of the air tubes from the pressure of tumors, or from a thickened fold of mucous membrane, or from a spasmodic contrac- tion of the air tubes. Moist rales are those produced by the air passing through thin fluids, such as mucus, blood, serum, or pus, during the respiratory movements. When the fluid exists in the smaller bronchial tubes, the rales are termed S7nall bubbling, mucous, or subcrepitant. When the fluid exists in the large bronchial tubes, the rales are said to be large bubbling or mucous. Moist rales are not persistent, but vary in intensity, and shift their positions as the air drives the liquid which occasions them before it, or during violent attacks of coughing, or after copious expecto- ration. Laryngeal and tracheal rales are those produced within the larynx and trachea, and may be either moist or dry. The moist or bubbling sounds, produced when mucus or other liquids accumulate in this part of the air tubes, frequently occur in the moribund state, and are then known as the " death rattles." When not due to this condition, they denote either insensibility to the presence of liquid, as in stupor or coma, or inability to remove liquid by the acts of expectoration, as in croup or inflammation of these parts in the very feeble. The dry rales produced within the larynx or trachea are generally DISEASES OF THE RESPIRATORY SYSTEM. 1S9 caused by spasm of the glottis, to wit: laryngismus stridulus, whooping cough or croup, or from the presence of a foreign body in the part. Bronchial rales, resulting from the passage of air through the thin liquid, occasion bubbling sounds. When the liquid is present in the larger-sized bronchial tubes, the rales are said to be large bubbling, or large mucous rales, and are heard in acute or chronic bronchitis. When the liquid is in the smaller bronchial tubes, the resulting rale is called stnall bubbling, small mucous, or subcrepitant, also occurring in acute or chronic bronchitis. Bronchial rales due to the narrowing of the tube by its spasmodic contraction, or to the presence of tough, tenacious mucus, which is set in vibration by the passage of the air through the bronchial tubes, are termed dry bronchial rales. Frequently they are suggestive of cer- tain familiar sounds, such as snoring, cooing, humming or wheezing, or they are often musical notes. When produced in the smaller bronchial tubes, they are termed sibilant, or high-pitched rales : when produced in the larger bronchial tubes, they are termed sonorous or low-pitched rales. They principally occur in the dry stage of bron- chitis, or during an asthmatic paroxysm. The vesicular rale, or, as it is more commonly termed, the crepitant rale, is produced within the air vesicles or at the terminal portion of the smaller bronchial tubes. It is to be distinguished from very fine bubbling sounds, or the sub- crepitant rale. " // is a very fine sound, or rather series of very fine uniform sounds, occurring in puffs arid limited to inspiration." It resembles the noise occasioned by throwing salt on the fire, or alter- nately pressing and separating the thumb and finger, moistened with a solution of gum arabic, and held near the ear, or rubbing together a lock of dry hair near the ear. The crepitant rale is produced by the movement of fluid in the air cells or in the finest extremities of the bronchial tubes, or by the forcing open, during the act of inspiration, of the air cells aggluti- nated by exuded lymph. These sounds may be defined as being very fine, dry, crackling sounds, heard at the end of inspiration. They are usually present in the first stage of pneumonia, and when limited to the apices, are significant of the incipient stage of phthisis. Cavernous rales, or, as they are commonly termed, gurgling 190 PRACTICE OF MEDICINE. rales, are produced in a pulmonary cavity of considerable size, containing a large amount of liquid communicating freely with a bronchial tube. The sound is occasioned by the agitation of the liquid within the cavity, and may be compared to the sound produced by the boiling of liquid in a flask or large test tube. The sound is sometimes high-pitched or musical, whence it has been termed " amphoric gurgling," but it is generally low in pitch. The rale is heard almost exclusively during the act of inspiration, and its diag- nostic importance relates to the advanced stage of phthisis. Pleural rales may be either dry or moist. Dry pleural rales, or, as they are more commonly termed, friction sounds, are occasioned when the surfaces of the pleurae are covered with a glutinous substance preventing the unobstructed movements of the pleural surfaces upon each other during the respiratory acts, for in health these movements occasion no sound whatever. The sounds are generally interrupted or irregular, occurring" during the act of inspiration or expiration, or during both acts. The character of the sound is variable, being termed rubbing, grazing, rasping, grating or creaking, according to the intensity of the respiratory acts and the amount of exudation. They are distinguished by the apparent nearness of the sound to the ear, and are usually intensified by firm pressure of the stetho- scope upon the chest. When the chest is fixed, especially at the lower two-thirds, and the ear applied over the seat of the sound, it will be found to have disappeared. This sound is diagnostic of the first stage of pleurisy. Moist friction sounds are produced in the same manner as those just mentioned, the exudation being softened in character. This sound is frequently confounded with moist bronchial rales, and its discrimination is often only positive by a careful study- of the symp- toms and concomitant signs present. Metallic tinkling is a sign of a pneumo-hydrothorax with per- foration of the lung, and when found is usually diagnostic of this affection, although it occurs rarely in cases of phthisis with a large cavity, the physical conditions for its production being similar to those in pneumo-hydrothorax, to wit: a space of considerable size contain- ing air and liquid, the space communicating with the bronchial tubes. It consists of a series of tinkling sounds, of high pitch, silvery or metallic in tone, and is very well imitated by dropping a small marble DISEASES OF THE RESPIRATORY SYSTEM. 191 into a metallic vase. It occurs irregularly, not being present with every act of breathing, and may be produced by forced, when not heard during tranquil breathing. Were it not for the location and the absence of concomitant signs, it might be confounded with tinkling sounds sometimes produced within the stomach. THE VOICE IN DISEASE. The normal vocal resonance, as heard over the third rib of the chest anteriorly on either side, may have its intensity— I. Diminished or absent. 2. Increased or exaggerated. Or its resonance may be of the character of— 3. Bronchophony. 4. Pectoriloquy. 5. AZgophony. 6. Ai7iphoric voice. The vocal resonance may be diminished or feeble in bronchitis with free secretion, pleurisy with effusion, or in complete consolidation of the lung structure and the bronchial tubes. The vocal resonance is absent in pneumothorax and in pleurisy with effusion. Exaggerated vocal resonance differs from the normal vocal resonance in a slight increase of its density. It denotes a slight degree of solidification of lung tissue, and is chiefly of value in the diagnosis of tubercle. Bronchophony, or the voice concentrated near the ear, raised in pitch and in intensity, denotes complete consolidation of the pulmon- ary tissue in those parts in which the sound is abnormally present. Pectoriloquy is complete transmission of the voice to the ear, the articulated words being distinctly recognized. It has a close resemblance to the resonance heard over the larynx in health. Its presence indicates either a pulmonary cavity or more complete con- solidation—in other words, an exaggerated bronchophony. ^Sjgophony is a modification of bronchophony, consisting in tremulousness of the voice, its character nasal or bleating, somewhat suggestive of the cry of a goat. When heard, it may be considered a sign of pleurisy with slight effusion, or of pleuro-pneumonia. Amphoric voice, or "the echo," as it is sometimes called, is a musical sound, of a somewhat hollow, metallic character, like that 192 PRACTICE OF MEDICINE. produced by blowing into an empty bottle. It is sometimes pro- duced in large cavities within the lung, but is especially incident to pneumothorax. Increased bronchial whisper is a sound in which the whis- pered words are abnormally intense, and higher in pitch than the normal bronchial whisper. It has the same significance as exagger- ated vocal resonance. SUCCUSSION. The succussion or splashing sound is pathognomonic of one affection, namely, pneumo-hydrothorax. It is obtained by jerking the body of the patient with a quick, some- what forcible movement, the ear being very near or in contact with the chest. The sound is like that produced when a small keg, partially filled with liquid, is shaken. The only liability to error is in confounding this splashing sound with that sometimes produced within the stom- ach ; but attention to concomitant signs and the symptoms will always protect against this error. ASSOCIATION OF THE PHYSICAL SIGNS (DA COSTA). " As many of the signs elicited by the various methods of physical diagnosis depend on the same physical conditions, they may be studied in groups. The following will be usually found to be asso- ciated : "— Auscultation Percussion. of auscultation ^ vocal Physical Conditions. Auscultation Respiration. of »°ice- Clear. Tympanitic. Amphoric or Metallic. Cracked metal sound. Vesicular murmur or its modifi- cation. 1' Bronchial, or harsh respiration. Absent respi- t ration. Cavernous or feeble, ac- cording to cause. Amphoric or metallic. Cavernous respiration. Normal vocal resonance. Vocal Fremitus. Unimpaired. Bronchophony. Increased. Lung tissue healthy or nearly so; at any rate, no increased density from deposits, etc. Solidification of pulmon- ary structure. Absent voice. Diminished or Effusion into pleural sac. absent. Uncertain ; Uncertain ; Increased quantity of air cavernous or mostly di- within ihe chest, due to a diminished. minished. cavity or to overdisten- tion of the air cells. Amphoric or metallic. Cavernous respiration. Mostly di- Large cavity with elastic minished. walls. Uncertain. Generally a cavity commu- nicating with a bronchial tube. DISEASES OF THE NASAL PASSAGES. 193 DISEASES OF THE NASAL PASSAGES. ACUTE NASAL CATARRH. Synonyms. Acute rhinitis ; acute coryza ; " cold in the head." Definition. An acute catarrhal inflammation of the mucous membrane (pituitary or Schneiderian membrane) lining the nose and the cavities communicating with it; characterized by feverishness, feeling of fullness and discomfort in the head, and attended with dis- charges of fluid, watery, mucus, or muco-purulent in character. Pathological Anatomy. Hypera7nia of the mucous mem- brane, attended with redness, swelling and deficient secretion. This tumefaction is partly increased by an ede7natous infiltration, causing a quantity of colorless, salty and very thin liquid to flow from the nose. The secretion soon assumes the character of thick, tenacious mucus or muco-pus, due to the desquamation of the epithelium of the nasal mucous membrane, and a copious generation of young cells, the hyperaemia and the swelling of the membrane diminishing. The respiratory portions of the nasal fossae are more markedly affected than are the olfactory. Rarely, and then in new-born infants and those affected with the eruptive fevers, the exudation in the nasal passages is of a fibrinous nature, somewhat similar to that observed in diphtheria. Causes. Atmospherical changes are the most frequent and in- fluential. Exposure of the neck to a draught of cold air, or of the feet and ankles to cold and dampness, or changing from a warm to a cold atmosphere suddenly, are among the most usual causes. Irritating gases and vapors, dust, certain powders, as ipecac and tobacco, excite an irritation of the nasal mucous membrane. The scrofulous taint and the rheumatic diathesis seem to render the mucous membrane susceptible to frequent attacks. Acute coryza is usually present in the initial stage of measles and influenza. Epidemic influence occasionally prevails on an extensive scale. The poison of syphilis or the use of the iodide of potassium not un- frequently act as exciting causes. At times the catarrh seems to spread by contagion. Symptoms. " A cold in the head " is usually preceded by a feel- 17 194 PRACTICE OF MEDICINE. ing of lassitude or weariness and more or less frontal headache; then occur irregular chilly sensations in the back, followed by more or less feverishness and an uncomfortable feeling of dryness in the nares, with a strong inclination to sneeze. This is soon followed by an abundant watery and saline discharge, which is continually dripping from the nostrils, or occasions an attack of sneezing followed by blowing the nose, which relieves the congested and swollen mem- brane for. a few moments. The relief is temporary, however, the fullness of the head and difficult obstructed nasal respiration rapidly returning. The anterior nares are red and infia7ned, and the eyes red and suffused with tears, through partial or entire closure of the tear ducts. The discharge soon assumes a puruletit character. The voice has a peculiar tone, rather nasal and muffled in character. Within a few days the swelling subsides, the secretion lessens, health being restored in about ten days from the beginning of the attack. When the attack has almost terminated hard crusts may form within the nostrils, either on the septum or turbinated bones, which are with difficulty expelled by blowing the nose. Complications. Irritation and swelling of the upper lip, from repeated blowing of the nose and the constant contact of the irri- tating discharge. Extension of the catarrh to the eth7noid or sphenoid cavities or frontal sinus, causing increased and severe frontal headache; or to the antrwn of Highmore, causing tenderness over one or both cheeks. Extension to the Eustachian tube and middle ear, causing impaired hearing; or to the pharynx or larynx, causing cough. Duration. In mild cases about one week ; severe cases continue, more or less marked, for two weeks. Prognosis. Favorable if early and proper treatment be insti- tuted ; if neglected, the catarrh tends to become chronic. In very young infants, if the catarrh is not rapidly relieved, loss of flesh and strength occur, from inability to take the breast. Treatment. Attacks the result of atmospherical causes may be aborted by the early administration of quinine sulphas, gr. x-xv, with 77torphine sulphas, gr. %, or the early use of pulvis ipecacuanha et opii, gr. v repeated every two hours. The following errhine used at the very onset has proved successful in aborting many cases :— DISEASES OF THE NASAL PASSAGES. 195 R. Aluminis, Bismuthi carb., Pulv. talc,.......aa.......gr. xx Morphinae hydrochlor............gr. ij. M. et ft. chart. No. xx. Sig.—Insufflate one powder in each nostril after clearing the nose. (Sajous.) If the attack has already developed, relief is soon afforded by tinctura bellado7ine, 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; or the following combination of Dr. Sajous:— R. Ammonii chlor.,.............J}ij Tinct. opii,...............rtl^xxiv Sacch. alb. 3 J Aq. camphorae,......ad......f 2j. M. SiG.—One teaspoonful in water every hour or two. 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,.............g ij-iv Syrupi ipecac, Tinct. opii camph.,.....ail . . . 3 ij-iv Syr. limonis,..............3 iv Aquae,........ad........§ iij. M. SiG.—One or two teaspoonfuls every hour or two. Attacks of acute rhinitis unaccompanied by febrile reaction are gen- erally promptly aborted by a four per cent, solution of cocaine dropped in the nostrils, repeated every half hour. With either of the above plans may be added one of the following errhines :— R. Bismuth, subnit.,............3yj Pulv. acacise,..............^ij Morphinae hydrochlor.,..........gr- ij- M. SiG.—Every hour or two.—(Ferrier.) Or— R. Pulv. cubebae,..............3J Bismuth, subnit.,.............31J Morphinse muriat.,............gr. ij. M. SiG.—Used by insufflation every two or three hours. 196 PRACTICE OF MEDICINE. Or— R. Pulv. fol. belladonnas,..........5J Pulv. morphinae sulph.,..........gr. ij Pulv. g. acaciae,......ad......^ss. 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 saccharui/i album and ca7nphore, or Robinson's errhine of saccharum alba and camphora, each half ounce finely powdered and acidum tan7iicu77t, 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. 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 of fullness in the nares, increase of the secretion, the character being thick and greenish, which, dropping DISEASES OF THE NASAL PASSAGES. 197 posteriorly into the pharynx, causes paroxysms of " hawking," which are more marked in the morning immediately after arising. The special setise of S7iiell is more or less impaired, and in many cases, entirely abolished; the special se7ise of hearing is more or less diminished, from an extension of the inflammation to the Eustachian tubes; the voice has a peculiar nasal intonation. An almost constant dull frontal headache, associated with a feeling of weight, showing the extension of the disease to the infundibulum and frontal sinus. Sudden changes of temperature cause acute exacerbation of these symptoms, when there is 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 bbnes 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 medicated tepid waters, or a cleansing solution, such as Do- bell's, to wit :— R . Acidi carbolici,.............gr. j Sodii bicarbonat., Sodii borat., ....... aa......gr. v Glycerini,...............3J Aquae,................Ij. M. SiG.—As a spray or with a proper syringe. 198 PRACTICE OF MEDICINE. Or the following combination of Dr. Sajous :— R. Sodii bicarb., Sodii bibor.,.......aa......gr. viij Ext. pinus canad. fid.,..........ir^xy Glycerinae,...............f 7, ij Aquam,.........ad......f ^ Iv. M. Sig.—Apply with atomizer three or four times daily. after which decided benefit follows the use of one of the following :— R. Hydrargyri chlor. mite, Pulv. aluminis, .....aa......gss Morphinae hydrochlor., ..........gr. ij. M. R. Sodii borat................3 j Bismuth, subnit.,............gij Morphinae muriat.,............gr. j. M. Or—, R. Iodoformi,...............£j Acid, tannici,..............gr. v Pulv. .camphorae,............^j Bismuth, subnit.,............gj. M. SiG.—To be used by insufflation or as a snuff, every three or four hours; Or—, R. Ammonii muriat.,............^j Glycerini,...............zij Ext. pinus canad. fid.,..........f^j Aquam,.......ad........f ^ ij. M. Sig.—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. DISEASES OF THE PHARYNX. 199 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 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. Varieties. Exanthematous Pharyngitis is the form of the affec- 200 PRACTICE OF MEDICINE. tion complicating the acute infectious diseases, such as scarlatina, measles and smallpox. Erysipelatous Pharyngitis is the form complicating facial erysipelas, rarely, however, the affection begins in the pharynx, spreading to the face and other parts. Gangrenous Pharyngitis may occur with diphtheria, scarlatina, erysipelas, smallpox and typhoid fever. The symptoms assume a typhoid (depressed) character, the termination being usually fatal. Phlegmonous Pharyngitis is the variety in which is present an accu- mulation of pus in the submucous and deeper tissues of the pharynx, constituting a retro-pharyngeal abscess. This variety of pharyngitis may follow the penetration of a sharp piece of bone or be secondary to caries of the cervical vertebrae. Fibrinous Pharyngitis, or, as it is sometimes termed, pseudo-mem- branous, is considered with croup and diphtheria, of which it consti- tutes a part. 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. 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. Tinctura opii, n^v-x for a dose or two at the very onset of an attack, will often abort the catarrh. 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, cocaine painted over the inflamed parts, of the strength of a four per centum solution, or used in the form of lozenges, is a valu- able remedy. Holding small pellets of ice in the mouth is useful, as is the application of either heat or cold to the angles of the jaws. Gargles or sprays of aluminis (gr. viij-aquae f^j), a7/i7nonii murias (gr. xx-aquae f3j), or potassii chloras (gr. xij-aquae fjj), used at fre- quent intervals, often allays the congestion and consequent swelling. DISEASES OF THE PHARYNX. 201 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 majority of cases, the exposure is so slight that there must be a pre- disposition 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 1040 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 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 increase, 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. 18 202 PRACTICE OF MEDICINE. 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. " Lnstar specifici in hoc morbo operatur," well said Holmes when referring to guaiacum in the first hours of a true tonsillitis, for experience has amply proven its power to cut short an attack if administered early. I usually order tinctura guaiaci ammo- niata, fz, j, in water or milk every hour or two, until its good effects are produced. The drug is all the more successful if at the same time it be used locally in the form of trochiscus guaiaci (aa gr. ij) frequently repeated, or the following gargle at intervals of every half an hour to an hour:— R . Tincturae guaiaci ammoniat, Tincturae cinchonae comp., . . . . Hii .... f3 ij Mel. despumati,...........• • 3 vj- M. and shake together until the sides of the containing vessel are well greased, then Adde— Potassii chlorat.,.............^iv Aquae destil.,..............f g iv. M. and add gradually, continuing shaking. Should the febrile reaction be high, tinctura aconiti in small doses frequently repeated, either alone or alternating with guaiacum, rapidly reduces the temperature and the 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 glycerinui7i and painted over the affected parts. The author has seen excellent results follow the use of sodii salicylat., gr. x-xv in solution, every three hours. Prof. DaCosta has seen attacks of acute tonsillitis aborted by prompt emesis with pulvis ipecacuanha, gr. xx, also by the early administration of quinine sulphas, gr. xx for an adult, or gr. viij for children. Cases not seen until two or three days after the onset are benefited by the following:— R . Tincturae ferri chlor.,...........f 3 ij Glycerini,......ad.........f^ij- ^. Sig.—Teaspoonful every two hours. DISEASES OF THE LARYNX. 203 This palatable mixture, suggested by Dr. Bosworth, acts as a local astringent in passing over the inflamed tonsils, and should not be followed with water or food for an hour at least. Scarification, a long, sharp bistoury being used to make five or six cuts, affords great relief when the tonsils are much inflamed ; the ex- ternal use of zV. M. Sig.—In powder every two hours. Or— R. Hydrargyri chloridum mite,........gr. y% Pulvis opii et ipecacuanhae,........gr. x/z. M. Sig.—In 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. sV~jj gr. xv. M. M. 232 PRACTICE OF MEDICINE. 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." Hyperamia of the mucous membrane of the nares, pharynx, larynx and bronchial tubes, with diminished secretion, followed by an increased secretion of a transparent mucus, afterward becoming purulent, 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. 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. Ten7iinal 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 followedby 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 DISEASES OF THE BRONCHIAL TUBES. 233 will not cure the disease, but often modify the severity of the symptoms. Prof. Da Costa prefers quinine sulphas, in full doses, or chloral in good-sized doses, often advantageously combined with the bro7nides, and the use of a spray of sodii bromidu77i (gr. xx, and aquae, f^j) to which may be added extractum belladonnefluidwn, rnij. A remedy of great utility is ammonii bro7nidwn. I have seen excellent results from antipyrine in doses of gr. j-ij every three hours; if added to some expectorant mixture it seemed to act better. The paroxysms are lessened in severity by the following :— R. Codeinae sulph., Acid, carbolic, Syr. simplicis, Glycerini, Syr. limonis, SiG.—One teaspoonful every two or three hours gr-J nvviij f3ss f z ss. M. 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.......gj Tinct. belladonnae,............f.^j Glycerini,................ f5j Aquae rosae,......q. s. ad......f%xv- 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. 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 234 PRACTICE OF MEDICINE. 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 continued inspiration—the theory of inspiration—or the excessive mechanical distention of the vesicular walls by forced expiration— the theory of expiration. What is known as vicarious ei7iphysema 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- 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 DISEASES OF THE BRONCHIAL TUBES. 235 act of coughing—the peculiar "barrel-shaped" chest characteristic of this disease. The character of the respiratory movements is marked, there being 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 depressed and nearer to the sternum. Percussion. The resonance is increased (hyper-resonant) over all the emphysematous portions, and if the whole lung be involved, extends 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. 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 asth7na 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 sy7iiptoms and to endeavor to prevent its further progress. For the relief of the asthmatic paroxysms, morphine sulphas com- 236 PRACTICE OF MEDICINE. bined with atropine sulphas may be used hypodermically, or ext. quebracho fid., 3ss-j, every hour until relief, or large doses ofpotassii bro7nidum, frequently repeated. For attacks of bronchial catarrh use— R. Ammonii chloridi,...........J5 'J Spts. frument.,.............fsjiv Glycerini, ..............f3; j Syr. prun. virg.,.....ad......f^'v- M. Sig.—Half-tablespoonful every few hours. 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. ^ Liq. potassii arsenit,..........TTLv Aq. lauro-cerasi, ............f3j. 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. HAEMOPTYSIS. 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 disposi- tion in the walls of the minute bronchial arteries ; excessive cardiac action ; bronchial congestion; excessive bodily exertion, straining, lifting or running; a symptom of 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. DISEASES OF THE BRONCHIAL TUBES. 237 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 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. Hematemesis, 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 of ten it is the prog- nostic sign of phthisis. 238 PRACTICE OF MEDICINE. 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 hypodermic injection of ergotin, gr. x-xxx, or the internal administration of extractum ergote fluidum, 3ss-j are valuable, or :— R. Acid, gallic,..............gr. xv Acid, sulph. dil.,............rnjc Aqua cinnamon,............3 iv. M. Repeated every fifteen or twenty minutes. Or tinctura 7natico, Z], or extractwn hamamelisfld., vt^xx-S}, alumen, gr. xx, or acidwn gallicum, gr. v-x, frequently repeated. If the hemorrhage causes great nervous excitement, or depression, opiu77i, either hypodermically or internally, to quiet the patient, is indicated. Inhalations, by means of the steam atomizer, of either Monsel's solution or tinctura ferri chloridum, are recommended when the above means fail. Prof. Da Costa recommends, for frequent small hemorrhages, con- tinuing day after day, cupri sulphas, gr. (^), ext. opii, (gr. ^V), 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 congestion when the result of an accel- erated circulation; passive congestion when caused by an impeded outflow from the capillaries. 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. DISEASES OF THE LUNGS. 239 Pathology. The hyperaemic lung has a bloated, dark red appearance, its vessels are distended to the uttermost, the tissues succulent 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 thoracic distress and difficulty of breathing, flushed face, strong, full pulse, throbbing caro- tids, cardiac palpitation and congested eyes, with a short, dry cough, followed by scanty, frothy expectoration slightly streaked with blood. 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 catharsis with saline purgatives. Passive. Dry or wet cups over the chest, hydragogue cathartics, and the internal administration of digitalis; if much depression of the vital powers, stimulants such as spiritus vini gallici and ammonii carbonas are indicated. 240 PRACTICE OF MEDICINE. OEDEMA 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. Result of cardiac diseases; Bright's disease; over- exertion ; alcoholic excesses; mental excitement; inhalation of cold or hot air. Pathological Anatomy. The lung tissue is swollen, and does not collapse when the chest is open. 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 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 are great oppression of and extreme rapidity in breathing, with a strong sense of oppression, great anxiety, rapid'and tumultuous 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 vesiculotympanitic. Auscultation. The vesicular murmur is supplanted by sub- crepitant and bubbling rales. Diagnosis. Pneumonia in the earlier stages is the only condition likely to be confounded with oedema of the lungs, and the subsequent course of the two maladies soon determines the diagnosis. Prognosis. GEdema 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. DISEASES OF THE LUNGS. 241 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 ammonium, either the carbonas or iodidmn, to liquefy the effusion, produce marked relief. The above means may be aided by counter-irritation to the chest, hot mustard foot-baths, active saline purgatives, and diuretics. CROUPOUS PNEUMONIA. Synonyms. Lobar pneumonia; pneumonitis ; fibrinous pneu- monia ; 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 ; 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, although the belief is growing, as it presents such a marked difference from other inflammations in that it is self- limited, and terminates by crisis. It is most common in winter, at times occurring 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 21 242 PRACTICE OF MEDICINE. 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 transfonnation, 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- 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 of 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. DISEASES OF THE LUNGS. 243 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 usually protracted chill (in children often convulsions, adults, vomiting), followed by a rapid rise of temperature, I03°-I04° F., a strong, full, but rapid pulse, soon showing evidences of embarrassed cardiac action from obstructed respiratory circulation, 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, ringing and harsh, soon followed by a scanty, frothy mucus, soon becoming semi-trans- parent, 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; rarely cases occur with bloody or blood- streaked sputum during the continuance of the fever. There are present headache, sleeplessness, rarely delirium, save in drunkards, epistaxis, flushed countenance, and especially over the malar bones is a well-defined mahogany blush ; gastric disturbances and scanty, high-colored urine, with diminished chlorides, often albuminuria. From the very onset of the disease the prostration is of the most marked character. 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 pneu7iionia is a term applied to those cases which are 244 PRACTICE OF MEDICINE. accompanied by signs of extreme prostration, delirium, trei7ior, 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 mala/ial ox 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 inte7nperate habits usually begins with symptoms closely resembling an attack of delirium tremens, cough and 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 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 frei7iitus 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. DISEASES OF THE LUNGS. 245 Bronchophony, ox distinctly transmitted voice, at times pectoriloquy, or distinct transmission of articulated sounds. Third stage, breathing changing from bronchial to vesiculo-bron- chial, the crepitant (crepitatio redux) rale returning, and if resolution proceed, the breath sounds are associated with large and small moist and bubbling rales. " The morbid phenomena, physical signs and symptoms of the malady correspond usually in this manner."—(Da Costa.) I. Stage of engorgement Crepitant rale ; slight percus- Cough; rbeginning dyspnoea and beginning exuda- sion dullness. and rapidly developed fever tion. heat. II. Stage of solidification of Percussion dullness; bron- lung-tissue (red hepat- chial respiration; broncho- ization). phony. Rusty-colored sputum; dysp- noea ; cough; high fever, with marked evening ex- acerbations and morning remissions. III. Stage of softening (gray The same physical signs as Chills; prostration, etc.; puru- hepatization). in the second stage, unless lent or brownish sputum; large abscesses have formed generally high temperature. 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 failure and impaired nerve force. If abscesses occur, there are exhausting sweats, frequent cough, with a large amount of yellowish-gray, at times blood-streaked, expectoration. 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. CEdema 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 pain and the physical signs of pneumonia soon determine the diagnosis. Complications. Acute pleuritis is a frequent complication of croupous pneumonia, occurring as often as from ten to twenty-five 246 PRACTICE OF MEDICINE. per cent, of cases. The more acute localized pain, the greater em- barrassment of respiration, and the usual physical signs of effusion are the evidences of a pleuro-pneumonia. Capillary bronchitis is a rare but dangerous complication. Pericarditis, rheumatism and gout are rare complications. 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, the dangerous features of croupous pneumonia being cardiac failure, the result of the embarrassed respiratory circulation, and the rapid tissue waste associated with extreme fever, 105°, resulting in impaired nerve force ; double pneumonia is a very grave prognosis, but is not near so frequent as was at one time supposed. The co-existence of pleuritis adds to the gravity of the prognosis, although not as fatal as it formerly was Pneumonia of drunkards almost invariably terminates fatally. Typhoid pneumonia, the so-called bilious pneumonia, purulent infiltra- tion, abscesses of the lungs and gangrene, all give a grave prognosis. Treatment. If pneumonia be regarded as a constitutional malady with a local lesion, then the consolidated lung no more calls for treatment than does the intestinal ulcer of typhoid fever, but the general condition of the patient is to govern in the management of the case and not the local changes going on in the thorax. A simple pneumonia attacking persons previously in good health requires no more active treatment than any of the so-called self-limited diseases, provided only that the extent of the disease be moderate, and there be no complication. The much discussed question of venesection is now a settled problem in the affection, if we bleed it is " not because of pneumonia, but in spite of pneumonia." Called to a case in the first stage of the disease, or early in the second stage, who has been vigorous and otherwise healthy, with a high temperature, 1050 or more, with frequent pulse, one hundred and twenty beats or more, or a slow, full pulse showing cardiac oppression, flushed surface and marked dyspnoea, a copious bleeding is indicated, and the same may be said when symptoms of collateral oedema threaten ; this is bleeding for symptoms and not for the disease per se. Called to the majority of cases, during the first stage, after a rapidly acting purgative, administer quinina sulphas, gr. v, with or without DISEASES OF THE LUNGS. 247 antipyrine, gr. iij-v, every three hours until their effects are produced, using at the same time small doses of such arterial sedatives as aconitum, veratrum viride or digitalis until a decided impression is made on the circulation. It is also in this stage that either wet or dry cups over the chest, followed by the application of poultices, seems to act beneficially. In the feeble or aged poultices are to be used from the onset. Second Stage. It is at this period of a severe attack of acute pneu- monia that two prominent indications for treatment arise,—heart- insufficiency and high temperature. To reduce the tetnperature, we have at least two safe and reliable drugs, if administered in sufficient amounts. I refer to quinina sulphas and antipyrine. The dose of quininae sulphas as an antipyretic in pneumonia is gr. x-xv, repeated as needed. The doses of thirty and forty grains recommended I have never seen required; in fact, it would seem to me to be contraindicated on account of the cardiac depression such amounts would produce. Antipyrine is also a very reliable antipyretic either alone or combined with the quinine. The use of the cold pack or of cold baths for reducing the temperature in acute pneumonia has not met with the approval of practical clinicians. To sustain the heart is one of the most important indications in the treatment of an acute pneumonia, for experience shows that cardiac failure is responsible for a large number of deaths in this affection. Without question, alcoholic stimulants judiciously employed are the most efficient means for preventing or overcoming the cardiac failure. The amount can only be determined by a careful study of each case, as a few ounces in the twenty hours may answer in one case, while another may require eight or ten ounces. It is well to begin with small doses, increasing or decreasing as its effects are good or bad. The indicator of the heart's condition is the pulse. In the aged, the feeble, or in those accustomed to the use of alcohol, stimulation is indicated from the onset. Other indications would be a frequent, feeble, irregular or intermitting pulse; a dicrotic pulse; delirium, muscular tremor and subsultus; immediately following crisis, and the period of collapse. Other cardiac stimulants that may be used are ammonii carbonas, digitalis and moschus. It is also during this period that the diet must be of the most nutri- tious but easily digestible character, and given at periods of every three hours. 248 PRACTICE OF MEDICINE. Third Stage. The treatment is a continuation of the second stage, gradually reducing the antipyretics as the fever declines, and adding one of the preparations of ferrum. Convalescence. Nutritious diet, quininae sulphas in tonic doses, ferrum, together with a good blood-making wine or a good prepara- tion of malt. If the consolidation shows a disposition to linger, blisters may be used. The various symptoms other than those particularly mentioned are to be met, as they arise, by their proper remedies. For typhoid pneumonia, purulent infiltration, abscess of the lungs, or pneumonia in drunkards, the weak or the aged, quinina, ferrum, nutritious diet and bold stimulation, and the free use of ammonii carbonas are the indications. The so-called antiseptic treatment of acute pneumonia is still under trial, and no definite opinion can be expressed concerning it. CATARRHAL PNEUMONIA. Synonyms. Broncho-pneumonia; lobular pneumonia ; capillary bronchitis (?). Definition. An acute catarrhal inflammation of the bronchioles 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; most frequently seen in childhood and old age. Pathological Anatomy. Hyperamia 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 DISEASES OF THE LUNGS. 249 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 begins as a 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 of tei7ipera- ture to io2°-io3° F., the febrile phenomena assuming a typical remit- tent character, 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 imperfect, 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 7nuco-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. 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 a rest- lessness giving place to apathy and a continually augmented somnolence. Resolution, when it occurs, is by lysis, several weeks elapsing before complete recovery. Percussion. Dulbiess, 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 22 250 PRACTICE OF MEDICINE. 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, pneui7ionic 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 the clinical history and course of the two maladies. CEde7na 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- 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. Have seen cases continuing up and down for eight and ten months, and finally make a good re- covery. 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, quinina sulphas, gr. xv-xx each day, is the most re- liable of all antipyretics, or antipyrine in full doses may be substituted. For the catarrhal process, the air of the apartment should be main- DISEASES OF THE LUNGS. 251 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, regulating the dose in accordance with the age of the patient:— R. Ammonii carbonat., Ammonii iodidi, . Mucil. acaciae, . . S\r. glycyrrh., . . Syr. prun. virg., . SiG.— Every three hours. q.s gr- ■ gr. v-x . q.s. ad ^ ij—iv. M. 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. Terpene hydrate acts remarkably well in many cases. Yox convalesce/ice, nutritious food, ferri iodidum, quinina sulphas, and oleum morrhua. 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. PNEUMONIC PHTHISIS. Synonyms. Chronic catarrhal pneumonia ; catarrhal phthisis ; caseous pneumonia; caseous phthisis. Definition. A form of pulmonary consumption characterized by the destruction of the pulmonary tissue resulting from 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. 252 PRACTICE OF MEDICINE. 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 meta7norphosis. 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, the chronic, the sub-acute and the acute. Chronicform. The origin is rather insidious, the individual being susceptible to " colds," or " catarrhs," on the slightest exposure; grad- ually a persistent cough, with the expectoratio7i of' 77iuco-pus, is estab- lished, each severe cold being accompanied with chill, fever, pain in the chest, and either slight he7norrhage or blood-streaked sputa. Finally the catarrhal symptoms become persistent, with morning chills, evening fevers and rather profuse night sweats, dis- tressing cough, profuse muco-purulent sputa, great weakness and exhaustion, loss of appetite and feeble digestion, the symptoms DISEASES OF THE LUNGS. 253 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, 77iuco-purulenl 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. Bicreased 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 ty7npanilic or holloiv note. If the cavities communicate with a bronchial tube the cracked-pot ox cracked-7netal sound is elicted. 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 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. 254 PRACTICE OF MEDICINE. 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 chironic 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 contraction 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,......... ......5 ij Syr. prun. virg.,.............gij. M. Every five hours, alternating with R. Liq. potassii. arsenitis, Mass. ferri carb., . . Vini xerici, .... Aquae, dest, . . . 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 7iior- rhua, 3j-ij, three times a day. For the fever, quinina sulphas, gr. xv-xx, is more successful than the combination of quinina and digitalis in small doses ; experience has demonstrated that the antipyretic properties of quini7ia are markedly increased if rest in bed for the time being be enjoined. ■ • n\v . . gr. v . q. s. ad f 3ss. M. DISEASES OF THE LUNGS. 255 Loomis has found that the antipyretic properties of quinina in phthisis are increased by the addition of morphina to each dose, Night sweats are best controlled by atropina sulphas, gr. ^, at bedtime, or R. Extract, belladonnae,...........gr. ss Zinci oxidi,...............gr. iij. M. At bedtime. For the cough and sleeplessness, codeina 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. 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, irritable heart, a light, dry, hacking cough, referred to the throat or stomach, 256 PRACTICE OF MEDICINE. scanty, glairy expectoration, gradual loss of weight, impaired muscular strength, pallid appearance, more or less copious hai7ioptysis 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 fre77iitus is slightly increased. Percussion. First stage, slight ii7ipairment 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 ty7npanitic 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-bronchial breathing, 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. 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. DISEASES OF THE LUNGS. 257 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. While I have never seen a case of incipient phthisis cured in the broad acceptation of that term, I have repeatedly seen life prolonged for a number of years, and the deposition of tubercle long delayed by a change of climate early in the history of the case, warm clothing, life and exercise in the open air short of fatigue, and systematic bathing and a nutritious plan of dieting. If the diet is arranged in accordance with the appetite, the latter will gradually increase, but should it not, it may be stimulated by such bitters as nucis vomicis, ignatia amara, coloi/ibo ox gentian. The symptoms are to be met as they arise, and drugs are not to be used simply because the patient has the physical signs of beginning tubercle. For the general debility and malaise that accompanies the early stages of this malady, any one, or a combination of the follow- ing drugs, exercising care that they in no way interfere with the appetite: 01. rnorrhue, ferri iodidum, arsenicum, hypophospkites, or the elixir quinine ferri et strychnine. Great temporary improvement in the symptoms of phthisis some- times follows 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 sulphuretted hydrogen, using: "At first half an 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 half a 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. 258 PRACTICE OF MEDICINE. For the fever the " Niemeyer pill" is usually recommended; its formula being— R. Quininae sulph.,............gr. j. Pulv. digitalis,.............gr. ss Pulv. opii,..............gr. y( Pulv. ipecac..............gr. %. M. From a very considerable experience with this "famous" pill, I can recall few cases in which it has proven of the least benefit. The following is much more effectual:— R. Quininae 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, atropina sulphas, gr. e^-gp, at bedtime, is an effective agent. It is claimed that sulphonal, gr. vij-x, at bedtime, controls the night sweats and also produces a quiet, refreshing sleep. For cough, if not modified by the arrest of temperature and night sweats, the following is of use :— R. Codeinse sulphat, .............gr. Y~% Acid, hydrocyanici dil.,.........rnjj Syr. tolu,.............., gj. M. SiG.—Several times a day. The dyspeptic symptoms are wonderfully relieved by the following:— R. Pepsini cryst,.............gr. ij Acid, muriat. dil.,...........TTTx Glycerini,...............tT^xx Succi limonis,.............Ttixv Aquae aurantii flor. ad..........3 ij. M. Sig.—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 DISEASES OF THE LUNGS. 259 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- 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. 260 PRACTICE OF MEDICINE. 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, axe recommended. Oleum morrhue is of benefit. The bronchial catarrh, hectic fever and night sweats should be treated only when their severity becomes marked. ACUTE PHTHISIS. Synonyms. Acute miliary tuberculosis ; galloping consumption. Definition. An acute febrile affection, due to the rapid deposition throughout the body, but especially in the lungs, of the gray tubercle- granule : characterized by high fever, rapid pulse, hurried respiration, pain in the chest, cough, profuse expectoration 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, I02°-I04° 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. DISEASES OF THE PLEURA. 261 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 ox even slightly ty77ipanitic. 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 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. Loomis says: " Morphia in small doses—one-twentieth of a grain hypodermically every six or eight hours—has, in my hands, been more satisfactory in staying the progress of the disease, pro- longing life, and keeping the patient comfortable, than any other plan." Dr. McCall Anderson claims that subcutaneous injections of atro- pina check the exhausting sweats ; and that quinina, digitalis and opium reduce the temperature, and if they fail, ice cloths to the abdo- men will accomplish the desired result. The various symptoms should be met as they occur, the patient at the same time being supplied with large quantities of stimulants. 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, 2(32 PRACTICE OF MEDICINE. 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. Chro7iicpleurisy 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. DISEASES OF THE PLEURA. 263 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 respiratio7is 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 dysp7iea becomes r.j'jravated, 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 ii7ipaired. Second stage, dulbiess 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 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 264 PRACTICE OF MEDICINE. 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. Acutepneui7io7iia 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. E77ipyema, 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, follow- ing the use of either wet or dry cups with poultices or turpentine stupes. The severe pain is promptly relieved by the hypodermic in- jection of morphine sulphas, over its site, repeated as indicated, or the frequent use of small doses of pulvis opii et ipecacuanhe. 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 fluidui7i, gtt. xx, every two or three hours, or in drachm doses every other day for a week or two, after which twice weekly, or— R. Potassii acetat,..............gr. xxx Infus. digitalis,..............gij. M. 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 DISEASES OF THE PLEURA. 265 the fluid may be evacuated by aspiration, using at the same, time full doses of 77iisturaferri et a77imonii acetatis (Basham's mixture']. Locally in the arm-pits, groins, or over the site of the effusion, un- guent um hydrargyri. The effusion of pleuritis is rapidly removed by the method of treat- ment suggested by Prof. Matthew 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 3iv-vj to gj-ij magnesii sulphatis 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 of potassii iodidum, alternating with " Bashai7i's mixture," and blisters, the secretions being regularly attended to. If, however, the liquid is pus (empyema), the aspirator should be used at once, the patient placed upon " BasJiai7i'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. Pathological Anatomy. More or less clear serous fluid in both pleural sacs, compressing the lungs. No signs of inflammation are present. 23 266 PRACTICE OF MEDICINE. 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 fluid. 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 coughhig. In severe cases there is never a moment's cessation of the acute pain and distressing dyspnoea, causing orthop- noea from the onset until death. DISEASES OF THE PLEURA. 267 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 becomes 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 hypodermic injection of 7norphi7ie 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. 268 PRACTICE OF MEDICINE. 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 ii/ipulse 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 of 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 of 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 ii7ipulse. The impulse is diminished by cardiac dilatation, fatty degenera- tion 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 mami/ialis ; and the right lateral boundary is an imaginary vertical line situated one- half an inch to the right of the sternum. These boundaries vary DISEASES OF THE CIRCULATORY SYSTEM. 269 somewhat in health, but are sufficiently accurate for all practical purposes. 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 270 PRACTICE OF MEDICINE. and rhythm, or they may be accompanied, preceded or followed by adventitious or new sounds, the so-called endocardial inur77iurs. The intensity is increased by cardiac hypertrophy, irritability of the heart or consolidation of adjacent lung structure. The inte7isity is di77iinished 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 the valves being 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 rhythi7i 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 mwinurs, or friction sounds, are made by the rubbing upon one another of the roughened surfaces of the pericardial mem- brane during the early stages 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. Endocardialrnurmurs are of two kinds, to wit: organic and func- tional. DISEASES OF THE CIRCULATORY SYSTEM. 271 Functional endocardial ox blood murmurs are the result of changes in the natural constituents of the blood. 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 pursuing 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 ventricle 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 mitral 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, 272 PRACTICE OF MEDICINE. 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. The 7nitral regurgitant, or systolic 7/iurmur, 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 occurs 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 car- tilage. This murmur is exceedingly rare. The tricuspid regurgitant murmur 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 DISEASES OF THE CIRCULATORY SYSTEM. 273 at the same instant that the aortic direct murmur occurs, and is dis- tinguished from the latter by its not being transmitted into the carotid artery, whereas the aortic direct murmur is always thus transmitted. The pub/ionic 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 the aortic regurgitant murmur by the absence of aortic lesions and symptoms. ACUTE PERICARDITIS. Definition. An acute fibrinous inflammation of the pericardium; characterized by slight fever, pain, precordial distress and disturbed cardiac action and circulation. If the inflammation be limited to the parietal or visceral layer, or to a part of either, it is termed partial or circumscribed pericarditis ; if it involve the whole of both surfaces it is termed general or diffused pericarditis. Causes. May follow injuries of the chest walls, or be the result of taking cold, but generally secondary to either acute articular rheu- matism, pneumonia, pleurisy, erysipelas, Bright's disease or pyaemia. Pathological Anatomy. The same as serous membranes in other situations. Hypere>7iia 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. Symptoms. Acute pericarditis may be well marked and still present none of the characteristic subjective symptoms. It usually begins with rigors, fever of the remittent type, frequently nausea and vomiting, precordial distress, acute shooting pabis, increased by breathing and coughing, te7iderness, dry, suppressed cough, bicreased cardiac action and sometimes violent palpitation. An attack of peri- carditis secondary to an existing disease presents no marked symp- toms other than those mentioned to indicate its onset. Duration of this early stage from a few hours to a day. Effusion stage : the symptoms of this stage depend upon the amount 24 274 PRACTICE OF MEDICINE. and rapidity of the effusion: precordial oppression, tendency to syncope, dyspnea, sometimes amounting to orthopncua, dysphagia, hiccough, nausea and vomiting, feeble, irregular pulse, sometimes either melancholia, delirium, or acute maniacal excitement. Abso7ptio7i 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. 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- cardial 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 soioid {exocaxdiai 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 dis- cussing that affection. Cardiac hypertrophy or dilatation is sometimes confounded with DISEASES OF THE CIRCULATORY SYSTEM. 275 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 patient being really drowned in his own fluid. Adherent pericardium is a frequent sequela. Treatment. Perfect rest in bed ; for vigorous patients, the appli- 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: animonii carb., gr. v, every two hours, with liquor ammonii acetatis, or potassii acetatis, or potassii carbo7iatis, with quinina, nutritious liquid diet and stb/iulants, 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. Dr. Roberts, in his monograph, gives an account of sixty cases of paracentesis with twenty-four recoveries. He advises that the tapping be done in the fossa between the ensi- form and costal cartilages on the left side, or in the fifth left interspace near the junction of the sixth rib with its cartilage. 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 aggluti7iaied by several layers of lymph, which in- crease the thickness of the membranes half an inch or more, and the outer surface of the pericardium becomes adherent to the chest walls. 276 PRACTICE OF MEDICINE. If the fluid be not absorbed it may progressively accumulate, dis- tending the sac in all directions, displacing the diaphragm and inter- fering 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 cir- culation. 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. 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 iodidu77i 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. DISEASES OF THE CIRCULATORY SYSTEM. 277 HYDRO-PERICARDIUM. Synonym. Pericardial dr* psy. Definition. The accumulation of water in the pericardial sac, minus inflammation ; characterized by precordial 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. 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 ca/'diac 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. Acute endocarditis occurs in two distinct forms: plastic or simple exudative endocarditis ; ulcerous or diphtheritic endocarditis. Causes. Usually secondary to acute articular rheumatism, pleu- ritis, pneumonia, pericarditis or Bright's disease. In the ulcerative or diphtheritic variety, a depressed condition of the vital forces, probably the result of the diphtheritic poison, seemsto be the determining cause. 278 PRACTICE OF MEDICINE. 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 vegetation, their size being in- 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. In the ulcerative variety a process of softening takes place in the fibrinous deposits, leading to ulcerations and perforations. 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 dysp7iea, 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 DISEASES OF THE CIRCULATORY SYSTEM. 279 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, veratntm 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 in the valves or orifices. If alkalies fail and the inflammation shows a tendency to linger, good results are often obtained by a slight hyd> argyrum impression. If signs of oppressed circulation appear, the hands becoming blue, the face and extremities ©edematous, with congestion of the lungs, the free use of ammonii carbonas, digitalis and stimulants axe indi- cated. The free use of ammonii carbonas will 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 sec- ondary to pyaemia; characterized by pain, feeble circulation, symp- toms 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-sanguineous 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 250 PRACTICE OF MEDICINE. 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 being the usual termination, in from three to five days. Chronic myocarditis pursues a very latent course. Treatment. Largely symptomatic. Perfect rest of mind, gen- erous diet, free stimulation and the administration of quinina and ferrwn. 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 DISEASES OF THE CIRCULATORY SYSTEM. 281 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 a7id 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 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 ventricle 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 hypertrophy is said to be compensatory. If the result of Bright's disease, emphy- 282 PRACTICE OF MEDICINE. sema of the lung, or if occurring late in life, or associated with athero- matous 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. j-ij, three times a day, or veratrum viride, gtt. j-ij, three times a day, at the same time keeping the bowels, kidneys 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, avoiding all forms of stimulants, such as liquors, tobacco, tea and coffee. Cases of cardiac hypertrophy associated with Bright's disease are relieved by digitalis, the cardiac distress being secondary to the kid- ney disease for which the digitalis is used. Cases of cardiac hypertrophy associated with anaemia should, in addition to the above, be placed upon a course offerrum. 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; insuffi- ciency 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 hypertrophy; the cavities being enlarged and the walls increased in thickness, the so-called "dilated hypertrophy." III. Passive dila- tation, 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 DISEASES OF THE CIRCULATORY SYSTEM. 283 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 consequence 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- lowing phenomena of venous congestion ; of the lungs, dyspnea ; liver, jaundice; stomach, dyspepsia; intestines, constipation; kid- neys, scanty often albuminous urine ; brain, dulbiess 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 sounds 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. 284 PRACTICE OF MEDICINE. 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. Dilatation of the heart is incurable. Palliative measures are of but temporary benefit. In all cases there are two important indications to be met, the first to maintain the general nutrition of the patient to the uttermost, and the second to control or prevent all irregular or violent cardiac action. The first indication is accomplished by a generous diet, moderate exercise, with bitters to increase the appetite and fernmi to improve the blood, and, in a majority of cases, the more or less free use of a good red wine. The second indication is met by the observance of strict rules in regard to exercise and such heart tonics as digitalis in powder or infusion, tinctura strophanthus rnij-x, t. d., ext. convallarie fid., gtt. v, t. d., quinina, caffeina and 7norphine sulph., in small doses, the latter when the dropsy becomes great and associated with marked cyanosis, hypodermically, as suggested by Prof. Bartholow, " often acts like magic in restoring the circulation." The following pill is often of great advantage,— K . Ferri redact.,..............gr. j-ij Quininse sulph.,.............gr. j-ij Pulv. digitalis,..............gr. j Morphinse sulph.,.............gr. ¥V 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, 77iorphine sulph. hypodermically, or spts. elheris 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 coi7ip., 3j-ij, in water, before breakfast. DISEASES OF THE CIRCULATORY SYSTEM. 285 If the dropsy is uninfluenced by the above means, success will follow the use of hydrargyri chloridi mite, gr. iij, guarded with pulv. opii, gr. TV, 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. Symptoms. Those of weak heart, anaemia of organs and venous stasis, to wit: feeble, irregular, but slow cardiac action, coi7ipressible 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 gastro-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 2S6 PRACTICE OF MEDICINE. 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. Incurable, there being no plan of treatment that can restore the degenerated muscular fibre. Generous diet, very moderate exercise, stimulants, oleui7i niorrhue, and the "triple elixirs,"—elixir ferri, quinine et strychnine. All the excreting organs must be kept active, so as to relieve the crippled heart as much as possible. To sustain the cardiac action, caffeina or morphina in small doses, or hypodermically for the so-called cardiac asthma. Digitalis is contra-indicated in advanced cases. Quain says : " Galvanism applied from the back of the neck to the praecordium, by the interrupted current, has been found useful." 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. DISEASES OF THE CIRCULATORY SYSTEM. 2X7 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 tendine, 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- diac hypertrophy, to compensate for the diminished amount of blood sent onward by the ventricular systole. When the " compensation ruptures" there occurs 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. 288 PRACTICE OF MEDICINE. 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 particularly 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 mine, ascites and dropsy. If mitral insufficiency is now superadded, general venous stasis and death rapidly occur. 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 tnurmur 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 DISEASES OF THE CIRCULATORY SYSTEM. 289 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. PULMONIC REGURGITATION. Pathological Anatomy. Insufficiency of the pulmonary valves is of rare occurrence, but when present the changes correspond more or less with 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 ves- sels, palpitation of the heart, prascordial distress, sudden suffocative attacks and dropsy. Percussion. The cardiac dullness extending to the right of the sternum. 25 290 PRACTICE OF MEDICINE. 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. Vegetations 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, bronchorrhcea 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 77iurmur, heard most distinctly in the mitral area, lessening in 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 DISEASES OF THE CIRCULATORY SYSTEM. 291 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 surfaces, 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 soiaid, 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 7iiurmur 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. 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- 292 PRACTICE OF MEDICINE. 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 of 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 murmur. 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, signi- fies regurgitation at the tricuspid orifice—tricuspid systolic murmur. A murmur heard with the first sound of the heart, high-pitched, rasping or grating in character, with its point of intensity greatest at the second right cpstal cartilage, signifies obstruction at the aortic orifice—a7i aortic systolic murmur. A mun7iur heard with the first sound of 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 pub/ionic systolic murmur. A 77iur/>iur 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 mun7iur. A murmur heard with or taking the place of the second sound of the DISEASES OF THE CIRCULATORY SYSTEM. 293 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 regurgitations 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 77iitral 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 be 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. Prof. DaCosta says,-"I hold that the precise valve affected is not, with our present resources, the keynote to the treatment of valvular heart disease. We are to take as indications: I. The state of the heart-muscle and of the cavities. 2. The rhythm of the heart-action. 3. The condition of the arteries and veins and of the capillary system. 4. The probable length of existence of the malady, and its likely cause. 5. The general health. 6. The second- ary results of the cardiac affection." The important point to bear in mind in the treatment of valvular disease of the heart is that it is associated either with cardiac hyper- trophy or dilatation, and the treatment, if any at all be required, is directed toward this secondary condition. If compensation be complete, attention to the condition of the bowels, kidneys and diges- tion, with some general directions as to exercise, is all that is required. If the hypertrophy become marked and excessive, it is best con- trolled by either aconitum, veratrum viride, or nitro-glycerin. If dilatation have occurred, the heart weak and feeble, the circula- tion impeded, and venous stasis has followed, digitalis, strophanthus, or sparteine sulphate, with more or less active purgation, is indicated. 294 PRACTICE OF MEDICINE. If fatty degeneration of the heart result, the indications are for cardiac rest, stb/iulants, strophanthus and attention to the excretions. If the cardiac rhythm is disturbed, add belladonna to whatever other plan of treatment is being used. If the capillary circulation is weak, strophanthus and nitro-glycerin (glonoinum) act better than digitalis, which has the power of con- tracting the arterioles. Any of the secondary results of the valvular affection are to be treated according to the particular indications. 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 irregu- larity of the rhythm, with a strong tendency toward hypertrophy. Causes. Over-exertion, "the heart strain" of Da Costa; dys- pepsia; 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 impe7iding 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 DISEASES OF THE CIRCULATORY SYSTEM. 295 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. 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, accom- panied by a feeling of constriction of the thorax and a strong sense of impending death. Causes. Depending upon the variety, whether nervous origin or organic. 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. Nervous form, " 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 con- stant." Organic fon7i, a disease of the arteries, ossification and occasion- ally obliteration of the cardiac arteries, producing cardiac ischaemia. 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- ness 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." 296 PRACTICE OF MEDICINE. The unpleasant sensations of these patients dining 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. Treatment. During the intervals between the attacks, an attempt should be made to remove the exciting cause or diminish its predis- posing power. For the organic form, no one remedy is comparable with a long course of potassii iodidi, gr. x-xx, three times daily, as the frequency and intensity of the attacks are diminished and a fair number of cases are cured, proving the axiom, "the iodides are the digitalis of the arteries." For the nervous form, all violent emotions and active physical exercise is to be avoided, the diet regulated and the excretions watched. Among the drugs that are useful are ferrum, arsenicum, strych7iina, phosphorus and zincum. If the cardiac action be weak, use strophanthus. Trousseau urges the administration of belladonna in continuous small doses, on the ground of the analogy of the affec- tion to epilepsy. Ouain states that a continuous current, the positive pole on the sternum and the negative pole on the lower vertebrae, lessens the severity and frequency of the anginal paroxysms. For the attack, prompt relief follows the use of amyl nitris, n\jij, inhaled at the instant, or 77iorphine sulphas, gr. yi-}(, to which may be added with advantage atropine sulphas, gr. y^, hypodermically, or nitro-glyccrin, gr. 110-r15-^g, every three or four or five hours. In many cases the use of gr. ^ of this powerful drug, three or four times a day for a long time, lessens not only the frequency but the severity of the paroxysms. DISEASES OF THE NERVOUS SYSTEM. 297 DISEASES OF THE NERVOUS SYSTEM. CONGESTION OF THE BRAIN. Synonyms. Cerebral hyperaemia; cerebral congestion. Definition. An abnormal fullness of the vessels (capillaries) of the brain ; active, when arterial fullness; passive, when venous full- ness ; characterized 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; dimin- ished amount of arterial blood in other parts, the result of the com- pression 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 of the convolutions unduly red; the convo- lutions 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 vision and hearbig, buzzing in the ears and sparks before the eyes, 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 limbs. If the attack be sudden (apoplectiform), sudden unconsciousness with muscular relaxation occur. Cerebral hyperaemia in children often presents alarming symptoms, 26 298 PRACTICE OF MEDICINE. such as great restlessness, insoi7inia, night terrors, gnashing of the teeth during sleep, vomiting, contraction of pupils followed by general convulsions. Any or all of these symptoms may continue more or less marked from an hour or two to a day, the child enjoying its usual health after a sound sleep, save some fatigue. 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 for771. 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 apoplectifon7i variety venesection, to diminish the intercranial blood pressure; compression of the carotids, or ligatures about the thighs, have been recommended. An active purgative or an enemata of water and vinegar is also indicated, to lessen the vascular tension. In mild cases the application of cold and potassii bromidum, gr. xxx-xl, repeated, controls the congestion; extractum ergote fluidum is often beneficial; in more severe cases any or all of the above-men- tioned 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 ANAEMIA. Definition. An abnormal decrease in the quantity of blood in the cerebral vessels ; ge7ieral, when the diminished supply includes all the vessels ; partial, when the diminished supply is limited in area; char- acterized 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, during convalescence from severe attacks of fevers, sudden shock, feeble cardiac action and general anaemia. Pathological Anatomy. The cerebral vessels contain less blood than normal; the brain is pale and milky in color, and on DISEASES OF THE NERVOUS SYSTEM. 299 transverse section there are no bloody points; the ventricles and perivascular lymph spaces are well filled with fluid. In partial anaemia the local conditions differ somewhat from the above. Symptoms. General a7iamia: headache, relieved by the re- cumbent position ; vertigo, aggravated by exertion ; general pallor and anaemia, with attacks of fainting; when the general cerebral anaemia is sudden and decided, convulsions occur. Partial anai/iia ; sudden loss of power, of a limited muscular area, gradually returning to the normal condition. Prognosis. Favorable in all cases save those the result of severe and repeated hemorrhages. Treatment. Regulated nourislmient, 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.,...........WLXV Acid, phosph. dil.,...........rn^v Liq. arsenici chloridi,..........injij Syr. limonis,............. n\xx Syr. zingiberis, ....... q. s. ad .. 3 ij. M. SiG.—Every six hours, well diluted. Or— R. Extracti erythroxyli cocose fid.,.....f^ss Vini albi fort.,............f 3 ss. M. SiG.—One hour after meals. CEREBRAL THROMBOSIS AND EMBOLISM. Synonyms. Partial cerebral anaemia; occlusion of cerebral ves- sels ; cerebral apoplexy (?). Definition. The occlusion of a cerebral vessel, from the forma- tion of a thrombus, or the presence of an embolus, thus causing ana7nia of some portion of the brain ; characterized by the gradual—when the result of thrombosis, and the sudden, when due to embolism—devel- opment 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 300 PRACTICE OF MEDICINE. endarteritis, as seen in the aged, together with a slowing and weaken- ing of the blood current. Chronic alcoholism and syphilis are the usual causes of cases occurring in young adults. Emboli, in the great majority of cases, 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 obstructed by emboli or thrombi; the cerebral veins and sinuses by thrombi only. The changes in the cerebral tissue are those of anae- mia of the part or parts supplied by the occluded vessels. The sub- sequent 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 77iiddle cerebral artery, which sends branches to the second and third frontal convo- lutions, the anterior and superior portions of the three temporal con- volutions, 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,—the motor centres. Symptoms. Two distinct modes of onset; gradual, when the result of thrombosis; sudden or apoplectic, when due to embolism. Cerebral thrombosis. Most common in the aged. Persistent head- ache and vertigo, at one time severe and at another mild. Next, DISEASES OF THE NERVOUS SYSTEM. 3()J alterations of the patient's character; irritable, morose and despondent, with periods of absent-mbidedness, disorders of vision, and impairme7it of mei/iory, speech becoming hesitating and mumbling. Mpairedloco- motion, the result of the vertigo, and of 77iuscular weakness and trembling, followed sooner or later by hemiplegia, which may be pre- ceded by sudden insensibility or occur gradually, the symptoms slowly proceeding 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 circulation." Cerebral embolism. The symptoms are sudden, but either mild or grave in character. Mild variety; sudden and severe vertigo, confusion of 7/ii7id, mus- cular twitchings, usually one-sided, and vomitbig, followed by hemi- plegia, most frequently of the right side, the intellect clear but hesi- tating. After some weeks or months the paralysis usually disappears and recovery is complete. Grave or apoplectic variety. Sudden headache, vertigo, flushing ox pallor of the face, or the patient may utter a sharp cry, fall to the ground with sudden unconsciousness and complete muscular resolution, followed by death, or a gradual return of consciousness with he7ni- plegia, which is generally right-sided, remaining for several weeks or months, or is persistent, the mind remaining normal or enfeebled and the emotional nature highly excitable and the reason and judgment clouded, continuing thus for years, or gradually developing into de77ientia, 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. Embolis77i 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 condition in the majority of instances. Recovery is a rare termination. Embolism may be followed by a perfect recovery. Usually, how- ;;i>2 PRACTICE OF MEDICINE. ever, some evidences of the plugging remain permanently. Death may be the result within a day or two, from the plugging of a large 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. The indications in the early stage of embolism and thrombosis is the reestablishment of the circulation within the district deprived of blood-supply, in order to prevent the changes incident to defective nutrition ; this is accomplished by means to strengthen the heart's action, tonics, 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 :" Am7nonii carbonas, gr. x, with a7nmonii iodidi, gr. v, three times a day, continued for several months, " the object being dual—to increase the action of the heart and arte- ries and to effect a solution of thrombi forming by maintaining the alkalinity of the blood." In the aged, presenting indications of degeneration, much benefit results from the use of— R . Liquor potassii arsenitis,........... tt^iij-v Syr. calcii lacto-phosphat.,.......... 3J_'j- M. SiG.—After meals. It may be combined with oleum 77iorrhua with decided advantage. For ei7ibolis77i, the immediate and persistent use of the following may dissolve the plug :— R . Ammonii carbonat.,............. gr. v Liquor ammonii acetatis,...........f3J. 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 relaxa- tion. DISEASES OF THE NERVOUS SYSTEM. 303 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. Pathological Anatomy. The most common locations of cere- bral hemorrhage are the corpus striatum and thalamus opticus ; less common the anterior and 77iiddle lobes and the cerebellui7i; next in frequency the pons and 7/iedulla oblo7igata; 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 pro- dromes or " warnings." Prodroi/ies. 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 vo77iiting, followed by either partial or com- plete insensibility; respiration slow, irregular and noisy; during the inspiration the paralyzed cheek is drawn in, and puffed out in expira- tion ; pulse slow and full ; pupils uninfluenced by light, the face flushed, the eyes congested and the carotids throbbing; the tei7ipera- ture declines below the norm, a degree or two. The muscular syste7ii 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 fro7n 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, con- 304 PRACTICE OF MEDICINE. fusion 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. Sequelae. Pa7-alysis of the muscles of the face, tongue, body and extremities of one side, opposite to the location of the hemorrhage, termed unilateral paralysis or right or left hei/iiplegia. Paralysis of both sides of the body, due to simultaneous hemorrhage on both sides, termed bilateral hemiplegia. 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 ionic contractions 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-hemi- plegic chorea, due, according to Charcot, to changes in the motor centres. The 77ienlalpowers are always more or less permanently impaired, the patient irritable and emotional, and the same holds good concern- ing the mei7iory. Diagnosis. Insensibility fro7n 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. I have satisfactorily used Dr. von Wede- kind's test for temulence, to wit: "By simply pressing on the supra- orbital notches with a steadily increasing force you may, with certainty of success, bring an unconscious alcoholic to his senses, and thus dif- ferentiate between alcoholic and other comas." 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. Uramia causes a coma that closely resembles apoplexy. A history DISEASES OF THE NERVOUS SYSTEM. 305 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. Cerebralembolis7n 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. 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, or extractum ergota fluidum, f^ss-j, may be substituted. Fer the attack, loosen clothing, elevate the head, remove constric- tions, place in a cool room, have perfect quiet, placing the patient sufficiently on his side, with the face somewhat downward, for the tongue and palate and secretions to fall forward instead of backward into the pharynx, and at once venesection, cold to head, a mustard foot bath, and oleum tiglii, gtt. j-iij, with glycerinum, gtt. xv, placed on back of tongue ; if the pulse be full and strong, when conscious- ness 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 e7iema of tere- binthina. 30G PRACTICE of medicine. For the secondary fever, either tinctura aconiti or ti7ictura veratri viride ; for the headache and delirium, camphora broi/iidum. For promoting the absorption of the clot, keep the secretions active a good diet and a course of potassii iodidum or hydrargyri chloridum corrosivum, alternated with— R . Liq. potassii arsenit.,............ gr. v Syr. calcii lacto-phosph.,..........f.3'J- Three times a day. After two or three months a weak galvanic current applied directly t,o the brain, by placing an electrode on each mastoid process, pro- motes absorption. For 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 hypodermic injections of strychnina sulph., gr. r\,, three times a week. ACUTE MENINGITIS. Synonyms. Cerebral fever; arachnitis. Definition. An acute inflammation of the cexebxalpia 7naler and arachnoid me7nbranes; 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 hyperamia 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 DISEASES OF THE NERVOUS SYSTEM. 307 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 coma, 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. Cerebro-spbial fever closely resembles acute menin- gitis, the points of distinction between which are the first named occurring epidemically, associated with marked spinal symptoms and an eruption. The cerebral sy/ziploms of rheumatism are differentiated from idio- pathic meningitis by the association of thejoint trouble. Cerebral sy7/ipto77is of tyohoid and typhus fever have a close resem- blance to idiopathic meningitis, and are only determined by a study of the clinical history. In acute uramia 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 oleui7i tiglii, gtt. ij, glyceri7iu/7i, V(\y, 308 PRACTICE OF MEDICINE. dropped on the tongue; and if the urinary secretion be scanty, dry cups or 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 aconitum in full doses, frequently repeated, combined with potassii bromidu7n, gr. xx-xl, or use extrac- tui7i ergota fluidum, f^ss-j every few hours. The cerebral circulation may be markedly influenced by compression of the carotids. 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 watched, the catheter being fre- quently used in the stage of collapse. If the case show a disposition to linger, small doses of hydrargyri chloridum mite or potassii iodidimi are of benefit. Third stage : Free stimulation, nutxitious food, ferri iodidum and flying blisters. PACHYMENINGITIS. Synonyms. Meningitis; haematoma of the dura mater. Definition. Inflammation of the dura mater; when the external layer is primarily involved it is termed pachymeningitis externa; when the internal layer is primarily involved it is termed pachymen- ingitis interna. Causes. Pachymeningitis externa is a surgical malady, excited by fractures, penetrating wounds, and other injuries of the skull. Pachy77ieningitis interna is due to blows upon the head without injury to the skull. A predisposition may be created by chronic al- coholism, scurvy, Bright's disease and syphilis. Chronic internal otitis and suppurative inflammation of the orbit may cause it, also in- flammation in the venous sinuses the result of a thrombus undergoing suppurative changes. Pathological Anatomy. Pachy7neningitis 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. DISEASES OF THE NERVOUS SYSTEM. 309 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 corres- pondingly, the convolutions being flattened, the sulci almost obliter- ated, and the ventricle lessened one-half in size. In Pachymeningitis syphilitica, the pathological lesion is in the form of gummatous tumors or masses which may degenerate and become either cheesy masses or be converted into a purulent-looking fluid. In old age the dura mater becomes thick, cartilaginous and of a dull white color. The sheaths of the arteries are also thickened. Symptoms. Very obscure; principally those of cerebral pres- sure. Cases of persistent headache, vertigo, photophobia, anorexia, insomnia, gradual impain7ient of intellect and loco77iotion, followed by delirium, and convulsions and coma, or by apoplectic attacks and paralysis; in the aged, or those in whom some one of the causes of the affection are present, an inflammation of the dura mater may be suspected. Circumscribed painful oedema behind the ear and less fullness of the jugular of the corresponding side, the phlegmasia alba dolens en miniature of Griesinger, are indicative of thrombosis in the transverse sinus, as was first shown by Virchow. ■ Diagnosis. Always problematical, as the symptoms are masked and so obscure that a positive diagnosis is impossible. Prognosis. Most unfavorable for either forms, although the course of the malady is usually slow. Surgical treatment in traumatic cases offers some hope. Treatment. Pachymeningitis externa is to be treated surgically. Trephining is indicated in some cases. It is claimed that benefit has followed a thorough course of potassii iodidum. In the great majority of, cases, however, all that can be done is to treat symp- toms. 310 PRACTICE OF MEDICINE. TUBERCULAR MENINGITIS. Synonyms. Basilar meningitis ; acute hydrocephalus. Definition. An inflammation of the membrane of the brain, more particularly the basal pia mater, attended with or due to the de- posit 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 between the ages of twenty and thirty years; scrofulous diathesis; inherited 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. Prodromes: 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 or sleeplessness. 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, convulsions, 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. 311 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 movements of the muscles, 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 ; tei7iperature de- pressed; tendency to so/7inolence 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 iodidum and hydrargyrum, are all useless. If the hereditary tendency be marked, nutritious food, oleum morrhua, ferri iodidwn 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 develop- ment of cerebral excitation, followed by depression and usually death. 312 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: co77iatose, convulsive and the ordinary. Co7natose 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 of potassii iodidu77i. DISEASES OF THE NERVOUS SYSTEM. 313 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. A disease of infants or very young children. Causes. Imperfect or arrested 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 albumin 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 depressed and flattened, the roof of the ventricles thinned and the foramen 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. Hilton, in Rest and Pain, says, " In almost every case of internal hydrocephalus which I have examined after death I found that this cerebro-spinal opening (between the fourth ventricle and the spinal canal) was so completely closed that no cerebro-spinal fluid could 27 314 PRACTICE OF MEDICINE. escape from the interior of the brain ; and, as the fluid was being constantly secreted, it necessarily accumulated there, and the occlu- sion formed, to my mind, the essential pathological element of internal hydrocephalus." 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- 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. The proper situation for the puncture is the coronal suture, about an inch or an inch and a half from the anterior fontanelle. Firm but gentle compression of the cranium with adhesive strips should be made during the escape of the fluid and afterward. A few ounces of fluid only should be withdrawn at a time. The internal use of potassii iodidui7i is recommended. All measures that tend to promote the constructive metamorphosis are to be used. DISEASES OF THE NERVOUS SYSTEM. 315 CEREBRAL ABSCESS. Synonym. Acute encephalitis ; suppurative encephalitis. Definition. An acute suppurative inflammation of the brain structure, either localized or diffused, primary or secondary ; charac- terized by impairment of intellect, sensation and motion. Causes. Primary cerebral abscess is exceedingly rare. Pyaemia ; glanders ; embolus from ulcerative endocarditis. Secondary cerebral abscesses result from injuries to the cerebral tissues, 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 inclosed 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- 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 albumin and fibre in solution, occur simultaneously. 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 assumes 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 affec- tions to which it is secondary. The onset varies according to the cause, although all cases are asso- ciated with headache, irritative fever, persistent and spreading paraly- sis, and convulsions. If following apoplexy, thrombosis, or emboli, there occurs fever and 316 PRACTICE OF MEDICINE. 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. Surgical treatment has been attended with marked success in some cases of abscess of the brain, the withdrawal of the pus being followed by recovery. For traumatic abscess the operation of trephining is indicated. Symptomatic treatment for relief of the various symptoms as they arise. INTRA-CRANIAL TUMORS. Synonym. Cerebral tumors. Definition. Tumor of the brain is either a growth in the cere- bral tissue, on the meninges, or in the vessels ; characterized by symp- toms 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 tui7iors—cysticercus ; diathetic tumors—tu- bercle 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 in- terferes 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- DISEASES OF THE NERVOUS SYSTEM. 317 ness, defects of hearing, taste and of speech, the result of paresis of the vocal cords, vertigo, associated with nausea and vo7nitbtg; con- 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 no loss of consciousness; palsies, beginning first as strabismus, ptosis and dilatation of the pupil, of the facial muscles, paraplegia and general hemiplegia ; defects of sensibility, to wit: sensations of numbness, and coldness in the limbs and body. Oc- casionally disturbances of equilibrium manifested by a tendency to go backward or turn to the right or left; intellectual faculties well pre- served 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; but it is to be borne in mind that all syphilitic tumors of the brain do not have a favorable termination. Treatment. Unsatisfactory. Mostly symptomatic. As benefit occasionally follows the use of potassii iodidum, gr. xx, three times a day, or ext. ergotafld., 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. The surgical treatment of tumors of the brain was given a great im- petus from the report of the case operated upon in the practice of Hughes-Bennett. The surgical treatment is promising for the future. 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. 318 PRACTICE OF MEDICINE. 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 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 DISEASES OF THE NERVOUS SYSTEM. ,1!|9 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. VERTIGO. Synonym. Dizziness. Definition. Vertigo or dizziness is a subjective state, in which the individual affected, or the objects about him, seem to be in rapid motion, either of a rotary, circular, or a to-and-fro kind. Causes. The etiology of an attack of vertigo depends upon the particular variety. Ocular vertigo results from the paresis of one or more of the ocular muscles, eye-strain or astigmatism. Aural or Auditory vertigo, or Meniere's disease, results from disease of the semicircular canals and cochlea. Meniere's disease properly so-called, is a sudden severe vertigo, the result of either a hemorrhage or a serous or purulent exudation into the semicircular canals. Gastric vertigo is the most common variety, and results from either stomachic or intestinal dyspepsia, disordered hepatic function or consti- pation. " The mechanism of the vertigo is complex. There are two factors; one consists in the toxic effect of the imperfectly oxidized materials which accumulate in the blood; the other is reflex. An impression made on the end organs of the pneumogastric in the stomach is reflected over the sympathetic ganglia." (Bartholow.) Nervous vertigo is associated with migraine, sick or nervous head- ache, and is also caused by physical or nervous excesses, also to the immoderate use of tea, coffee, alcohol and tobacco. It is also a result of many of the organic diseases of the brain. Senile vertigo is the result of the disordered cerebral circulation resulting from changes in the heart and vessels. 320 PRACTICE OF MEDICINE. Symptoms. In all varieties of vertigo the symptom of a sensa- tion of objects moving a7vund the patient or the patient moving arou7id objects which remain stationary is present in some degree. The attack of giddiness comes on suddenly, with an indistinctness of vision and slight confusion of the thoughts. The patient may fall unless he grasps something to steady himself. Nausea and vomiting and cardiac palpitation with tinnitus auriwnaxe often associated with the vertiginous sensations. There is no loss of consciousness. In the ocular vertigo the attack is usually the result of reading, writing, sewing, or other close application of the eyes, the ordinary symptoms of vertigo being preceded by headache, nausea, specks before the eyes, and pain in the eye-balls. In Meniere's disease the vertigo is associated with serious tinnitus aurium and the vertiginous sensations being of various forms, such as a see-saw movement, a gyratory motion, right or left; a vertical whirl, or a sensation of rising and falling like unto the swell of the ocean. The symptoms are of long duration, becoming marked in paroxysms. The attack of aggravated vertigo is so sudden and overwhelming at times that the person is suddenly thrown to the ground as if struck with a blow, associated with nausea and vomiting. As the condition continues the character of the individual changes, becoming morose, irritable and suspicious. Not all cases of Meniere's disease become permanent, but it may occur in isolated attacks, the interval being free from all sensations. Gastric vertigo is by far the most frequent variety. Persons subject to vertigo of this kind live in constant dread of cerebral disease, which frequently results in true melancholia. The vertiginous sensations usually occur during the course of well- marked and long-standing stomach and intestinal disorders, such as pain or oppression after meals, nausea, pyrosis, heartburn, frequent eructations and constipated or rarely diarrhoea. The abdomen is often distended with flatus. Great pain in the nucha is a very frequent occurrence. The attack may be associated with either hyperaemia or anaemia of the brain. The symptoms are not constant, but recur at intervals, sometimes remote, at others very close on each other. In nervous vertigo the vertiginous symptoms are usually associated with more or less irritability of temper, restlessness and insomnia. The onset is sudden, after some one of the etiological factors. In megrim there is headache, nausea and vomiting. This form of vertigo DISEASES OF THE NERVOUS SYSTEM. 321 often precedes or replaces the epileptic convulsion, it also often pre- cedes softening of the brain. In senile vertigo the vertiginous symptoms are the result of anaemia of the brain. The attacks are developed by any exertion, often by merely assuming the erect posture. There is a swimming sensation in the head, darkness falls on the eyes with a sensation of chilliness and prostration. Diagnosis. The diagnosis of the various forms of vertigo can only be determined after a close study of the history and course of the attack. The existence of organic cerebral disease must always be kept in mind in solving any case. Prognosis. This will be influenced by the variety of the vertigo. The prognosis is favorable in ocular and gastric vertigo. Unless the result of organic disease the prognosis is good in nervous vertigo. In auricular vertigo the prognosis is fair, but in genuine Meniere's disease the prognosis is unfavorable, as it also is in senile vertigo. Treatment. For ocular vertigo rest for the eyes and properly adjusted glasses. For cases of Meniere's disease rest in the recumbent position and the use of full doses of quinina (grs. x to xv) daily for a long period, as suggested by Charcot. For gastric vertigo a careful regulation of the diet. At the begin- ning of the treatment it is often of great advantage to place the patient on an exclusively milk diet, gradually widening the variety as improvement occurs. In these cases a course of arsenicum is often serviceable. If the digestion is torpid, the use of tinctura nucis vomicis is indicated. If the bowels are constipated, benefit is obtained from extractu77i cascare sagrada fluidum. For nervous vertigo the removal of the exciting cause and the use of such remedies as ferrum, quinina and strychnina, either alone or variously combined. For senile vertigo, a highly nutritious but easily digested diet, the use of a good spiritus fru/nenti and a course of hydrargyri chloridum corrosivwn or arsenicum with tinctura ferri chloridui7i. MIGRAINE. Synonyms. Megrim ; hemicrania ; sick-headache. Definition. A unilateral paroxysmal pain in the head, periodical, accompanied with nausea, often vomiting, intolerance of light and 28 322 PRACTICE OF MEDICINE. sound and incapability of mental exertion, the brain for the time being temporarily prostrated and disturbed. Causes. In the majority of patients the nervous predisposition to migraine is inherited, but whether inherited or acquired, it commonly develops before the age of thirty. Among the many exciting causes are disturbances of digestion, irri- tation of the ovaries or womb, worry, exacting mental labor, sexual excesses and insufficient sleep. The causes of many attacks, how- ever, are wrapped in mystery. Symptoms. Attacks of migraine occur in irregular paroxysms, the intervals between being free from pain or nervous disturbance. For a day or two preceding the paroxysm, it will be ascertained, on close questioning, that there was a feeling of fatigue without apparent cause, heaviness over the eyes, with some flatulency and indigestion. The attack proper is ushered in by chilliness, nausea, often vomiting, yawning and general 77iuscular soreness, with intolerance of light, and noises in the ears and incapability for mental exertion and pain of a sharp, shooting character of great intensity and persistency localized most frequently in either the frontal, temporal or occipital regions of the left side, at the same time there is tenderness over the whole side of the head. Rarely the pain is felt on the right side and still more rarely on both sides at the same time. The nausea and other diges- tive symptoms may follow the onset of the pain instead of preceding it. There is more or less disturbance of the circulation, temperature and secretions of the affected parts. At times there is marked con- traction of the vessels, when the face is pale, the eyes shrunken and the pupils dilated; again, the vessels may be dilated, when the face is flushed, the conjunctivae injected and the pupils contracted. Motion, sound and light aggravate the acute suffering. The attack may continue with more or less intensity for a few hours to two or three days, the average duration being twenty-four hours. Diagnosis. The symptoms are so characteristic that an error seems impossible. It may, however, be confounded with anaemic headache, hyperaemic headache, dyspeptic or bilious headache and neuralgic or rheumatic headache. Prognosis. While few cases of trite migraine are permanently cured, the affection is free from danger to life. In a fair number of DISEASES OF THE NERVOUS SYSTEM. 323 cases the susceptibility to attacks declines as the person advances in years, it being rarely seen after fifty years. Treatment. To abort an attack of migraine or dispel a paroxysm after its onset, two remedies are almost infallible—one is a hypodermic injection of 7/torphina sulphas (gr. \) with atropina sulphas (gr. TJ^), or antipyrine (gr. xx) repeated in an hour or two ; a large experience with the latter convinces me that the sufferings of those subject to this distressing malady is a thing of the past. A combination for attacks associated with contraction of the vessels is— R. Potassii bromid.,..........gr. xxx Morphinae sulph............gr- X vel Codeinse sulph.,...........gr. j vel Tr. opii deodorat,..........rr^ xxx Aquse menth. p.,.........adfgss. M. Sig.—Repeated p. r. n. In the intervals between the paroxysms measures to improve the general system should be used, and to overcome as far as possible any of the etiological factors in its production. " If the disposition to the malady is inherited, the prophylaxis is very important, and should include diet, exercise, clothing, and the avoidance of all those conditions which tend to develop an abnormal excitability of the nervous system. The best results have been ob- tained from galvanization of the superior ganglia of the sympathetic ; the positive pole over the ganglion and the negative on the epigas- trium in the tetanic (contraction of vessels) form; and the poles re- versed in the paralytic (dilatation of vessels) form." (Bartholow.) ALCOHOLISM. Varieties. Acute alcoholism ; chronic alcoholism. Synonyms. Acute variety, temulentia ; mania-a-potu. Chronic variety, delirium tremens ; dipsomania or oinomania. It would hardly be correct to consider these terms interchangeable; they are rather names applied to various conditions due to acute or chronic alcoholic poisoning. Definition. Alcoholism is the term used to designate the physi- cal and mental phenomena induced by the abuse of alcohol. Temulentia, meaning drunkenness ; 7nania-a-potu is an acute men- 324 PRACTICE OF MEDICINE. tal derangement, occurring in those of strong neurotic tendencies; delirium tremens is an attack of delirium associated with tremors in persons with the numerous changes resulting from chronic alcoholism; dipsomania or oinomania, an alcoholic insanity in which an individual at longer or shorter intervals has paroxysms of alcoholic desires, be- tween which he neither wishes nor craves alcohol. Causes. Predisposing causes are influences arising from unfavor- able moral, social and personal conditions. Heredity. Exciting causes are the immoderate use of alcoholic beverages, of which there are three groups : I, spirits, or distilled liquors ; 2, wines, or fermented liquors, and 3, malt liquors. Pathological Anatomy. Acute alcoholism. The brain is the seat of an active hyperaemia ; the mucous membrane of the stomach and duodenum is markedly injected and covered with a ropy mucus slightly tinged with blood, and the gastric juice is altered in quality and quantity. The kidneys are also the seat of an active hyperaemia. Chro7iic alcoholis77i. In this condition of the economy there are no organs or tissues which do not present morbid changes. The gastro-intestinal mucous membrane presents the changes of chronic catarrhal inflammation ; the liver, the first organ to receive the poison after the stomach, presents the changes of congestion, cirrhosis or fatty degeneration; the kidneys show chronic congestion and often the changes incident to chronic interstitial nephritis; the muscular structure of the heart may undergo fatty degeneration and the vessels the senile changes of the aged. The brain structure presents the changes of sclerosis in various stages, and there may be chronic meningitis and pachymeningitis with haematoma. The nerves are altered, atrophied and hardened, and the neuroglia, vessels and ganglion cells of the spinal cord show similar changes. Symptoms. Acute alcoholism, resulting from the use of a large quantity of alcoholic fluid, occurs with symptoms of mild intoxica- tion, to drunkenness passing to acute delirium and acute coma. The condition begins with a period of exhilaration, passing to semi- delirium and ending in an acute coma, when the breathing is ster- torous, the face bloated and congested, the lips swollen and purplish, the pupils contracted, the pulse feeble and slow, the skin cold and clai7i7ny, the tei/iperature depressed and frequently control of sphincte7S lost. An individual so affected is said to be " dead drunk." DISEASES OF THE NERVOUS SYSTEM. 325 The cases of ordinary drunkenness do not often pass beyond the stage of exhilaration ending in a mild coma or sleep. Mania-a-potu, or acute alcoholic delirium, is the direct result of alcoholic excess in those engaged in a sudden debauch, or who have drunk alcoholic beverages very "hard" for a comparatively short period. The individuals grow more and more excitable, lose all desire for food, are unable to sleep, become the prey of horrible hallucinations—"the horrors"—finally terminating in mania which resembles delirium tremens in all save the tremor, which is absent. Chronic Alcoholism. The condition to which tnis term has been given is truly a disease. It is the result of the continued use of alco- holic beverages until one or more of the morbid organic changes have occurred. These persons are markedly dyspeptic, with coated tongue, fetid breath and early morning vomiting, straining or retch- ing, attended with much distress. There is a gradually developing muscular tremor, progressing to the ataxic gait, and insomnia. The face may either become pallid, flabby and bloated with an imbecile expression, or swollen, rough and dusky, with great bladders under the eyes, with yellow injected conjunctivae. There is headache, vertigo, and attacks of hallucinations; the memory grows weaker, the judgment less accurate, the moral sense blunted and the will power weak and erratic. These and many other symptoms add to the distress of the individual, which he attemps to overcome by the use of more and more of the poison. Delirium Tremens. In the majority of instances delirium results from a prolonged debauch, in an old drinker. It begins by an in- creased tremor, insomnia, irritable, excitable manner, followed by the characteristic hallucinations and illusions, during which snakes and all forms of repulsive reptiles are seen, causing the most intense hor- ror and abject fear. There also occur illusions of smell and hearing. This marked excitement is followed by great depression, the skin is cold and clammy, the pulse feeble, the muscular system weak, the mind in a condition of coma-vigil, and a febrile condition, typhoid in character, develops. The ordinary duration of an attack of delirium tremens is about two weeks, although death may occur at any time from cardiac failure, cerebral hemorrhage, or alcoholic pneumonia. Convalescence dates from the beginning of refreshing sleep, the patient awakening with a clear mind and desire for food. Should the delirium subside, but the 326 PRACTICE OF MEDICINE. patient continue to mutter and pick at the bed-clothing, the tongue become dry and cracked and the regurgitation of dark brownish and bilious matter occur, the condition is critical and an early fatal termi- nation may be expected. Dipsomania or oinomania is the inherited mental condition which craves the drinking of intoxicating liquors. This is a true mental disease. It manifests itself in periodical attacks of excessive indulgence in alcoholic drinking, or this symptom of this sad disease may be replaced by other irresistible desires of an impulsive kind, such as lead to the commission and repetition of various crimes, the gratification of other depraved appetites, robbery, or even homi- cide. The paroxysms at first occur at long intervals, but gradually the intervals become shorter and shorter until the individual entirely sur- renders himself to alcoholic and other excesses. Diagnosis. Profound drunkenness or alcoholic coma may and often is confounded with apoplectic and uraemic coma. Von Wede- kind suggests the following method for diagnosing drunkenness: " By simply pressing on the supraorbital notches with a steadily increasing force you may, with certainty of success, bring an un- conscious alcoholic to his senses, and thus differentiate between alcoholic and other comas." The symptoms of chronic alcoholism often bear a close resem- blance to the following maladies: general paralysis, paralysis agitans, locomotor ataxia, cerebral and spinal softening, epilepsy, dementia and nervous dyspepsia. In individuals whose habits are secret the question of diagnosis is attended with considerable difficulty. Anstie lays much stress upon the importance of the following four points, diagnostic of chronic alcoholism ; inso77inia, morning voi7iiting, muscular trei7ior and causeless mental restlessness. Prognosis. In acute alcoholism the prognosis is good if the patient is manageable. In chronic alcoholism the organic changes the direct result of the alcoholic habit tend to shorten life by the production of fatty heart, Bright's disease, insanity, impotence, epilepsy, melancholia and organic brain diseases. The danger in delirium tremens is heart failure or a deepening coma. Acute lobar pneumonia is a very fatal complication of all forms of alcoholism. DISEASES OF THE NERVOUS SYSTEM. 327 Treatment. The treatment of a case of drunkenness requires no consideration, as the rapid elimination of the alcohol soon occurs if its ingestion be stopped. Liquor a77imonii acetatis in large, frequently repeated doses, assists the elimination of the poison. For mania-a-potu the immediate and complete withholding of alco- holic beverages is essential for its successful treatment. If the stom- ach will tolerate food, and usually it will, milk, diluted with liquor calcis, or seltzer water, or hot beef tea strongly seasoned with capsi- cum, should be frequently administered, together with such cerebral sedatives as potassii bromidum and chloral. If the attack be associated with symptoms of cardiac depression, brisk frictions, artificial warmth, stimulating enemata and hypodermic injections of morphina sulphas (gr. 4;) with atropina sulphas (gr. -j^) or digitalis, axe indicated. " If chloral be inadmissible by reason of weakness of the circulation, paraldehyde may be substituted, in doses of from half a drachm to one drachm, repeated at intervals of from one to two hours until quietude is produced." (J. C. Wilson.) For the collapse following a lethal dose of alcohol, the stomach should be immediately emptied by emetics or the stomach tube or pump and the organ washed out with warm water or coffee, the patient placed in the recumbent position and surrounded with artificial warmth, hot frictions to the lower extremities, the use of artificial respiration or the use of faradism to the thorax, inhalations of ammonia, hypo- dermic injections of digitalis, strophanthus or atropina. " The flag- ging heart may be stimulated by occasionally tapping the praecordia with a hot spoon—Corrigan's hammer." (J. C. Wilson.) Chronic Alcoholism. — The combine of symptoms termed chronic alcoholism, are the direct result of the continuous action of a single toxic principle, and no success of even a temporary kind can be expected unless the poison be withdrawn. The rapidity with which this can be accomplished is a question for the skill, judgment and experience of the physician to determine ; the chief obstacles to its success will be found moral rather than physical. Next to the disuse of alcohol is the question of diet. Much progress will be made as the appetite and digestion improve, and so great attention should be given to it. The general health will also be benefited by fresh air, exercise, mental occupation and cold or tepid sponging and an occa- sional hot bath at bedtime. For the combination of symptoms of spirit craving, morning vomiting, muscular tremor, mental restless- 328 PRACTICE OF MEDICINE. ness and insomnia, no drug is comparable with strychnia sulphas, either hypodermically twice weekly or, what is preferable, per the stomach to secure its local action on the mucous membrane. If the in- somnia be persistent, in spite of the foregoing treatment, the temporary use may be made of such remedies as chloral, morphina, paraldehyde, or extractum lupulin ethereal (gr. j-iij). In many cases it is desirable, for its mental effect, if no other, to administer what the patient terms a substitute for his alcoholic beverages. The following is a good com- bination for that purpose :— R. Tincturae nucis vom.,..........J^ss Tincturae capsici,.........■ • ■ %) Ex. lupulin fid.,............^ iij Inf. gent, co.,.............§iss- M- SiG.—Dessertspoonful three or four times daily. For the amemia, loss of strength, and mental debility, benefit may follow the use of syrupus hypophosphilis. Delirium Tremens.— The patient should be isolated, have a skillful, sensible nurse, the quantity of alcohol entirely withdrawn or greatly reduced, supplied with easily digested nutritious diet, and remedies used to combat the excited nervous system. For this latter purpose no one combination is comparable with hypodermic injec- tions of morphina sulphas (gr. %), with atropina sulphas (gr. yi^), repeated p. r. n. ; chloral in the following combination also acts well, if the stomach be not too irritable :— R . Chloral,................^ ss Tr. capsici,..............f.^ss Aquae menth. p.,............f^vss. M. SiG.—Tabbspoonful every two hours until sleep, alternated with a cup of hot beef tea to which has been added a bolus of capsicum, gr. xx. Care is necessary that a condition of coma be not produced by the remedies mentioned. For depression and cardiac weakness the internal use of any one of the following drugs is serviceable : Spiritus chloroformi, ammonii carbonas, tinctura strophanthus, or digitalis. Dipsomania.—The management of these cases is much the same as has already been mentioned for chronic alcoholism, although the strychnina treatment should be given the preference. DISEASES OF THE NERVOUS SYSTEM. 329 HEAT STROKE. Synonyms.—Insolation; sun-stroke; thermic fever; coup-de-soliel; heat exhaustion. Definition.—A depression of the vital powers, the result of exposure to excessive heat. The condition manifests itself as acute meningitis (rare), heat exhaustion (common), and as true sun- stroke. Causes.—Exposure to the influence of excessive heat, either to the direct rays of the sun or artificial heat in confined quarters, or diffused atmospheric heat without proper ventilation. Among the predisposing causes, which act by lessening the power of the system to resist the heat, are great bodily fatigue, overcrowding and intemperance. Pathological Anatomy.—The action of the heat upon the organism is so sudden, and the malady so rapid in its course, that structural changes have not developed. The left ventricle is firmly contracted (Wood). The right heart and vessels are gorged with dark fluid blood. All the tissues and organs of the body are in a state of great venous congestion. The blood is dark, thin, and either but feebly alkaline or decidedly acid, and its power of coagulability is destroyed. The post-mortem rigidity is early and marked. Symptoms. Depending upon the variety. Acute Meningitis the result of exposure to heat is similar to that due to other causes. Heat-exhaustion develops with a rapid feeling of weakness and prostration, the surface cool, the face pale, the voice weak, the pulse rapid and feeble, the respirations increased, the vision growing dim and indistinct, noises develop in the ears, the individual, overcome, becomes partially or completely unconscious. In some cases the attack of prostration is sudden, the person falling unconscious, with perhaps convulsions or tremors, and shrunken features. Sun-stroke. The symptoms, developing suddenly, with or without prodromata, are, insensibility, with or without delirium, or convulsions, ox paralysis, the surface flushed and hot, the conjunctiva injected, the breathing either rapid and shallow or labored and stertorous, the pulse quick and either bounding or weak, and the temperature in the axilla ranging from 1050, to 1080, to uo°, with suppression of all glandular 330 PRACTICE OF MEDICINE. action. Death occurring, the result of asphyxia, or from a slow failure of respiration and cardiac action. Diagnosis. It is of great importance, therapeutically, to distin- guish at once between attacks of sunstroke and heat-exhaustion. Cases of sun-stroke are to be differentiated from cerebral hemor- rhage and alcoholic insensibility, for which purpose the clinical thermometer is indispensable. Prognosis. Attacks of heat-exhaustion, if properly and promptly treated, favorable. The prognosis of sun-stroke or heat-fever is unfavorable in the majority of cases, death resulting in from half an hour to several hours. Unfavorable indications are, increased tem- perature, cardiac failure, convulsions, absent reflexes, followed by complete muscular resolution. Favorable indications are, decline in surface heat and axillary or rectal temperature, stronger pulse, increased depth of respirations, restored reflexes, and return of consciousness. Treatment. Cases of heat-exhaustion are successfully treated by placing the patient in the recumbent position, with the head low, and the use of stimulants. If able to swallow administer at once spiritus vini gallici, £ss-j, with tinctura opiideodorata, rnjtx-xxx, to be repeated p. r. n. ; if he be unable to swallow, the remedies may be thrown into the rectum, or spiritus frumenti and tinctura digitalis can be used hypodermically. As convalescence occurs tonic doses of quinina sulphas and strychnina sulphas should be prescribed. For sunstroke, the indications for treatment are the very opposite. The patient is in imminent danger from the extraordinary temperature and measures to reduce it must at once be instituted. Of these none give such excellent results as rubbing with ice, or the cold bath or cold pack, and cold effusions, cold enemata, and the hypodermic use of qui- nine sulphas or antipyrine. The tendency to subsequent rise of tem- perature is met by wrapping the patient in a wet sheet, or the repetition of the hypodermics mentioned if consciousness has not been regained, when they can be given by the mouth. If convulsions and restless- ness occur, the hypodermic use of morphina sulphas, gr. %-yi, cau- tiously repeated, is successful. If symptoms of depression occur, the stomachic, rectal or hypodermic administration of stimulants is indi- cated. For convalesence, use quinina sulphas, strychnina sulphas or fer- rum. DISEASES OF THE SPINAL CORD. 331 DISEASES OF THE SPINAL CORD. SPINAL HYPEREMIA. Synonyms. Spinal congestion ; plethora spinalis. Definition. An abnormal fullness of the vessels of the meninges and cord; active when arterial hyperaemia; passive when venous hyperaemia ; characterized by pain in the back, with more or less pro- nounced disorders of sensation and 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. 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 dorsal or lumbar region, shooting into the hips and thighs, persistent and increased by pres- sure; tenderness on motion ; tingling sensations in the limbs and feet, and sometimes in the hands and arms; a feeling of constriction about the abdomen is often present, with rigidity of the abdominal muscles. Increased reflexes, with disorders of motility, and when the patient is in the recumbent position, jerking of the limbs. On attempt- ing to walk it is accomplished with difficulty, from an incoi7iplete 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 benumbed and heavy, the movements weak. The electro-contractility is preserved, and in many cases even in- creased or exalted. 332 PRACTICE OF MEDICINE. Duration. From a few hours to several days ; if longer, myelitis may result. Diagnosis. Anei7iia 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. Spinal 77ienbigeal hemorrhage is more sudden in its onset, its vio- lence and its range of symptoms. Myelitis and spinal meningilishave 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. If the result of suddenly arrested perspiration, pilocarpus. If fol- lowing suddenly arrested menses, aconitum. If associated with an active circulation, potassii broi/iidum ox fluidum gelsemii extr-actu/n, n\,v, every four hours, or extractum ergote fluidum, f3ss-j, repeated p. r. n. ; 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; charac- terized by pain in the back, rigidity of the muscles, disorders of motility and sensibility. It may be acute or chronic. Causes. Exposure to cold and dampness ; injuries to the vertebrae 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 oedematous. Chronic. Adhesions of the membranes, with more or less accu- mulation of fluid, resulting in atrophic degeneration of the cord from pressure. DISEASES OF THE SPINAL CORD. 333 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 constriction around the body, " the girdle." Spasmodic contractions 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 movements 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. Electro-contractility lessened or absent, both as to motility and sen- sibility, in the affected parts. Chronic form 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, whereas irritation of the skin does not in spinal meningitis produce muscular contractions,but movements of the limbs does do so; progressively increasing and not associated with fever. Prognosis. Grave. Death is either sudden, from paralysis of the respiration and 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 recovering 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. 334 PRACTICE OF MEDICINE. To reduce the amount of blood in the vessels of the cord, aconitum and ergota combined with an opium impression. When paralysis (depression) occurs, quinine sulphas, gr. iij, combined with ext.bella- do7i7ie alcoholic, gr. %., three times a day, or potassii iodidum, gr. xx-xxx, three times a day, with flying blisters along the spine. If the paralysis still persist, a hydrargyriwi impression often benefits. For paralysis, the galvanic current to the spine and nerve trunks, and the faradic current to the affected muscles, with the deep injec- tion of strychnina 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. Causes. Exposure to cold and damp; alcoholism ; syphilis; gout ; injuries. Pathological Anatomy. Hypertrophic pachymeningitis 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 pachymeningitis. In the pseudo-me7nbranous 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 of the painful parts begin to atrophy, followed by spasmodic contraction and paralysis. The general health deteriorates with the progress of the muscular symptoms. The electro-contractility is lost. DISEASES OF THE SPINAL CORD. 335 Prognosis. If early recognized and promptly treated, the hyper- trophic form may be cured. Treatment. Rest; nutritious diet; oleum morrhua and the hypophoiphites; 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^r^r matter alone is inflamed, it is termed central myelitis ; when the white matter and the meninges, it is termed cortical myelitis ; it may be ascending, de- scending or transverse in its extension. The disease is characterized by more or less sudden and complete loss of motion and sensation. 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 the 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 appear- ance and consistency of cream. The membranes also undergo 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, 103°', frequentpulse, with alterations in sensibility and motility, 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 7teuralgicpains. The distinction between anesthesia, insensibility to touch, and analgesia, insensibility to pain, must be clearly determined. A sensation of constriction around the body and limbs, 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- 336 PRACTICE OF MEDICINE. 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 motion a7id sensibility axe associated with more or less pronounced vomiting, hepatic disorders, irregularity of the heart, dyspnoea, dysphagia, apncea and painful priapisms. The urine is markedly alkaline in reaction. Among the late manifestations are shooting pains and spasi/wdic 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 meni7igitis is distinguished from acute myelitis by severe pains, increased by pressure, with muscular con- 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 symp- toms, 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 persistent sloughing (bedsores) 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 pylo- nephritis and cystitis and changes in the joints ; death from exhaus- tion, in several weeks. Central myelitis, or inflammation of the gray 77iatter, is rapid in its progress, death occurring in 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. DISEASES OF THE SPINAL CORD. 337 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, bromides, ci7iiicifuga 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 of 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 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 rtot 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 of 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 centre 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 ; it 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 29 338 PRACTICE OF MEDICINE. 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 movements axe impaired or abolished. The elect7-o-co7itractility 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 :— 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 a7iode 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 con- tractions. 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, DISEASES OF THE SPINAL CORD. 339 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. If proper treatment be not pursued for several months or years, the question of final recovery can be determined by testing for the " reac- tions of degeneration " with the galvanic current. There is no dan- ger 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 internally, quinina, belladonna and ergota. With the improvement that follows the above measures, use inter- nally, tinctura nucis vomice, rnj-iij t. d., or hypodermic injections of strychnine sulphas, gr. -fa to ^y twice a week, and faradism to the uaralyzed muscles. 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 in 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 and pharyngeal muscles, causing difficulty in deglutition, the orbicu- laris oris, preventing closure of the lips, the laryngeal muscles inter- fering with articulation. When the disease is fully developed the con- dition of the patient is most pitiable, indeed; articulation is impaired 340 PRACTICE OF MEDICINE. or impossible, deglutition interfered with, the lips remaining apart allowing the saliva to dribble from the mouth, and liquids to return through the nose if attempts are made to swallow them. As the malady advances soon the pneumogastric nucleus becomes involved, causing loss of voice, difficulty of respiration and cardiac irregularity. The general health gradually suffers from insufficient nutrition and imperfect respiration, although the mind is clear until the end. 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. " Galvanism is the most promising remedy. Stabile applications, the electrodes on the mas- toid processes, and in the opposite direction, galvanization of the sym- pathetic, and applications to the lips, tongue and fauces, should be persistently used." (Bartholow.) 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. Lateral sclerosis; II. Cerebro-spinal sclerosis; III. Posterior sclerosis or loco/nolor ataxia. 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. It is said that railroad enginemen and firemen as well as conductors and other trainmen, suffer from this and other spinal diseases by reason of the concussion. Pathological Anatomy. The changes in the cord are gradual in their development and follow a longitudinal instead of a transverse direction. The form, consistency 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. DISEASES OF THE SPINAL CORD. 341 LATERAL SCLEROSIS. Synonyms. Antero-lateral sclerosis ; spasmodic tabes dorsalis, (Charcot) ; spastic spinal paralysis (Erb). Pathogeny. The site of the lesion is the lateral white columns, in some cases extending to the anterior horn, extending the whole length of the cord The changes consist in an interstitial hyperplasia of the connective tissue and an atrophy of the nerve elements. Symptoms. The chief symptom is paraplegia, or entire loss of motion in the lower extremities. Preceding the paralysis there occur jerking and twitching, with cramps 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 greatly 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. CEREBRO-SPINAL SCLEROSIS. Synonyms. Multiple sclerosis of the brain and cord; cerebral sclerosis ; spinal sclerosis ; disseminated sclerosis (Charcot). Pathogeny. The disease consists of the development of patches of grayish, translucent, tough nodules, varying in size from a minute microscopical object up to the size of a walnut, varying in number and widely distributed in the white matter of the hemispheres, ven- tricles, optic thalamus, corpus striatum, peduncles, pons and cere- bellum, while in the cord they are found in both the white and gray matter and in the columns. The deposits are also found in the nerve roots and nerve trunks. The nodules are composed of the neuroglia much altered and a newly-formed connective tissue. The result of the nodules is pressure upon the nerve structure, ending in its degen- eration. Symptoms. Charcot divides this variety of sclerosis into three varieties, depending upon the site of the marked changes, as the brain, the cord or a combination of the two. The latter variety is the more common. 342 PRACTICE OF MEDICINE. Rarely the malady is ushered in with apoplectiform symptoms, but generally the onset is insidious, with pains more or less severe in the limbs and back, which are attributed by the patient to rheumatism. Also a feeling of formication, itching and burning in the limbs. Loss of coordination of the hands in writing, or the feet in walking, fol- lowed after a time by paresis, more or less general, with contracture of the muscles. Voluntary movements of the paretic limbs develop a tremor—the shaking tremor—which subsides when the limbs are at rest. It is these motor symptoms that have given rise to the "wad- dle," or "hop" gate when walking. There are also present head- ache, vertigo, mental disturbances, nausea, dyspeptic distresses, dis- orders of vision and hearing, sexual disturbances, vesical disorders, and often the development of bedsores. The disease is progressive, the symptoms developing as the various nerve tracts are invaded. Duration. Ranges from a year to twenty years, an average being five or ten years. PROGRESSIVE LOCOMOTOR ATAXIA. Synonyms. Posterior spinal sclerosis; tabes dorsalis. Pathogeny. The sclerosis begins and may be confined to the posterior columns in the upper lumbar and dorsal regions. Frequently it extends the entire length of the cord and invades the lateral col- umns. The sclerotic changes also invade the sciatic, crural and brachial nerves. Symptoms. Locomotor ataxia may be divided into three periods: I, disturbances of sensation; 2, loss of coordinating power; 3, paralysis. The onset of the disease is gradual by sharp, darting, electric-like pains in the lower limbs, with disorders of the gastro-intestinal and genito-urinary tracts. Associated with the pains is a loss of sensation in the feet, the patient being unable 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 suffi- ciently to button his clothing. A sensation of formication over the surface, especially over the lower limbs, and about the waist, the knee and the ankle. Loss of coordination, the subject being unable to walk upon a straight line with his eyes closed, and with difficulty if his eyes are DISEASES OF THE SPINAL CORD. 343 opened. Inability to preserve the erect position with the feet close together, and as the malady progresses he throws his feet and legs in the most grotesque manner. Although the patient is unable to coor- dinate the muscles, their power is not lost, for, on being supported, he can kick or strike with his usual force. The sight is early impaired ; either double vision or inability to dis- tinguish between different colors. As the disease progresses the sen- sation becomes more and more blunted and pain is slowly felt, in cases it being several minutes until the sticking of a pin is felt. A characteristic sign of the disease is the abolition of the patellar tendon- reflex as well as other reflexes in the lower limbs. Loss of the sensa- tion of temperature also occurs. The electro-contractility is decreased in the affected limb. General emaciation is marked. Paralysis finally ends the suffering of the patient. There is gener- ally an entire absence of cerebral phenomena. Diagnosis. The symptoms of these three varieties of sclerosis are so characteristic that with care an error in the diagnosis seems impossible. Chronic myelitis is characterized by paralysis, and the course of the affections are otherwise so different that an error should not occur. Disease of the cerebellum presents symptoms of disordered coordi- nation, but they are the result of vertigo, and associated with head- ache, nausea and vomiting. Paraplegia is a true paralysis, while sclerosis is not. Neuralgic pain is not a symptom of paraplegia. Paralysis agitans may be mistaken for disseminated sclerosis. Chief points in the diagnosis are the presence in paralysis agitans of the fine tremor continually without shaking of the head, while in cerebro- spinal sclerosis the tremor is produced only on movement of the muscle, and is associated with shaking of the head. Paralysis agitans, a disease of middle life, sclerosis under forty years. Changes in the voice, speech and vision are present in cerebro-spinal sclerosis, but absent in paralysis agitans. Prognosis. Unfavorable. Few if any recoveries are recorded of antero-lateral or disseminated sclerosis, although rarely their progress has been retarded for a long time. There are some claims of recov- eries of locomotor ataxia in the early stage, but that a cure of a gen- uine case, extending to the second stage, is ever effected, seems very questionable. 344 PRACTICE OF MEDICINE. Treatment. In the management of the various scleroses, rest, as near absolute as possible, is of the first importance,—it will be all the more effective if it be in bed, for a period of several months. Following the suggestion of Erb, use may be made of cold along the spine, in the shape of cold sponging, cold spinal pack or short application of the cold douche to the spine. The galvanic continuous current along the spinal column is warmly advocated, with faradism to the wasting muscles. Potassii iodidum, or hydrargyri chloridum corrosivwn, in full doses, or aurii et sodii chloridwn, gr. -^, three times a day, often remarkably retard the progress of the affection. The best results are obtained, however, from argenti 7iitras, gr. Y~%> or oxidwn, gr. yi, three times a day, withholding it at intervals of a few weeks, to prevent discolor- ation of the skin (argyria). Temporary success at least, seems to have followed, in some cases of locomotor ataxia, from the "suspension treatment" as recom- mended by Charcot. The treatment consists of the suspension of the patient during a period varying from one to four minutes, by means of the Sayre apparatus for applying the plaster jacket in spinal deformities. 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. The diet should be of a nutritious, easily-assimilated character. Nutrition can also be promoted by the use of oleum 7norrhue and syrupus calcii lacto-phosphatis. PROGRESSIVE MUSCULAR ATROPHY. Synonym. Wasting palsy. Definition. A gradual, progressive wasting and atrophy of the voluntary, muscular system, resulting from trophic changes due to a central nerve lesion. Causes. In many instances the disease is hereditary. A predis- posing cause seems to exist in those who habitually use one set of muscles. Exposure to cold and damp; lead, syphilis ; injuries to the spinal column. Pathological Anatomy. Two theories as to the origin of the pathological changes are held : one that the initial lesion is in the DISEASES OF THE SPINAL CORD. 345 cord (Charcot), the other in the muscular interstitial connective tissue (Friedreich). The morbid alterations are of two groups—spinal and muscular. The spinal changes consist in the atrophy and degeneration of the anterior columns, wasting and disappearance of the multipolar gan- glion-cells of the anterior horns, and hyperplasia of the neuroglia, and wasting, atrophy and degeneration of the anterior nerve roots. The muscular changes consist of a progressive wasting of the mus- cular tissue, with increase of the interstitial connective tissue. " The final result is, that the muscle is converted into a mere fibrous band with numerous fat-cells, the development of this latter material taking place outside of the muscular elements and in the newly-formed con- nective tissue." (Bartholow.) Symptoms. The invasion is gradual, the disease having been in progress some weeks or months before the patient discovers its existence. Wasting begins usually in the hand, the first dorsal inter-osseus being the first to be attacked, then the muscles of thenar and hy- pothenar eminence, then the deltoid, and so on from muscular group to group. Often, however, the extension is very erratic in its course, jumping from one group to another at some distance. In the immense majority of cases the disease is permanently lim- ited to one or a few groups of muscles in the upper, or more rarely in the lower extremities. The only muscles not yet known to be attacked are those of mastication and those that move the eye-ball (Roberts). Fibrillary contractions is an early symptom, continuing more or less marked so long as any muscular fibres remain. It consists of wave-like movements of the muscles, excited automatically, by draughts of air or percussion. Co-incident with the wasting is loss of power, disorders of sensation, coolness of the surface, and pallor of the surface. The natural roundness and contour of the body and limbs are changed, the bones standing out in unaccustomed distinctness, giving the individual the appearance of a skeleton clothed in skin. The hand is frequently the seat of a very singular deformity—the " claw- shaped" hand. The electro-contractility is preserved so long as muscular fibres remain. Diagnosis. When wasting palsy is fully developed its diagnosis 3° 346 PRACTICE OF MEDICINE. is a simple matter. In its early stages a doubt may exist, but atten- tion to the history, symptoms and progress will determine the ques- tion. Prognosis. Very unfavorable, although the danger to life is often very remote. The disease may be arrested and remain stationary for years. Treatment. Internal medication seems to have no effect on the malady, although if mineral poisoning be suspected potassii iodidum should be used, and if syphilis be suspected a course of potassii iodi- dum and hydrargyrui7i should be administered. If the disease is the result of overworking any set of muscles, these must be allowed a rest. " The most effective remedy in wasting palsy is, undoubtedly, gal- vanis7n. Numerous observations attest its value when applied locally to the affected muscles" (Roberts). I have seen improvement from the faradic current to the affected muscles, the strength being simply sufficient to produce contractions. Massage is a valuable adjuvant to the electrical treatment, as are hot sponging and rubbing along the spine. Prof. Bartholow "has apparently effected great improvement in a case, confined as yet to the left upper extremity, by the injection of glycerine solution into the wasting 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. CEREBRO SPINAL NEUROSES. 347 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 7notility ; in severe cases, inability of self-feeding or of 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- 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 agitans has general muscular tremor, beginning in one limb, gradually progressing, uninfluenced by treatment; a disease of the elderly. Post-he/niplegic chorea is the choreic movement of a paralyzed limb. Prognosis. The vast majority of cases recover, but relapses are very frequent. 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 axe indicated. Regulate the secretions. Arsenicui7i 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 for administration in this disease is liquor potassii arsenitis, gtt. v, increased to gtt. x, or even gtt. xv, three times a day. Extractum cimicifuge fluidum, rrixx-3j, t. d., is serviceable, especially in cases following a rheumatic attack. Cases resisting the arsenicum treatment may succumb to hyos- cya7nine, gr. aoo'iog' three times daily. A patient of mine, aged 16 years, that resisted all the remedies mentioned, was promptly 34S PRACTICE OF MEDICINE. cured by antipyrine, gr. x, 4 times daily. This same case in a former attack was arrested by morphina sulphas, gr. %, four times daily, but this latter remedy failed in the attack controlled by the anti- pyrine. If anaemia be present, combine or alternate arsenicum with ferrum. , 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 ; dypsepsia (?); syphilis ; uterine diseases. Pathological Anatomy. There are no constant anatomical lesions, as yet, associated with epilepsy. Varieties. I. Epilepsia gravior, le grand mal; II. Epilepsia mitior, le petit mal. 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, and pallor of the face, the body assuming a position of tetanic rigidity, succeeded after a few mo- ments by more or less pronounced clonic convulsions, followed by a coi7ia of several hours' duration. The subject awakens with a con- fused or sheepish 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 intervals, 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. Ura7nic convulsions closely resemble an epileptic CEREBRO-SPINAL NEUROSES. 349 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 amyl nitris, gtt. iij-v, a few whiffs of chloroformum, or the hypodermic injection of morphina. To prevent the return of attacks, remove the cause if possible; attention to the secretions, and the internal administration of potassii bromidum 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 argenti nitras, belladonna, or cannabis indica. Weak and anaemic subjects usually do better with strychnina in full doses than with potassii bromidum. If a history of syphilis can be obtained, the combination of potassii iodidum and potassii bromidum 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.,................rr\,x. M. Sir,.—Three times a day. Another good combination is the following :— B. Potassii bromid.,...............gr. xv Sodii bromid.,................gr. xv Liq. potassii arsenit.,.............ni ij Ext. conii fld.,................nv iij Aq. cinnamomi...............zj Inf. gentian comp.,......ad.......5<-s. SiG.—Two hours after meals. 350 PRACTICE OF MEDICINE. 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 " 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. HYSTERIA. Definition. A functional disorder of the nervous system, of the nature of which it is impossible to speak definitely ; characterized by disturbances of the will, reason, imagination and the emotions, as well as motor and sensory disturbances. Causes. A morbid condition confined almost exclusively to women. Young girls, old maids, widows and childless married women are the most frequent subjects of the disorder. The parox- ysms frequently develop during the menstrual epoch. The meno- pause is another frequent period for its manifestation. A peculiar condition of the nervous system, either inherited or acquired, is responsible for the phenomena of hysteria, the peculiar manifesta- tions being excited by disturbances of either the sexual, digestive, circulatory or nervous systems. Hypochondriasis, a peculiar mental condition, characterized by inordinate attention on the part of the patient to some real or sup- posed bodily ailment or sensation, as seen in males, is a condition much like the hysteria of the female. Pathogeny. Structural alterations have thus far not been detected in cases of hysteria; it is thus a functional disturbance of the nervous system. It should, however, be borne in mind that hysterical manifestations frequently develop during the prevalence of organic diseases. Symptoms. These will be considered under the headings of the hysterical paroxysm and the hysterical state. The Hysterical Paroxysm or Fit occurs nearly always in the pres- ence of others, and develops gradually with sighing, mea7iingless CEREBRO-SPINAL NEUROSES. 351 laughter, causeless moaning, nonsensical talking and gesticulations, or a condition of fidgets, followed with a sensation of choking, dyspnea and a ball in the throat, the globus hystericus. These and similar symptoms precede the fit, during which the unconsciousness is only apparent, the patient being aware of what is transpiring about her. During the paroxysm the patients may struggle violently, throwing themselves about, their thumbs turned in and their hands clenched. Again, spasmodic movements occur, varying from slight twitching in the limbs to powerful general convulsive movements to almost tetanic spasms. The paroxysm ends by sighing, laughing, crying and yawning, and a sensation of exhaustion. During the attack it will be noted that the surface and face are normal, showing absence of respiratory embar- rassment, the breathing varying from very quiet to spluttering and gurgling sounds, the pupils not dilated, the pulse normal, the tempera- ture normal, and absence of foaming at the mouth and wounding of the tongue. The Hysterical State is shown by disturbances of the mental, sensory- motor functions respectively. It may be a permanent condition or occur at intervals with greater or less severity. Mental disturbances. The patients are emotional, erratic, excitable, impatient and self-important, showing marked defects of will and mental power. Sensory disturbances. This is either a condition of exaggerated sensibility or hyperaesthesia, as shown by the marked effects from the slightest irritation and the cutaneous tenderness along the spine, or a condition of anaesthesia as shown by the apparent absence or recog- nition of pain after severe irritation, or a perverted sensibility as shown by the feeling of tingling, numbness and formication. Sensibility to heat or cold are often absent. There is great perversion of the special senses in many of the cases. Charcot, referring to the ovarian hyperaesthesia of hysteria, says: " It is indicated by pain in the lower part of the abdomen, usually felt on one side, especially the left, but sometimes on both, and occu- pying the extreme limits of the hypogastric region. It may be extremely acute, the patient not tolerating the slightest touch ; but in other cases pressure is necessary to bring it out. The ovary may be felt to be tumefied and enlarged. When the condition is unilateral, it may be accompanied with hemianaesthesia, paresis, or contracture 352 PRACTICE OF MEDICINE. on the same side as the ovarialgia ; if it is bilateral, these phenomena also become bilateral. Pressure upon the ovary brings out certain sensations which constitute the aura hysterica, but firm and systematic compression has frequently a decisive effect upon the hysterical con- vulsive attack, the intensity of which it can diminish, and even the cessation of which it may sometimes determine, though it has no effect upon the permanent symptoms of hysteria." Motor disturbances. These phenomena embrace every variety of motor disturbance, from exaggerated excitable movements to defect- ive or complete loss of power. With the paralysis that may occur, neither nutrition nor sensation are impaired. Hysterical paralysis is liable to frequent and sudden changes, the loss of power often disap- pearing suddenly. Aphonia, from paralysis of the laryngeal muscles, is a frequent form of paresis. Some hysterical patients refuse to even make an attempt at speech. "A curious-enlargement of the abdomen is observed sometimes, constituting the co-called J>hantom tumor. This region presents a symmetrical prominence in front, often of large size, with a constric- tion below the margin of the thorax and above the pubes. The enlargement is quite smooth and uniform, soft, very mobile as a whole from side to side, resonant but variable on percussion, and not pain- ful. Vaginal examination gives negative results, and under chloro- form the prominence immediately subsides, returning again as the patient regains consciousness." Among the numerous other symptoms that may develop in a hysterical patient are disturbances of digestion, the circulation, the respiration, disorders of micturition and menstrual disorders. Among other phenomena that belong to the Hysterical state are to be mentioned Hystero-epilepsy, a condition of hysteria to which is superadded the convulsion, epileptic in form; Catalepsy, a condition in which the will seems to be cut off from certain muscles, and in whatever position the affected member is placed, it will so remain for an indefinite time. There may or may not be unconsciousness and loss of sensation ; Trance, the individual lying as if dead, circulation and respiration having almost ceased ; Ecstasy, a condition in which the individual pretends to see visions and acts in the most ridiculous manner. Diagnosis. The hysterical state is so general in its manifestations hat it is to be borne in mind in diagnosing all ailments occurring in CEREBRO-SPINAL NEUROSES. 353 woman. The diagnosis is attended with great difficulty, however, and requires the display of all the skill of the clinician to prevent error. Prognosis. Death from either a hysterical fit or the hysterical state is the rarest of events, if it ever occur. The ultimate recovery of a hysterical patient is of frequent occurrence. Marriage has cured many cases, although it can hardly be advised by the physician. Treatment. For the hysterical fit little need be done, as a rule, unless the paroxysm is violent or prolonged, in which case ammonii valerianate, Hoffman's anodyne ox spiritus ammonie aromatkus may be administered. Charcot recommends the making of firm pressure over the ovarian region to check hysterical fits that are of a severe character. The management of a confirmed case of hysteria will tax the skill of the most astute physician. It is in connection with hysteria that the peculiar phenomena supposed to arise from applying different metals to the surface of the body have been noticed. Moral and hygienic measures are of the first importance in the management of an hysterical patient. The treatment by isolation of hysterical patients is strongly urged by many specialists. Dr. S. Weir Mitchell has devised a plan for bedfast hysterical patients, of massage, faradization and forced feeding, which is successful in a fair number of cases. There is no fixed therapeutical treatment for hysteria, the various symptoms calling for interference as they arise. It is well, however, to avoid the use of stimulants, opiates and chloral. NEURASTHENIA. Synonyms. Spinal irritation ; nervous prostration ; nervous ex- haustion. Definition. A debility of the nervous system, causing an inabilty or lessened desire to perform or attend to the various duties or occu- pations of the individual. Prof. Bartholow describes it as consisting " essentially in an exag- gerated susceptibilty to bodily impressions and false reasoning thereon." Causes. It may result from various chronic diseases; mental worry or emotion ; overwork, as " whenever the expenditure of nerve- force is greater than the daily income, physical bankruptcy sooner 354 PRACTICE OF MEDICINE. or later results" (Jackson). Neurotic temperament; sexual excesses; alcohol; tobacco. Symptoms. Nervous debility may affect any organ of the body. It is a condition of nerve-tire or exhaustion, and hence the nervous energy necessary for functional activity of any particular organ is wanting, a fair example being seen in cases of nervous dyspepsia. One of the earliest manifestations of nervous exhaustion is an irri- tability or weakness of the mental faculties, as shown by inability to concentrate the thoughts, and efforts to do so causing headache, ver- tigo, restlessness, fear, a feeling of weariness and depression, together with the army of symptoms attendant on nervousness. There may be ocular disturbances, cardiac palpitation, coldness of the hands and feet, chilliness followed by flashes of heat, followed in turn by slight sweating. Patients are troubled with insomnia, or fatiguing sleep accompanied with unpleasant dreams. In the male there are genito-urinary disorders with pains in the back giving the dread of impotence. In females, painful menstrua- tion, ovarian irritation and irritable uterus. Diagnosis. It is of importance to determine between a true ner- vous exhaustion, and nervous debility the result of organic disease. A study of the history of the case, together with the symptoms, should prevent error. Prognosis. Unless there be a tendency to mental disorders the prognosis is good. Treatment. Attention to the secretions, diet and surroundings. Rest and diversion of mind is essential to success. Travel, short of fatigue, pleasant companionship, and relief from responsibility. Bathing, massage and galvanism are important aids to the manage- ment of cases. Among the internal remedies that are of benefit may be mentioned, arsenicum, strychnina, fernmi, zinci valerianate, phosphorus, ex- tractui7i coce fluidum, vinum coce and syrupus hypophosphitis comp. EXOPHTHALMIC GOITRE. Synonyms. Grave's disease ; Basedow's disease. Definition. A disease of the nervous system ; characterized by protrusion of the eyeballs, enlargement of the thyroid gland, dilata- tion of the arteries and palpitation of the heart. CEREBRO-SPINAL NEUROSES. 355 Causes. An undemonstrative condition of the nervous system, either inherited or acquired, is the predisposing cause of Grave's disease. Among the exciting causes are, anaemia, shock, fright, chagrin, worry and reverses of fortune. It is more common in women than in men. Pathological Anatomy. " Some structural alterations have been found, in a majority of cases, in the sympathetic ganglia, and especially in the inferior ganglia." (Bartholow.) The veins and arteries of the thyroid gland are dilated, the result of a vasomotor paralysis. The enlargement of the gland is the result of the dilated vessels, a serous infiltration of its tissues, followed, if long continued, by hypertrophy. A considerable increase of fat behind the eyeballs has been observed. In the majority of cases more or less anaemia exists. Symptoms. The development of the quarternary of symptoms may occur suddenly, the result of some great shock to the nervous system, but in the majority of instances the symptoms develop slowly and insidiously, with cardiac palpitation, with paroxysms of more marked acceleration, the pulse rate varying from 90 to 120, 150 and rarely as high as 200 beats per minute; soon pulsations of the vessels of the neck and thyroid gland may be felt and seen. The enlargement of the thyroid gland—the goitre—appears gradually after the development of the circulatory disturbances, although rarely it may be the first symptom observed. The goitre is elastic, rather soft, and has a thrill similar to an aneurism. The degree of enlarge- ment varies in different cases, and in none ever attains a very great size. Following the development of the goitre occurs the protrusion of the eyeball—the exophthalmus—which may be confined to one eye, but usually occurs in both. Prominence of the eyeball may be the first symptom observed, but usually it does not develop until after the appearance of the goitre. The degree of protrusion varies from a slight staring expression to a point so great that the eyelids cannot cover the balls. Associated with the protrusion of the eyeballs is incoordination in the movements of the eyelids and the eyeball, the diagnostic rule of Graefe, so that when the eyes are quickly cast down the eyelids do not follow them, the sclerotic being visible below the upper lid. Vision is unimpaired. Conjunctivitis may arise, the result of the imperfect protection of the protruding ball by the eyelids. Associated with the pathognomonic symptoms are nervousness, 35G PRACTICE OF MEDICINE. irritability of temper, headache, insomnia, vertigo, fits of despondency, aphonia and cough the result of pressure of the goitre, disorders of digestion, increase of temperature, anaemia and loss of flesh. Diagnosis. The fully developed disease presents no difficulties in diagnosis, but during its incipiency, before the characteristic symp- toms have appeared, the disease may be confounded with such con- ditions as cardiac disease, neurasthenia, lithaemia, malaria, or incipient phthisis. Prognosis. Recovery occurs in a fair number of cases, but is slow and tedious. The disorders of the circulation lead to dilated heart in many cases, and ultimately death occurs from this cause. Relapses are frequent. Treatment. One of the first injunctions to be placed on a case of exophthalmic goitre is rest, both physical and mental, as well as freedom from worry or emotional excitement; little progress will be made if this point be neglected. The general nervousness, restless- ness and insomnia will often call for special treatment, when use may be made of chloral, potassii broi/iidum or sulphonal; it is better, how- ever, not to use this class of drugs in a routine manner, but for the special indications. The chief indication, next to rest, is the condition of the circulation. To control this two remedies are of inestimable value, they are digi- talis and strophanthus. The results I have seen from tinctura stro- phanthus, rr\,v from three to six times daily, have been most satisfac- tory. Dr. Bartholow " has had good effects from quinina, belladonna and ergotin, in combination." The associated anaemia is to be treated by ferrum, arsenicwn and an easily digestible and nutritious diet. Galvanism to the cervical sympathetic and pneumogastric is an important adjuvant to the medicinal treatment. DISEASES OF THE NERVES. 357 DISEASES OF THE NERVES. NEURITIS. Definition. An inflammation of the nerve trunks; character- ized by pain and paresis of the parts supplied by the affected nerve trunk. Causes. Wounds and injuries; cold and damp. 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 (neuritis descendens)." Symptoms. The onset may be accompanied with febrile reac- tion. The most decided symptom is pain along the course of the nerve trunk and its peripheral distribution, of a burning, tingling, tearing, intense character, increased by pressure or motion. If the affected nerve be a mixed one—sensory and motor—spasmodic co7i- tractions and muscular cramps occur, followed by impaired motion, terminating in paresis of the muscles innervated by the affected trunk. If the inflammation proceed 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 ofgalvanism or a feeble, slowly interrupted faradic current restores the interrupted function. For the pain and muscular contractions, hypodermic injections of morphina. 35S PRACTICE OF MEDICINE. 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 nerve; II. Ceivico-occipital neuralgia; III. Cervico-bracpial neuralgia; IV. Dorso-intercostal neuralgia ; V. Lu77ibo-abdominal neuralgia ; VI. Sciatica. Causes. Heredity; anaemia; malaria; syphilis; metallic poi- sons ; anxiety; mental exertion ; exposure to cold and damp ; injuries of a nerve trunk. 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 convulsive 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. Paroxys77ial 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 cramps in the cervical muscles, and with attacks of herpes. A sensation of cracking at the nape of the neck is an annoying symptom in many cases. CERVICO-BRACHIAL NEURALGIA. Symptoms. Paroxysmal pain, of a severe, boring, burning or tensive character, with sensalio7is of numbness and weakness of the DISEASES OF THE NERVES. 359 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 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. LUMBO-ABDOMINAL NEURALGIA. Symptoms. Paroxysmal pain 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 the 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. Rheu77iatism, 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. 360 PRACTICE OF MEDICINE. Treatment of Neuralgia. Rest; easily assimilated but nutri- tious diet; removal of the cause, if possible. If anaemic, ferrum and arsenicum. If rheumatic, alkalies. If syphilitic or the result of metallic poisons, potassii iodidwn. If malarial, quinina. For an attack, 77iorphina and atrophia, hypodermically, afford the most prompt and ready relief. Success usually follows the use of the well-known " Gross (Prof. S. D.) neuralgic pill:"— R. Quininae sulphas,............gr. ij Morphinae sulphas, ...........gr-f 2V Strychnine,..............gr. ^ Acidi arseniosi,.............gr- 2V Extracti aconiti,.............gr- !• M. Ft. pil. No. I. Sig.—One every one, two or three hours. Few attacks of trigeminal neuralgia will resist the following powerful prescription:— R. Aconitinse (Duquesnel),.........gr. ^ Glycerini, Alcoholis,........aa......^j Aqua menth. pip.,.....ad......j; ij. M. SiG.—Teaspoonful repeated from four to eight times daily, carefully watching. Facial neuralgia is often wonderfully benefited by the internal administration of ext. gelse77iiifid., gtt. iij-v, every three or four hours, until its physiological effects are produced. Excellent results often follow the administration of Moussette's pills (aconitine and quininum). For sciatica, antipyrine, gr. xx, repeated two or three times daily, has given relief. The deep injection of chlorofon7ium is recommended by Bartholow. A spray of chloride of methyl along the course of the nerve for a few moments, watching the skin, will relieve the distress- ing pain. Rarely full doses potassii iodidum with a blister along the course of the nerve gives relief. All forms of neuralgia are more or less benefited by— R . Quininae sulph.,.............gr. iij Ferri redact.,..............gr. j Acid arsenious,.............gr. ?L Aconitise,................gr. T^ M. In pill every four or five hours. DISEASES OF THE NERVES. ;;()[ The following formulae of Bardet is highly recommended for all varieties of neuralgia :— R. Exalgine,................^j Spts. rect.,...............'" K Aq. destii.,.......ad.......« v. M. SiG.—One to three tablespoonfuls during the twenty-four 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 anserinus—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 submaxil- lary glands, and, possibly, the sense of taste. It also furnishes 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 into the mirror the patient is surprised by the per- fectly blank, motionless side of the face, the corner of the mouth is depressed, the eyelids open, the face drawn toward the well side, and with inability to expectorate, whistle or swallow. Any of 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- plegia ; the points of differentiation are the presence of cerebral symptoms and the normal reflex excitability. Facial palsy with otorrhcea, 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. 3i 302 PRACTICE OF MEDICINE. 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 acetas, vel iodidum, arid blisters in front of ear, and the use of galvanism to the affected muscles. DISEASES OF THE BLOOD. ANAEMIA. Synonyms. Spanaemia; hydraemia. Definition. A deficiency of red corpuscles and albuminoid com- pounds—a poverty of the blood ; characterized by pallor and general weakness. Olige7nia is a lessening in the amount of blood ; Ischei7iia 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. Postmortem, 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 fibrin o-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 tei/iper, vertigo in the erect position, attacks of swooning, hysteria, and rarely epilepsy. Irritable heart, with soft systolic basic 77iunnurs and attacks of hysteria. Nocturnal emissions in male and deficient menses in female. Maras- DISEASES OF THE BLOOD. 3(j;j mus in children. More or less general ede,7ia of the eyelids and ankles. Long continued, symptoms of fatty changes in 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-pro- ducing diet. Fresh air, sunlight and exercise short of fatigue. Purga- tives 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.) " four chlorides," is frequently of value :— B. Hydrargyri chloridi corrosivum,......gr. j-ij Liq. arsenici chloridi............fzj Tinct. ferri chloridi, Acidi hydrochlorici dil,.....aa . . . . f Z iv Syrupi,.............. . . . f ^ iij Aqua.........ad........f^vj. M. Sig.—One dessertspoonful in a wineglassful of water after each meal. Cases of anaemia with weak stomach can take the following " iron lemonade " with ease :— E-- Tinct. ferri chloridi,............fzj Acid, phosphor, di'.,...........fzij Syr. limonis,..............f;5Jss Aquae,.................f^ ij. M. SiG.—One teaspoonful well diluted. 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." 364 PRACTICE OF MEDICINE. 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 morose 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 menorrhagic 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; brunettes 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 relapses. Treatment. A generous, nutritious diet; fresh air; moderate exercise; change of scene; cheerful surroundings. Ferrum and arsenicum are of the greatest utility. A good combination is— R. Ferri arseniatis,.............gr. fa—\ Ext. nucis vomicae,............gr. L-l. 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. purse, . ... aa .... ^ ss Tragacanthae,..............q. s. M. Ft. pi. No. xevj. SiG.—One to thiee or four pills three times daily. DISEASES OF THE BLOOD. 365 PROGRESSIVE PERNICIOUS AX.EMIA. 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 marrow 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 of syncope, edema and swelling about the ankles, with petechial spots scattered irregularly over the surface. The appetite is wanting, and nausea and vomiting occur, associated with marked dyspepsia and persistent diarrhea. As the disease pro- gresses a remittent form of fever develops, the temperature frequently showing 102-1040 F. Disorders of vision are the result of the retinal 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 leucocvthemia by the normal-sized spleen and liver, and the absence of increase in the white corpuscles. Prognosis. Unfavorable. Treatment. Symptomatic. 36G PRACTICE OF MEDICINE. 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 ly7nphatic, or a myelogenic 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 ly7nphatic glands all over the body also enlarge, 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 t0 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 iden- tical with that of simple anaemia, accompanied by swelling of the abdomen and a feeling of fullness and pain in the splenic region, due to enlargement of that organ. In the ly77iphatic variety, enlargement of the glands in the groin, neck and axillary region are associated with the great pallor. In the 77iyelogenic variety, the bones, more particularly the ribs and sternum, are tender on pressure, the patient developing a waxy ap- pearance. 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—1.020-1.030. 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." DISEASES OF THE BLOOD. 307 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 rem- edies with generous diet, fresh air, sunshine, pleasant surroundings, oleum morrhua and the hypophosphites have at times seemed of temporary utility, to wit: quinina, arsenicum, ferrum 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 to- ward death, which is characterized by intense development of pigment 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- 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 struc- ture of the skin. Similar pigment deposits occur in the mucous mem- brane 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 melan- amia, changing to icteroid, finally resembling the color of a mulatto, 368 PRACTICE OF MEDICINE. 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. ILEMOPHTLIA. Synonyms. Hemorrhagic diathesis ; "bleeder's disease." Definition. A congenital condition characterized by the habitual occurrence of hemorrhages. Cause. Hereditary. Symptoms. The bleeding 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. Traiwiatic hei7iorrhages 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. 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. DISEASES OF THE BLOOD. 369 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 stomach, 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 fox fresh vegetables and fruits. 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. 32 370 PRACTICE OF MEDICINE. PURPURA. Synonym. Hemorrhcea 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 bene.ath the epidermis. Varieties. Purpura simplex ; purpura hemorrhagica ; purpura urticans. Causes. Not properly understood. It may occur at any age, but is especially frequent in children and elderly people. Its occur- rence after the ingestion of certain articles of diet has been observed. 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 hemorrhagica 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 hei/iatemesis, 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- 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, DISEASES OF THE SKIN. 371 cerebral or pulmonary hemorrhage. Recovery occurs frequently, under judicious treatment. Treatment. Rest and a concentrated nutritious diet, and the moderate use of stimulants, to combat the resulting anaemia. The internal use of oleum terebinthine is one of the most reliable remedies for all forms of the disease. The following is an eligible formula :— R. 01. terebinthinas,............f 3 ij 01. amygdalae express.,..........f 5 j Tinct. opii deodorat.,...........f o ss Mucil. acaciae,..............f^j Aq. lauro-cerasi,......ad......f^ iij. M. Sig.—One teaspoonful every three or four hours. Among the other 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 iodidum. " If hemorrhages that are threatened come on with a strong pulse, flushed face, headache and excitement, digitalis, quinina and ergota are the approximate medicaments." (Bartholow.) Locally, to arrest bleeding, astringents and either hot or cold water or ice. DISEASES OF THE SKIN. DISORDERS OF SECRETION. SEBORRHEA. Synonyms. Acne sebacea ; pityriasis ; tinea furfuracea ; dan- druff. Definition. A functional disorder of the sebaceous glands of the' skin ; characterized by an excessive and abnormal secretion of seba- ceous matter, forming upon the skin either as an oily coating, or in crusts and scales. Varieties. Seborrhea oleoso ; seborrhea sicca. 372 PRACTICE OF MEDICINE. 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. Seborrhcea is a functional derangement of the glands; if it be allowed to become very chronic, there occurs 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 ox pityriasis 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 of 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 pre7nature 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 seborrhcea are very abundant and pale ; in eczema the scales are scanty and reddish, the parts irritated, infiltrated and thickened. Seborrhea sicca and psoriasis have many points of resemblance, whether occurring on the scalp or on the body. In seborrhcea 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 to eradicate. Treatment. The secretions require attention. If anaemia be present, ferrum and arsenicu77i are indicated. The following formula of Sir Erasmus Wilson, and lauded by Hebra, is valuable :— DISEASES OF THE SKIN. 373 R . Vini ferri.,...............f5iss Syr. simplex, Liquor potassii arsenit., . . . . aa.....5 ij Aquae destil,..............f ,5 ij. M. Sig.—Teaspoonful three times a day, with meals. Duhring recommends calcii sulphid., gr. xV"i> several times daily. Local measures are the most important in seborrhcea. 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 applied 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 washing with soap and warm water, or equal parts of soap, glycerine and water, or the following will be found valuable :— R . Saponis viridis (Hebra),..........f 3 iv Spts. vini rect.,.............f^'j- Solve et filtra. Sig.—Dilute and use 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 depend- ing upon the condition of the scalp. If much irritation, either vaseline or oleum amygdala expressum. If no irritation be present, a stimulating preparation will be found of great benefit. Either of the following may be used :— R. Tinct. canfharidis,............fgiij Tinct. capsici, .............f3uj 01. ricini,............" . . . f 3 ij Alcoholis,...............f 3 ij Spts. rosmarini,.............f 3 J- ^- —Duhring. Or— R. Bismufhi subnitratis,...........f.^j Ung. hydrargyri ammon.,.........J^ ij—iv Ung. aquae rosae,.....ad......%'). M. The above should be repeated every day or two, as the symptoms may require, until a cure is effected. 374 PRACTICE OF MEDICINE. The following combination is useful for dandruff:— R. Ammonii muriat.,............gr. x Glycerinae,...............f.^j Aq. rosae,...............3 v. M. Sig.—Apply to head. The seborrhcea of other portions of the body are to be treated upon the same general principles. 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, urethral irritations, 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 until a papule is formed. The duct sometimes contains small hairs, and also the micro- scopic mite—demodex folliculorum—having a length of from ^^o t0 ^ of an inch, and breadth of about z^ of an inch, which was at one time erroneously supposed to be the cause of the affection. 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 co7nedones. Each comedo is small, varying from a pin-point to a pin-head in size, having a brownish or blackish appearance, from the dust or dirt that has adhered to their unctuous surface. If they form in great numbers upon the face they are disfiguring, giving the individual the appearance of having had minute grains of powder implanted in the skin. There is no evidences of inflammation unless acne is associated, but, on the contrary, the skin has a dirty, greasy, unwashed appear- ance. DISEASES OF THE SKIN. 375 Diagnosis. There is no condition resembling comedo, so that its recognition is easy, unless complicated with acne; but even then the inflammatory appearance of acne should prevent an error. Prognosis. Favorable, although often remarkably obstinate. Treatment. Derangements of any of the functions of the body should be corrected, and strict attention be 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 return prevented by an unguenium medicated, to meet the indications, with either sulphur, alkalies or hydrargy- rum. Piffard's acne application I have found valuable :— R. Sulphur sublim., Alcoholis, Tinct. lavend. comp., Glycerini, Aquae camphorae,.....aa......f^ 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 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. 376 PRACTICE OF MEDICINE. 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, giving 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 hav- ing 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 chro7nici; or, the cyst may be destroyed by electrolysis. If a tendency to recur is shown, the plan may be repeated. SEBACEOUS CYST. Synonyms. Wen ; 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. Symptoms. The development of wens is slow and insidious. The 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 semi-globular; in consistency they are either hard or soft, and doughy ; they are freely movable and painless. DISEASES OF THE SKIN. 377 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 secretion of sweat. The sweating may be either general or partial. 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 char- acter of the secretion, chemically, may 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. Chroi7iidrosis is the designation when the fluid poured forth is vari- ously 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 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 378 PRACTICE OF MEDICINE. 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 fatidum ; all these together produce a most disagreeable, disgusting and persistent odor, which is termed bromidrosis 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 hyperidrosis. 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 treabnent 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.,..............Jj. M. Perhaps the very best local application is tbictUra belladonna, 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 carbolicmn :— R . Acidi salicylici,...... Cretae praep.,....... Aluminis exsic,...... M. et powder finely. SiG.—Apply to parts with puff ball Or— K. Acid, salicylici,.............3 parts Pulv. amyli...............10 parts Pulv. soapstone,.............87 parts. M. SiG.—Sift into shoes and stockings. Or— R-. Ungt. picis liquidae, Ungt. sulphuris,......aa......?j. S.G.—Spread on cloth and applied with bandage. (Wilson.) 3SS DISEASES OF THE SKIN. 379 Or— R. Potassii permanganat., Aquae destil., .... SiG.—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 greatest 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. K. Emplast. diachyli,............3" iv Olei ohvae,...............f % iv. The plaster to be melted, and the oil added and stirred until a homo- geneous 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. SUDAMIXA. 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 gr- ij 380 PRACTICE OF MEDICINE. surface, from some cause collects between the layers of the epidermis, 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. Sy>7iptomatic erythei7ia occurs most frequently in childhood, from diseases of the stomach and intestines; during the course of the vari- ous exanthemata. DISEASES OF THE SKIN. 381 Symptoms. A more or less rapidly developed redness of the skin, varying in color from pink or light red to dark red, which disappears 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- coloration. Diagnosis. Erythema resembles acute dermatitis in color, but the subjective symptoms of the latter are so decided that an error should not 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 persph'ation, which in turn softens the epidennis, 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 creta pra- parala, zinci oxidum, bisi7iuthi subnitras, amy hint, lycopodiu77i or buckwheat flour. 382 PRACTICE OF MEDICINE. 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. Eczei7ia erythe77iatosum ; eczema vesiculosum ; ecze7na pustulosum ; eczema papillosum ; eczema rubrit77i ; eczema squa77iosum ; eczenia fissum ; ecze7na verrucosum ; ecze77ia sclerosian. 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- amia 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 give away 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. DISEASES OF THE SKIN. It. chronic eczema the skin is sub-acutely inflamed ; is very much thickened, hardened and infiltrated with cells which extend through- cut 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 ot the part affected, .-:. effing, the result of the serous exudation, giving rise either to a discharge (weeping), with subsequent cnisting, or to the deposition of plastic material. The most constant, annoying and troublesome symptom is the itching, or at times burning, 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 even a lifetime. It may appear upon any portion of the body, or involve the whole integument {eczema universale). The varieties are named in the order which the lesions assume at its commencement. Eczema Erythematosum. An erythema or redness of the sunace. 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 (fry, exfoliating epidermis or scale {eczema squamosum). When a discharge (weeping) or moisture occurs, it is followed with more or less crusting. Intense itching is a constant symptom. Eczema Vesiculosum. Begins with burning, pain, redness and swelling, followed by an immense number of minute vesicles, either discrete or confluent, rapidly distending with a clear or yellowish fluid and attended with intense itching. Soon the vesicles rupture, the fluid rapidly diffusing over the surface and drying into yd.'oxAsh, honey-like crusts. New crops of vesicles soon follow, or if subsequent 384 PRACTICE OF MEDICINE. 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, moist 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. Ecze7na rubrum, or7nadidans, "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, yellowish or brownish crust; in the other the skin presents a bright or violaceous red, punctate, wounded surface, deprived in great part of its epider DISEASES OF THE SKIN. 385 mis, and exuding a scanty or profuse, clear or opaque, syrupy, yel- lowish fluid. Sometimes this is streaked with blood." The itching and burning axe severe. It may develop upon any portion of the body, but is most commonly seen upon the legs, particularly in elderly people. Its course is chronic and increasing in severity. Eczema Squamosum. This is also a clinical variety. It results from the erythematous, vesicular, pustular or papular varieties of the affection, but more particularly the first named. A typical case pre- sents 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 infil- trated 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 ox 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 hy- pertrophy of the papillae, showing itself as hard, thickened, infiltrated, 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 : 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. 33 386 PRACTICE OF MEDICINE. 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 spreading, with heat, swelling and oedema without moisture, giving the surface a deep red, shining and tense appearance, are character- istic 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 seborrhcea. 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 diffi- culty is marked. Both are frequent affections. Psoriasis should never be confounded with a typical case of eczema, but chronic eczema, with infiltrated, inflammatory, scaly patches, fre- quently looks veryr 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 Arpad, or a morning dose of magnesii 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 mite. If the urinary secretion be small and the urine heavy, use should be made of full doses of potassii acetas and large draughts of water. If either a rheumatic or gouty disposition exist, lithium salts, to which may be added vinum colchici seminis. If a scrofulous tendency exist, use oleinn morrhue and syrupus ferri iodidi. If anaemia, DISEASES OF THE SKIN. 387 ferrum, quinina, strychnina and the mineral acids, or syrupus hypo- phosphitis co77ip., 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 removal is to be secured by saturation with oily preparations, a starch or other mild poultice, or a saturated solution of acidum boracicui/i. After their removal the parts are to be cleansed with Castile soap and water. For acute erythematous 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. camphorse, Zinci oleat., . Pulv. amyli., . Sig.—Dusting powder For acute vesicular eczema, Dr. J. C. White recommends bathing the affected part with lolio nigra (hydrargyri chlor. mite gr. viij, liquor calcis fgj), 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 bora- cicum. There are cases which do better from the application of ointments, of which the following is valuable :— R. Zinci oleat., Olei olivje,.......aa.......3 iv. M. U j. M. 388 PRACTICE OF MEDICINE. Or, bis77tuth oleate, made according to the following formula of Dr, McCall Anderson :— R. Bismuthi oxidi,.............?j Acidi oleici,.............£j Cerae albae,...............^ iij Vaselini,................!?jx 01. rosae,................fr\,ij. M. If the discharge be excessive, the following formula of Prof. Bar- tholow I have seen useful:— R. Plumbi acetat., .............?ss Pulv. camphorae,.............gr. xv Ol. amygdal ,..............f ^ij Cerat. flav.,...............?j. 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 eczema papulosum the following lotions are particularly valuable:— R. Acid, carbolici,.............^j_jj Glycerini.,........... f:ziv Alcoholis.,............ ' fziv-vj Aquas destil.,......ail ....... Oj. M. —Duhring. Or— R. Thymol.,................gn x_xx Alcoholis.,............ f?j Aquae destil.,............ \ f ?j. jyj After the disappearance of the more acute symptoms, more stimu- lating applications are indicated, among which are acidum carboli- cu7n, thy7nol, pix liquida or oleiun 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 :— DISEASES OF THE SKIN. 389 R. Olei cadini,...............f^iss Cerati simplicis,.............3J 01. amygdal. amar.,...........git. x. M. Ft. ungt. Or— R. Picis liquidae,..............f^j Glycerini, ...............f^j Alcoholis.,..............f 3 vj 01. amygdal. amar.,...........gtt. xv. M. Sig.—To be rubbed firmly into the skin. The following is Dr. Bulkley's valuable " liquor picis alkalinus :"— R. Picis liquidae,..............f £ ij Potassae causticae.............3[j Aquae distillatse,.............f 3 v. M. The potassa to be dissolved in water and gradually added to the tar with rubbing in a morlar. SiG.—To be used diluted. A very elegant preparation of tar is the French mixture known as " Goudron de Guyot." For ecze7na 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 390 PRACTICE OF MEDICINE. 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 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........5jj Ol. 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 aisenici et hydrargyri iodidi, nrij-v, t. d., and— R. Ung. plumbi subacet............giv Acid, carbolici cryst.,..........gr. iij Ungt. petrolei,.............3 iv. M. SiG.—Apply freely on muslin strips. An excellent formula in eczema vulva is :— R. Iodoformi................sjss Bal. peru.,...............gj Vaseline,................f 3 j. M. Sig.—Apply on soft cloths. 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 squa77iosu77i, 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 DISEASES OF THE SKIN. 391 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, seborrhcea, syphilis, tinea favosa, and tinea tonsurans. Treatment. If the pustular variety, removal of the crusts is the first indication. This is accomplished by saturating the scalp either with oleum olive or oleutn ai/tygdale 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. iij Ung. petrolei,.......... . . *j. M. Sig.—Thoroughly applied. The late Prof. Ellerslie Wallace was fond of the following:— R. Sodii carb.................gr. xxx Ung. petrolei..............gj. M. SiG.—Apply thoroughly after removal of the crusts. I have usually been successful with cleanliness, proper dietary, the internal use of liquor arsenici et hydrargyri idodidi, rt\,ss-j, well diluted, after meals, and the local use of unguentum picis liquide diluted with vaseline. 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 3J Glycerini,...............f^j Alcoholis,...............f3vj 01. amygdalae amar.,...........gtt. xv. M. Sig.—Diluted or full strength, rubbed thoroughly into scalp. 392 PRACTICE OF MEDICINE. 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. Treab7ient. The same as eczema capitis, or the following:— R. Zinc oleat.................%] Ung. petrolei,.............%). 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. 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. Treabnent. Very difficult and discomforting to the patient. Among the remedies at times successful are: argenti nitras, potassa nitras, acidui7i carbolicum, pix liquida, oleum ergota and collodiwn flexile. Ecze7na palpebrarwn. A frequent occurrence in scrofulous chil- dren, showing itself along the edges of the eyelids. Pustules involve the hair follicles, followed by the usual crusting. The symptoms 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 zinci oleat. or glyceritwn 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 forma- tion of extensive pustules, with preference for about the hairs, drying as yellowish or greenish crusts, matting the hairs together and adher- DISEASES OF THE SKIN. 393 ing 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 gen- eral, 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 shva- ing, if the attack be acute, the same plan of medication as recom- mended 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.,..........gr. xv-xxx Sulphur,................£ss-j Ung. petrolei,.............^j. M. SiG.—To be thoroughly applied. In this variety of eczema I have seen marked benefit from the use of liquor arsenici et hydrargyri iodidi, tr\jj-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. Treatment. For acute vesicular or pustular eczema, removal of the crusts and the use of hydrargyri chloridi mite 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 :— 34 394 PRACTICE OF MEDICINE. R. Hydrargyri flav. oxid., Morphinae sulph., . . Vaseline,..... Sig.—Apply to the canal. Ecze7na genitalium. 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 by intense itching. In the female the affection attacks the labiae, and, rarely, the vagina and mons 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 acidimi boracicwn until the more pronounced inflammatory symptoms subside, when should be applied ointments of zinci oleat. or hydrargyri chloridum mite. Persistent cases will often succumb to the plan of treatment suggested by Hebra for eczema rubrum. Eczeitta ani. 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 burning, 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 acidutn boracicwn, after which a weak application of acidum carbolicum, either as a lotion or ointment. The late Prof. S. D. Gross recommended the application of the following:— gr- J-»J gr-j 3y- M. DISEASES OF THE SKIN. 395 R. Zinci oxidi,...............gvj Hydrargyri chlor. corrosiv.,........gr. j Glycerini,...............^ij. M. Sig.—Apply thoroughly to affected parts. Eczei7ia 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 erythematous eczema, which is frequently, but erroneously, termed erythema intertigo or chafing. The symptoms are: redness, heat, and a moist, macerated surface, aggravated by movement of the affected parts. Treatment. The application of a solution of acidum boracicum, or the use of dusting powders, such as zinci oleat., amylum or hydrar- gyri chloridum mile. It is essential for successful treatment that the opposing surfaces be separated by means of lint or cloths. Eczema ma77wiarum. The nipples, and more particularly those of primiparae, are at times the seat 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. Treatment. 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, ..............f^iss Pulv. calaminae praep.,..........3iss Glycerini,...............zj Adipis,........ad.......^j. M. " 3. I cover over the nipple with a lead nipple shield. This excludes the air, keeps the part from being chafed, and I think the lead docs 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." 396 PRACTICE OF MEDICINE. 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 : infiltration, thickening, callosity, moisture followed by dryness, and Assuring, 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 annoying symptom. The diagnosis is to be made between eczema of these parts and psoriasis or syphilis. Treatment. 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,...............% ss Cerat. simp.,..............3 iv M. SiG.—Rub well into part morning and night, first macerating with hot water. Eczema 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 this appendage. Treatment. Internally arsenicu77i is of the greatest value. Locally, the following :— R . Ung. picis liq.,.............3 iv Hydrargyri chlor. mite..........^ss Vaselini,................£iv. M. Sig.—Apply thoroughly. It is a remarkable clinical fact, that very many cases of eczema, whether acute, subacute or chronic, are rapidly cured by the use of potassii iodidui/i in variable doses. 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. DISEASES OF THE SKIN. 397 Causes. Very frequently the result of sudden surface hyperaemia, or rather too rapid circulation through the superficial capillaries, the result of exposure to heat. Irritants and poison produce an attack when brought in contact with the skin. Gastric, intestinal, hepatic, nephritic, ovarian, uterine and cystic derangements are very frequent causes. Certain medicaments; malaria; nervous disorders; asso- ciated with purpura and rheumatism ; pregnancy ; lactation ; meno- pause. 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 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 developed 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, tingling, crawling, pricking and stinging sensations, 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 varying 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 devel- opment on the summit of the wheal; urticaria bullosa, a bullous development at the summit; urticaria papulosa or lichen urticatus the wheal and a small papule are combined ; urticaria tuberosa, or 398 PRACTICE OF MEDICINE. giant wheals ; urticaria hemorrhagica or purpurata urticaria, a com- bination of urticaria and purpura; urticaria evanida, a rapid appear- ance and disappearance of the lesion ; urticaria perstans, slow disappearance ; urticaria conferta, when the wheals are confluent; urticaria pigmentosa, where 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 the general health, the diet and the secretions. The following remedies, alone or variously combined, are often of benefit: quinina, sodii salicylas, pilocarpus, atropina, tinctura bella ■ don7ie, ammonii chloridum, arsenicum and potassii bromidum. The following pill is valuable in many cases :— R. Pulv. pilocarpus, Ext. guaiaci,.......aa..... gr. iss Lithii benzoat.,.............gr. iij. M. Sig.—Two to four each twenty-four hours. If there be atonic dyspepsia and constipation, the following com- bination is useful:— R. Magnesii sulphat.,......... Ferri sulphat.,.......... Sodii chloridi,.......... Acidi sulphurici dil.,........ Inf. cascarillae, ...... ad . . 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,.............iziss Glycerini,...............fzjj Alcoholis,...............f ? viij Aq. amygdal. amar.,...........f^vhj. M. Sig.—Use as lotion, two or three times daily. gr. xvj fgiv. M. DISEASES OF THE SKIN. 399 Bulkley suggests the following:— R. Chloralis, Camphorae,.......aa.......f 3J 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,..............fx) Ung. zinci oxid.,.............J ij. 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 (herpesprogenitalis). Causes.—Herpes facialis : during the course of febrile and nervous disorders; in connection with digestive disorders and colds. Herpes progenitalis; 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 membranes of the mouth and tongue are 400 PRACTICE OF MEDICINE. 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 (herpespreputialis). In the female they are comparatively rare ; but when occurring it is upon the labia majora and 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. Herpes gestationis; 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 of herpes labialis protection with liquor gutta-percha or collodiui7i flexile promote desiccation. Herpes progenitalis ; cleanliness is of the first importance. Coating the eruption with the medicaments mentioned above or washing with a saturated solution of acidui7t boracicum, and afterward dusting with hydrargyri chloridii77i 77iite, are useful. The parts may be rendered less sensitive in frequently recurring cases by astringent lotions, as acidu77i ta7inicwn 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 corresponding to a definite nerve trunk, 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. DISEASES OF THE SKIN. 401 Pathology. An inflammation of either the ganglia, the nerve trunk or branches—probablv the trophic system—causing the devel- opment of vesicles in the lower strata of the rete, with "the infiltra- tion of serum and inflammatory cells" of the papillae and corium. Symptoms. Begins 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, coining 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 form- ation, each vesicle being well-shaped and seated on a bright red, inflamed patch of skin, and distended with a translucent, yellowish fluid. 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 ophthalmicus, zoster auricularis, zoster nucha, zoster brachialis, zoster pectorall's, zoster abdominalis, zoster femora/is. 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 dif- ferent 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 reme- dies to cut it short are useless. The following combination diminishes the pain and modifies the duration :— 402 PRACTICE OF MEDICINE. R. Zinci phosphidi, Ex. nucis vom........aa......gr, x. M. et. ft. pil. No. xxx. Sig.—One every two to four hours. (Butkley). 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. Anaemia or depression are benefited by full doses ferri et quinina citras. For the pain no remedy seems comparable with the hypodermic use of 77iorphina sulph., gr. yi~Y vrith atropina sulph., gr. y^p, near the lesion. Antipyrine, gr. xv, repeated every three or four hours, relieves the pain in many cases. Locally, relief follows coating the "shingles" with either collodium flexile or liquor gutta-percha, to which morphina sulphas 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 and millet-seed-sized papules, vesicles or vesiculo-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 ; miliaria 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 there 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. DISEASES OF THE SKIN. 403 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 (hyperi- drosis), and distressing tingling, pricking and burning 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 develop 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. 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 avoid undue perspiration. 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. 404 PRACTICE OF MEDICINE. 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, extractw/i grindclia fluidum well diluted, or cupri sulphas, in solution (gr. x, aqua, f ^j), or acidi carbolici, gr. xx, glyceriti amyli, giij, or a dusting powder, consisting of lycopodium, 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. Pe77iphigus vulgaris ; pe77iphigus 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 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 beneath the cuticle. Thus, hyperaemia of the skin may exist before exudation is poured out, or the latter may be formed before any congestion 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. Pemphigus vulgaris ; the onset is slow (pemphigus chronicus), without constitutional symptoms, or acute (pemphigus 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, of a round or oval shape, their walls dis* DISEASES OF THE SKIN. 40") tended with a colorless fluid, the color becoming yellowish or puriform as they grow older. They develop abruptly from the sound skin, with a definite line of demarcation, unattended with symptoms of inflam- mation. A characteristic phenomena of the lesion is their successive appearance ; a crop no sooner disappears than another forms, through- out 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 (pemphiguspruriginosus). Pei7iphigus malignus 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. Per/iphigus 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. All portions of the body are liable to the lesion, as also the mucous membrane of the mouth and vagina. It is most common, however, 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 latter be used, the dose should be large. 406 PRACTICE OF MEDICINE. 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, a77iylui7i, or violet-powder, or lotions of liquor plumbi subacetatis dilutui7i, 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 with 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 detritis. 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 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 umbilication, 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. DISEASES OF THE SKIN. 407 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-percha, 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 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 a 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 duration of each pustule is between two and three weeks, new ones forming, until the cause is removed. The most prominent sites are the thighs, legs, shoulders, and back. Diagnosis. Ecthyma and eczema pustulosum have points of resemblance, but a study of the clinical history of the latter should prevent error. Impetigo differs from ecthyma in the size of the pustule and crust. Ecthyma differs from a boil in not having a central core. 408 PRACTICE OF MEDICINE. Prognosis. With care and the 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, arsenicum, quinina, strych7iina and mineral acids. Locally: remove the crusts by first soaking with oil or fat, or water dressings, and apply— R. Ungt zinci oxid. benz.,...........^ss Vaselini, .... ...........5 *s Hydrargyri ammoniati,..........9J- M. Ft. ungt. —Duhring. Pustules showing a sluggish disposition to heal should be stimulated by touching with either argenti nitras 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 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, a 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 the 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, DISEASES OF THE SKIN. 409 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, of a highly inflai7ied 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. 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 follows. 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 35 410 PRACTICE OF MEDICINE. treatment should be both constitutional and local. The economy being below par, such tonics as arsenicum, quinina and ferru77t are of value. Calcii sulphid., gr. x£-i> 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 tinctura iodi, are also recom- mended ; a paste made by adding together equal parts of glycerinui/i and extractum belladonne will often abort a boil; the same is also claimed for unguentum hydrargyri nitratis. 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. A deep-seated bruise is a supposed cause. Perhaps, as in furuncle, impairment of the general health is the important factor. It is generally noted to occur in middle life and old age, and in men more 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 adipose tissue, must either form an abscess or become diffuse. In phlegmo- nous erysipelas the latter condition is observed. But when the inflam- mation is in the dermoid texture, the exudates infiltrate the skin and naturally follow the canals occupied by the ' columnae adiposae.' The pressure thus exerted upon the whole dermoid tissue cannot fail to DISEASES OF THE SKIN. 411 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 understood 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 subcuta- neous 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, 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 burning character. The constitutional symptoms 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, the multiple points of suppuration, and the character of the slough, Also by the pain ; in furuncle, sen- sitive and painful to the touch, carbuncle not being particularly 412 PRACTICE OF MEDICINE. sensitive. Furuncles generally occur in numbers or in crops; car- buncle 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 tinctura ferri chloridi, quinine sulphas, arsenicum and ammonii carbonas are beneficial. Good results are reported from calcii sulphid., gr. yi 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 sloughing tissues, by the aid of an hypodermic syringe. The pain is severe but short-lived." Prof. Agnew recommends painting collodium 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 pres- sure by means of adhesive plaster applied in much the same manner as used for swelled testicle. Success often follows the application of un- guentum hydrargyri nitratis, spread at least one-eighth of an inch thick and covered with adhesive plaster, changing every twenty-four hours. The resulting ulcer, after expulsion of the slough, is to be treated on general principles. DISEASES OF THE SKIN. 413 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 ; acne 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, urethral irritation, scrofula, and the use of large doses of the bromides and iodides. Acne may exist alone or be associated with comedo or seborrhcea. 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 pus- tulosa). If the inflammatory action be severe, destruction of the gland with a resulting cicatrix occurs. Symptoms. Acne papulosa or acne punctata. 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 of pus. It is characterized by the occurrence of pin-head to pea-size, flat, more or less pointed papules, situated about the sebaceous follicles, 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 pustule be handled. 414 PRACTICE OF MEDICINE. 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 con- stitutional 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 consti- pation should be corrected. If anaemia be present, ferrum and arseni- cum axe indicated. Scrofula is an indication for olewn morrhua and ferri iodidum. Uterine disorders, if present, should receive proper attention. In young adult males I have seen wonderful improve- ment follow the passage of a fair-sized bougie once or twice weekly. Calcii sulphid., gr. -x^-\, every two or three hours, is valuable in many cases, as is hydrargyri chloridui7i corrosivum, gr. Trnr-w> three times daily. A remedy highly spoken of by Dr. Bulkley is glycer- inum in tablespoonful doses, two or three times daily. Dr. Duhring recommends that it be given in combination with ferri et quinina citras. Prof. Bartholow "has seen excellent results from the use of syrupus hypophosphitum comp. in acne indurata." Local treabnent. In acne of not very long duration I have seen excellent 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 subli/nalum, 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 DISEASES OF THE SKIN. 415 tolerated ; and while the part is still wet, it is thoroughly scrubbed with lotio saponis viridis, then cleansed with water, carefully dried and anointed with a sulphur ointment. Prof. Bartholow suggested, in a case of acne indurata seen with the author, the following successful plan. To dissolve the sebaceous matter— R. Liquor potassae,............ft^j 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,..............|j. M. Sig.—Apply twice daily. Dr. Duhring recommends the use of the following, after washing the parts with hot water :— R. Sulphuris praecip.,............3J Glycerini, .......'........f<5ss Adipis benz.,..............3J. Ol rosae,................gtt. 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 the part, and the development of more or less acne. The nose and cheeks are the most frequent location. Causes. 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 or of large amounts of condi- ments are frequent causes, as is constant exposure to the weather. It is frequently associated with seborrhcea. 416 PRACTICE OF MEDICINE. 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 hyperplasia, 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 hyperaemic 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 connective 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). 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, followed by crusts and cicatrices, which never occur in acne rosacea. DISEASES OF THE SKIN. 417 Lupus erythematosus may be confounded with acne rosacea if it occurs 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 accomplished. 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,...........X iv Pulv. camphorae,............gr. x Pulv. tragacanthae,............►) j Aquae calcis...............f'■? ij Aquae rosae, ..............f?ij- M. SiG.—Shake the bottle before using and apply every few hours. Or— R. Hydrargyri chlor. corrosiv.,........gr. ij Ung. petrolei...............gj. m. Sig.—Apply thoroughly. Or, the following, suggested by G. H. Fox— R. Chrysarobini,..............xss Collodii,.................2j. M. SiG.—Put a brush through the cork and paint lesion every evening. 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. 36 418 PRACTICE OF MEDICINE. 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 and 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 the 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 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 or 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- DISEASES OF THE SKIN. 419 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 tb/ie. 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. Psoriasis punctata. 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 i/iummularis. The eruption resembles variously-sized coins. This is frequently as large as the patches grow. Psoriasis circinata. 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. Psoriasis palmaris 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 incrustation. 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. 420 PRACTICE OF MEDICINE. 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. Seborrhcea 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. 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. yi, 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 treatment. 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 DISEASES OF THE SKIN. 421 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 oliva 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- X j Athens et alcoholis,.....ad.....q. s. Collodii.................%). 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 sulphuretiwi and acidum carbolicui/i. 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. 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. 422 PRACTICE OF MEDICINE. 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.,.........fgj Alcoholis,...............f§j Glycerini,...............f% ss Aquae rosae,......ad.......f$lv- 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), 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 DISEASES OF THE SKIN. 423 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, melanoderma). 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 367. 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 dysmenorrhcea, 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, 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- 424 PRACTICE OF MEDICINE. 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 prolonged 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 Zinci sulphat.,................^ss Plumbi acetatis,..............." ss Aquae...................f3 iv. M. Sig.—Lotion. Apply morning and evening. —Hardy. Or— R. Hydrargyri chloridi corrosiv.,.........gr. vj Acidi acetici dil.,.............f 3 ij Boracis,..................Qij Aquae rosse,................f ^ iv. M. Sig.—Lotion. Apply twice daily. —Bulkley. Or— R. Hydrarg. ammoniat.,..........■ • • 3J Bismulhi subnit.,...............x) Ung. petrolei.,................3J. M. Sig.—Apply frequently. For argyria, the first step is the withdrawal of the argentum, and, according to Prof. Bartholow, " a persistent and long-continued use of potassii iodidum and sodii hypophosphis has, in a few fortunate instances, caused the absorption and excretion of the silver deposits. The action of these systemic remedies for the discoloration may be aided by baths of the hyposulphites, and by the cautious use of lotions containing potassii cyanidum, which possesses a decided solvent power over the silver deposits." DISEASES OF THE SKIN. 42") CALLOSITAS. Synonyms. Tyloma; callus ; callosity. Definition. Callositas or tyloma consists in the development of a hard or horny, thickened patch of skin, variable in extent, and of a grayish, yellowish or brownish color, and unattended with pain. The most frequent location is upon the hands and feet. Causes. The result of pressure or friction, as in the case of the hands of the mechanic, the effect of his tools ; or, if upon the foot, the result of ill-fitting shoes or from unusual walking. Cal- losities are also seen upon the fingers of violin, banjo and harp players. Pathology. A hypertrophy of the horny layer of the skin, the corium remaining normal. The cells of the epidermis become so closely packed together as often to simulate horn substance. Symptoms. Callositas consists in an increase in the thickness of the skin of the affected part, presenting a firm, dense, more or less circumscribed structure, the extent of hardness varying considerably, sometimes being horny. The patch of hardness is generally about the size of a coin, roundish in shape and somewhat elevated above the surrounding skin. The color of the patch may be either grayish, yellowish or brownish. Callositas are usually upon the palms, fingers, soles and toes, although other parts, if exposed to the cause, may also be the seat. At times great pain and discomfort are experienced from the growth. Occasionally callositas are complicated by hyperaemia, fissure, acute inflammation, abscess, erysipelas, and serve readily as foci for such cutaneous diseases as eczema and psoriasis. Course. Their formation and development is always slow and gradual. If the cause be removed, the prognosis is favorable. Treatment. If the removal of the callous growth be desirable, the part should be repeatedly soaked in warm water, or a poultice applied, or warmed oil kept in contact by compresses of flannel, which will soften the induration and permit its removal by paring or scraping, layer by layer, with a sharp knife. Success has been re- ported from the use of a plaster of india-rubber containing acidu/n salicylicum. 426 PRACTICE OF MEDICINE. CLAVUS. Synonym. Corn. Definition. A corn is a small, circumscribed, usually .flat, deep- seated hypertrophy of the epidermis, having a horny feel, projecting slightly from the skin, painful upon pressure, situated, for the most part, about the toes. Cause. Continued pressure or friction, usually from ill-fitting or tight boots or shoes. Pathology. A clavus consists of a circumscribed, excessive hypertrophy of the epidermis, of the same character as occurs in callosity and of a central portion—the core. The core extends deeply into the tissues, in the shape of an inverted cone, the base of the cone being directed outward and appearing upon the surface as a roundish elevation, its apex resting upon the papillary layer of the corium. The core of a clavus consists of a whitish, opaque, firm, tenacious body, composed of epidermic cells, arranged in concentric laminae. The pain attending the presence of corns results from pressure upon the true skin by the hard core, causing irritation of the nerve filaments of the papillae. Corns existing between two toes are constantly bathed with the moisture of the part, which macerates and softens the formation, which thus receives the name of soft corn, in contradistinction to the hard corn. Symptoms. Until the growth attains a considerable size no dis- comfort, as a rule, is felt. After, however, its depth has reached the true skin, pain of an intermittent character, aggravated by pressure, is the chief symptom. Corns are often weather-sensitive, being unusually painful before, during or after the occurrence of storms, and should, therefore, not be confounded with gouty or rheumatic deposits below the skin. Treatment. If freedom from these annoying formations be de- sired, the use of a properly-fitting foot covering must be practiced. The pressure which results in the severe pain is limited by the use of the ringed protective plasters in common use. To remove the corn, soaking with hot water or a poultice kept in contact over night, will soften the part and permit of its ready removal with the knife. DISEASES OF THE SKIN. 427 For soft corns, the application of argenti nitras, in solid stick form, is highly spoken of, to be used after the growth has been sufficiently softened. VERRUCA. Synonym. Wart. Definition. A wart consists of a circumscribed hypertrophy of the papillary layer, with more or less epidermal accumulation, char- acterized by the appearance of a hard or soft, rounded, flat or acumi- nated formation, of variable size. Varieties. The following varieties have chiefly a descriptive value: verruca vulgaris; verruca plana ; verruca filiformis; verruca digitata ; verruca aciwiinata. Cause. Obscure. The various assigned causes are probably incapable of producing the affection. Pathology. While the anatomy of warts differs somewhat accord- ing to their variety, in all forms there exist as a basis of their forma- tion a connective-tissue growth, from which the papillary hypertrophy takes place. The interior of the growth is supplied by one or more vascular loops, from which their vitality is obtained. Symptoms. The various forms are so different as to require a separate description. Verruca vulgaris, or the ordinary wart, commonly seen on the hands, consists of a small, circumscribed, elevated growth, having a broad base seated securely upon the skin. Their consistency is either soft or firm, the surface smooth or rough, the color that of the surrounding skin, or yellowish, brownish or even blackish. They may develop upon any region of the body, but are most commonly seen upon the hands and fingers. Verruca plana differs from the vulgaris in being flat and broad in form, and but slightly raised above the level of the surrounding skin. Their most common location is either on the back or forehead. Verruca filiformis assumes the shape of a minute, thin, conical or thread-like formation, about an eighth of an inch in length. The most frequent location is the face, eyelids and neck. Verruca digitata consists of a slightly elevated, broad formation, about the size of a split pea, and marked by a number of digitations coming from its border, giving an appearance, in marked cases, resembling a crab. 428 PRACTICE OF MEDICINE. Their most frequent site is upon the scalp. Verruca acuminata, known, also, as the pointed wart, the moist wart, the pointed condyloma, cauliflower excrescence and venereal wart, consists of one or more groups of irregularly-shaped elevations, often so closely packed together as to form a more or less solid mass of vegetations (verrucae vegetantes). Their color depends somewhat upon the degree of vascularity, varying from a pinkish, bright red to a purple color. They occur, for the most part, about the genitalia of either sex. Upon the penis, they usually spring from the glans and the inner surface of the prepuce; the inner surface of the labia and from the vagina in the female. They are also seen about the anus, mouth, axillae, umbilicus and toes. They may be either moist or dry, according to their location; about the genitalia, a yellowish, puriform secretion usually covers their surface, due to friction and maceration, which, owing to the heat of the parts, rapidly decomposes, producing a highly offensive, penetrating and disgusting odor. Their size varies from that of a pea to that of an almond, an egg, or even the fist. Their development is rapid, attaining considerable size in a few weeks. Prognosis. Favorable. Treatment. For the smaller warts, excision by means of the knife or scissors affords the most satisfactory results. If the growth be large and likely to be attended with considerable hemorrhage, as in cases of the condyloma about the genitalia, the galvano-caustic wire, or the Paquelin cautery are to be preferred. Transfixing the growth in several directions with long needles dipped in a fifty per cent, solution of acidum chro7nicum has been recommended. The topical application of caustics, such as acidum aceticum, acidum nitricu77i, argenti nitras or ferri perchloridiwi are often satisfactory. I have been successful in some cases by painting the growth with tinctura thuja occidentalis until their size was considerably reduced, and then snipping them off with the scissors. The following formula for warts and corns is generally sold by pharmacists :— R . Acidi salicylici,..... Ext. cannab. indicae, . . Collodii,....... Sig.—Apply once or twice daily 3SS gr. v-x gss-j- M. DISEASES OF THE SKIN. 429 An excellent formula is :— R. Acidi salicylici, Acidi boracici,.......aa . Hydrargyri chlor. mite,...... Sig.—Sprinkle over twice daily. ICHTHYOSIS. Synonyms. Ichthyosis vera ; fish-skin disease. Definition. Ichthyosis is a congenital, chronic deformity or hyper- trophic disease of the skin, characterized by dryness, harshness or general scaliness of the skin, or, in the outgrowth of larger masses of a corneous consistency. Varieties. Ichthyosis simplex ; ichthyosis hystrix. Cause. Often hereditary, but not in all cases. It is to be regarded as an affection which is born with the individual, although it does not usually manifest itself until after the first or second year of life. Pathology. "The diseased, or, better, deformed skin is found microscopically to be hypertrophied in various degrees, according to the development of the malady; the proliferation of its elements occurring in the connective tissue, papillae, stratum corneum and blood vessels. In well-marked cases of ichthyosis hystrix, the elongated papillae are surmounted by dense cones of the horny layer of the epidermis, more or less concentrically disposed, with sclerosis of the connective tissue and a relatively unchanged rete. In this last particular the dense plaque of ichthyosis differs in texture from the wart." (Hyde.) Symptoms. Ichthyosis displays a wide variation in its symptoms. In one individual it amounts to but a slight inconvenience, while in another it may manifest itself in so pronounced a manner as to be the source of great discomfort and deformity. The two varieties named represent merely accentuated types of the disorder, rare in its fullest development, and, in its slightest, much more common than is generally believed. A simple dryness and harshness of the skin, with only slight fur- furaceous exfoliation, is termed xeroden7ia. Ichthyosis simplex is the more common variety, consisting of a harsh, dry condition of the whole surface, accompanied by the pro- gr. xv gr. x. M. 430 PRACTICE OF MEDICINE. duction of variously sized and shaped reticulated scales, either small, thin and furfuraceous, like bran, or large and thick, resembling fish scales. Upon the extremities the scales usually form diamond-shaped or polygonal plates, separated from one another by furrows or lines, which extend down to the normal skin. In color the scales are either whitish, grayish or yellowish, and often have a silvery or glistening appearance. Rarely the color is olive-green or blackish (ichthyosis nigricans). The amount of scaling depends upon the age of the patient, and the duration and severity of the disease. Ichthyosis hystrix. With or without the developments of the above variety, in this, the hypertrophy of the skin may occur in circum- scribed patches or large areas, consisting of irregularly-shaped, ver- rucous, corneous, corrugated, wrinkled or rugous masses, usually darker in color than those of the simple variety. They may occur upon the arms, as solid, warty patches, or upon the back, in the form of elongated, linear patches. They may constitute roughened, corru- gated, papillary growths, or uneven, horny, blunt or pointed, spinous, warty formations. In the latter case the elevations may reach several lines or more, and stand out from the skin like quills upon the back of a porcupine—hence the name hystrix. The amount and extent of the hypertrophy varies ; the older the patient the more highly devel- oped it will usually be. Course. Ichthyosis simplex may involve the entire surface uni- formly or appear more marked on the extremities, from the hips to the ankles and the arms and forearms. The affection is always worse in winter than in summer ; the increased activity of the sweat glands at this season producing the most beneficial results. The course of the affection is essentially chronic, continuing throughout life, now better, now worse. Slight itching usually occurs. Diagnosis. The characteristics of the affection are so peculiar that an error in diagnosis is hardly possible. It is to be distinguished from the inflammatory affections of the skin which terminate in des- quamation, by the absence of any history of inflammation. Prognosis. While much can be done to alleviate the affection, the prognosis is unfavorable as regards permanent relief. Treatment. Local measures are alone of value for ichthyosis. The maceration of the accumulated masses of epithelial hypertrophy is accomplished by water baths, either simple or medicated. The relief thus afforded the patient, while temporary, is comforting. DISEASES OF THE SKIN. 431 Duhring says : " It may be stated, then, that, as a rule, the more fre- quently the ichthyotic patient bathes, and the longer he is able to remain in the water, the less will the deformity show itself." Vapor and alkaline baths are also serviceable. Another valuable agent is sapo 77iollis in conjunction with baths, or alone, as a discutient. For severe cases, " a sufficient quantity is to be rubbed into the skin twice daily, for four or six days, during which period the patient is to refrain from bathing. A bath is first to be taken four or five days after the last rubbing, when, in fact, the epidermis has begun to peel off; afterward inunction with a simple ointment is to be applied, in order to prevent Assuring of the new skin." The following is a useful formula :— R. Adipis benz.,..............3J Glycerini,...............rn_xl Ung. petrolei...............^ss. M. Sig.—Apply daily, after washing or bathing. —Duhring. Or- R. Potassii iodidi,.............gr. xx Olei bubuli, Adipis,........aa.......^ss Glycerini................15 j. M. Sig.—Apply after bathing. —Milton. PARASITIC DISEASES OF THE SKIN. TINEA FAVOSA. Synonyms. Favus; porrigo favosa ; honeycombed ringworm. Definition. A contagious affection of the skin, due to a vegetable parasite—Achorion Schonleinii ; characterized by the development of either discrete or confluent, small, circular, cup-shaped, pale yellow, friable crusts, usually perforated by hairs. Cause. The presence and growth of a vegetable parasite known as the Achorion Schonleinii is the cause of tinea favosa. It is com- moner in children than in adults, attacking the former, in the first place, either de novo or through direct contagion, and is from them communicated to adults. It is a disease confined almost exclusively to the lower classes. It is rare in the United States. Pathology. Tinea favosa may have its seat either in the hair 432 PRACTICE OF MEDICINE. follicle and hair, or upon the surface of the skin or the nails ; the former, however, are the structures most commonly attacked. It is purely a local affection, due solely to the presence and growth of the vegetable parasite discovered by Schonlein, of Berlin, in 1839, and named after him—Achorion Schonleinii. The crusts are made up almost entirely of fungus, which is seen, upon section, with the naked eye, to be composed of a porous mass and to possess a pale- yellow or whitish color. Under the microscope it is seen to consist of both mycelium and spores in great quantity, and in all stages of development, Symptoms. When the affection attacks the hairs and follicles it is termed tinea favosa pilaris, when the epidermis, tinea favosa epiden7iis, and when the nails, tinea favosa unguium. Rarely all the structures may be attacked at one and the same time ; its usual seat, however, is the scalp. The disease begins by the development of one or of several pin- head-sized,pale-yellow crusts, seated about the hair follicles. In about a fortnight these crusts have increased in size and are umbilicated, termed the favus cups, are circumscribed, circular in form and very slightly elevated above the level of the skin. In their normal condition they are of a pale-yellow or sulphur- yellow color, but after a time, from dust and other matters, they become brownish-or greenish-yellow in color. The number of crusts vary from a very few to immense numbers. The usual size is about that of a split-pea. In tinea favosa pilaris et capitis the affection is often accompanied with pediculi, while swelling of the glands of the neck and small abscesses upon the scalp are not uncommon. The hairs become lustreless, opaque, brittle, and at times split longitudi- nally, and from atrophy of the follicles and sebaceous glands per- manent baldness may result. In tinea favosa unguium the nails become thickened, yellow, opaque and brittle. The disease has a peculiar odor, resembling that of mice, or of musty, stale straw. Diagnosis. In a recent case the characteristic favus cups, the pale-yellow color, the odor and the history of contagion, should render the diagnosis easy. If of long standing, however, and the favi destroyed by scratching, some doubt may exist; but if a small fragment of a crust be placed upon a glass slide with a drop of DISEASES OF THE SKIN. 433 liquor potassa, covered with a thin glass and placed under a micro- scope with a power of from two hundred and fifty to five hundred diameters, the features of the Achorion Schonleinii will determine the affection to be tinea favosa. Prognosis. Tinea favosa of the epidermis readily responds to treatment. Tinea favosa pilaris is more obstinate, and if of long duration may result in baldness. Treatment. The general health, in the majority of instances, requires tonics. Cleanliness is essential to successful management. For tinea favosa pilaris et capitis, two remedies are essential— parasiticides and depilation. The hair should be cut as short as possible, the crusts removed by the use of oil, or soap and hot water, or poultices, again well oiled and the hairs removed by means of broad-bladed forceps, a few hairs being removed at a time and only a small surface cleared at each sitting, when the following lotion is to be thoroughly applied :— R. Hydrarg. chlorid. corrosiv.,........gr. v-x Ammonii chlorid. pur.,..........t^ss Misturae amygdalae amar.,.........^iv. M. Sig.—Apply thoroughly. —Bulkley. Or— R. Sulphur,................3J Hydrarg. ammoniat.,...........gr. xx Ung. petrolei,..............fgj. M. Sig.—Rub in well. Tinea favosa of non-hairy parts requires 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 37 434 PRACTICE OF MEDICINE. vegetable parasite discovered by Bazin, in 1854, termed the tricho- 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 decline 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 cincinata 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 DISEASES OF THE SKIN. 435 opaque, whitish, thickened and soft and brittle, especially along their 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 his- tory of ringworm should prevent error. Chronic ringworm is more difficult, however. Seborrhcea and psoriasis often assume a somewhat circular form, and then have a resemblance 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.,........ Ung. aquae rosae,...... Sig.—Keep in contact with the patch Or— R. Hydrargyri ammoniat., .... Ung. petrolei,........ Sig.—Keep in contact with tie patch .....l\- M. .....gr. xx-xxx .....5J- M. 436 PRACTICE OF MEDICINE. " In obstinate tinea circinata cruris the following, recommended by Tilbury Fox, may be employed : "— R. Creasoti,................Vt\xx Olei cadini,...............f .^ iij Sulphuris sublimati,...........3 j'J Potassii bicarb ,.............3J Adipis,................3J- M- 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 trie hop hyt07i fungus ; characterized by the development of cir- cumscribed, vesicular or squamous, more or less bald patches, showing 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 child- hood, 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 tonsu- rans" invades the hair, hair follicles and epidermis of the scalp, ihe 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 keriori). 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 DISEASES OF THE SKIN. 437 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, oedematous 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, while 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 a white, shiny, ivory-like, bald patch, devoid of scales, eruption, 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 potassa 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. Re- lapses are of frequent occurrence. Treatment. Local measures are satisfactory in the majority of instances of tinea tonsurans. 438 PRACTICE OF MEDICINE. Mild cases should be treated by cutting the hair as close as possible and thoroughly scrubbing the patches with sapo viridis and water and the application twice daily of a six per cent, solution of oleatum hy- drargyri, or either of the following :— R. Sodii borat.,..............7,') Aceti destil.,.............^ ij. . M. SiG.—Apply thoroughly several times daily. Or— R . Acidi boracici,.............gr. xv Sulphur, nor.,.............gr. xv Vaselini,...............i% iss. M. SiG.—Apply morning and night. Or, use may be made of Morris' thymol solution, to wit:— R. Thymol,...............Xss Chloroformi,..............3 ij 01. olivae,...............3 vj. 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...................^ij Olei picis,...............f^j. M. The iodine and oil of tar should be gradually and slowly mixed. An excellent application in rebellious cases is— R . Potassae (caustic),............gr. ix Acid carbolici,.............gr. xxiv Lanoline,................^ss 01. fheobromae,.............^ss. M. SiG.—A small amount rubbed into head night and morning. If the scalp is not shaved the application is retained better. 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 forceps, 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. DISEASES OF THE SKIN. 439 TINEA SYCOSIS. Synonyms. Tinea trichophytina barbae; sycosis parasitica; bar- bers' itch ; ringworm of the beard. Definition. A co7itagious, parasitic affection of the hair, hair follicles and subcutaneous tissues of the hairy portion of the face and 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 dispo- sition 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, while 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. 440 PRACTICE OF MEDICINE. 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. Itching, burning pain and swelling 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 non-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 affection of the hair follicles, characterized by the development of pap- ules 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, Z], aqua, f^j, after which the parts are again thoroughly washed with hot water, carefully dried and smeared with an un- guentum sulphur., containing 3j-ij to the ounce. This procedure is DISEASES OF THE SKIN. 441 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, 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 contagious, parasitic affection of the skin, due to the microsporon furfur; characterized by the occurrence of variously- sized, irregularly-shaped, dry, slightly furfuraceous, yellowish spots upon the chest or other portions of the bodv. 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, 38 442 PRACTICE OF MEDICINE. 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 potassa, and covered with a thin glass cover and placed under a microscope 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,.............X iij Glycerini,...............f X ij Aquae,........ad........f^iy- M. SiG.—Apply frequently. Or— R. Hydrargyri chlorid. corrosiv.,.......gr. iv Alcoholis,...............f/5vj Ammonii muriat.,............^ss Aquae rosae,......ad.......f^ vj. M. SiG.—Apply frequently. —Tilbury Fox. SCABIES. Synonym. 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 in 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, baiely visible to the naked eye as a yellowish-white, rounded body. The female is the most commonly met with, the males being said to DISEASES OF THE SKIN. 443 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 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 constitutes 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 cunicula upon their summits. The pustules represent the completion of the inflammatory action, their size and number varying with the severity of the irritation. 444 PRACTICE OF MEDICINE. 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. 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, Ung. sulphuris, . . Ung. petrolei, Sig.—Apply after washing Or— R. Sulphuris sublimat., Balsam. Peruviani, . Adipis,..........'..'.'.'.' §'j7 M. SiG.—For children. —Duhring. .......3U .......p; ij—iv ^......l\. M. —BUI.KLEY. DISEASES OF THE SKIN. 445 PEDICULOSIS. Synonyms. Phthiriasis ; morbus pedicularis ; lousiness. Definition. A contagious, animal parasitic disease of the head, body or pubes, due to the presence of pediculi and characterized by the wounds inflicted by the parasite, together with excoriations and scratch marks. Varieties. Pediculosis capitis ; pediculosis corporis ; pediculosis pubis. Cause. The cause is the presence of the parasite, the result of contagion, direct or indirect. The view of "a spontaneous genera- tion " of pediculi is not accepted by the great majority of observers. Pathology. The lesion produced by the presence of the pediculi is a minute hemorrhage, caused by the parasite inserting its sucking apparatus, or, as it is termed, its haustellum, into a follicle, and obtain- ing blood by a process of sucking, and not by biting, as is generally supposed. The presence of the parasite in any great numbers brings about a peculiar irritable state of the skin, which gives rise to an irre- sistible desire to scratch, as a consequence of which the surface is markedly excoriated and lacerated. Symptoms. The symptoms which arise from the presence of the parasite in different localities are somewhat different, and call for separate consideration. Pediculosis capitis. This variety is caused by the presence of the pediculus capitis or head louse. The ova, or nits, are readily recog- nized at a distance. Their favorite seat is the occipital region, either upon the surface of the scalp or upon the hair. Their presence gives rise to considerable irritation, itching and consequent scratching, resulting in the wounding of the scalp, with oozing of a serous or purulent fluid mixed with blood, which soon mats the hair and forms into crusts. In those predisposed to eczema, the presence of the para- site will give rise to that condition. The general health is usually unaffected by the presence of the pediculi. Pediculosis corporis. This variety of pediculosis is caused by the presence of the pediculus corporis or body louse, or more properly termed the pediculus vestimenti or clothes louse. Its color, when devoid of blood, is dirty-white or grayish, with a dark line around the margin of its abdomen. Its habitat is the clothing covering the 446 PRACTICE OF MEDICINE. general surface, remaining upon the skin onlyr long enough to obtain sustenance. The ova are usually deposited in the seams of the cloth- ing, the lice being hatched within the week. Occasionally a few of the pediculi may be observed crawling about the surface, or in the act of drawing blood. As they move over the surface they give rise to an intensely disagreeable itching sensation, to relieve which the patient scratches, which in turn gives rise to the characteristic lesions of the affection. The lesions are numerous. The scratch marks are scattered here and there, either long and streaked, in other places short and jagged; the excoriations and blood crusts varying in size from a pin head to a split pea or even larger, with irregularly-shaped pustules. In addition to the lesions resulting from the scratching, are seen the prii/iary lesions, consisting of minute reddish puncta with slight areolae, the points at which the parasite has drawn blood. In cases of long stand- ing, a brownish pigmentation of the whole skin may result from the long-continued irritation and scratching. The favorite site of the lesions are the back, especially about the scapular region, the chest, abdomen, hips and thighs. Pediculosis is seen most commonly among the poorer classes, and especially the middle-aged and elderly. Pediculosis pubis. This variety of pediculosis is caused by the pre- sence of the pediculis pubis or crab louse. Although having its seat of predilection about the pubes, it may also infest the axillae, sternal region in the male, beard, eyebrows and even eyelashes. They may be found crawling about the hairs, but more commonly hugging the surface closely. They infest adults chiefly, and occasion symptoms similar to those described in connection with other species. They are usually contracted through sexual intercourse, although occasionally they are present in cases in which they have not been communicated in this way, and where no explanation as to the mode of contagion can be suggested. The itching varies from slight to severe. Diagnosis. When violent itching exists in any case, without marked eruption, the possibility of the presence of pediculi should always be entertained, and if carefully sought after are found. Prognosis. Favorable, if the treatment be thoroughly carried out. Treatment. Local measures alone are all that is necessary for the removal of the various forms of pediculosis. DISEASES OF THE SKIN. 447 Pediculosis capitis. The most effective application for this variety is to thoroughly soak the head two or three times a day with ordinary petroleum or keroserie oil, and keep it wrapped in a cloth for twenty- four hours. At the end of this time the head should be thoroughly washed with soft soap and hot water, dried and saturated with the official unguentum hydrargyri ammoniati. If required, this entire procedure may be repeated, but usually any pediculi escaping the petroleum are destroyed by the unguentum. Pediculosis corporis. In this variety the habitat of the parasite being the clothing, they must be boiled or baked at a temperature sufficiently high to destroy life. After this the clothing should be changed every day or two, carefully inspected, and if pediculi are seen they must again be baked or boiled. It is folly to expect satis- factory results unless these directions be faithfully adhered to. For the irritation, itching and excoriations, mild alkaline baths or lotions of acidum carbolicum are sufficient. Pediculosis pubis. The parts should be washed twice daily with soft soap and water, after which the thorough application of tinctura cocculus indicus, full strength or diluted, or a lotion of hydrargyri chloridum corrosivum or unguentum hydrargyri ammoniati will be effectual. INDEX. Abdominal dropsy, 105. typhus, 19. Abscess, cerebral, 315. of the liver, 112. perityphlitic, 94. Acne, 413. artificialis, 414. disseminata, 413. indurata, 413. papulosa, 413. Piffard's solution for, 375. punctata, 374. pustulosa, 413. rosacea, 415. sebacea, 371. tubercula, 413. vulgaris, 413. Aconite in erysipelas, 50. Aconitinse in neuralgia, 360. Acute articular rheumatism, 150. Bright's disease, 125. gastric catarrh, 58. gastritis, 60. general diseases, 143. hepatitis, 112. meningitis, 306. yellow atrophy, 114. AddLon's disease, 367, 423. Ague, 30. brow, 31. cake, 30. dumb, 30. Agraphia, 318. amnesic, 318. Albumin, tests for, 120, 121. Albuminuria, 126. chronic, 127. Alcoholism, 323. acute, 323. chronic, 323. Anaemia, 362. Blaud's pill for, 364. Anaemia, cerebral, 298. essential, 365. of fatty heart, 365. progressive pernicious, 365. splenica, 366. Anaematosis, 365. Anatomy, morbid, 11 Angina pectoris, 295. Anidrosis, 380. Antipyrine in migraine, 323. Anodynes, compound of, 70. Anthrax, 410. Aphasia, 317. amnesic, 317. ataxic, 318. Aphonia, 318. Aphthae, 53. discrete, 53. confiuens, 53- Apncea, 13. Apoplexy, 302. serous, 311. Arachnitis, 306. Argyria, 423. Arteries, Cohnheim's terminal, 300. Arthritis deformans, 157. mono-, 151- poly-, 151. Ascaris lumbricoides, 100. Ascites, 105. Asthenia, 13. Asthma, 227. bronchial, 227. hay, 229. Kopp's, 214. nervous, 227. Ataxia, locomotor, 342. Atonic dyspepsia, 70. Atrophy, acute yellow, 114. of the liver, 115. Aura epileptica, 348. Auscultation, 181. 449 450 Auscultation, DaCosta's rules for, 182. Autumnal fever, 19. Bacillus, comma, 168. malaria, 30. tuberculosis, 255. typhosus, 19. Bacteria of decomposition, 168. Barber's itch, 439. Basedow's disease, 354. Basham's iron mixture, 126. Bell's palsy, 361. Belt, hydropathic, 112. Biliary calculi, 109. Bile, test for, 122. pigment, test for, 122. Bilious fever, 32. malignant fever. 37. remittent fever, 32. typhoid fever, 29. Biliousness, 110. Black-heads, 374. Bladder, catarrh of, 138. Blaud's pill, 364. Bleeders' disease, 368. Blepharospasm, 347. Blisters in rheumatism, 154. water, 404. Blood currents, direct, 271. indirect, 271. test for, 121. white cell, 366. Bloody flux, 90. Boil, 408. Borborygmus, 67. Bothriocephalus latus, 98. Bowels, inflammation of, 79. Brain, congestion of, 297. Break-bone fever, 51. Bright's disease, acute, 125. chronic, 127, 130. Bromidrosis, 377. pedum, 378. Bronchial dilatation, 224. hemorrhage, 236. Bronchitis, acute, 216. capillary, 219, 248. catarrhal, 216. chronic, 224. croupous, 222, diphtheritic, 222. Bronchitis, fetid, 225. membranous, 222. peri-, 249. plastic, 222. secondary, 224. Broncho-pneumonia, 219, 248. Bronchorrhagia, 236. Bronchorrhcea, 225. Bronzed-skin disease, 367. Caecum, catarrh of, 93. Calculi, alternating, 137. biliary, 109. cutaneous, 375. hepatic, 109. oxalate of lime, 137. phosphatic, 137. renal, 136. uric acid, 137. Callositas, 425. Callus, 425. Cancer, gastric, 65. hepatic, 117. Carbuncle, 410. Carbunculus, 410. Carcinoma, gastric, 65. Cardiac dilatation, 282. fatty degeneration, 285. hypertrophy, 280. murmurs, 270. paralysis, 147. see-saw murmurs, 291. valvular diseases, 286. Cardialgia, 69. Catalepsy, 352. Catarrh, acute bronchial, 216. acute gastric, 58. acute nasal, 193. autumnal, 229. chronic bronchial, 224. chronic gastric, 61. chronic nasal, 196. contagious, 17. dry, 225. mucous, 225. of the bile ducts, 107. of the bladder, 138. of the caecum, 93. of the mouth,. 52. of the rectum, 95. sec. of Laennec, 225. Catarrh, suffocative, 219. Catarrhal enteritis, 79. jaundice, 107. nephritis, 124. stomatitis, 52. tonsillitis, 198. Cephalodynia, 155. Cerebral abscess, 315. anaemia, 298. congestion, 297. embolism, 299. fever, 306. hemorrhage, 302. hyperaemia, 297. softening, 303. thrombosis, 299. tumors, 316. Cerebro-spinal fever, 26. neuroses, 346. Cervico-brachial neuralgia, 358. Cervico-occipital neuralgia, 358. Chicken-pox, 48. Child-crowing, 208. Chills and fever, 30. Chloasma! 422. uterinum, 423. Chlorides, test for, 120. Chlorosis, 363. Cholera, 168. Asiatic, 168. asphyxia, 170. bilious. 82. English, 82. epidemic, r68. infantum, 87. malignant, 168. morbus, 82, saline fluids in, 172. solution, Bartholow's, 172. spasmodic, 168. sporadic, 82. typhoid, 169. Cholerine, 186. Chorea, 346. post-hemiplegic, 304, 347. Chromidrosis, 377. Chronic dyspepsia, 61. gastric catarrh, 61 ■ gastritis, 61. • Clark's treatment of peritonitis, 104. Clavus, 426. Clinical history, 12. Cohnheim's terminal arteries, 300 Cold on the chest, 216. in the head, 193. Colic, hepatic, 109. intestinal, 74. lead, 74. ovarian, 75. renal, 136. stomachic, 69. uterine, 75. Colitis, 90. ulcerative, 90. Coma, 13. uraemic, 135. Comedo, 374. Comedones, 374. Comma bacillus, 168. Congestion, cerebral, 297. of the kidneys, 124. of the lungs, 238. Congestive fever, 33. Constipation, 75. glycerinum for, 76. Consumption, pulmonary, 251, galloping, 260. Contagious fever, 25. catarrh, 17. Convulsions, uraemic, 135. Corns, 426. soft, 427. Corrigan's disease, 258. hammer, 327. sign, 66. Coryza, acute, 193. chronic, 196. Coster's paste, 438. Costiveness, 75. Cough, winter, 224. Crackling, 244. Crepitatio redux, 245. Crisis, 13. Croup, catarrhal, 208. false, 208. membranous, 210. pseudo, 214. spasmodic, 208. true, 210. Croupous enteritis, 81. laryngitis, 210. stomatitis, 53, 452 INDEX. Cry, hydrocephalic, 311. Cyst, renal, 133. sebaceous, 376. Cysticercus cellulosus, 98. bovis, 98. Cystitis, 138. acute, 138. chronic, 138. Dandruff, 371. Dandy fever, 51. Death, 13. Declat syrup, 42. Degeneration, caseous, 252. reaction of, 338. Delirium tremens, 325. Dengue, 51. Dewees' mouth caustic, 55. Diabetes insipidus, 166. mellitus, 162. Diagnosis, 13. by exclusion, 13. differential, 13. direct, 13. physical, 174. Diarrhoea, 77. acute, 77, 79. bilious, 77. choleriform, 87, chronic, 78. feculent, 77. inflammatory, 85. lienteric, 77. mixture, Squibb's, 78. Diathesis, 12. Dilatation, bronchial, 224. cardiac, 282. gastric, 67. Diphtheria, 144. bronchial, 222. laryngeal, 146, 210. nasal, 146. Diphtheritic, paralysis, 147. stomatitis, 54. Dipsomania, 326. Discharges, chopped spinach, 86. rice water, 80,83, 169. Disease, 9. acute, 12. Addison's, 367, 423. Basedow's, 354. Disease, bleeders', 368. Bright's, 125, 127, 130. causes of, 11. chronic, 13. Corrigan's, 258. defined, 9. Duchenne's, 340. fish-skin, 429. flesh-worm, 172. Fothergill's, 358. functional, 9. Grave's, 354. Meniere's, 319. organic, 9. predisposition to, II. subacute, 13. termination of, 13. Diseases, acute, general, 143. of the biliary passages, 107. of the blood, 362. of the bronchial tubes, 216. of the circulatory system, 268. of the intestinal canal, 72. of the kidneys, 118. of the larynx, 203. of the liver, no. of the lungs, 238. ofthe mouth, 52. of the nasal passages, 193. ofthe nerves, 357. of the nervous system, 297. ofthe peritoneum, 102. ofthe pharynx, 198. ofthe pleura, 261. of the respiratory system, 174. ofthe skin, 371. of the spinal cord, 331. of the stomach, 58. Disorders of secretion, 371. Dizziness, 319. Dropsy, cutaneous, 40. ofthe abdomen, 105. pericardial, 277. peritoneal, 105. pleural, 265. Duchenne's disease, 340. Duodenitis, 79. Dysentery, acute, 90. epidemic, 90. sporadic, 90. washing rectum in, 92. 4">3 Dyspepsia, 70. acid, 71. atonic, 70. chronic, 61. drunkard's, 61. flatulent, 71. hot water in, 62. intestinal, 72. irritative, 71. nervous, 71. Ecstacy, 352. Ecthyma, 407. Eczema, 382. acute, 385. ani, 394. aurium, 393. barbae, 392. capitis. 390, chronic, 385. erythematosum, 383. faciei, 392. fissum, 385. genitalium, 394. impetiginosum, 384. intertrigo, 383, 395. labiorum, 392. madidans, 384. mammarum, 395. marginatum, 434. palmarum, 396. palpebrarum, 392. papillomatosum, 385. papulosum, 384. plantarum, 396. pustulosum, 384. rimosum, 385. rubrum, 384. sclerosum, 385. squamosum, 385. unguium, 396. universale, 383. verrucosum, 385. vesiculosum, 383. Electrical storm, 348. Elixir, triple, 286. Embolism, cerebral, 299. Emetic, Dr. Fordyce Barker's, 213. Emphysema, 233. Empyema, 262. Encephalitis, acute, 315- Encephalitis suppurative, 315. Endocarditis, acute, 277. Enteralgia, 74. Enteric fever, 19. Enteritis, catarrhal, 79. croupous, 81. membranous, 81. Enterocolitis, 85. mesenteric fever, 19. Enterorrhrea, 77. Ephemeral fever, 16. Epidemic catarrhal fever, 17. cerebrospinal fever, 26. roseola, 44. Epilepsy, 34S. Errhine, Ferrier's, 195. Robinson's, 196. Erysipelas, 49. ambulans, 49. of the brain, 49. phlegmonous, 49. Erysipelatous dermatitis, 49. Erythema simplex, 380. intertrigo, 381. Erythema*ous stomatitis, 52. Essential anaemia, 365. Etiology, II. Eucalyp'ol in cys'itis, 140. Exophthalmic goitre, 354. Facial paralysis, 361. Famine fever, 29. Favus, 431. Febricula, 16. Ferrier's errhine, 195. Fever, 14. abdominal typhus, 19. autumnal, 19. bilious, 32. bilious remittent, 32. bilious typhoid, 29. breakbone, 51- catarrhal, 17. cause of, 14. cerebral, 306. cerebro spinal, 26. congestive, 33. contagious, 25. continued, 16. dandy, 51. enteric, 19. 454 Fever, entero-mesenteric, 19. ephemeral, 16. epidemic cerebro-spinal, 26. essential, 15. famine, 29. gastric, 19, 58. hay, 229. intermittent, 30. irritative, 16. jail, 25. lung, 241. malarial, 30. malignant intermittent, 23- malignant remittent, 33. marsh, 32. Mediterranean, 37. nervous, 19. neuralgic, 51. pernicious, 33. relapsing, 29. remittent, 32. rheumatic, 150. rose, 229. sailors', 37. scarlet, 39. secondary, 15. ship, 25. simple, continued, 16. spotted, 26. swamp, 30. typhoid, 19. typho-malarial, 32. thermic, 329. typhus, 25. winter, 241. yellow, 37. Fevers, 14. continued, 16. eruptive, 39. essential, 15. general treatment of, 15. periodical, 30. primary cause of, 14. secondary, 15. Fish-skin disease, 429. Flesh-worm disease, 172. Floating kidney, 141. Fluxes, vicarious, 77. Follicular stomatitis, 53. Fothergill's disease, 358. fever mixture, 17. Freckles, 421. Fremitus, bronchial, 176. friction, 176. tussive, 176. vocal, 176. Furuncle, 408. Furunculus, 408. Furunculosis, 408. Gall stones, 109. Gastralgia, 69. Gastric cancer, 65. carcinoma, 65. dilatation, 67. fever, 19. hemorrhage, 68. neuralgia, 69. ulcer, 63. Gastritis, acute, 60. chronic, 61. subacute, 61. toxic, 60. Gastrodynia, 69. Gastrorrhagia, 68. Gastroscope, uses of, 66. German measles, 44. Girdle, a, 400. Glossitis, 56. Glottis, oedema of, 206. spasm of, 214. Glycosuria, 162. simple, 164. Goudron de Guyot, 389. Gout, 150. half, 161. rheumatic, 157. Gravel, 136. Grave's disease, 354. Green sickness, 363. Gripes, 74- Gross', Prof. S. D., neuralgic pill, 360. Grutum, 375. Gutta rosea, 415. rosacea, 415. Haematemesis, 68. Haematoma of the dura mater, 308. Haemophilia, 368. Haemoptysis, 236. Heat stroke, 329. Heart, anaemia of fatty, 365. INDEX. Heart, dilatation of, 282. fatty degeneration of, 285. hypertrophy of, 280. irritable, 294. neuralgia of, 295. palpitation of, 294. physical examination of, 268. valvular diseases of, 286. Heartburn, 70. Hemicrania, 321. Hemiplegia, 304. Hemorrhage, bronchial, 236. cerebral, 302. gastric, 68. renal, 137. Hemorrhagic diathesis, 368. Hemorrhcea petechialis, 370. Hepatic cancer, 117. colic, 109. calculi, 109. Hepatitis, acute, 112. general parenchymatous, 114. interstitial, 115. parenchyma' ous, 112. suppurative, 112. Herpes, 399. circinatus, 433. facialis, 399. gestationis, 400. labialis, 399. praeputialis, 400. progenitalis, 400. tonsurans, 436. zoster, 400. Histology, 11. Hives, 396. Hooping cough, 231. Hydraemia, 362. Hydro-adenitis, 409. Hydrocephalus, acquired, 311. acute, 310, 311. chronic, 313. congenital, 313. Hydropathic belt, 112. Hydropericardium, 277. Hydropneumothorax, 266. Hjdrosis, 377. Hydrothorax, 265. Hyperaemia, cerebral, 297. renal, 124. spinal, 331. I Hyperaemias of the skin, 380. Hyperidrosis, 377. | local, 377- | unilateral, 378. I Hypertrophies of the skin, 421. Hypertrophy, cardiac, 280. [ Hysteria, 350. j Hystero epilepsy, 352. Ichthyosis, 429. Icterus, 107. hemorrhagic, 114. Ileocolitis, 79. Impetigo, 406. Incubation, period of, 12. Indigestion, 70. acute, 58. intestinal, 72. Inflammations of the skin, 382. Influenza, 17. Insolation, 329. Inspection, 175. Intercostal neuralgia, 400. Intermittent fever, 30. Intestinal colic, 74. dyspepsia, 72. obstruction, 96. parasites, 98. stricture, 96. torpor, 75. Intestines, diseases of, 72. irrigation of, 97. Introduction, 9. Invagination, 96. Ipecacuanha in dysentery, 92. Iron lemonade, 363. Irritative fever, 16. Ischaemia, 362. I Itch, 442. barbers', 439. j Jail fever, 25. I Jaundice, catarrhal, 107. malignant, 114. Kidneys, amyloid, 131. congestion of, 124. contracted, 120. diseases of, 118. floating, 141. i gouty, 130. 456 Kidneys, lardaceous, 131. movable, 141. sclerosis of, 130. small red, 130. wandering, 141. waxy, 131. white, large, 127. Klebs' micrococci, 39. Kummerfield's lotion, 417. Laryngismus stridulus, 214. Laryngitis, acute catanhal, 203. croupous, 210. oedematous, 206. spasmodic, 208. Law of parallelism, 151. Lentigo, 421. Lepra, 418. Leprosy, English, 418. Leptomeningitis, spinalis, 332. Leucaemia, 366. Leucocythemia, 366. Lichen simplex, 384. tropicus, 402. Liquor picis alkalinus, 389. Lithaemia, 161. Lithiasis, 161. Liver, abscess of, 112. albuminoid, 116. amyloid, 116. atro hy of, 115. carcinoma of, 117. cirrhosis of, 115. congestion, 110. diseases of, no. gin drinkers', 115. hob nailed, 115. hypertrophic sclerosis of, 115. lardaceous, 116. nutmeg, in. sclerosis of, 115. scrofulous, 116. spots, 422, 441. torpid, no. waxy, 116. yellow atrophy of, 114. Locomotor ataxia, 342. Lotio nigra, 387. Lousiness, 445. Lumbago, 155. Lumbo-abdominal neuralgia, 359. Lumbodynia, 155. Lungs, cirrhosis of, 258. congestion, 238. consumption of, 251. gangrene of, 242. hyperaemia of, 238. oedema of, 240. Lysis, 13. Malignant intermittent fever, 33. remittent fever, 33. Mal le grand, 348. Mal le petit, 348. Malarial fever, 30. Mania a-potu, 325. Marsh fever, 32. Measles, 42. black, 43. false, 44. French, 44. German, 44. Mediterranean fever, 37. Megrim, 321. Melanaemia, 30. Melasma, supra-renalis, 367. Melituria, 162. Meniere's disease, 319. Membranous enteritis, 81. Meningitis, acute, 306. basilar, 310. cerebro-spinal, epidemic, 26. spin.il, 332. tubercular, 310. Mensuration, 176. Metastasis, 13. Migraine, 321. Miliaria, 402. alba, 400. papulosa, 403. rubra, 402. vesiculosa, 403. Milium, 375. Mixture, Birtholow's cholera, 84. Basham's iron, 128. Brown Sequard's, for epilepsy, 350- Da Costa's muscular cramps, 84. Davis' asthma, 229. Fothergill's fever, 17. Hartshorne's cholera, 84. Hope's camphor, 87. INDEX. 457 Mixture, Keating's pertussis 233- Pepper's asthma, 229. Smith's tonic, 363. Squibb's diarrhoea, 78. Morbid anatomy, 11. Morbilli, 42. Morphina in acute uraemia, 136. in cardiac dilatation, 284. Morris' thymol solution, 438. Moth, 422. Moussette's pill, 360. Mouth, catarrh of, 52. diseases of, 52. psoriasis of, 57. white, 55. Movable kidney, 141. Mucus, test for, 120. Muguet, 55. Mumps, 143. Murmurs, aortic, 272. endocardial, 270. exocardial, 270. mitral, 271. pericardial, 270. pulmonic, 272. see-saw, 291. tricuspid, 272. Muscles, insanity of, 346. Myelitis, acute, 335. Myocarditis, 279. Nasal acute catarrh, 193. chronic catarrh, 196. Nephritis, acute desquamative, 125. catarrhal, 124. chronic parenchymatous, 127. interstitial, 130. parenchymatous, 125. peri, 134. pyeio, 133. suppurative, 133. tubal, 125, 127. Nephro lithiasis, 136. Nephrosis-pyelo, 136. Nervous dyspepsia, 71. exhaustion, 353. fever, 19. prostration, 353. Nettle-rash, 396. Neuralgia, 358. 39 , | Neuralgia, cervico-brachial, 358. ! cervico-occipital, 358. I dorso-intercostal, 359. i intercostal, 400. I lumbo-abdominal, 359. I of the fifth nerve, 358. j of the heart, 295. j sciatic, 359. 1 Neuralgic fever, 51. Neurasthenia, 353. I Neuritis, 357. Neuroses, cerebo-spinal, 346. | Nickel in epilepsy, 350. i Nomenclature, g, 10. I Nystagmus, 347. [ Obstruction, aortic, 290. intestinal, 96. mitral, 290. pulmonic, 291. pyloric, 67. tricuspid, 291. Occlusion of cerebral vessels, 299. Oidium albicans, 55. Oinomania, 326. Ointment, diachylon, Hebra's, 390. Oligaemia, 362. Oxyuris vermicularis, 100. Ozaena, 197. Pachymeningitis, 308. spinalis, 334. Pains, the girdle, 335. Palpition, 176. Palsy, Belt's, 361. wasting, 344. Paragraphia, 318. Paralysis, 304. bilateral, 304. bulbar, 339. cardiac, 147. chronic progressive bulbar, 339. crossed, 304. diphtheritic, 147. essential, of infants, 337. facial, 361. glosso-labio-laryngeal, 339. infantile spinal, 337. of the tongue, 318. pharyngeal, 147. | unilateral, 304. 458 INDEX. Paraphasia, 318. Parasites,intestinal, 98. Parasitic diseases of the skin, 431. Parotiditis, 143. metastatic, 143. Paste, Coster's, 438. Pathogenesis, II. Pathognomonic, 13. Pathology, 9. Pediculosis, 445. capitis, 445. corporis, 445. pubis, 446. Pemphigus, 404. foliaceus, 405. malignus, 405. pruriginosus, 405. vulgaris, 404. Percussion, 177. auscultatory, 181. immediate, 177- mediate, 177. objects of, 178. respiratory, 181. Pericarditis, acute, 273. chronic, 275. dry, 273. Pericardium, adherent, 276. effusion of, 273. hydro-, 277. Peri-nephritis, 134. Periodical fevers, 30. Peri-proctitis, 95. Peritoneal dropsy, 105. Peritonitis, 102. saline purgatives in, 104. Peri typhlitis, 95. Pernicious fever, 33. Pertussis, 231. Pharyngeal paralysis, 147. Pharyngitis, acute catarrhal, 198. erysipelatous, 200. exanthematous, 199. fibrinous, 200. gangrenous, 200. phlegmonous, 200-201. Phosphates, tests for, 120. Phosphoridrosis, 377. Phthiriasis, 445. Phthisis, 251. acute, 260. Phthisis, caseous, 251. catarrhal, 251. chronic, 258. fibroid, 258. Florida, 253. incipient, 255. pneumonic, 251. pulmonalis, 251. subacute, 251. tubercular, 255. Physical diagnosis, 174. signs, 13. signs, association of, 192. Piffard's acne solution, 375. Pill, Bartholow's gout, 160. Blaud's, 364. DaCosta's, for hemorrhage, 238. Gross' neuralgic, 360. Loomis' gout, 161. Moussette's, 360. Niemeyer's, 258. Pilocarpus for spreading erysipelas, 5°- Pitting, to prevent, 47. Pityriasis, 371. versicolor, 441. Pleurisy, 261. Pleuritis, 261. chronic, 262. dry, 262. Pleurodynia, 155. Pleuro-pneumonia, 241. Pneumonia, bilious, 244. caseous, 251. catarrhal, 248. chronic catarrhal, 251. chronic interstitial, 258. croupous, 241. lobar, 241. lobular, 248. typhoid, 243. Pneumonitis, 241. Pneumothorax, 266. Podagra, 159. Poliomyelitis anterior acuta, 337. , Polyuria, 166. Posterior spinal sclerosis, 342. Poultice, pilocarpus, 156. spice, 87. Predisposition, 11. acquired, 12. 459 Predisposition, inherited, 12. Prickly heat, 402. Proctitis, 95. Proctitis, peri-, 95. Prodromes, 12. Prognosis, 13. Progressive muscular atrophy, 344. pernicious anaemia, 365. Psoriasis, 418. circinata, 419. diffusa, 419. guttata, 419. gyrata, 419. mummularis, 419. of the mouth, 57. ofthe tongue, 57. palmaris, 419. plantaris, 419. punctata, 419. unguium, 419. Pulse, Corrigan, 288. receding, 288. Purging, 77. Purpura, 370. hemorrhagia, 370. simplex, 370. urticans, 370. Pus, test for, 121. Pyelitis, 133. Pyelo-nephritis, 133. nephrosis, 133. Pyloric obstruction, 67. stenosis, 67. Pyrosis, 70. Quinina in trichinosis, 174. Quinsy, 201. guaiacum in, 202. malignant, 144. Rales, 187. bronchial, 189. cavernous, 189. dry, 188. laryngeal, 188. moist, 188. pleural, 190. tracheal, 188. vesicular, 189. Reactions of degenerations, 338. Rectitis, 95. I Rectum, catarrh of, 95. I washing out the, 92. Regurgitation, aortic, 288. I mitral, 2S7. pulmonic, 289. tricuspid, 289. Relapsing fever, 29. j Remittent fever, 32. I Renal cyst, 133. Respiration, Cheyne-Stokes', 285. oscillating, 286. 1 Rheumatic fever, 150. I g°ut> I57- Rheumatism, acute articular, 150. gonorrhceal, 152. hyperpyrexia of, 151. inflammatory, 150. muscular, 154. Rheumatoid arthritis, 157. Rhinitis, acute, 193. chronic, 196. Rhinophyma, 416. Ringworm, honeycombed, 431. of the body, 433. of the scalp, 436. of the beard, 439. Robinson's errhine, 196. Rosacea gutta, 415. Rosea gutta, 415. Rose, the, 49. Rotheln, 44. Round worms, 100. Rubeola, 42. Sailors' fever, 37. Saline fluids in cholera, 172. Salt rheum, 382. Sand, renal, 138. Sapo viridis, 389. Scabies, 442. Scall, 382. Scarlatina, 39. mixture, Smith's, 363. Scarlet fever, 39. Sciatica, 359. Sclerosis, lateral, 341. cerebro-spinal, 341. disseminated, 341. hepatic hypertrophic, 115. of the liver, 115. 460 Sclerosis, posterior, 342. spinal, 340. Scorbutus, 368. Scurvy, 368. Sebaceous cyst, 376. Seborrhcea, 371. capitis, 372. faciei, 372. oleosa, 372. sicca, 372. Secondary processes, 13. Shingles, 400. Ship fever, 25. Sick-headache, 321. antipyrine in, 323. Sickness, green, 363. Sign, Corrigan's, 66. Signs, 12. physical, association of, 192. Skin, hyperaemias of, 380. inflammation of, 382. Silver nitrate in phlegmonous erysipe las, 50. Smallpox, 44. Smith's, Dr. A. H., tonic, 363. Solution, Dobell's, 197. Tanret's, of pelletierine, 100. Sore throat, acute, 198. putrid, 144 Sounds, in disease, chest, 184. in health, chest, 183. normal cardiac, 269. Spanaemia, 362. Spasm, histrionic, 347. Spinal sclerosis, 340. hyperaemia, 331. irritation, 353. meningitis, 332. Spinalis pachymeningitis, 334. Splenification, 239. Spotted fever, 26. Sprue, 55. St. Anthony's fire, 49. Stomach, cancer of, 65. diseases of, 58. neuralgia of, 69. remorse of, 71. spasm of, 69. washing out the, 97. Stomatitis, catarrhal, 52. cioupous, 53. Stomatitis, diphtheritic, 54. erythematous, 52. follicular, 53. simple, 52. ulcerative, 54- vesicular, 53. Stonepock, 413. Stones, chalk, 160. Stools, chopped spinach, 88. Storm, electrical, 348. Stiicture, intestinal, 96. St. Vitus's dance, 346. Succussion, 192. Sudamen, 379. Sudamina, 379. Sugar, test for, 122, 123. Summer complaint, 87. Sun stroke, 329. Swamp fever, 30. Sweating, excessive, 377. Sycosis parasitica, 439. Synocha, 16. Symptoms, 12. Syncope, 305. Syrup, Declat, 42. Tabes dorsalis, 342. Taenia saginata, 98. solium, 98. Tapeworm, armed, 98. unarmed, 98. Temulentia, 323. Test for albumin, 121. bile, 122. bile pigment, 122. blood, 121. chlorides, 120. mucus, 120. phosphates, 120. pus, 121 sugar, 122, 123. urates, 119. urea, 119. Tetter, 382. Throat, acute sore, 198. putrid sore, 144. Thrombosis, cerebral, 299. Thrush, 55. Thymol solution, Morris', 438. Tic-douloureux, 358. INDEX. 401 Tincture, Warburg's, 35. Tinea circinata, 433. favosa, 431. furfuracea, 371. kerion, 336. sycosis, 439. tonsurans, 436. versicolor, 441. Tinkling, metallic, 190. Tone, bandbox, of Bamberger, 228. Tongue, strawberry, 40. Tonic, Dr. A. H. Smith's, 363. Sir Erasmus Wilson's, 373. Tonsillitis, acute, 201. catarrhal, 198. Tormina, 74. Torticollis, 155. Toxic gastritis, 60. Trance, 352. Treatment, 14. abortive, 14. expectant, 14. preventive, 14. restorative, 14. Tremens, delirium, 325. Trichinae, 172. spiralis, 172. Trichinosis, 172. Tubercular meningitis, 310. Tuberculosis. 255. acute miliary, 260. Tumor, phantom, 352. sebaceous, 376. Tumors, abdominal, 66. intra cranial, 316. Turpentine in purpura, 371. Tu peth mineral in croup, 209. Tyloma, 425. Tympanites, chronic, 106. Typhlitis, 93. Typho malarial fever, 32. Typhoid fever, 19. T)phus fever, 25. icterode, 37. Ulcer, duodenal, 64. gastric, 63. peiforating, 63. Ulcerative colitis, 90. stomatitis, 54. / I Ulcerosa gingivitis, 54. Uraemia, acute, 135. morphina in, 136. Uraemic coma, 135. convulsions, 135. Urates, test for, 119. Urea, test for, 119. Uric acid diathesis, 161. test for, 119. Uridrosis, 377. Urine, 118. hysterical, 227. normal color, 118. normal constituents, 118. normal quantity, 118. reaction, 118. Urticaria, 396. Vaccination, 47. Vaccinia, 47. Valvular diseases of the heart, 286. diagnosis of, 292. Valvulitis, 277. Varicella, 48. Variola, 44. Varu% 413. Verruca, 427. Ve.tigo, 319. aural, 319. auditory, 319. nervous, 319. senile, 319. stomachic, 58, 319. Vesicular stomatitis, 53. Voice in disease, 191. Vomit, black, 37. coffee ground, 37. Waddle, the, 341. Warburg's tincture, 35. Wart, 427. venereal, 428. Water blisters, 404. colored, as a treatment, 152. Wens, 376. Wheals, 397. While blood, 366. cell blood, 366. mouth, 55. 462 Whooping-cough, 231. Wilson's, Erasmus, tonic, 373. Worms, tape, 98. round, loo. seat, ioo. INDEX. Xeroderma, 429. Yellow fever, 37. Zona, 400. JUST PUBLISHED. THIRD EDITION. Human Physiology, BY LANDOIS AND STIRLING. Third American, from the Sixth German Edition. A Text-book of Human Physiology, including Histology and Microscopical Anatomy, with special reference to the requirements of Practical Medicine. By Dr. L. Landois, Professor of Physiology and Director of the Physiological Institute, University of Greifswald. Trans- lated from the Fifth German Edition, with additions by Wm. Stirling, m.d., Sc.d., Brackenbury Professor of Physi- ology and Histology in Owens College and Victoria Uni- versity, Manchester; Examiner in the Honors School of Science, University of Oxford, England. Third Edition, revised and enlarged. 692 Illus. " A BRIDGE BETWEEN PHYSIOLOGY AND PRAC- TICAL MEDICINE." One Volume. Royal Octavo. 974 Pages. Cloth, $6.50; Leather, $7 50. PRESS NOTICES. 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Physical Diagnosis, Physiology, . Practice of Medicine, Prescription Books, ? Quiz-Compends ? Skin Diseases, Surgery, Therapeutics, Throat, 6 7 8 :. 8 9 10 9 9 9 Jo | Venereal Diseases , 16 13 '3 9 M Urine and Urinary Organs, 14 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. "An excellent Series of Manuals."—Archives of Gynacology. A NEW SERIES OF STUDENTS' MANUALS On the various Branches of Medicine and Surgery. Can be used by Students of any College. Price of each. Handsome Cloth, $3.00. Full Leather, $3.50. The object of this series is to furnish good manuals for the medical student, that will strike the medium between the compend on one hand and the prolix text- book on the other—to contain all that is necessary for the student, without embarrassing him with a flood of theory and involved statements. They have been pre- pared by well-known men, who have had large experience as teachers and writers, and who are, therefore, well informed as to the needs of the student. Their mechanical execution is of the best—good type and paper, handsomely illustrated whenever illustrations are of use, and strongly bound in uniform style. Each book is sold separately at a remarkably low price, and the immediate success of several of the volumes shows that the series has met with popular favor. No. 1. SURGERY. 236 Illustrations. A Manual of the Practice of Surgery. By Wm. J. Walsham, m.d., Asst. Surg, to, and Demonstrator of Surg, in, St. Bartholomew's Hospital, London, etc. 228 Illustrations. Presents the introductory facts in Surgery in clear, precise language, and contains all the latest advances in Pathology, Antiseptics, etc. " It aims to occupy a position midway between the pretentious manual and the cumbersome System of Surgery, and its general character may be summed up in one word—practical."— The Medi- cal Bulletin. " Walsham, besides being an excellent surgeon, is a teacher in its best sense, and having had very great experience in the preparation of candidates for examination, and their subsequent professional career, may be relied upon to have carried out his work successfully. Without following out in detail his arrange- ment, which is excellent, we can at once say that his book is an embodiment of modern ideas neatly strung together, with an amount of careful organization well suited to the candidate, and, indeed, to the practitioner."—British Medical Journal. Price of each Book, Cloth, $3.00; Leather, $3.60. THE NEW SERIES OF MANUALS. No. 2. DISEASES OF "WOMEN. 150 Illus. NEW EDITION. The Diseases of Women. By Dr. F. Winckel, Professor of Gynaecology and Director of the Royal University Clinic for Women, in Munich. Translated from the German by Dr. J. H. Williamson, under the supervision of, and with an introduction by, The- ophilus Parvin, m.d., Professor of Obstetrics and Diseases of Women and Children in Jefferson Med- ical College. 150 Engravings, most of which are new. Second Edition, Enlarged. " The book will be a valuable one to physicians, and a safe and satisfactory one to put into the hands of students. It is issued in a neat and attractive form, and at a very reasonable price."—Boston Medical and Surgical Journal. No. 3. OBSTETRICS. 227 Illustrations. A Manual of Midwifery. By Alfred Lewis Galabin, m.a., m.d., Obstetric Physician and Lecturer on Mid- wifery and the Diseases of Women at Guy's Hospital, London; Examiner in Midwifery to the Conjoint Examining Board of England, etc. With 227 Illus. "This manual is one we can strongly recommend to all who desire to study the science as well as the practice of midwifery. Students at the present time not only are expected to know the principles of diagnosis, and the treatment of the various emergen- cies and complications that occur in the practice of midwifery, but find that the tendency is for examiners to ask more questions relating to the science of the subject than was the custom a few years ago. * * * The general standard of the manual is high; and wherever the science and practice of midwifery are well taught it will be regarded as one of the most important text-books on the subject"—London Practitioner. No. 4. PHYSIOLOGY. Fourth Edition. 321 ILLUSTRATIONS AND A GLOSSARY. A Manual of Physiology. By Gerald F. Yeo, m.d., f.r.c s., Professor of Physiology in King's College, London. 321 Illustrations and a Glossary of Terms. Fourth American from second English Edition, revised and improved. 758 pages. This volume was specially prepared to furnish students with a new text-book of Physiology, elementary so far as to avoid theories which have not borne the test of time and such details of methods as are unnecessary for students in our medical colleges. " The brief examination I have given it was so favorable that I placed it in the list of text-books recommended in the circular of the University Medical College."—Prof. Lewis A. Stimson, m.d., J7 East 33d Street, New York. Price of each Book, Cloth, $3.00; Leather, $3.50. 4 THE NEW SERIES OF MANUALS. No. 5. ORGANIC CHEMISTRY. Or the Chemistry of the Carbon Compounds. By Prof. Victor von Richter, University of Breslau. Au- thorized translation, from the Fourth German Edition. By Edgar F. Smith, m.a., ph.d. ; Prof, of Chemistry in University of Pennsylvania; Member of the Chem. Socs. of Berlin and Paris. " I must say that this standard treatise is here presented in a remarkably compendious shape."—J. W. Holland, m.d., Professor of Chemistry, Jefferson Medical College, Philadelphia. " This work brings the whole matter, in simple, plain language, to the student in a clear, comprehensive manner. The whole method of the work is one that is more readily grasped than that of older and more famed text-books, and we look forward to the time when, to a great extent, this work will supersede others, on the score of its better adaptation to the wants of both teacher and student."—Pharmaceutical Record. " Prof, von Richter's work has the merit of being singularly clear, well arranged, and for its bulk, comprehensive. Hence, it will, as we find it intimated in the preface, prove useful not merely as a text-book, but as a manual of reference."—The Chemical News, London. No. 6. DISEASES OF CHILDREN. A Manual. By J. F. Goodhart, m.d., Phys. to the Evelina Hospital for Children; Asst. Phys. to Guy's Hospital, London. American Edition. Edited by Louis Starr, m.d., Clinical Prof, of Dis. of Children in the Hospital of the Univ. of Pennsylvania, and Physician to the Children's Hospital, Phila. Containing many new Prescriptions, a list of over 50 Formulae, conforming to the U. S. Pharmacopoeia, and Directions for making Artificial Human Milk, for the Artificial Digestion of Milk, etc. " The author has avoided the not uncommon error of writing a book on general medicine and labeling it ' Diseases of Children,' but has steadily kept in view the diseases which seemed to be incidental to childhood, or such points in disease as appear to be so peculiar to or pronounced in children as to justify insistence upon them. * * * A safe and reliable guide, and in many ways admirably adapted to the wants ofthe student and practitioner."__ American Journal of Medical Science. Price of each Book. Cloth, $3.00; Leather, $3.50. THE NEW SERIES OF MANUALS. No. 6. Goodhart and Starr .—Continued. " Thoroughly individual, original and earnest, the work evi- dently of a close observer and an independent thinker, this book, though small, as a handbook or compendium is by no means made up of bare outlines or standard facts."— The Therapeutic Ga- zette. "As it is said of some men, so it might be said of some books, that they are 'born to greatness.' This new volnme has, we believe, a mission, particularly 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. The work of Dr. Goodhart (admirably conformed, by Dr. Starr, to meet American require- ments) is the nearest approach to clinical teaching without the actual presence of clinical material that we have yet seen."—New York Medical Record. No. 7- PRACTICAL THERAPEUTICS. FOURTH EDITION, WITH AN INDEX OF DISEASES. Practical Therapeutics, considered with reference to Articles of the Materia Medica. Containing, also, an Index of Diseases, with a list of the Medicines applicable as Remedies. By Edward John Waring, m.d., f.r.c.p. Fourth Edition. Rewritten and Re- vised. By Dudley W. Buxton, m.d., Asst. to the Prof, of Medicine at University College Hospital. " We wish a copy could be put in the hands of every Student or Practitioner in the country. In our estimation, it is the best book of the kind ever written."—N. Y. Medical Journal. No. 8. MEDICAL JURISPRUDENCE AND TOXICOLOGY. NEW, REVISED AND ENLARGED EDITION. By John J. Reese, m.d., Professor of Medical Jurispru- dence and Toxicology in the University of Pennsyl- vania; President of the Medical Jurisprudence Society of Phila.; 2d Edition, Revised and Enlarged. "This admirable text-book."—Amer.Jour. of Med. Sciences. " We lay this volume aside, after a careful perusal of its pages, with the profound impression that it should be in the hands of every doctor and lawyer. It fully meets the wants of all students. • ■ • • He has succeeded in admirably condensing into a handy volume all the essential points."—Cincinnati Lancet and Clinic. Price of each Book, Cloth, $3,00; Leather, $3.50. 6 STUDENTS' TEXT-BOOKS AND MANUALS. ANATOMY. Holden's Anatomy. A manual of Dissection of the Human Body. Fifth Edition. Enlarged, with Marginal References and over 200 Illustrations. Octavo. Cloth, 5.00; Leather, 6.00 Bound in Oilcloth, for the Dissecting Room, $4.50. *' No student of Anatomy can take up this book without being pleased and instructed. Its Diagrams are original, striking and suggestive, giving more at a glance than pages of text description. * * * The text matches the illustrations in directness of prac- tical application and clearness of detail."—New York Medical Record. Holden's Human Osteology. Comprising a Description of the Bones, with Colored Delineations of the Attachments of the Muscles. The General and Microscopical Structure of Bone and its Development. With Lithographic Plates and Numerous Illus- trations. Seventh Edition. 8vo. Cloth, 6.00 Holden's Landmarks, Medical and Surgical. 4th ed. Cloth, 1.25 Heath's Practical Anatomy. Sixth London Edition. 24 Col- ored Plates, and nearly 300 other Illustrations. Cloth, 5.00 Potter's Compend of Anatomy. Fourth Edition. 117 Illus- trations. Cloth, 1.00; Interleaved for Notes, 1.25 CHEMISTRY. Bartley's Medical Chemistry. Second Edition. Atext-book prepared specially for Medical, Pharmaceutical and Dental Stu- dents. With 50 Illustrations, Plate of Absorption Spectra and Glossary of Chemical Terms. Revised and Enlarged. 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 and physics 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. Seventh Edition. Enlarged and Rewritten. Nearly 300 Illus- trations. Cloth, 4.50; Leather, 5.50 Richter's Inorganic Chemistry. A text-book for Students. Third American, from Fifth 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 W See pages 2 to 5 for list of Students' Manuals. STUDENTS' TEXT-BOOKS AND MANUALS. 7 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. Third Edition. 8vo. Cloth, 1.50 Tidy. Modern Chemistry. 2d Ed. Cloth, 5.50 Leffmann's Compend of Chemistry. Inorganic and Organic. Including Urinary Analysis and the Sanitary Examination of Water. New Edition. Cloth, 1.00; Interleaved for Notes, 1.2s Muter. Practical and Analytical Chemistry. Second Edi- tion. Revised and Illustrated. Cloth, 2.00 Holland. The Urine, Common Poisons, and Milk Analysis, Chemical and Microscopical. For Laboratory Use. 3d Edition, Enlarged. Illustrated. Cloth, 1.00 Van Niiys. Urine Analysis. Illus. Cloth, 2.00 Wolff's Applied Medical Chemistry. By Lawrence Wolff, m.d., Demonstrator of Chemistry in Jefferson Medical College, Philadelphia. Cloth, 1.00 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 Formula?, conforming to the U. S. Pharmacopoeia, and Directions for making Arti- ficial Human Milk, for the Artificial Digestion of Milk, etc. Cloth, 3.00; Leather, 3.50 Day. On Children. A Practical and Systematic Treatise. Second Edition. 8vo. 752 pages. Cloth, 3.00; Leather, 4.00 Meigs and Pepper. The Diseases of Children. Seventh Edition. 8vo. Cloth, 5.00 ; Leather, 6.00 Starr. Diseases of the Digestive Organs in Infancy and Childhood. With chapters on the Investigation of Disease, and on the General Management of Children. By Louis Starr, m.d., Clinical Professor of Diseases of Children in the Univer- sity of Pennsylvania; with a section on Feeding, including special Diet Lists, etc. Illus. Cloth, 2.50 , m.d. 71 Illustrations, 39 Formulae. Second Enlarged and Improved Edition. Index. No. 9. SURGERY. Illustrated. Third Edition. Including Fractures, Wounds, Dislocations, Sprains, Amputations and other operations; Inflammation, Suppuration, Ulcers, Syphilis, Tumors, Shock, etc. Diseases of the Spine, Ear, Bladder, Tes- ticles, Anus, and other Surgical Diseases. By Orville Horwitz, a.m., m.d., Demonstrator of Anatomy, Jefferson Medical Col- lege. Revised and Enlarged. 77 Formulae and 91 Illustrations. No. 10. CHEMISTRY. Inorganic and Organic. For Medical and Dental Students. Including Urinary Analysis and Medical Chemistry. By Henry Leffmann, m.d., Prof, of Chemistry in Penn'a College of Dental Surgery, Phila. A new Edition, Revised and Rewritten, with Index. No. 11. PHARMACY. Based upon " Remington's Text-book of Pharmacy." By F. E. Stewart, m.d., ph.g., Quiz-Master at Philadelphia College of Pharmacy. Second Edition, Revised. Bound in Cloth, $1. Interleaved, for the Addition of Notes, $1.25. Jg®"" These books are constantly revised to keep up with the latest teachings and discoveries, so that they contain all the new methods and principle's. No series of books are so complete in detail, concise in language, or so well printed and bound. Each one forms a complete set of notes upon the subject under consideration. NATIONAL LIBRARY OF MEDICINE NLM QDDflSflSM fl NLM000858548